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ACADEMIAEVEHARVARDIANAESIGILLVMCHRISTINNOVVANCSLARHarvard College LibraryFROMPresident CharlesW. ElectERRATΑ .Page 58, foot -note-For " deducted " read deduced.Page 70, line 14-For " actue " read acute.Page 80, line 2-After word " populations " insert foot -note indicator.Page 138 , opposite No. 22-Delete figure " 7. "Page 160, second foot-note-For " 1882 " read 1822.Page 168, last line-For " p. 394 " read p. 364.Page 174, top of table-For " vaccination " read vaccinated.Page 183, line 20-For " 1874 " read 1894.Page 233, line 4-For " 1802 " read 1892.Page 245, line 4-For " stratas " read strata.Page 267, first foot-note-For " Worlomont " read Warlomont.Page 296, first item oftable-For " Undine " read Udine.Page 326, first foot- note , line 5-For " p. 187 " read p. 178.
A CENTURY OF VACCINATION .
A CENTURY OF VACCINATIONAND WHAT IT TEACHES.BYW. SCOTT TEBB, M.A. , M.D. (Cantab. ) , D.P.H.SECOND EDITION.LONDON :SWAN SONNENSCHEIN & CO . , LIM .1899.Med 1858.98.2HAY NISBET AND COMPANY LIMITED ,PRINTERS,GLASGOW AND LONDON .HARVARCOLLEGELIBRARTO MY FATHER,WILLIAM TEBB ,THIS BOOKIS AFFECTIONATELY DEDICATED .
PREFA СЕ .So long as the practice of vaccination remains establishedand enforced by law, it will be the duty of everycitizen, who is also the father of a family, to form ajudgment upon it ; unless, indeed, it is to be held thatthe infallibility of the legislature and of the medicalprofession, which in this instance directed legislation ,is so well assured that enquiry is superfluous, if notculpable. But it is a sounder doctrine that the existenceof the law does not relieve parents of responsibilitytowards their children, and more especially parents(nowadays the majority) who have heard that theefficacy of this operation has been called in question bycompetent men, while its risks, so long denied, are nowon all hands admitted. I am, therefore, not withouthopes that among my readers will be included a fairnumber of the " general public" interested in the subjectby the pressure of compulsion, and anxious before theysubmit a child to vaccination to feel assured that theyare doing the right thing, being also resolved to withholdthe child from the operation if they cannot besatisfied of this.But I here address myself more particularly to twoclasses-to my medical brethren, and to those whosePREFACE.business it is to legislate for the country on this subject.On the former, I desire, with all respect, to urge thefollowing considerations :-Can itbe said that the Jennerian doctrine ofvaccinationhas ever been placed on a truly scientific basis?I specify the "Jennerian doctrine," for there are otheraspects of the vaccination or inoculation theory whichI expressly rule out of my enquiry. It is a generallyreceived opinion that in the case of certain diseases oneattack affords some degree of immunity against asecond. It is certain that there are exceptions to therule, and it is further certain that the rule has neverbeen scientifically established as such . Nevertheless, itis a generally accepted belief, with evidence in itsfavour, and in the pages that follow I do not reject oreven attack that belief. Further, it is a postulate of themodern inoculation doctrine that a mild or modifiedattack suffices to secure this immunity. Whether thisbe so or not, I cannot tell. It is a matter into which Ihave not been led to enquire, and I am willing to grantit for the sake of argument, since it does not really concernthe position which I am calling in question. WhatI do deny, as the result of my enquiries, is that anattack of cow- pox secures immunity against small-pox .To use technical terms in order to make the distinctionclear : while I may allow within limits the truth ofhomoprophylaxy or homoeoprophylaxy, I am satisfiedthat there has never been shown any sort of scientificbasis for heteroprophlaxy. If the reply be made that,granting it is wrong to teach that vaccination is homoprophylactic,it is fair to claim for it that it is homoeoprophylactic,I should deny that such a claim can bePREFACE .sustained ; and, though I am, of course, aware thatvariolous matter can be so modified by being taken atan early stage and passed once or twice through thecalf as to produce, when inoculated, not an attack ofsmall-pox, but local effects similar in appearance tothose of vaccination, yet that is not what is doneevery day by medical men who vaccinate. What theyare doing they really do not know, nor does any oneknow, for the ultimate origin of the vaccine lymph incommon use has long ago been lost sight of ; but if itbe true that that ultimate origin is cow-pox, if, that isto say, when we vaccinate we are carrying out theteaching of Jenner, then, certainly, we are acting as ifheteroprophylaxy had been established scientifically ;for the investigations of Dr. Creighton and ProfessorCrookshank have proved conclusively that cow-pox isa disease radically different from that against which itis said to protect. Effects similar to those of vaccinationcan be produced in a variety of ways, and,therefore, to produce them as Dr. Klein and othersclaim to have done, by means of small -pox virus , attenuatedor in other ways concocted , does not identify thedisease on which Jenner relied for protection with thedisease against which he claimed that it protected, anymore than does the production of a vaccine vesicle fromcattle- plague identify vaccination with that disease.Many of my brethren, while willing to acknowledgethat there is no true pathological relation betweenCOW pox and small - pox, fall back on the allegedevidence of statistics, and claim to find in them ascientific vindication of vaccination. The majority ofthe Royal Commissioners took this view, and ratherPREFACE .deprecated the idea that any other scientific vindicationwas necessary . To the questioning of theposition that trustworthy statistics do provide sucha vindication my pages are partly devoted. I donot deny that the " century of vaccination " synchronisesroughly with a century in which small -pox (in Europe,at any rate) has largely declined. But this coincidenceby no means involves any connection in theway of cause and effect. Small-pox, like typhus, hasbeen dying out since 1780. Vaccination in this countryhas fallen largely into disuse since people began torealise how its value was discredited by the great smallpoxepidemic of 1871-72 . So that, while small-pox hasdeclined during the last one hundred and twenty years ,twenty years may be cut off from each end of thisperiod, as contributing no evidence whatever of thedecline being due to vaccination, and as involving theconclusion that some other causes have been at workto promote this result. I am, of course, only speakingapproximately. To the evidence afforded by detailedcases criticism of another kind is applicable, and to thisI will presently refer. But, first, in passing, I would callattention to the ease with which an alleged protectiveoperation can acquire a great reputation as successful,more especially if its adoption should coincide with adecline from other causes of the disease against which itis supposed to protect. A local epidemic of small-poxis seldom so severe as to attack more than 5 per cent .of the population. If, therefore, a small minority hasadopted some alleged prophylactic, it is very unlikelythat the disease will count among its victims any considerableproportion of those who are thus fortified,PREFACE .particularly as they would be likely to be more thanordinarily careful in matters relating to health. Inthis way their prophylactic will acquire a great reputation,and the vastly greater number who have equallyescaped without having recourse to the protectiveoperation will be overlooked. This is what happens inpretty nearly every epidemic in regard to re- vaccinationand the security it is alleged to provide. In the caseof primary vaccination other but not less misleadinginferences are drawn. Should there be an epidemic ofsmall -pox in a locality where 85 per cent. of the populationare vaccinated, it is obvious that the 95 per cent.of the population who escape the epidemic (assuming, asbefore indicated, a maximum of 5 per cent. attacked byit) will largely coincide with the 85 per cent. vaccinated ;and vaccination thus gains credit. But it will be objected,if the 5 per cent. attacked coincide, in however small adegree, with the 15 per cent. unvaccinated, this is strongtestimony to the risk of being unvaccinated ; and so, nodoubt, it would be, but for the fact that in localitieswhere the vaccination law is vigorously carried out,the unvaccinated , as a class, will be found to consistlargely of the outcasts of society, nomads whom the lawhas failed to reach, and of weakly children who onaccount of their health have been excused the operation .This class, therefore, is likely to furnish a disproportionatenumber of the victims of the epidemic ; andthus again the prophylactic acquires reputation. Addto this the facts, often overlooked , that medical men,even if officials and highly placed, are still liable as mento err, and that their errors will probably accord withtheir cherished beliefs, and it will readily be understoodPREFACE.thatthe evidence ofdetailed cases-which is really theonly evidence on which the credit of vaccination dependscannot be accepted wholesale as if it werenot open to question. A vaccinated patient with novisible signs of vaccination is likely to be described asunvaccinated ifhis case is severe, and especially ifdeathensues; while if the marks are not plainly visible, theexplanation of"not properly performed " is an obviousone; and the patient will be included as " belonging tothe unvaccinated or imperfectly vaccinated class " inthe list of cases, and, tout court, as " unvaccinated " orhaving no marks" in the official summary. I think itwould be advisable for my medical brethren to acceptasauthentic only published and tested cases, or such ashave come under their own personal observation.To those who are about to legislate for the countryonthis vexed question I also address myself particularly.The Queen, in her Speech at the opening of the presentSession of Parliament, called for " earnest consideration "of the subject. Hitherto vaccination bills have beenpassed into law without adequate discussion or debate.Parliament has been assured (incorrectly) that there iscomplete unanimity in the medical profession concerningthe nature, value, necessity, and safety of vaccination ;and that has sufficed. Lords and Commons have atonce bowed before this alleged unanimity, with theresult, as vaccinists claim, but cannot possibly prove ,that small-pox has been practically stamped out, butundoubtedly also with the result that hundreds ofinfants have died from the effects of the operation,that thousands of otherwise blameless citizens have beenfined or imprisoned for their very natural and properPREFACE .Iresistance to this extraordinary law, and hundredsof thousands of pounds of public money have beenspent on what I am satisfied is nothing but a uselessand mischievous fallacy. It is strange that membersof Parliament do not perceive that the strength of thepro- vaccinist party lies in the public endowment of thepractice. Right through the century there has existeda body of officials , ostensibly paid to promote thepractice of vaccination, but also, partly at least, paidto vindicate it theoretically, and to explain away itsfailures and its accompanying disasters. But for thisState aid, vaccination would long ago have been consignedto the same limbo as has received a thousandother similar fads which, fortunately for the public,have not secured official recognition and support.hardly expect that legislators will have time to readthe numerous cases I adduce-some showing thatimmunity from small -pox exists without vaccination ,others that mild attacks of small- pox were recordedlong before there was any alleged mitigating powerin vaccination to which to ascribe them, and, again ,others proving that neither vaccination nor re- vaccinationnor recent vaccination can be depended upon toprotect from small -pox or even from death from thatdisease. But to the cases of injury and death resultingfrom vaccination I trust they will not refuse to givesome attention . This evidence should be enough todetermine any fair- minded enquirer that the enforcementof vaccination by law is indefensible. Take away firstthe compulsory law, and then take away (if vestedinterest is not too strong for you) the endowment ofthe practice, and when this has been effected, medicalPREFACE .men will find themselves for the first time since 1803 .free to discuss the vaccination question as a scientificone on its own merits. To what result that unfettereddiscussion will lead I have myself (now that I havestudied the matter carefully for some years) no sortof doubt.In conclusion, I desire to express my obligationsfor the valuable assistance of Mr. A. W. Hutton, whoseletters on " The Vaccination Question," addressed toMr. Asquith and Mr. Balfour in 1894 and 1895, I canrecommend as an introduction to the rational study ofthis vexed problem .April, 1898.PREFACE TO THE SECOND EDITION .THE interval that has elapsed between the first andsecond editions of this book has witnessed a considerablestrengthening of the position of those whodissent from the popular belief in the value ofvaccination . It is true that the debates in Parliamentshowed how very far the general public is yetfrom a just appreciation of the present position ofthis controversy . So far as I noticed, apart from thevery few newspapers that definitely supported the antivaccinistcause, only one-the Westminster Gazetteadmittedthat there is a real weakness on the other side,viz. , the fact that there exists among medical men themPREFACE.selves a doubt, and a growing doubt, whether vaccinationis, after all, what it professes to be. But it canhardly be questioned that a recognition of this doubtand of its grave significance also underlay the excellentspeeches of Mr. Balfour and of Lord Salisbury, to whomthe passing of the measure into law was largely due.Reasons of expediency had, of course, to be urged insupport of such a measure of relief; but these wouldhardly have sufficed, apart from the weightier considerationthat it is unjustifiable to enforce under penalties amedical doctrine concerning which doctors themselvesdisagree. There is no reason to suppose that either Mr.Balfour or Lord Salisbury has any special knowledge ofthe subject, or has abandoned the current belief concerningit ; but as statesmen, and as thinkers, they couldnot fail to recognise the limits beyond which matters ofopinion cannot be enforced.When the Act itself is administered in the spirit inwhich it is framed it will afford a much- needed relief,and may even do something to retard the progress ofthe movement for the disestablishment and disendowmentof vaccination. But the unfortunate andindefensible provision about " satisfying " two justicespermits men on the bench, who are often, it appears,fanatical believers in vaccination, to use the Act as aweapon of terror against timid conscientious objectors .They actually have the assurance to inform claimantsfor exemption, with all the authority that comeswith a declaration ex cathedra, that if the child inquestion is not vaccinated it will certainly take smallpox,whereas, if it is vaccinated, it will as certainlyescape. No medical man could or would speak thusPREFACE.positively. If this misuse of the new law becomesgeneral, it will shortly be as unworkable as the oldone was ; but it is to be hoped that this deplorablemaladministration will only be temporary.That the movement against vaccination will spreadand will ultimately triumph everywhere is certain. Thealleged unanimity of the medical profession on thesubject-the argument on which pro-vaccinists mostlyrely-is far more apparent than real. That a majorityof medical men would, if polled at this moment, passa vote of confidence in vaccination is probably true .But votes need to be weighed as well as counted ; andI am satisfied that, if the poll were confined to thosepractitioners who have studied the subject, and havehonestly endeavoured to form an independent judgmenton the evidence, the majority would be the other way.Even now very few care to defend the practice openly.And it must be remembered that it has never been theway of the medical profession, as a body, to confess todoubts as to the value of any established medicalpractice. They will allow such practices gradually tofall into desuetude when they no longer commandconfidence ; and this is especially the case when othermethods of treatment can acceptably be substituted ;but a positive declaration against any doubtful practiceis not to be looked for.Nothing would more quickly undeceive the publicthan the rapid and complete abandonment of thepractice of vaccination in rural districts. Small -pox ismainly an urban disease ; and on this point the statisticsare so clear that the firmest believers in the protectivepower of vaccination must admit that in rural districtsPREFACE.it is unnecessary ; but, while townspeople can combineto free themselves from the pressure of the law, countryfolk cannot. Local epidemics will still occur in townswhere the sanitary conditions are defective ; and if, in asingle instance, the town happens to be unvaccinatedas well as insanitary, an epidemic there will render allother evidence nugatory, and throw back the movementperhaps for years. Nevertheless, in spite of such drawbacks,a practice that has been so thoroughly discreditedby competent men on scientific grounds must sooner orlater be consigned to the limbo of discarded superstitions.That the practice has been definitely discredited onscientific grounds is not open to serious question.The investigations of Dr. Creighton and ProfessorCrookshank have been very generally ignored by themedical profession ; but it is true that some effortshave been made to rehabilitate vaccination by bacteriologists, who assert that they have discovered " thespecific organism on which vaccinia depends. " Theirmain object is, of course, to reassure the public inregard to the now admitted risks of vaccination ashitherto practised. We are to have " pure cultures, " towhich it is supposed no one will take any objection.But surely the public will demand something positiveas a scientific demonstration that vaccine really has aprophylactic power against variola, and will not besatisfied with the mere assurance that now at last itwill do no harm. It is not long since it was announcedin the papers that Dr. Klein had identified the vaccinewith the variolous bacillus, but who now believes thathe did ? A later claim, not indeed to have made thisidentification of the bacilli of the two diseases, but to1PREFACE.business it is to legislate for the country on this subject.On the former, I desire, with all respect, to urge thefollowing considerations :-Can it be said that the Jennerian doctrine of vaccinationhas ever been placed on a truly scientific basis ?I specify the " Jennerian doctrine," for there are otheraspects of the vaccination or inoculation theory whichI expressly rule out of my enquiry. It is a generallyreceived opinion that in the case of certain diseases oneattack affords some degree of immunity against asecond. It is certain that there are exceptions to therule, and it is further certain that the rule has neverbeen scientifically established as such. Nevertheless, itis a generally accepted belief, with evidence in itsfavour, and in the pages that follow I do not reject oreven attack that belief. Further, it is a postulate of themodern inoculation doctrine that a mild or modifiedattack suffices to secure this immunity. Whether thisbe so or not, I cannot tell. It is a matter into which Ihave not been led to enquire, and I am willing to grantit for the sake of argument, since it does not really concernthe position which I am calling in question. WhatI do deny, as the result of my enquiries, is that anattack of cow- pox secures immunity against small -pox.To use technical terms in order to make the distinctionclear: while I may allow within limits the truth ofhomoprophylaxy or homoeoprophylaxy, I am satisfiedthat there has never been shown any sort of scientificbasis for heteroprophlaxy. If the reply be made that,granting it is wrong to teach that vaccination is homoprophylactic,it is fair to claim for it that it is homoeoprophylactic,I should deny that such a claim can bePREFACE .sustained ; and , though I am, of course, aware thatvariolous matter can be so modified by being taken atan early stage and passed once or twice through thecalf as to produce, when inoculated, not an attack ofsmall -pox, but local effects similar in appearance tothose of vaccination, yet that is not what is doneevery day by medical men who vaccinate. What theyare doing they really do not know, nor does any oneknow, for the ultimate origin of the vaccine lymph incommon use has long ago been lost sight of; but if itbe true that that ultimate origin is cow- pox, if, that isto say, when we vaccinate we are carrying out theteaching of Jenner, then , certainly, we are acting as ifheteroprophylaxy had been established scientifically ;for the investigations of Dr. Creighton and ProfessorCrookshank have proved conclusively that cow -pox isa disease radically different from that against which itis said to protect. Effects similar to those of vaccinationcan be produced in a variety of ways, and,therefore, to produce them as Dr. Klein and othersclaim to have done, by means of small-pox virus, attenuatedor in other ways concocted, does not identify thedisease on which Jenner relied for protection with thedisease against which he claimed that it protected, anymore than does the production of a vaccine vesicle fromcattle-plague identify vaccination with that disease.Many of my brethren, while willing to acknowledgethat there is no true pathological relation betweenCOW pox and small - pox, fall back on the allegedevidence of statistics, and claim to find in them ascientific vindication of vaccination.the Royal Commissioners took thisThe majority ofview, and ratherPREFACE .deprecated the idea that any other scientific vindicationwas necessary. To the questioning of theposition that trustworthy statistics do provide sucha vindication my pages are partly devoted. I donot deny that the " century of vaccination " synchronisesroughly with a century in which small-pox ( in Europe,at any rate) has largely declined. But this coincidenceby no means involves any connection in theway of cause and effect. Small-pox, like typhus, hasbeen dying out since 1780. Vaccination in this countryhas fallen largely into disuse since people began torealise how its value was discredited by the great smallpoxepidemic of 1871-72. So that, while small-pox hasdeclined during the last one hundred and twenty years ,twenty years may be cut off from each end of thisperiod, as contributing no evidence whatever of thedecline being due to vaccination, and as involving theconclusion that some other causes have been at workto promote this result. I am, of course, only speakingapproximately. To the evidence afforded by detailedcases criticism of another kind is applicable, and to thisI will presently refer. But, first, in passing, I would callattention to the ease with which an alleged protectiveoperation can acquire a great reputation as successful,more especially if its adoption should coincide with adecline from other causes of the disease against which itis supposed to protect. A local epidemic of small-poxis seldom so severe as to attack more than 5 per cent.of the population. If, therefore, a small minority hasadopted some alleged prophylactic, it is very unlikelythat the disease will count among its victims any considerableproportion of those who are thus fortified,PREFACE .particularly as they would be likely to be more thanordinarily careful in matters relating to health. Inthis way their prophylactic will acquire a great reputation,and the vastly greater number who have equallyescaped without having recourse to the protectiveoperation will be overlooked. This is what happens inpretty nearly every epidemic in regard to re- vaccinationand the security it is alleged to provide. In the caseof primary vaccination other but not less misleadinginferences are drawn. Should there be an epidemic ofsmall -pox in a locality where 85 per cent. of the populationare vaccinated, it is obvious that the 95 per cent.of the population who escape the epidemic (assuming , asbefore indicated, a maximum of 5 per cent. attacked byit) will largely coincide with the 85 per cent. vaccinated ;and vaccination thus gains credit. But it will be objected,if the 5 per cent. attacked coincide, in however small adegree, with the 15 per cent. unvaccinated, this is strongtestimony to the risk of being unvaccinated ; and so, nodoubt, it would be, but for the fact that in localitieswhere the vaccination law is vigorously carried out,the unvaccinated , as a class, will be found to consistlargely of the outcasts of society, nomads whom the lawhas failed to reach, and of weakly children who onaccount of their health have been excused the operation.This class, therefore, is likely to furnish a disproportionatenumber of the victims of the epidemic ; andthus again the prophylactic acquires reputation. Addto this the facts, often overlooked, that medical men,even if officials and highly placed, are still liable as mento err, and that their errors will probably accord withtheir cherished beliefs , and it will readily be understoodPREFACE.that the evidence of detailed cases-which is really theonly evidence on which the credit of vaccination depends-cannot be accepted wholesale as if it werenot open to question. A vaccinated patient with novisible signs of vaccination is likely to be described asunvaccinated if his case is severe, and especially if deathensues ; while if the marks are not plainly visible, theexplanation of " not properly performed " is an obviousone ; and the patient will be included as " belonging tothe unvaccinated or imperfectly vaccinated class " inthe list of cases, and, tout court, as “ unvaccinated " or" having no marks " in the official summary. I think itwould be advisable for my medical brethren to acceptas authentic only published and tested cases, or such ashave come under their own personal observation .To those who are about to legislate for the countryon this vexed question I also address myself particularly.The Queen, in her Speech at the opening of the presentSession of Parliament, called for " earnest consideration "of the subject. Hitherto vaccination bills have beenpassed into law without adequate discussion or debate.Parliament has been assured (incorrectly) that there iscomplete unanimity in the medical profession concerningthe nature, value, necessity, and safety of vaccination ;and that has sufficed. Lords and Commons have atonce bowed before this alleged unanimity, with theresult, as vaccinists claim, but cannot possibly prove,that small-pox has been practically stamped out, butundoubtedly also with the result that hundreds ofinfants have died from the effects of the operation,that thousands of otherwise blameless citizens have beenfined or imprisoned for their very natural and properPREFACE .Iresistance to this extraordinary law, and hundredsof thousands of pounds of public money have beenspent on what I am satisfied is nothing but a uselessand mischievous fallacy. It is strange that membersof Parliament do not perceive that the strength of thepro-vaccinist party lies in the public endowment of thepractice. Right through the century there has existeda body of officials, ostensibly paid to promote thepractice of vaccination, but also, partly at least, paidto vindicate it theoretically, and to explain away itsfailures and its accompanying disasters. But for thisState aid, vaccination would long ago have been consignedto the same limbo as has received a thousandother similar fads which, fortunately for the public,have not secured official recognition and support.hardly expect that legislators will have time to readthe numerous cases I adduce-some showing thatimmunity from small-pox exists without vaccination ,others that mild attacks of small-pox were recordedlong before there was any alleged mitigating powerin vaccination to which to ascribe them, and, again ,others proving that neither vaccination nor re-vaccinationnor recent vaccination can be depended upon toprotect from small-pox or even from death from thatdisease. But to the cases of injury and death resultingfrom vaccination I trust they will not refuse to givesome attention. This evidence should be enough todetermine any fair- minded enquirer that the enforcementof vaccination by law is indefensible. Take away firstthe compulsory law, and then take away (if vestedinterest is not too strong for you) the endowment ofthe practice, and when this has been effected, medicalPREFACE .men will find themselves for the first time since 1803 .free to discuss the vaccination question as a scientificone on its own merits. To what result that unfettereddiscussion will lead I have myself (now that I havestudied the matter carefully for some years) no sortof doubt.In conclusion, I desire to express my obligationsfor the valuable assistance of Mr. A. W. Hutton, whoseletters on " The Vaccination Question," addressed toMr. Asquith and Mr. Balfour in 1894 and 1895, I canrecommend as an introduction to the rational study ofthis vexed problem .April, 1898.PREFACE TO THE SECOND EDITION .THE interval that has elapsed between the first andsecond editions of this book has witnessed a considerablestrengthening of the position of those whodissent from the popular belief in the value ofvaccination. It is true that the debates in Parliamentshowed how very far the general public is yetfrom a just appreciation of the present position ofthis controversy . So far as I noticed, apart from thevery few newspapers that definitely supported the antivaccinistcause, only one-the Westminster Gazetteadmittedthat there is a real weakness on the other side,viz. , the fact that there exists among medical men themPREFACE.selves a doubt, and a growing doubt, whether vaccinationis, after all, what it professes to be. But it canhardly be questioned that a recognition of this doubtand of its grave significance also underlay the excellentspeeches of Mr. Balfour and of Lord Salisbury, to whomthe passing of the measure into law was largely due.Reasons of expediency had, of course, to be urged insupport of such a measure of relief; but these wouldhardly have sufficed, apart from the weightier considerationthat it is unjustifiable to enforce under penalties amedical doctrine concerning which doctors themselvesdisagree. There is no reason to suppose that either Mr.Balfour or Lord Salisbury has any special knowledge ofthe subject, or has abandoned the current belief concerningit ; but as statesmen, and as thinkers, they couldnot fail to recognise the limits beyond which matters ofopinion cannot be enforced.When the Act itself is administered in the spirit inwhich it is framed it will afford a much-needed relief,and may even do something to retard the progress ofthe movement for the disestablishment and disendowmentof vaccination. But the unfortunate andindefensible provision about " satisfying " two justicespermits men on the bench, who are often, it appears ,fanatical believers in vaccination, to use the Act as aweapon of terror against timid conscientious objectors .They actually have the assurance to inform claimantsfor exemption, with all the authority that comeswith a declaration ex cathedra, that if the child inquestion is not vaccinated it will certainly take smallpox,whereas, if it is vaccinated, it will as certainlyescape. No medical man could or would speak thusPREFACE.positively. If this misuse of the new law becomesgeneral, it will shortly be as unworkable as the oldone was ; but it is to be hoped that this deplorablemaladministration will only be temporary.That the movement against vaccination will spreadand will ultimately triumph everywhere is certain . Thealleged unanimity of the medical profession on thesubject-the argument on which pro-vaccinists mostlyrely is far more apparent than real. That a majorityof medical men would, if polled at this moment, passa vote of confidence in vaccination is probably true.But votes need to be weighed as well as counted ; andI am satisfied that, if the poll were confined to thosepractitioners who have studied the subject, and havehonestly endeavoured to form an independent judgmenton the evidence, the majority would be the other way.Even now very few care to defend the practice openly.And it must be remembered that it has never been theway of the medical profession, as a body, to confess todoubts as to the value of any established medicalpractice. They will allow such practices gradually tofall into desuetude when they no longer commandconfidence ; and this is especially the case when othermethods of treatment can acceptably be substituted ;but a positive declaration against any doubtful practiceis not to be looked for.Nothing would more quickly undeceive the publicthan the rapid and complete abandonment of thepractice of vaccination in rural districts. Small -pox ismainly an urban disease ; and on this point the statisticsare so clear that the firmest believers in the protectivepower of vaccination must admit that in rural districtsPREFACE.it is unnecessary ; but, while townspeople can combineto free themselves from the pressure of the law, countryfolk cannot. Local epidemics will still occur in townswhere the sanitary conditions are defective ; and if, in asingle instance, the town happens to be unvaccinatedas well as insanitary, an epidemic there will render allother evidence nugatory, and throw back the movementperhaps for years. Nevertheless, in spite of such drawbacks, a practice that has been so thoroughly discreditedby competent men on scientific grounds must sooner orlater be consigned to the limbo of discarded superstitions.That the practice has been definitely discredited onscientific grounds is not open to serious question.The investigations of Dr. Creighton and ProfessorCrookshank have been very generally ignored by themedical profession ; but it is true that some effortshave been made to rehabilitate vaccination by bacteriologists,who assert that they have discovered " thespecific organism on which vaccinia depends. " Theirmain object is, of course, to reassure the public inregard to the now admitted risks of vaccination ashitherto practised. We are to have " pure cultures, " towhich it is supposed no one will take any objection.But surely the public will demand something positiveas a scientific demonstration that vaccine really has aprophylactic power against variola, and will not besatisfied with the mere assurance that now at last itwill do no harm. It is not long since it was announcedin the papers that Dr. Klein had identified the vaccinewith the variolous bacillus, but who now believes thathe did ? A later claim, not indeed to have made thisidentification of the bacilli of the two diseases, but to1PREFACE .have ascertained what is the cause of the vaccinedisease, is due to the researches of Mr. Stanley Kent,and paragraphs have gone the round of the papersproclaiming the immense value of his discovery. Butit is at least doubtful, from the publications which havehitherto appeared on this alleged discovery, whether themethods adopted have been adequate to permit theassertion that this organism, independent of otheragencies, is to be regarded as the vera causa of vaccine,and it is at any rate true that not less emphatic assertionsas to the discovery of such a cause have beenput forward from time to time, only to be discardedor repudiated as the result of maturer investigation .Finally, I should like to bear testimony to the noblepart in this controversy that has been played by myvenerable friend, Dr. Alfred Russel Wallace. It is areproach sometimes levelled against men of science,that, though in principle they admit that their teachingis subject to revision, yet in practice they often showthemselves dogmatic and unteachable. Of Dr. Wallacethis is certainly not true. Whether in physical science,or in psychology, or in politics, he has always kept anopen eye and an open mind ; nor has he ever lackedthe courage to stand by a cause which he believed tohave right on its side. His essay, entitled, " Vaccinationa Delusion, its Penal Enforcement a Crime, " reprintedin his recent work, " The Wonderful Century," is asable as it is outspoken, and cannot fail to convince thosewho read it how unsound is the basis on which thewhole fabric of vaccination legislation has been reared.METHODS OF SMALL- POX INOCULATION. II1721 , Lady Mary, who had returned to London, hadher daughter inoculated by Maitland. In the sameyear this surgeon experimented on some condemnedcriminals at Newgate, and in 1722 variolation wasencouraged by Royalty.Another of the early inoculators was Thomas Nettleton,of Halifax, who recommended long and deep incisions,and the using of matter from ripe pustules. Theseverity of the disease induced was a great bar to theprogress of small -pox inoculation, and by the year 1728the practice had almost ceased. It was revived about1740, and in 1754 was authoritatively sanctioned by theRoyal College of Physicians, who pronounced it to be" highly salutary to the human race." About the year1763 a milder method of procedure came into vogue ;this was first introduced by Gatti, the French inoculator,and was taken up in this country by Daniel Sutton andDr. Dimsdale, the latter of whom has published accountsof his practice. Dimsdale says :-" It seems not improperto add, that the method I now generally use inperforming the inoculation, as believing it to be the bestis simply this : the point of a lancet slightly dippedin the recent variolous matter, which I prefer takingduring the eruptive fever, is introduced obliquely betweenthe cuticula and the cutis, so as to make the smallestpuncture possible, rarely producing a drop of blood. " 1Dimsdale preferred inoculating from mild cases andfrom arm to arm, for he says :-" If neither an inoculatedpatient is at hand, nor anyone in the neighbourhoodhas a distinct kind of the natural disease, a threadmay be used as in the common manner, provided the" Tracts on Inoculation," p. 130. Hon. Baron T. Dimsdale. London. 1781 .12 THE EARLY HISTORY OF VACCINATION .thread be very recently infected." ¹ About the results,he adds " In general, the complaints in this state arevery moderate, and attended with so little illness thatthe patient eats and sleeps well the whole time : a fewpustules appear, sometimes equally dispersed . " 2He also had some very mild cases which not only hadlittle or no pustular eruption on the body or fever, but didnot even present a pustule at the seat of inoculation, therebeing simply local inflammation ; and in his book he givesa list of twelve such cases, which, however, he consideredprotected from any future attack of small -pox.Another writer, Dr. Giles Watts, in referring to thisnew method of inoculation, says :-" To say the truth ,it is a fact well known to inoculators, in this way, andI have sometimes known the same happen in the old,that the patients pretty often pass through the smallpoxso easily as to have no more than five pustules.Nay, it happens every now and then, in this way ofinoculation, that even an adult patient shall pass throughthe distemper without having one, or even so much asa single complaint, other than, perhaps, a slight shivering,chill, or some such trifling disorder, which he wouldhardly have taken the least notice of at any other time. " 3Thus the inoculation- system of Sutton and Dimsdale,which produced such mild results, depended upon gettingmatter from the eruption of small-pox at an earlystage of the disease, using it when fresh, inoculatingfrom mild cases or from arm to arm, taking the smallest" The Present Method of Inoculating for the Small -pox, " p. 29.Thomas Dimsdale, M. D. London. 1767 ." A Vindication of thep. 10. Giles Watts, M.D.2 Ibid. , p. 37.New Method of Inoculating the Small-pox,"London. 1767 .JENNER'S VARIOLOUS TESTS. 13quantity of matter and introducing it by a superficialpuncture. This, it may be noted, is precisely the sortof inoculation Jenner recommended should be used inapplying the variolous test in cases which had beenvaccinated. Jenner says :-" In some of the precedingcases I have noticed the attention that was paid to thestate of the variolous matter previous to the experimentof inserting it into the arms of those who had gonethrough the cow-pox. This I conceived to be of greatimportance in conducting these experiments. " 1 Now, ifwe refer to the case of John Phillips, aged sixty- two ,who had had the cow-pox at the age of nine years, welearn that the matter for inoculation was taken fromthe arm of a boy just before the commencement of theeruptive fever, and instantly inserted. A little furtheron he relates a story of a medical man who used stalesmall-pox lymph for inoculation, with serious results.Then he continues-" As a further cautionary hint, Ishall again digress so far as to add another observationon the subject of inoculation. Whether it be yet ascertainedby experiment that the quantity of variolousmatter inserted into the skin makes any difference withrespect to the subsequent mildness or violence of thedisease, I know not ; but I have the strongest reasonfor supposing that, if either the punctures or incisions bemade so deep as to go through it, and wound the adiposemembrane, that the risk of bringing on a violent diseaseis greatly increased. " ?With regard to these ten cases of casual cow -pox in1 " An Inquiry into the Causes and Effects of the Variolæ Vaccine,”pp. 55 , 56. Edward Jenner, M.D. , F.R.S. London. 1798 .2 Ibid. , pp. 58, 59.14 THE EARLY HISTORY OF VACCINATION .milkers who had been subsequently inoculated withsmall -pox, the method of inoculation then in vogue wasprobably used ; therefore, from the conditions underwhich the test was made, on Jenner's own showing, aslight and trivial result was the most that should havebeen anticipated. Jenner, however, admits a certainamount of local inflammation supervening in all thecases he describes, which , if we make allowance for thegeneral looseness and ambiguity of his statements ,may, not inconceivably, include the appearance of alocal pustule at the seat of inoculation .In 1796 Jenner vaccinated his first case, James Phipps .In less than seven weeks from the insertion of thecow-pox matter Phipps was inoculated with small-pox,with the result that " the same appearances were observableon the arms as we commonly see when a patienthas had variolous matter applied, after having either thecow -pox or the small -pox. " ¹Now, the question is, What appearances did Phippsactually have on his arms as the result of the varioloustest? And to guide us in forming an opinion, there is aletter of Jenner's to a medical man, Mr. John Shorter, whowrote to him about two cases in which he had appliedthe test six months after successful vaccination, with theresult of producing a pustule at the seat of inoculationin each case. Jenner, in his reply, December 29, 1799 ,says :-" Pray, recollect how seldom we find the skininsensible to the action of variolous matter in those whohave previously gone through the small -pox. Thecow-pox leaves it in the same state. The patients you1" An Inquiry into the Causes and Effects of the Variola Vaccina,”p. 34. Edward Jenner, M.D. , F.R.S. London. 1798.THE VALUE OF JENNER'S TESTS . 15mention were not insensible to the local action of thevariolous virus." Thus, if the skin is seldom insensibleto variolous matter after cow- pox or small -pox, andthese cases of Shorter's are samples of the result, itseems not improbable that when Jenner applied thevariolous test in the case of Phipps he got a localpustule at the seat of inoculation; for the same appearances,he says, were produced, as commonly observed,when variolous matter was applied to a person who hadhad either cow- pox or small -pox.Mary James is another of the few cases Jenner isknown to have subjected to the variolous test. This wasapplied eight months after vaccination, with the resultof a local pustule, fever, and the faint appearance of arash about the wrists; matter taken from the arm of thiscase produced small - pox when inoculated on her brother.To sum up the value of these tests. It amounts tothis : that Jenner, in applying them, used a form of inoculationwhich produced little more than a local result,and the appearances he obtained were not very differentfrom what would be produced by that form of inoculationwhen there was no question of cow- pox at all .Apparently the test broke down, not only in the caseof Mary James, but in other instances. Mr. Thornton ,surgeon, of Stroud, published his experience. Thecases are important as being the first independentevidence after the publication of Jenner's " Inquiry."` Medical and PhysicalJournal, vol. iii . , p. 351. ( April , 1800. )2 " Further Observations on the Variola Vaccine , or Cow-pox,"pp. 34-36. Edward Jenner, M.D. , F.R.S. London. 1799.3 Letter dated February 7 , 1799, and published in Dr. Beddoes' " Contributionsto Physical and Medical Knowledge," p. 398. Bristol . 1799.16 THE FARLY HISTORY OF VACCINATION .He vaccinated a Mr. Stanton and four of his childrenfrom a milker on the Stonehouse Farm, a source used byJenner himself. The matter was taken from a purulentpock, the only one which was not degenerated into asordid and painful ulcer. In the four children the inflammationwas severe and protracted, the scabs falling offabout the twentieth day. " From the long continuedlocal excitement," Mr. Thornton adds, " I began to entertaina hope that the virus might imperceptibly have creptinto the habit, and proved a security against the variolousinfection . " So, to relieve his own doubts, and to ensurethe safety of the patients, he inoculated them with smallpox,with the result that " all the children received theinfection , and passed through the different stages of thedisease in the usual slight manner. " Mr. Stanton, inwhom the inflammation had not been so severe, was theonly one who resisted the variolous inoculation .At the end of 1798, six months after the publicationof Jenner's " Inquiry," the case for vaccination stoodthus: Most of the children's arms had ulcerated, andthe variolous test, in the few cases in which it had beenapplied, had produced equivocal results. Moreover, allJenner's stocks of lymph had been lost, so that no furtherexperiments could be made. Dr. Beddoes, of Bristol, inwriting to Professor Hufeland, of Berlin, said :-" Youknow Dr. Jenner's experiments with the cow-pox. Hisidea of the origin of the virus appears to be quite indemonstrable,and the facts which I have collected are notfavourable to his opinion that the cow-pox gives completeimmunity from the natural infection of smallpox.Moreover, the cow-pox matter produces foul ulcers,and in that respect is a worse disease than the mildlyinoculated small-pox. " The celebrated Dr. GeorgeWOODVILLE AND PEARSON. 17Gregory, Physician to the London Small -pox Hospital,in his lectures at St. Thomas's Hospital, has alluded tothe inconclusiveness of Jenner's thesis. " When we wereengaged in tracing the early history of vaccination, youmust have been struck with the extraordinary contrastbetween the absolute scepticism concerning the prophylacticvirtue of cow - pox which prevailed before thepublication of Jenner's first essay and the unlimited confidencereposed in it, within two years afterwards, in allparts of the world. A calm and dispassionate examinationof Jenner's first essay is calculated to awaken somesurprise at this sudden conversion of men's minds. " 1It can thus be quite understood that the professionrequired more satisfactory proof before accepting the newdoctrine; and they shortly afterwards obtained evidencewhich to them appeared to support Jenner's theories.On January 20, 1799, Dr. William Woodville, Physicianto the London Small-pox Hospital, received intelligenceof an outbreak of cow- pox among the cows at a dairy inGray's Inn Lane. The disease on a milker's hand wascompared with Jenner's plates and pronounced genuine.It was then decided to give it a trial ; and the experimentswere conducted by Drs. Woodville and Pearsonat the Small-pox Hospital. The first inoculations weremade from the cow and from the hand of a dairymaid,and the subsequent ones, to the number of five hundred,from arm to arm. With regard to the testing of thecases by small-pox inoculation, Dr. Woodville says : -" Of all the patients whom I inoculated with variolousmatter, after they had passed through the cow- pox ,1 " Lectures on the Eruptive Fevers , " p. 207. London. 1843 .18 THE EARLY HISTORY OF VACCINATION.amounting to upwards of four hundred, none wereaffected with the small-pox. "1 Concerning these tests,M'Ghie says:-" Suffice it to observe, that the trialswhich were made by the profession, to communicatevariola to thosewhom they had vaccinated, completelyfailed. The cow-pox having thus triumphantly undergonethe experimentum crucis, vaccination was soon eagerlyadopted by the unprejudiced and disinterested in everycountry towhich the vaccine lymph was conveyed."2Ifwe analyse these so-called vaccinations, we find thatthree-fifths ofthe patients had pustules about thebodyanditis no longer disputed that these pustular cases werecases ofsmall-pox-and hence the subsequent varioloustests were ofno value in settling the question ofthe protectivevalue of cow-pox. Let us now consider the remainingtwo-fifths, which only presented a local pustuleatthe seat ofinoculation; and to do this it is importantto discuss the means by which Woodville's cases becamecontaminated. As the Vaccination Commissioners havepointed out, small-pox may have been introduced-(1) By infection at the Hospital or at the patients'homes.(2) Bythe inoculation of small-pox; several patientsbeing purposely inoculated with small-pox afew days after " vaccination. "(3) The lymph with which the patients were " vaccinated"may have become contaminated withsmall-pox.1"Reports of a Series of Inoculations for the Variola Vaccina, orCow-pox," p. 155. William Woodville, M.D. London. 1799."Thoughts on Vaccination," p. 11. Dumfries. 1827 .3 Final Report, Royal Commission on Vaccination, Appendix i. , p. 147.sTi,sf"mWHpcotto"hstoaoeoonhhhfhorltodsnleeoewaltdiptywioevgiiinwrirtnnilaeugnleleged'st-.spswpuuhmiobsartxjtloheuluclgtehssG.ILCRNAOANNWYE'STCB......ERPPRMo.u.aae.lcyydlknndileeinagnnrgiddge S,.dRaairicarehymaidS. topped1 1Talley.Brown.Price .Stopped .Wise ..StoppedP. ink.)p(1u7s0tules.Stoppedi...HBFauornxrkiesr ..DCernonuicshStopped . Stopped.Pedder Hoole Hickland .Morton Munday George Butcher Dorset .Stopped S.TlarardaentS.toppedStopped .C...KMCoeoolyrwesgmaann's .TurnerS.topped....SHHHJHBWW..uuue.u.elllwmllslepltus.Stopped S(uppliedtloymphJ.)ennerFontoihtveersaussedV. accinifersS.topped.TurnerS. treeton .Smith .Meacock..).()()(pp13C3Muu00r5.ss50o0ttuuuclleehssCR'.,.s5DVSoCe0iaootnocscmyamtsctmamieieilionnmsnstaesistnieiitonootnnnersS. topped20 THE EARLY HISTORY OF VACCINATION.This pedigree shows that Woodville's lymph passedexclusively through Collingridge, inoculated direct fromthe cow, and Streeton, Smith, and Meacock, inoculatedfrom a cow at one remove, from a pustule on the handof a dairymaid at the Gray's Inn Lane dairy. Allhad a large number of small-pox pustules, and henceWoodville's cases were from first to last hopelesslycontaminated with small-pox.In the case of Buckland, " vaccinated " direct from thecow, on the seventh day two pustules exactly resemblingthose of small- pox appeared near to the inoculated part ,and on the tenth, several pustules on different parts ofthe body ; the symptoms strongly suggesting that thepatient was inoculated when he was supposed to havebeen vaccinated. In Streeton, Smith, and Meacock thefacts are consistent with the small-pox being acquiredin the same manner as in the case of Buckland.Besides these three persons, Collingridge was the onlyother case through which Woodville's strain continued.She was inoculated at the same time and with the samematter as Buckland, and the margin of the inoculationswelling, was beset with minute confluent pustules, suggestinginoculated small-pox. The difficulty, however ,in this case is that on the fifth day after " vaccination "she was purposely inoculated with small-pox (on theopposite arm to the " vaccination "), and the pustuleswhich appeared about the body on the thirteenth daymay possibly have been due to this inoculation. Theusual day for the eruption to appear in ordinary inoculatedsmall - pox was the tenth or the eleventh, and thusthe pustules on the thirteenth day were rather late ifdue to the first inoculation, and early (eighth day) ifdue to the second ; and therefore it is just as likely" VACCINATION " WITH VARIOLOUS LYMPH. 21as not that Collingridge was variolated on her firstinoculation.Hence it is probable that the whole of Woodville's" Hospital matter " was contaminated at its sources, andthe absence of pustules in two-fifths of the cases does notprove that these were of other than variolous origin ; for,as Dr. Collins and Mr. Picton¹ say, " on the assumptionthat Woodville was dealing with arm- to - arm variolation,he only succeeded in obtaining what inoculatorsbefore and since claimed to have obtained when workingwith undoubted small-pox matter. " There is the furtherargument that matter from secondary small -pox pustulesin several instances produced only a local pustule in thenext remove.Woodville's lymph, when used by others away fromthe Hospital, produced eruptions : thus Jenner was suppliedwith a thread from Bumpus, who had three hundredand ten variolous pustules. In the first case inoculatedby him, " spots " appeared on the face; and in thesecond, the local vesicle assumed " more perfectly thevariolous character than is common with the cow-poxat this stage," and the areola was studded over with" minute vesicles. " Baron tells us that " the eruptionswhich attended many of the early cases of vaccination inLondon were unfortunately also propagated in differentparts of the country, where the contaminated matter hadbeen distributed by Dr. Pearson. " 3 Moore says :—" Variolous matter, under the denomination of vaccinelymph, was spread widely through England, and trans1 Royal Commission on Vaccination .Statement , section 50.2 Baron's " Life of Jenner," vol. i. , p. 245.Dissentient Commissioners'* Ibid. , p. 339.22 THE EARLY HISTORY OF VACCINATION .ported to Germany, and even to the Island of Madeira ,where a physician described the vaccine as a pustulardisease." 1Woodville's lymph, or the " world's vaccine, " as it hasbeen called, had an enormous circulation both in Englandand abroad, at a time when Jenner had no stocks ; itwas this lymph, in fact, which convinced the world ofthe efficacy of vaccination .aIn summing up the value of the Woodville evidence,Dr. Collins and Mr. Picton say :-" It is, therefore,probable that the whole of Woodville's five hundredcases, which appeared to confirm Jenner's thesis, andsecured the support of professional authority, were, infact, only a series of mild variolations. It is certainthat they were, from first to last, contaminated withsmall - pox. We agree with Professor Crookshankthat, in either case, they must be set aside for thepurpose of arriving at decision as to whetheruncontaminated cow- pox confers immunity towardssmall-pox. Woodville's cases, therefore, which did somuch to establish the practice of vaccination, and whichfor nearly a century have been cited as demonstratingthe truth of Jenner's doctrine, must be rejected asfurnishing false evidence, and valueless as a scientificexperiment. " Although at first some of the casesinoculated with Woodville's lymph were undoubtedlyinfectious, after a time, whether from attenuation ordilution of the original matter, from the selection ofmild cases, or from other causes, the number of pustules" History of Vaccination," p. 36.2 Royal Conımission on Vaccination. Dissentient Commissioners' Statement,section 51 .OPINION OF THE ROYAL COMMISSION . 25slight local appearances, whereas in the later ones theresults of the tests are for the most part given collectively,and we obtain such vague expressions as " no diseaseensued ; " concerning Nos. 89, 90, and 91 we read, " noneof the above three patients took the small-pox, " ¹ and inreferring to sixty-seven tests (Nos. 132 to 200, omittingNos . 193 and 194), all the information we have is that" the above patients had variolous matter insertedin their arms but it produced no disorder. " 2 IfWoodville had given details in each instance, it seemsprobable that a considerable number would have beendescribed as presenting some local manifestation, andif, as suggested by the Commissioners, we are tomake allowance for the expectant attitude of mindbetrayed by the sanguine experimenter, these cases wereevidently not so immune as generally believed ; but, asshown above, even if we accept the position that thewhole of Woodville's four hundred cases were immuneto inoculated small-pox, this proves nothing in favour ofJenner's thesis.Instances of the variolous test breaking down werenot uncommon. Thus a surgeon, named Boddington ,found in the case of his own child that the inoculationtest produced not only a local pustule, but also a generalsmall - pox eruption. He wrote to Jenner on the subject,who replied , " How a gentleman, following a professionthe guardian angel of which is Fame, should have socommitted himself as to have called this a case of smallpoxafter cow-pox, is not only astonishing to me, butmust be so to all who know anything of the animal1 " Reports of a Series of Inoculations for the Variola Vaccina , or Cowpox,"p. 86. William Woodville , M. D. London. 1799. 2 Ibid. , p. 113 .314 THE EARLY HISTORY OF VACCINATION .milkers who had been subsequently inoculated withsmall -pox, the method of inoculation then in vogue wasprobably used ; therefore, from the conditions underwhich the test was made, on Jenner's own showing, aslight and trivial result was the most that should havebeen anticipated. Jenner, however, admits a certainamount of local inflammation supervening in all thecases he describes, which, if we make allowance for thegeneral looseness and ambiguity of his statements ,may, not inconceivably, include the appearance of alocal pustule at the seat of inoculation.In 1796 Jenner vaccinated his first case, James Phipps.In less than seven weeks from the insertion of thecow-pox matter Phipps was inoculated with small-pox,with the result that " the same appearances were observableon the arms as we commonly see when a patienthas had variolous matter applied, after having either thecow- pox or the small-pox. " ।Now, the question is, What appearances did Phippsactually have on his arms as the result of the varioloustest ? And to guide us in forming an opinion, there is aletter of Jenner's to a medical man, Mr. John Shorter, whowrote to him about two cases in which he had appliedthe test six months after successful vaccination, with theresult of producing a pustule at the seat of inoculationin each case. Jenner, in his reply, December 29, 1799,says :-" Pray, recollect how seldom we find the skininsensible to the action of variolous matter in those whohave previously gone through the small-pox. Thecow- pox leaves it in the same state. The patients you1 " An Inquiry into the Causes and Effects of the Variola Vaccina,”p. 34. Edward Jenner, M.D. , F.R.S. London. 1798.THE VALUE OF JENNER'S TESTS . 15mention were not insensible to the local action of thevariolous virus." Thus, if the skin is seldom insensibleto variolous matter after cow-pox or small -pox, andthese cases of Shorter's are samples of the result, itseems not improbable that when Jenner applied thevariolous test in the case of Phipps he got a localpustule at the seat of inoculation ; for the same appearances, he says, were produced, as commonly observed ,when variolous matter was applied to a person who hadhad either cow- pox or small -pox.Mary James is another of the few cases Jenner isknown to have subjected to the variolous test. This wasapplied eight months after vaccination, with the resultof a local pustule, fever, and the faint appearance of arash about the wrists ; matter taken from the arm of thiscase produced small- pox when inoculated on her brother.To sum up the value of these tests. It amounts tothis : that Jenner, in applying them, used a form of inoculationwhich produced little more than a local result,and the appearances he obtained were not very differentfrom what would be produced by that form of inoculationwhen there was no question of cow-pox at all .3Apparently the test broke down, not only in the caseof Mary James, but in other instances. Mr. Thornton,surgeon , of Stroud, published his experience. Thecases are important as being the first independentevidence after the publication of Jenner's " Inquiry."Medical and PhysicalJournal, vol. iii . , p. 351. (April, 1800. )2 " Further Observations on the Variola Vaccine, or Cow- pox, "pp. 34-36 . Edward Jenner, M.D. , F.R.S. London. 1799.3 Letter dated February 7 , 1799, and published in Dr. Beddoes' " Contributionsto Physical and Medical Knowledge," p. 398. Bristol . 1799.16 THE EARLY HISTORY OF VACCINATION.He vaccinated a Mr. Stanton and four of his childrenfrom a milker on the Stonehouse Farm, a source usedbyJenner himself. The matter was taken from a purulentpock, the only one which was not degenerated into asordid and painful ulcer. In the four children the inflammationwas severe and protracted, the scabs falling offabout the twentieth day. " From the long continuedlocal excitement," Mr. Thornton adds, "I began to entertaina hope that the virus might imperceptibly have creptinto the habit, and proved a security against the variolousinfection. " So, to relieve his own doubts, and to ensurethe safety of the patients, he inoculated them with smallpox,with the result that "all the children received theinfection, and passed through the different stages of thedisease in the usual slight manner. " Mr. Stanton, inwhom the inflammation had not been so severe, was theonly one who resisted the variolous inoculation .At the end of 1798, six months after the publicationof Jenner's " Inquiry," the case for vaccination stoodthus: Most of the children's arms had ulcerated, andthe variolous test, in the few cases in which it had beenapplied, had produced equivocal results. Moreover, allJenner's stocks of lymph had been lost, so that no furtherexperiments could be made. Dr. Beddoes, of Bristol, inwriting to Professor Hufeland, of Berlin, said :-" Youknow Dr. Jenner's experiments with the cow- pox.idea of the origin of the virus appears to be quite indemonstrable,and the facts which I have collected are notfavourable to his opinion that the cow-pox gives completeimmunity from the natural infection of smallpox.Moreover, the cow-pox matter produces foul ulcers,and in that respect is a worse disease than the mildlyinoculated small -pox. " The celebrated Dr. GeorgeHisWOODVILLE AND PEARSON . 17Gregory, Physician to the London Small-pox Hospital,in his lectures at St. Thomas's Hospital, has alluded tothe inconclusiveness of Jenner's thesis. " When we wereengaged in tracing the early history of vaccination, youmust have been struck with the extraordinary contrastbetween the absolute scepticism concerning the prophylacticvirtue of cow - pox which prevailed before thepublication of Jenner's first essay and the unlimited confidencereposed in it, within two years afterwards, in allparts of the world. A calm and dispassionate examinationof Jenner's first essay is calculated to awaken somesurprise at this sudden conversion of men's minds . " 1It can thus be quite understood that the professionrequired more satisfactory proof before accepting the newdoctrine; and they shortly afterwards obtained evidencewhich to them appeared to support Jenner's theories.On January 20, 1799, Dr. William Woodville, Physicianto the London Small-pox Hospital, received intelligenceof an outbreak of cow - pox among the cows at a dairy inGray's Inn Lane. The disease on a milker's hand wascompared with Jenner's plates and pronounced genuine.It was then decided to give it a trial ; and the experimentswere conducted by Drs. Woodville and Pearsonat the Small-pox Hospital. The first inoculations weremade from the cow and from the hand of a dairymaid,and the subsequent ones, to the number of five hundred,from arm to arm . With regard to the testing of thecases by small - pox inoculation, Dr. Woodville says : -"Of all the patients whom I inoculated with variolousmatter, after they had passed through the cow-poх,1 " Lectures on the Eruptive Fevers," p. 207. London. 1843.18 THE EARLY HISTORY OF VACCINATION.amounting to upwards of four hundred, none wereaffected with the small-pox. " 1 Concerning these tests,M'Ghie says:-" Suffice it to observe, that the trialswhich were made by the profession, to communicatevarioia to thosewhom they had vaccinated, completelyfailed. The cow-poxhaving thus triumphantlyundergonethe experimentum crucis, vaccination was soon eagerlyadopted by the unprejudiced and disinterested in everycountry to which the vaccine lymph was conveyed."2Ifwe analyse these so-called vaccinations, we find thatthree-fifths ofthe patients had pustules about the bodyanditis no longer disputed that these pustular cases werecases ofsmall-pox-and hence the subsequent varioloustestswere ofno value in settling the question of the protectivevalue of cow-pox. Let us now consider the remainingtwo-fifths, which only presented a local pustuleat the seat of inoculation; and to do this it is importantto discuss the means by which Woodville's cases becamecontaminated. As the Vaccination Commissioners havepointed out, small-pox may have been introduced-(1) By infection at the Hospital or at the patients 'homes.(2) By the inoculation of small - pox ; several patientsbeing purposely inoculated with small -pox afew days after " vaccination."(3) The lymph with which the patients were " vaccinated" may have become contaminated withsmall-pox.1" Reports of a Series of Inoculations for the Variola Vaccine, orCow-pox, " p. 155. William Woodville, M.D. London. 1799."Thoughts on Vaccination, " p. II . Dumfries. 1827 .3 Final Report, Royal Commission on Vaccination, Appendix i . , p. 147 .mT,is"fHWpctoso"hstaoooeohnhfhorltsodneloeawltpditywioeivgiinwtrirnnialeugnlleeged'sTt-.spswpuuhmiobsartxjtlhoeuluclgtehssG.ILCRNAOANNWYE'SB.....CERPRMo..uae.lcydlkndileinagnnrgiddgeTalley .Brown .S. topped.Price S..WtiospepedS. toppedP. ink dS,.Raaiircraeyhmaid.p)1(u7s0tulesS. toppedPedder .Hoole Hickland .Morton Munday .George Butcher .Dorset .Stopped .1.Slade T. arrantS. topped...HBFauornxrkiesr C..Drenonuicsh.Stopped S. toppedS. toppedTColeman'sCow.Keys.Morgan.Turner .S. toppedW..SHHJHBW..uue..uellwmllespltus.Stopped S(uppliedltyomphJ.)enner|FontoihtveersaussedV. accinifersS. topped.Turner.Streeton S. mith M. eacockp..()..)(()p1C33Muu0r50.ss5o00ttuuucllheessR'.,、Ds5VSCoCie0oatonosccyammstcatmmeiileiinonmstsnaesistneiiitnoootnnnersS.toppedTHE EARLY HISTORY OF VACINATIONThis pedigree shows that Woodrille's lymph passedexclusively through Collingridge, inoculated direct fromthe sow, and Streeton, Smith and Meacock, inoculatedfrom a cow at one remove, from a pustule on the handof a dairymaid at the Gray's Inn Lane dairy. Alfare a large number of small-pex pustules, and hencees cases were from first to last hopelesslyexcreted with small-pox.In the case ofBuckland, "vaccinated " direct from thecow on the seventh day two pustules exactly resemblingwave of small-pcx appeared near to the inoculated part,and on the tenth, several pustules on different parts ofthe body; the symptoms strongly suggesting that thesacient was inoculated when he was supposed to haveLeser vaccinated. In Streeton, Smith, andMeacock theFacts are consistent with the small-pox being acquiredthe same manner as in the case of Buckland.Besides these three persons, Collingridgewas the onlyOther case through which Woodville's strain continued.She was inoculated at the same time andwith the samematter as Buckland, and the margin of the inoculationswelling, was besetwith minute confluent pustules, suggestinginoculated small-pox. The difficulty, however,in this case is that on the fifth day after " vaccination "the was purposely inoculated with small-pox on theopposite arm to the " vaccination "), and the pustuleswhich appeared about the body on the thirteenth daymay possibly have been due to this inoculation. Theusual day for the eruption to appear in ordinary inoculatedsmall-pox was the tenth or the eleventh, and thusthe pustules on the thirteenth day were rather late ifdue to the first inoculation, and early (eighth day) ifdue to the second; and therefore it is just as likely" VACCINATION " WITH VARIOLOUS LYMPH. 21as not that Collingridge was variolated on her firstinoculation .66Hence it is probable that the whole of Woodville'sHospital matter " was contaminated at its sources, andthe absence of pustules in two-fifths of the cases does notprove that these were of other than variolous origin ; for,as Dr. Collins and Mr. Picton¹ say, " on the assumptionthat Woodville was dealing with arm - to - arm variolation,he only succeeded in obtaining what inoculatorsbefore and since claimed to have obtained when workingwith undoubted small-pox matter. " There is the furtherargument that matter from secondary small -pox pustulesin several instances produced only a local pustule in thenext remove.Woodville's lymph, when used by others away fromthe Hospital, produced eruptions : thus Jenner was suppliedwith a thread from Bumpus, who had three hundredand ten variolous pustules. In the first case inoculatedby him, " spots " appeared on the face ; and in thesecond, the local vesicle assumed " more perfectly thevariolous character than is common with the cow- poxat this stage," and the areola was studded over with" minute vesicles. " Baron tells us that " the eruptionswhich attended many of the early cases of vaccination inLondon were unfortunately also propagated in differentparts of the country, where the contaminated matter hadbeen distributed by Dr. Pearson. " 3 Moore says : —" Variolous matter, under the denomination of vaccinelymph, was spread widely through England, and trans1 Royal Commission on Vaccination .Statement, section 50.2 Baron's " Life ofJenner," vol . i. , p. 245.Dissentient Commissioners '* Ibid. , p. 339.22 THE EARLY HISTORY OF VACCINATION.ported to Germany, and even to the Island of Madeira,where a physician described the vaccine as a pustulardisease." 1Woodville's lymph, or the " world's vaccine," as it hasbeen called,had an enormous circulation both in Englandand abroad, at a time when Jenner had no stocks; itwas this lymph, in fact, which convinced the world ofthe efficacy of vaccination .aIn summing up the value of the Woodville evidence,Dr. Collins and Mr. Picton say :-" It is, therefore,probable that the whole of Woodville's five hundredcases, which appeared to confirm Jenner's thesis, andsecured the support of professional authority, were, infact, only a series of mild variolations. It is certainthat they were, from first to last, contaminated withsmall - pox. We agree with Professor Crookshankthat, in either case, they must be set aside for thepurpose of arriving at decision as to whetheruncontaminated cow-pox confers immunity towardssmall-pox. Woodville's cases , therefore, which did somuch to establish the practice of vaccination, and whichfor nearly a century have been cited as demonstratingthe truth of Jenner's doctrine, must be rejected asfurnishing false evidence, and valueless as a scientificexperiment. " Although at first some of the casesinoculated with Woodville's lymph were undoubtedlyinfectious, after a time, whether from attenuation ordilution of the original matter, from the selection ofmild cases, or from other causes, the number of pustules1 " History of Vaccination," p. 36 .* Royal Conımission on Vaccination . Dissentient Commissioners' Statement,section 51 .OPINION OF THE ROYAL COMMISSION . 25slight local appearances, whereas in the later ones theresults of the tests are for the most part given collectively,and we obtain such vague expressions as " no diseaseensued ; " concerning Nos. 89, 90, and 91 we read, " noneof the above three patients took the small-pox," ¹ and inreferring to sixty- seven tests (Nos. 132 to 200, omittingNos. 193 and 194), all the information we have is that" the above patients had variolous matter insertedin their arms but it produced no disorder. " 2 IfWoodville had given details in each instance, it seemsprobable that a considerable number would have beendescribed as presenting some local manifestation, andif, as suggested by the Commissioners, we are tomake allowance for the expectant attitude of mindbetrayed by the sanguine experimenter, these cases wereevidently not so immune as generally believed ; but, asshown above, even if we accept the position that thewhole of Woodville's four hundred cases were immuneto inoculated small-pox, this proves nothing in favour ofJenner's thesis.Instances of the variolous test breaking down werenot uncommon. Thus a surgeon, named Boddington,found in the case of his own child that the inoculationtest produced not only a local pustule, but also a generalsmall -pox eruption. He wrote to Jenner on the subject,who replied , " How a gentleman, following a professionthe guardian angel of which is Fame, should have socommitted himself as to have called this a case of smallpoxafter cow-pox, is not only astonishing to me, butmust be so to all who know anything of the animal1 " Reports of a Series of Inoculations for the Variola Vaccina , or Cowpox," p. 86. William Woodville, M. D. London. 1799. 2 Ibid. , p. 113 .326 THE EARLY HISTORY OF VACCINATION .Ultieconomy." Baron refers to this as a sample of Jenner'smethod of dealing with " rumours " of this kind.mately Jenner discarded the test, for in 1804 hewrites :-" I will just remark that the fairest of all testsis exposure to variolous contagion. This is the naturaltest; inoculation is not. Who does not know (all medicalmen ought to know) that the insertion of the variolouspoison into the skin of an irritable person will sometimesproduce great inflammation, disturbance of the system ,and even eruptions ? " 2Any other evidence brought forward by Jenner isentirely discounted by his invention of the term" spurious cow-pox." This was first used to describecases of cow-pox which did not originate from greasein the horse, and subsequently as an excuse when it wasdiscovered that the vaccinated were liable to be attackedby small-pox. In his paper on " The Origin of theVaccine Inoculation," he gives the following ingeniousexplanation :-" In the course of the investigation of thissubject, which, like all others of a complex and intricatenature, presented many difficulties, I found that some ofthose who seemed to have undergone the cow-pox, nevertheless,on inoculation with the small - pox, felt itsinfluence just the same as if no disease had been communicatedto them by the cow. This occurrence ledme to enquire among the medical practitioners in thecountry around me, who all agreed in this sentiment,that the cow- pox was not to be relied upon as a certainpreventive of the small-pox." This for a while damped, but did not extinguish,1 Baron's " Life ofJenner," vol. i. , p. 445.2 Letter from Jenner to Dunning, July 22, 1804. Baron's " Life ofJenner," vol. ii . , p. 339.SPURIOUS COW- POX. 27my ardour ; for as I proceeded, I had the satisfactionto learn that the cow was subject to some varieties ofspontaneous eruptions upon her teats : that they wereall capable of communicating sores to the hands of themilkers ; and that whatever sore was derived from theanimal , was called in the dairy the cow-pox." Thus I surmounted a great obstacle, and in consequence,was led to form a distinction between thesediseases, one of which only I have denominated the true,the others the spurious cow-pox, as they possess nospecific power over the constitution. " ¹I may here remark that Jenner never gave any signs bywhich the true and spurious cow -pox could be distinguished,and the mystery remains unsolved until this day.66In some concluding remarks of the Inquiry," herelates the cases of Hannah Pick and Elizabeth Sarsenet,who contracted cow-pox with all the other servants ata farm in the parish of Berkeley. These cases fairlypuzzled him ; for Hannah, when inoculated with smallpox,was found protected ; but Elizabeth, on exposureto the infection, contracted the disease. In the lattercase, although there were multiple vesicles , there was noglandular or constitutional affection. Jenner says :-" This impediment to my progress was not long removedbefore another, of far greater magnitude in its appearances,started up. There were not wanting instances toprove that, when the true cow- pox broke out among thecattle at a dairy, a person who had milked an infectedanimal , and had thereby apparently gone through thedisease in common with others, was liable to receive thesmall -pox afterwards . "1 " The Origin of the Vaccine Inoculation," pp. 2 , 3. Edward Jenner ,M.D. , F.R.S. London . 1801 .28 THE EARLY HISTORY OF VACCINATION.Baron observes-" Most men would, at this stage,have abandoned the investigation in despair. It wasnot so with Jenner. " ।Jenner continues-" This, like the former obstacle,gave a painful check to my fond and aspiring hopes ;but reflecting that the operations of Nature are generallyuniform, and that it was not probable the human constitution(having undergone the cow-pox) should in someinstances be perfectly shielded from the small -pox, andin many others remain unprotected, I resumed mylabours with redoubled ardour." The result was fortunate ; for I now discovered thatthe virus of cow-pox was liable to undergo progressivechanges, from the same causes precisely as that of smallpox;and that when it was applied to the human skin inits degenerated state, it would produce the ulcerativeeffects in as great a degree as when it was not decomposed,and sometimes far greater : but, having lost itsspecific properties, it was incapable of producing thatchange upon the human frame which is requisite torender it unsusceptible of the variolous contagion ; sothat it became evident a person might milk a cow oneday, and having caught the disease, be for ever secure ;while another person, milking the same cow the next day ,might feel the influence of the virus in such a way as toproduce a sore or sores, and in consequence of this mightexperience an indisposition to a considerable extent ;yet, as has been observed, the specific quality being lost,the constitution would receive no peculiar impression. " 21 Baron's " Life of Jenner," vol . i. , p. 132 .2 " The Origin of the Vaccine Inoculation," pp. 3 , 4. Edward Jenner,M.D. , F.R.S. London. 1801 .CONDEMNED BY THE COLLEGE OF PHYSICIANS. 29Only think of the absurdity of it. One day, matterfrom the nipple of the cow, when inoculated on ahuman being, produces true cow-pox , and renders thatperson for ever afterwards secure from small -pox ; thevery next day, matter from the same cow will produceidentical symptoms, but the cow-pox having lost itsspecific properties, the second person remains entirelyunprotected !The " spurious cow-pox " cry contributed largely toestablish vaccination ; for before the Committee appointedby the House of Commons to consider Jenner'sclaim for reward, some of the leading medical mengravely asserted that cases of failure must have beendone with spurious matter.It is only fair to mention that this explanation wascondemned by the College of Physicians. " Somedeviations from the usual course have occasionallyoccurred, which the author of the practice has calledspurious cow- pox, by which the public have beenmisled, as if there were a true and a false cow-pox. "This condemnation, however, came too late to arrestthe mischief, for cow-poxing had already become anestablished practice.It was also unfortunate that the early opponents ofvaccination were almost entirely an interested opposition,being pledged to small -pox inoculation ; and it wasespecially unfortunate that if they had questioned thevalidity of the variolous test they would have exposedtheir own nostrum, which , as I have shown, was in somecases little else than an imposture.1 " Report of the Royal College of Physicians of London on Vaccination , "p. 5. ( Ordered to be printed, by the House of Commons, July 8 , 1807. )30 THE EARLY HISTORY OF VACCINATION .Another thing which largely contributed to establishvaccination was the misleading name of “ variolavaccina," or small -pox of the cow, given to the diseaseby Jenner ; and this, giving as it did a truly scientificring, most materially assisted the cow-pox propagandistsin their innovation. The theory that cow- pox was smallpoxof the cow was quite new to the veterinary surgeonsand other practical people of that time, and was objectedto by one of Jenner's leading contemporaries, Dr. GeorgePearson, on the ground that " cow-pox is a specificallydifferent distemper from the small-pox in essential particulars,namely, in the nature of its morbific poison, andin its symptoms." 1 Dr. George Gregory, a more recentauthority, was also entirely opposed to the identitytheory. " On all these grounds, I demur to the theoryof identity, and hold that small-pox and cow-pox areantagonistic affections that cow- pox, instead of being,as Dr. Baron maintains, of a variolous, is, in fact, of ananti- variolous nature-that it alters and modifies thehuman constitution so as to render some individualswholly, others partially, and for a time, unsusceptible ofsmall - pox . " 2 The total unlikeness of cow - pox to smallpoxin all respects, save their names, has been muchdwelt upon by several modern pathologists, to whosewritings I refer my readers .1 " An Inquiry concerning the History of the Cow- pox, " p . 109. GeorgePearson , M.D. , F.R.S. London. 1798 .2 " Lectures on the Eruptive Fevers, " p. 207. London. 1843 .36" Vaccine et Variole, " p. 100. Chaveau. Paris. 1865. " Human andAnimal Variola," p. 4. George Fleming , F.R.C.V.S. London. 1881 ." The Natural History of Cow-pox and Vaccinal Syphilis. " CharlesCreighton , M. D. London. 1887. " History and Pathology of Vaccination." Edgar M. Crookshank, M. B. ( 2 vols. ) London. 1889.CHAPTER II .THE DECLINE IN SMALL- POX SINCE THE INTRODUCTIONOF VACCINATION .THE argument that small-pox has declined since theintroduction and more efficient enforcement of vaccinationis an important one. It is commonly assertedthat in former times this disease raged like the plague, ¹but a careful examination of the London Bills of Mortalitywill show the absurdity of the claim. In thewhole history of small-pox it never raised the totaldeaths so as to make them stand out conspicuouslyamong surrounding years ; but this was very far frombeing the case with the plague.Burials within the London Bills of Mortality from plague and" all causes " for the plague years 1603, 1625, 1636, and 1665. "Years. Deaths from plague. Deathsfrom all causes.1603 ...... 30,561 ...... 37,2941625....35,417 ..... 54,2651636 ...... 10,400 ...... 23,3591665 ...... 68,596 97,306" Your Committee, however, believe that, if vaccination hadnot been general, this epidemic ( 1871-72 ) would probably have becomea pestilence, raging with destructive force, like the plague of the MiddleAges. " ( Draft Report proposed by the chairman of the Select Committeeon the Vaccination Act, 1867. )• Second Report, Royal Commission on Vaccination, pp. 289, 290.32 THE DECLINE IN SMALL- POX .For the non - plague years, 1604-24, the averageannual number of deaths from all causes was 8,548 ;for the years 1626-35 , 8,986 ; and the years 1637-64,12,554. It is thus evident that the plague made anenormous difference to the total mortality, which wasnever the case with small -pox.Let us now see what small-pox was at its worst.The only continuous set of figures we have extendingover a long period of time are those for London, and, inthe absence of any reliable information about the population,we are forced to the imperfect method of comparingthe ratios of deaths from small-pox to those forall causes. The following figures give the highest yearsfor small-pox in the seventeenth, eighteenth, and nineteenthcenturies :-Years.DeathsfromDeathsfromsmall -pox. all causes .Ratio per 1,000fromsmall-pox.Seventeenth century ( 1634) 1,354 10,400 130Eighteenth century ( 1796) 3,548 19,288 184Nineteenth century ( 1871) 7,912 80,430 98Although there is not a great difference between themaxima of the seventeenth and nineteenth centuries ,a sensible decline has nevertheless taken place, forthe small-pox epidemics appear at much less frequentintervals than formerly.Since the commencement of the Registrar- General'sreturns in 1838 we have the advantage of exact figures ,and the interval from this date to the present time maybe conveniently divided by the great epidemic of 1871-72 .It was during the first of these periods that most of theimportant laws relating to vaccination came into force.In 1840 an Act (3 and 4 Victoria, cap. 29) was passedmaking it the duty of Guardians to provide facilitiesTHE VACCINATION ACTS. 33for vaccination ; but it was not until 1853 ( 16 and 17Victoria, cap. 100) that neglect of vaccination was madepunishable by fine, or imprisonment in default of distress.The effect of this law was seen in the large increase ofthe number of vaccinations in 1854. By the Act of 1861(24 and 25 Victoria, cap. 59), Guardians were authorisedto appoint officers to institute and conduct proceedingsfor the purpose of enforcing obedience to the law. Themost important Act of all, however, was that of 1867(30 and 31 Victoria, cap. 84), which imposed on theGuardians the duty of seeing that children were dulyvaccinated, and empowered them to pay any officerappointed by them to prosecute persons charged withoffences against the Act. It also introduced a provision(section 31 ) to secure the vaccination of childrenborn before the Act came into force ; but the most importantprovision of all was that relating to repeatedpenalties for the non-vaccination of the same child, andthis harsh process of the law could hardly fail, in the thenstate of public opinion, to greatly increase the numberof vaccinations . Referring to this Act, the SelectParliamentary Committee 2 say :-" Your Committee areglad to find that wherever the Guardians endeavour tocarry out the law, it is very generally, and indeed almostuniversally, enforced ; " and they proposed an amendmentto the effect that the appointment of vaccination officers1 Dr. Seaton informed the House of Commons' Committee of 1871 thatof two hundred and sixty Unions inspected in 1870, only one hundred andtwenty were reported as not having vaccination officers ; a large number ofthese , however, had appointed officers since ( before May, 1871 ) .2 " Report from the Select Committee on the Vaccination Act ( 1867 ) , 'p. xiii . ( Ordered to be printed, July 13, 1871. )34 THE DECLINE IN SMALL- POX.should be made obligatory-a suggestion which wasembodied in the Act of 1871 (34 and 35 Victoria ,cap. 98).The Act of 1871 made other alterations. By the27th section of the 1867 Act, it was provided that theGuardians shall make inquiry, and " if they find thatthe provisions of the Act have been neglected, shallcause proceedings to be taken against the persons indefault. " This clause was repealed by the Act of 1871 .The repeal of this section absolved the Guardians fromthe duty of prosecuting for the time being ; but in1874 an Act was passed ( 37 and 38 Victoria, cap. 75 )empowering the Local Government Board to make" rules , orders, and regulations prescribing the duties ofGuardians and their officers in relation to the institutionand conduct of proceedings to be taken for enforcingthe provisions of the said Acts ( 1867 and 1871 ). " TheLocal Government Board have acted on this power, andin their General Order, dated October 31 , 1874, haveintroduced a clause (art. 16) which takes the place ofthe repealed 27th section of the Act of 1867.If we refer to the diagram in the Appendix, whichgives the proportion of public vaccinations under oneyear of age to the births, from 1845 to 1896, we find thatthe Act of 1853 doubled the number of vaccinations ;after this the number diminishes, to increase again in1863-64. This increase was probably due to an outbreakof small-pox. After another decline, there is anincrease of vaccinations in 1868-69, which may be attributedto the Act of 1867 ; and a still further rise in1871 , due, no doubt, to the great epidemic of small -poxthen prevailing. The effect of the legislation of 1871SMALL- POX AND VACCINATION SINCE 1872. 35is not apparent, for there is no further increase in thenumber of vaccinations in 1872, when the Act cameinto operation .Another method of testing the increasing efficiency ofthe Vaccination Acts is the proportion of the small - poxcases vaccinated. The figures for the London Small -poxHospital work out as follows : -Years.Percentage of small -poxcases vaccinated.1826-341835-451845-551855-6518671871354464788492An examination of the diagram referred to showsthat with the gradually increasing proportion of thepopulation vaccinated there is no diminution in smallpox,and the epidemic of 1871-72, coming whenEngland was thoroughly vaccinated, points forcibly tothe inutility of the operation.Let us now examine the history of small -pox andvaccination subsequent to the great epidemic. Thesame diagram shows that the infantile public vaccinationsremained practically stationary until 1881 or 1882 ,when they began to decline ; from 1881 to 1896 theydecreased from 57.3 to 34.9 per cent. of the births ,which is a considerable reduction. It will be seen thatsince the great epidemic ( 1871-72), and coincident withthe decline in vaccination, small-pox has diminished ,and quite recently, markedly so .An examination of the statistics for London, since theopening of the hospitals of the Metropolitan Asylums36 THE DECLINE IN SMALL- POX .Board, also shows conclusively that the enormous declinein the small-pox mortality in recent years cannotbe attributed to vaccination. The figures are takenfrom the published reports of the Metropolitan Asylumsand Local Government Boards.Estimatedpopulation in themiddle of each .year.Percentage of birthsnot finally accountedfor in regard tovaccination .No return.Years.Deaths fromsmall-pox .Small-poxdeath-rateper million.1871 3,267,251 7,912 2,4211872 3,319,736 1,786 5378.81873 3,373,065 113 33 8.71874 3,427,250 57 16 8.81875 3,482,306 46 12931876 3,538,246 736 207 6.51877 3,595,085 2,551 709 711878 3,652,837 1,417 387 711879 3,711,517 450 120 7.81880 3,771,139 471 124 701881 3,824,964 2,367 617 5.71882 3,862,876 430 110 6.61883 3,901,164 136 34 6.51884 3,939,832 1,236 3076.81885 3,978,883 1,419 347 701886 4,018,321 24 5 7.81887 4,058,150 9 2 901888 4,098,374 92 10.31889 4,138,996 1161890 4,180,021 4 I 13.91891 4,221,452 8 2 16.4.1892 4,263,294 41 10 18.41893 4,306,411 206 48 18.21894 4,349,166 89 22 20.61895 4,392,346 55 131896 4,421,955 9 2Thus it will be seen that with an increasing proportionof the population vaccinated, up to the great epidemicDECLINE OF TYPHUS FEVER. 37of 1871-72 , there was no corresponding decline in thesmall-pox mortality, and more recently, while the reductionin small-pox has been enormous, the vaccinationshave also declined .As pointed out above, however, if this century becompared with the two previous ones, a large decline insmall-pox has taken place ; and this has been accompaniedby an equal if not a greater decline in anotherzymotic disease, which is spread by overcrowding andinsanitation-viz.: typhus fever. In 1685-86 the countrysuffered from a severe epidemic of a fever which hasbeen described by Sydenham, and, according to Dr.Murchison, ¹ presented all the symptoms of typhus-viz.:headache, pains in the limbs, dry brown tongue, delirium ,and an eruption resembling that of measles, and oftenaccompanied by true petechiæ. According to theLondon " Bills " there were 3,832 deaths from feverin 1685 , or a rate of 165 per 1,000 of the total deaths(23,222) in the year; and 4,185 deaths in 1686, or oneof 185 per 1,000 (total deaths, 22,609) .The most severe fever year was in 1741. In London7,528 died, or a rate of 234 per 1,000 from all causes(32,169). This considerably exceeds the figures forsmall -pox, which, at its worst, in 1796 , had only a rate of184 per 1,000 total deaths. Dr. Murchison, in speaking ofthe fever epidemic in 1741 (p. 34), says :-" In London itis said to have broken out among the poor, who had beenhalf- starved for two years, and obliged to eat uncommonand unwholesome things. In all the accounts mentionis made of the eruption : in some cases it is described1 " The Continued Fevers of Great Britain," p. 30. (Second edition. )1873.38 THE DECLINE IN SMALL- POX .as like that of measles , in others as like so many smallflea-bites, while in a few instances it is said to have beenmixed up with petechiæ and vibices." From the descriptiongiven by one of the writers at the time-Barker, ¹ ofSalisbury-there can be but very little doubt that thisepidemic was one of true typhus. The patient, afterhaving languished for several days, was seized withrigors or cold chills , and with a heavy pain in the foreheador over the eyebrows, which rendered him stupidand dejected. About the seventh day petechiæ or spotssometimes appeared upon the breast or arms ; thesewere commonly of a pale red colour, like measles, andsometimes purple, like so many small flea-bites. In avery few the eruption was of a deep violet colour, and inothers very broad, like scurvy spots or bruises. In thelater stages the patient became delirious, the breathingwas often laboured, and there was also convulsivetwitching of the tendons, and fumbling with the bedclothes.In 1837-38 , epidemics of small-pox and typhus tookplace simultaneously. In England and Wales , duringthe eighteen months ending December 31 , 1838, 27,822died from typhus, and 22,079 from small-pox ; while inthe Metropolis during the same period, there were6,011 deaths from typhus, and 4,580 from small-pox.In London we know that this epidemic of fever wasalmost wholly typhus. Of sixty cases in 1837-38, ofwhich notes were kept by West, under Latham, atSt. Bartholomew's Hospital, none that died and wereexamined post-mortem had ulcerations of Peyer's patches1 " An Inquiry into the Nature, Cause, and Cure of the presentEpidemic Fever," pp. 39-42. J. Barker, M.B. London. 1742 .DECLINE OF TYPHUS FEVER.39pathognomonic of enteric or typhoid fever, althoughsome had congestion of Peyer's patches, the casesbeing all reckoned typhus exanthematicus.¹ Sir ThomasWatson has also testified to the nature of this epidemic:-" Fever is very rife in St. Giles's and inother crowded parts of this town, just now ( 1838).Our wards at the Middlesex are full of it ; andscarcely a case presents itself without these spots.We speak of it familiarly as the spotted fever, or (from theresemblance which the rash bears to that of the measles,hereafter to be described ) as the rubeoloid fever. " 2The 1847 epidemic of fever in England was almostentirely one of typhus, there being 30,320 deaths, or anumber considerably exceeding any year for smallpoxover the whole period of registration. Since thisepidemic, typhus fever has largely diminished ; but ithas been noticed that at the London Fever Hospital allthe great annual rises in the deaths from fever inLondon since 1849 (after which year enteric feverand typhus were first separated in the returns of theHospital) have corresponded to a greatly increasedadmission of typhus, and not of enteric cases.In the returns of the Registrar-General it was separatedfrom enteric fever in 1869 ; and from 1871-75 to1891-95 the average annual typhus death-rate in Englandand Wales has declined from 81 to 4 per million, ora fall of 95 per cent. on the earlier rate. The fact thatthis complaint, which was formerly more prevalent thansmall -pox , should have diminished to such an extent as1 " A History of Epidemics in Britain," vol. ii. , p. 194. CharlesCreighton, M.A. , M.D. Cambridge. 1894." Lectures on the Principles and Practice of Physic," vol. ii . , p. 732 .(Third edition. ) 1848.40 THE DECLINE IN SMALL- POX .to have become practically extinct, has a very importantbearing on the decline of small-pox, for it is admittedthat typhus fever is a disease which is spread by overcrowdingand insanitation, and in subsequent chaptersit will be seen also that small-pox is largely disseminatedin the same manner.The following table shows the decline that has takenplace in small -pox, fever, typhus fever, and scarlet feversince the commencement of registration. It is dividedinto five-year periods .England and Wales.-Average annual death-rate per millionliving, from small-pox, fever, 1 typhus fever, and scarlet fever,in five-year periods from 1838-95.2Years. Small-pox.3 Fever. Typhus fever. Scarlet fever.1838-42 576 1,0531847-50(4years)292 1,2461851-55 248 9831856-60 198 8421861-65 219 922 9821866-70 105 850 9601871-75 408 599817591876-80 82 380 346801881-85 83 273 23 4361886-90 16 202 7 2411891-95 24 185 4182Over the whole period it will be found that thesmall -pox death-rate declined 96 per cent. , while feverdeclined 82 per cent. But the most extraordinary featureof the table is the large small -pox death-rate in 1871-75 ,1 The term " fever " includes typhus , typhoid , and simple and ill-definedfevers.From 1843-46 the causes of death were not abstracted .3 The figures for small-pox include chicken-pox.CAUSE OF DECLINE OF FEVERS. 41twenty years after vaccination had been made compulsory.Thus, between 1838-42 and 1871-75 the deathratefrom small-pox had only abated 29 per cent. , whilefever diminished 43 per cent.; and, therefore, since thecommencement of registration there was practically noimportant decline in small- pox until after the 1871-72epidemic, although the death-rate from fever had materiallydiminished. Let me call attention to what hashappened with the other diseases in the table. Since1871-75 , typhus (for which we have no State- enforcedpreventive inoculation) has declined 95 per cent. , or afall as great as there has been in small- pox over thewhole period of registration ; and scarlet fever showsthe important reduction of 81 per cent. since 1861-65 .An objection has been made to the fever figures, onthe ground, it is said, that formerly fever included otherdiseases, such as pneumonia, influenza, etc. , which nowappear under their respective headings. The followingquotation, however, from the Registrar-General's fortysecondannual report ( 1879) proves that this is not thecase to any large extent. The cause of the decline isalso explained. The Registrar- General says ( p. xxx.) :-" Had the deaths from one or more of this group ofcauses fallen , while those from others in the same grouphad risen, or had the fall been trifling, or the totals dealtwith insignificant in amount, it might have been suspectedthat the alteration was a mere alteration in name.as the deaths under each heading have declined, as thefall in the death- rate from them has been enormous62.4 per cent. in the course of ten years-and as thetotals are by no means small, it may be accepted asan indisputable fact that there has in truth been aBut442 THE DECLINE IN SMALL- POX.notable decline in these pests, and it may be fairlyassumed that the decline is due to improved sanitaryorganisation. "I will now allude to the alterations that have takenplace from time to time in the age-incidence of thesmall -pox mortality. Dr. Creighton has pointed outthat, in all probability, in the seventeenth century smallpoxwas more a disease of adults than in the eighteenthcentury, when it was largely a disease of children ; atany rate, it was on account of its incidence on adultsthat the disease obtained its evil repute. In the diaryof John Evelyn, we read that he himself had small-poxwhen a young man. His two daughters died of it inearly womanhood within a few months of each other ;and a suitor for the hand, of one of them died of it aboutthe same time. Among the medical writers, Willis givesfour cases, all in adults ; and Morton, sixty-six clinicalcases of small-pox, twenty -three of which were undertwelve and the rest over twelve years of age.¹Again, in their writings the physicians of that timeindicated that small-pox was a mild disease in infants.Willis says, " There is less danger if it should happen inthe age of childhood or infancy ; " again, " the sooner thatanyone hath this disease, the more secure they are, whereforechildren most often escape. " 2 Dr. Walter Harris, ina treatise on the acute diseases of infants , says :-" Thesmall-pox and measles of infants, being for the most parta mild and tranquil effervescence of the blood, are wontto have often no bad character, where neither the helping1 " A History of Epidemics in Britain , ” vol . ii . , pp. 443, 444. Creighton .2 Thomas Willis , M.D. , on " Fevers ." Translation by S. Pordage ,pp. 139, 142. London. 1681 .AGE - INCIDENCE OF SMALL- POX . 43hands of physicians are called in, nor the aboundingskill of complacent nurses is put in requisition. " ।In the eighteenth century, on the contrary, the incidenceof the small-pox mortality, especially in themanufacturing towns, was almost entirely on infants andyoung children, as is shown in the following table 2 :-Sınall-pox Percentagedeaths under under five years Years.Small-poxdeaths atall ages. five years of age . ofage.Kilmarnock , 1728-63 622... 563 90.5Manchester, 1769-74 ... 589 559 94.9Warrington, 1773 209 197 94.3Chester, 1774 202 180... 89.1Carlisle, 1779-87 ... 241 229 950In country districts, however, where small -pox appearedat less frequent intervals, there was time for thechildren to grow up without having the disease ; andthus, in some instances, there were very few cases anddeaths in the early years of life. Aynho, a smallmarket town in Northamptonshire, is an instance inpoint. The following figures are recorded by the rectorof the parish for fifteen months in 1723-243 :-Ages. Cases. Deaths .0-11-22-3 3 23-4 4 I4-565-10 15 110--15 33 315-20 14 I20-25 16325-30 9 3" A History of Epidemics in Britain, " vol . ii. , p. 441. Creighton .2 Ibid. , pp. 527 , 536 , 538 , 554. 3 Ibid. , p. 520.44 THE DECLINE IN SMALL- POX .Ages. Cases. Deaths.30-40 12...40-50 103450-60 4 160-70 4 2Above 70 2 I...Totals, 132 25Thus, in the eighteenth century, although there mayhave been exceptions in some country districts, in townsthe rule was for small-pox to be almost entirely achildren's disease. This continued to be the case untilafter the 1837-38 epidemic. The Registrar-General firstseparated ages for all England in 1847, and the followingtable gives the proportion of small-pox deaths under fiveyears of age from that time.England and Wales. For small-pox¹ the deaths at all ages andunder five, and the percentage of deaths under five to deathsat all ages in five-year periods from 1847-95 .Percentageunderfive years of age.Small-pox deathsYears. atSmall-pox deathsunderall ages. five years of age.1847-50(4 years)20,439 14,307 7001851-55 22,801 15,09166.21856-60 ... 19,270 11,010 57 11861-65 23,007 12,477 54.21866-70 11,779 6,403 54.41871-75 47,696 14,929 31'31876-80 10,243 2,938 28.71881-85 11,025 3,002 27.21886-90 ... 2,32082035.31891-95 ... 3,515 1,313 37.41 These figures include chicken-pox ; if this disease be omitted from thecalculations , 26.9 per cent. of the total deaths from small-pox were underfive years of age in the period 1891-95 , or a percentage reduction of 62since 1847-50 .INCREASE IN ADULT MORTALITY OF SMALL- POX. 45The figures in this table are corrected for chicken-pox ;this disease was included with small-pox until 1874, butsince that date chicken- pox deaths have been separatelyclassified. My authority for adding them is containedon page x. of the fifty- second annual report of theRegistrar - General ( 1889) : -" There were, however,eighty-three deaths ascribed to chicken-pox, and it isvery probable that most of these were in reality cases ofmodified small -pox, true chicken-pox being an ailmentthat is rarely, if ever, fatal." It will be seen from thetable that over the whole period the percentage of deathsfrom small -pox under five years of age has declined from700 to 37.4, or a percentage reduction of 47 .Not only has the children's share of the small -poxdeath-rate diminished, but at ages above ten the mortalityhas actually increased ; that is to say, there hasbeen an age-shifting of the small - pox death- rate. This isshown by the following figures taken from the forty- thirdannual report of the Registrar- General ( 1880, p. xxii.).England and Wales. Mean annual deaths from small- pox atsuccessive life-periods, per million living at each life-period._Age-periods.Under5.Vaccination optional, 1847-53 ... 1,617Vaccination compulsory, 1872-80 3235- 10- 15- 25-45andupwards.337 94 109 66 22186 98 173 141 58The increase in the adult mortality of small-pox duringthe period of compulsory vaccination has been urged byDr. Bridges as a sufficient ground for altering the law.He thought that, if these facts had been generally knownat the time, the Legislature would have hesitated beforemaking vaccination compulsory. Dr. Collins and Mr.46 THE DECLINE IN SMALL- POX.Picton have also shown that since the last century therehas been an alteration in the share borne by children ofthe small -pox deaths independently of vaccination.From 1881 the Registrar-General has classified thesmall -pox deaths into three groups-the vaccinated, theunvaccinated , and those in which there is no statement.In the unvaccinated class, from 1881-93 , there were in all3,746 deaths, 1,483 , or 39.5 per cent. , of which were underfive years of age ; during the last century, as pointed outabove, the proportion under five years of age was morethan double this figure. It is not easy to understandhow vaccination can have brought about this change inthe unvaccinated .Comparisons have been instituted with other diseases.In this connection Dr. Ogle, the late Superintendent ofStatistics to the Registrar-General, informed the RoyalCommission (Q. 516 and 518) that the zymotic diseaseswere the better ones with which to compare small -pox ;but he said , " It is impossible to make similar comparisonsin the case of scarlet fever or measles, and diseases thatonly affect children. Fever is the only one of thezymotic headings that you can take, because it is theonly one that affects all ages to any extent. Fever is ,therefore, the only one which it is possible to subject tothis kind of investigation. "The following table gives the children's proportionof deaths for fever in five-year periods from 1847-95.Corrections have been made for remittent fever.1869 to 1880 the deaths from remittent fever, under fiveyears of age, were classed with typhoid, and therefore IFrom1 Royal Commission on Vaccination. Dissentient Commissioners ' Statement,section 147 .AGE - INCIDENCE OF TYPHUS FEVER . 47have added these deaths to fever for the other years inthe table-viz.: from 1847-68 and from 1881-95.Englandand Wales.-For fever the deaths at all ages and underfive, and the percentage of deaths under five to deaths at allages in five-year periods from 1847-95.Fever deathsYears. atFever deathsunderPercentageunderall ages. five years of age. five years of age.1847-50(4years) J88,093 15,880 1801851-55 92,440 19,539 2111856-60 82,847 19,072 23.01861-65 95,723 19,166 20.01866-70 94,057 17,352 18.41871-75 70,109 12,994 18.51876-80 47,524 8,375 17.61881-85 37,005 4,692 12.71886-90 28,698 2,908 1011891-95 27,628 2,180 7.9Over the whole period the children's proportion ofdeaths from fever has declined from 18 to 7.9 per cent. ,or a percentage reduction of 56. This is greater or lessthan the figure for small-pox, according to whether thechicken-pox deaths are included or not in the smallpoxtotals.Not only has there been an alteration in the ageincidenceof fever as a whole, but there is every reasonto believe that the same change has taken place in theseveral diseases composing the group. Except in quiterecent years this is difficult to prove in the case oftyphoid fever; but in typhus there is very little doubt thatsuch has been the case. In order to compare presentdaytyphus with some former period, it is necessaryto find, not only years of undoubted typhus, but also48 THE DECLINE IN SMALL- POX .years in which the ages are separated. The epidemicyears, 1837-38, are out of the question, because deathswere not classified at different ages ; but the epidemictook place later in the North of England, and for 1839we have the figures for Manchester and Liverpool. Ialso give the statistics for all England and London forthe epidemic of 1847, which was almost exclusivelytyphus fever.Deaths from typhus fever at all ages and under five, with percentageunder five years of age, for Manchester and Liverpoolin 1839, and for England and Wales and London in 1847 .Percentageunder fiveyears of age .Years.Typhusdeaths atTyphus deathsunder fiveall ages. years of age .Manchester 1 1839 323 51 15.8Liverpool ¹ ... 1839 305 46 151England and Wales 1847 30,320 4,364 144England and Wales(excluding London)Vales 1847 27,136 3,823 141London " 1847 3,184 541 170In 1869 the typhus deaths were separated fromtyphoid in the returns of the Registrar- General. Thefollowing gives the figures for typhus from 1871-95 forEngland and Wales and for London :-Typhusdeathsatall ages.Percentageunderfive yearsofage.TyphusYears.deaths underfive yearsofage.England and Wales 1871-95 18,206 1,040 5.71England and Wales 1871-95(excluding London ) j15,955 848 5.31London ... 1871-95 2,251 192 8.531 Third Annual Report of the Registrar- General , pp. 194 and 206 .Tenth Annual Report of the Registrar- General .AGE - INCIDENCE OF INFLUENZA. 49Thus it would appear that there has been a greatalteration in the age- incidence of typhus fever from thecommencement of registration. Since the separationof typhus and typhoid fevers in the returns of theRegistrar-General , both diseases have shown a changein this particular. The percentages under five years ofage are as follows :-TyphusTyphoid1871-75 . 1876-80. 1881-85 .6.4 613.517.4 160 1121886-90. 1891-95 .3.4 518.4 6.6In typhoid, there has been a marked change inthe age-incidence ; but in typhus, the quinquennium,1891-95 , shows only a slight decline in the children'sshare of deaths as compared with the earlier period,1871-75.The age-shifting of the small-pox death-rate-thatis to say, the lessened death-rate in children combinedwith an increased death-rate in adults-has beenclaimed as a " phenomenon " which is " without a parallelin the history of human mortality. " 2 Mr. AlfredMilnes³ has, however, pointed out that a similar " phenomenon" has occurred in the case of influenza. TheRegistrar-General, in his fifty-fourth annual report(1891 , p. xx. ) , gives the death-rates per million living1 The figures up to 1890 are those given by Mr. Alfred Milnes in theVaccination Inquirer for February, 1893. The last column has beencalculated by me from the returns of the Registrar-General. The typhoidfever percentages have been corrected for remittent fever deaths under fiveyears of age.2 " Vaccination Vindicated, " p 18. John C. M'Vail, M.D. 1887 .3 The Vaccination Inquirer, May, 1893.50 THE DECLINE IN SMALL- POX .at different ages in the influenza epidemics of 1847-48and 1890-91 .Under5.5- 10- 15-25-_Age-periods..35- 45- 55- 65- 75- 85-1847-48 ... 713 80 49 51 79 139 284 809 2,372 5,510 11,2431890-91 ... 306 55 46 115 197 347 595 1,060 1,985 3,355 4,821On comparing this table with that on page 45, it willbe seen that both small-pox and influenza show adecline up to ten years of age. In the next age -period,10-15 , the death - rate at both periods is nearly the same,while from fifteen onwards the later period shows agreater mortality from both diseases ; but the influenzamortality in persons aged sixty- five and upwards showsa decline in the later epidemic of 1890-91 as comparedwith the earlier one of 1847-48 .6Before leaving the subject of age- incidence, I woulddraw the attention of my readers to a table in section171 of the Final Report of the Royal Commission.It gives for England and Wales the deaths from smallpoxat certain age-periods to 1,000 deaths from smallpoxat all ages. The figures under one year of age areas follows :-Deaths from small-pox under oneyear ofage to 1,000 deaths fromsmall -pox at all ages.Years.1848-54 ... ... 2511855-59 ... ... ... 2311860-64 2371865-69 ... ... 2311870-74 ... ... ... 1431875-79 1121880-84 ... ... ... 1131885-89 112...1890-94 166AGE - INCIDENCE OF SMALL - POX. 51From 1848-54 to 1855-59 the proportion of infantilesmall -pox deaths declined from 251 to 231 , or a reductionof 8 per cent. The successful public vaccinations ofinfants under one year of age are given in the Appendix.1On calculation it will be found that from 1848-54 theyaveraged 36.9 per cent. of the births , and from 1855-59,51.5 per cent.; that is to say, that between the twoperiods the proportion increased from 36.9 to 51.5 percent. , or a percentage increase of 39.6. By a similarcalculation, from 1865-69 to 1870-74 they increasedfrom 48.5 to 55.6 per cent. , or a percentage increase of14.6. Between the latter periods the proportion ofsmall- pox deaths under one year of age declined from231 to 143 , or a reduction of 38.1 per cent. To put itin tabular form :From the period1848-54 to 1855-591865-69 to 1870-74...Percentage increasein the proportion ofsuccessful publicvaccinations underone year of age tothebirths.39.614.6Percentage decline in theproportion of small- gxdeaths under one yearof age to 1,000 deathsfrom small-pox at allages.8.038.1It is obvious from the above that there is some causeother than vaccination contributing to the alterationthat has taken place in the age- incidence of the smallpoxmortality.There is another point on which the Commissionershave laid considerable stress . They show that at Leicesterand Gloucester the proportion of small-pox deaths1 It will be observed in the Appendix that the returns are made up toSeptember 29, but for the purposes of these calculations, the proportion ofsuccessful public vaccinations under one year of age to the births has beenestimated to December 31 for the years in question .52 THE DECLINE IN SMALL- POX.under ten years of age is greater than in the wellvaccinatedtowns of Sheffield and Warrington. Thefigures given are as follows :-Epidemics.Small-poxdeathsatall ages.Small-pox deathsunder tenPercentageunder ten yearsyears ofage. ofage.Warrington, 1892-93 62 14 22.5Sheffield, 1887-88 500128 25.6London, 1892-93182 67 36.8Dewsbury, 1891-92 110 57 51.8Gloucester, 1895-96 434280 64.5Leicester, 1892-93 2115 {(or 66:6)71.41If the reader will consult the diagram in the Appendix,he will find that England and Wales, for seventeenyears previous to the epidemic of 1871-72, wasvery well vaccinated. In that epidemic there were42,220 deaths from small-pox, of which 20,094, or 47.6per cent. , were under ten years of age. This is doublethe proportion at Warrington and Sheffield , and verynearly the same as at Dewsbury, where, according tothe Commissioners, vaccination had been greatly neglected.In 1892, the second year of the Dewsburyepidemic, the percentage of children born and notfinally accounted for with regard to vaccination was37.7 . In England and Wales, in 1872 , the default wasonly 5.1 per cent .As the Commissioners have, in two of the townsnamed, based their conclusions on a small number of1 The 66.6 per cent. is an alternative figure put forward by the Commissionersin their desire to state the case fairly, and is obtained bysubtracting certain deaths which resulted from small-pox taken in consequenceof the proximity of a scarlet fever ward to the hospital in whichsmall-pox cases were treated.AGE - INCIDENCE OF SMALL- POX . 53deaths, perhaps I may be forgiven if I add the following:-Small-poxdeathsatall ages.44Small-pox deathsunder fiveyears ofage.Percentageunder five yearsofage.Epidemics.1Mold, 1871-72Willenhall , 1894Keighley, 1893 ...47715 34116 3400 00I shall have occasion to refer to Mold and Willenhallin subsequent chapters. It is sufficient to say here that,at the time of their respective epidemics, both were verywell-vaccinated districts. With regard to Keighley ,there is no reason to believe it to be better vaccinatedthan Leicester or Gloucester; indeed, evidence pointsto the contrary. I do not wish to infer from the experienceof these districts that vaccination increases theshare of the small-pox mortality borne by children ;the figures are too small for accurate inferences, as alsoare those of the Commissioners .To sum up the contents of the present chapter, it willappear that, although there has been a marked declinein small-pox since the last century, there has beenan equal, if not a greater, reduction in typhus fever.It has also been shown that since the commencement ofregistration the vaccination of a gradually increasingproportion of the population previous to the great1 'The local Registrar has kindly supplied me with the figures for theregistration sub-district of Mold.At Leicester , in 1892-93 , of twenty- one small -pox deaths , nine wereunder five years of age. If the deaths of those children who sufferedfrom the proximity of the scarlet fever ward to the hospital in whichsmall -pox cases were treated be left out of the calculation, 412 per cent .of the total deaths from small-pox at Leicester were under five years ofage, a proportion not much higher than that of Willenhall or Mold.54 THE DECLINE IN SMALL- POX .epidemic of 1871-72 had very little effect on the smallpoxdeath - rate, although there was an appreciablediminution in fever. From this epidemic to the presenttime, with an increasing neglect of vaccination since1881 , an enormous decline in small-pox has taken place,and a corresponding diminution in typhus and scarletfevers ; the reduction in all three diseases being due, nodoubt, in large measure to the sanitary improvementsintroduced by the Public Health Act of 1875 .With regard to the age- incidence, when small -poxfirst began to be much known, in the Stuart period, itwas chiefly as a malady attacking adults ; as it becamemore generally diffused, in the eighteenth century(except in a few country districts where epidemicscame infrequently), it was almost entirely a disease ofchildhood ; and more recently it is recognised again asa disease attacking adults as well as children. Thatthis is not due entirely, or even principally, to vaccination,seems clear from the fact that a similar alterationof incidence has taken place in the unvaccinated.Another notable point is that, since the commencementof registration, the most important decline in the proportionof infantile small-pox deaths has not coincidedwith the period representing the greatest increase inthe public infantile vaccination ; nor is there sufficientevidence to show that the children in well- vaccinatedtowns suffer less than in those districts where vaccinationhas been largely neglected. When we come tocompare the behaviour of other diseases in this particular,we find that in the only group which are fairlycomparable with small-pox a similar change has beenobserved .POCK -MARKED FACES. 55Before concluding the chapter, I must allude to afavourite argument in defence of vaccination, whichseems to weigh with a large number of people that is,the rarity of pock-marked faces at the present time,as compared with some former period . As to thedisfigurement of the population in the seventeenth andeighteenth centuries, there is little or no evidence ; butit is significant that in the issues of the London Gazette,from 1667-1774, of one hundred advertisements forrunaway apprentices, servants who had robbed theirmasters , horse-stealers, highwaymen, etc., only sixteenwere described as more or less marked with small-pox,four being black men or boys. This consecutive hundredincluded only those who were so particularlydescribed in feature that pock-marks would have beenmentioned had they existed. Apparently pock -markedfaces were not so common as is generally imagined .The argument that vaccination has lessened the numberis an old one, for in their annual report for 1821 theNational Vaccine Board say :-" We appeal confidentlyto all who frequent the theatres and crowded assembliesto admit that they do not discover in the rising generationany longer that disfigurement of the human facewhich was obvious everywhere some years since. "In the report for 1825 we read :-" What argumentmore powerful can be urged in favour of vaccination,than the daily remark which the least observant mustmake, that in our churches, our theatres, and in everylarge assemblage of the people, to see a young personbearing the marks of small -pox is now of extremely1 " A History of Epidemics in Britain, " vol . ii. , p. 454. Creighton .56 THE DECLINE IN SMALL- POX .rare occurrence ? " Half a century afterwards, in 1872 ,the Lancet, of June 29 (vol. i. , p. 907), lamented " thegrowing frequency with which we meet persons in thestreet disfigured for life with the pitting of small-pox.Young men and, still worse, young women are to beseen daily whose comeliness of appearance is quitecompromised by this dreadful disease."Thus, while with the limited vaccination of 1825 thedisfigurement of the young was extremely rare, yet,after nineteen years of compulsion, pock-marked faceshad conspicuously increased. It is difficult to constructany scientific theory of protection from these facts,and we may therefore conclude that the argument sooften brought forward as conclusive is illusory anduntrustworthy.CHAPTER III .SOME OF THE CAUSES OF THE DECLINE IN THESMALL - POX MORTALITY.IN the last chapter attention was directed to the factthat although some of the epidemics of small -pox inthe present century have been nearly as severe asthose of the two previous ones, yet they took placeat longer intervals ; and thus there has been an importantreduction in the mortality from this malady.The disease began to subside, however, before theintroduction of vaccination, and was part of a generalimprovement in the public health which was takingplace about this time. This is seen in the followingtable compiled by Dr. Farr.London. Average annual death-rates per 100,000 living at sixdifferent periods, from 1629-1835.1All causes. Small -pox.2 Fever.1629-35 5,000 189 6361660-79 8,000 417 7851728-57 5,200 426 7851771-80 5,000 502 6211801-10 2,920 204 2641831-35 3,200 83 III1 " M'Culloch's Statistical Account of the British Empire," vol. ii. ,p. 579. (Second edition. ) London. 1839.*In a pamphlet by Mr. Ernest Hart , entitled , " The Truth About Vaccination" ( 1880, p. 35), it is stated that " In Dr. Farr's valuable article onVital Statistics in ' M'Culloch's Account of the British Empire,' it is shownthat in the twenty-seven years , 1629-35 and 1660-79, the annual mortality558 CAUSES OF DECLINE IN SMALL- POX .Commenting on these figures, Dr. Farr says :-" Smallpoxattained its maximum mortality, after inoculationwas introduced. The annual deaths of small -pox registered1760-79 were 2,323 ; in the next twenty 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."Considering, also, that since the commencement ofregistration small-pox has completely ignored thefluctuations in the amount of vaccination, it is beggingthe question to assume that this is in any way relevantto the diminution that has been recorded. I propose,therefore, in the present chapter, to indicate someof the causes which have led to the decline of thedisease.It will be convenient at this juncture to consider theeffect produced on the small-pox mortality in the displacementof small-pox inoculation by vaccination. Asit was only in rare instances that the inoculated weresubjected to any form of isolation, it cannot be deniedthat they must often have acted as centres of infectionand have diffused the disease. Dr. Wagstaffe,¹ writing in1722, related an instance where, in consequence of a fewinoculations, small-pox was spread in the town of Hertford,and occasioned a considerable mortality. In Paris,in 1763 , the unusual severity of small-pox was attributedfrom small- pox in London was equal to nearly 16,000 per million personsliving ; and in the forty years, 1728-57 and 1771-80, to nearly 18,000 permillion living." It is not at first sight apparent how these high rates havebeen deducted from Dr. Farr's figures.1 A Letter to Dr. Freind, p. 38. London. 1722.SMALL- POX DIFFUSED BY INOCULATION . 59to increased infection from inoculation, and a decreewas issued prohibiting the practice. The advocates ofvaccination were almost unanimous in their opinionthat inoculation was responsible for much loss of lifefrom small-pox; thus Moore¹ declared that the neglect oftheprecaution ofpreventing the spread of infection fromthe inoculated had occasioned the loss of millions oflives." The last statement must, however, for obviousreasons, be received with caution.If we consult the London Bills of Mortality, we findthat the small-pox mortality in the eighteenth centuryexceeded that of the seventeenth century. There arereasons, however, for believing that other causes besidesinoculation must be sought for to explain the highsmall-pox rates in the eighteenth century. One ofthese is, that small-pox rose to a higher level of mortalityabout the year 1710 ; whereas inoculation wasnot introduced into this country until 1721. Dr.Creighton informs us, that " from 1721 to 1727 theinoculations in all England were known with considerableaccuracy to have been 857 ; in 1728 they declinedto 37 ; and for the next ten or twelve years theywere of no account." In London inoculation wasrevived about 1740, and after a few years became alucrative branch of surgical practice, but was restrictedalmost exclusively to the well-to-do. Gratuitous inoculationcommenced with the opening of a hospitalin 1746 ; but it was not till 1751-52, that any consider-1" History of Small-pox," pp. 232, 233. James Moore. London." A History of Epidemics in Britain," vol . ii. , p. 504.1815.60 CAUSES OF DECLINE IN SMALL- POX .able number of people were inoculated in connectionwith the charity.According to the London Bills it does not appearthat the few inoculations which took place during theyears 1721-28 had any appreciable effect on the smallpoxmortality, nor should we expect them to do so ; butif a diagram be prepared showing year by year the ratesof small-pox deaths to those for all causes, it will befound that from 1751 to 1781 a still higher level ofsmall-pox mortality was reached than that whichprevailed from 1710 to 1751 ; this seems to suggestan inoculation factor in the case. After 1781 smallpoxwas certainly at a lower level than that obtainedbetween 1751 and 1781 (although in the one year,1796, it touched the highest point in the century) .This diminution, as Dr. Farr has pointed out, was associatedwith a decline in the general death -rate, and wasno doubt brought about by the sanitary improvementsintroduced at that period ; and thus small -pox becameless prevalent, in spite of the fact that inoculation stillremained in full operation .To sum up the case, it is evident that the largemortality from small-pox in the last century cannot bewholly attributed to inoculation ; but from the facts herepresented I am led to believe that the augmentationwhich took place in 1751 , and continued for a largenumber of years, might with fairness be put down to thiscause. The first sign of any diminution in the small -poxdeath- rate commenced after 1781. This cannot be dueto any falling off in the amount of inoculation, but mustbe associated with a general improvement in the publichealth then observable ; the further decline after theFLUCTUATIONS IN SMALL- POX MORTALITY. 61introduction of vaccination was in part probably broughtabout by the substitution of a non- infectious process.¹One of the causes of the spread of small-pox is overcrowdingand want of air-space in and around houses.The fifth annual report of the Registrar-General givesthe country and the town mortality from various causesfor the four years 1838-41 ; in the case of small -pox theformer is 507, and the latter 1,045 per million ; for allcauses the figures are 19,300 and 27,073 respectively.This shows that small-pox is much more influenced bythe aggregation of the population than by all othercauses of disease combined. The mortality from smallpoxappears to vary according to the greater or lesserproportion of open spaces in towns.table illustrates this point.The following1As most of the lymph with which the early " vaccinations " were performedwas of variolous origin, it is important to show that after a timethe cases inoculated with Woodville's lymph ceased to be infectious Thefollowing , in a letter from Jenner to Lord Egremont (Baron's " Life ofJenner," vol. i. , p. 342), is very much to the point. Referring to thethreads distributed by Dr. Pearson, Jenner says :-" In many places wherethe threads were sent , a disease like a mild small-pox frequently appeared ;yet, curious to relate, the matter , after it had been used six or seven months,gave up the variolous character entirely , and assumed the vaccine ; thepustules declined more and more, and at length became extinct. I nadesome experiments myself with this matter, and saw a few pustules on myfirst patients ; but in my subsequent inoculations there were noneود62 CAUSES OF DECLINE IN SMALL- POX.For twenty large towns¹ the acres of town area to one acre ofpark, and the average annual death-rate per 1,000, for the tenyears 1870-79, from small-pox, measles, scarlet fever, fever,and whooping- cough.Acresof Average annual death-rate per 1,000 living,for the ten years 1870-79.town areato one acre Smallofpark.ScarletMeasles. Fever.Whoopingpox.fever. cough.Bristol 10...21... 45 99 50 54LiverpoolBrighton10... 58 76 1.35 95-88... ...22 13 '29 472649London ... ... 23 *48 52 71 42 79Leicester ... ... 32 33 *38 84 *48 49Bradford 34 09 46 112 65 58Manchester ... 34 19 57 1'02 69 88Birmingham ... 38 37 42 115 48 84Leeds ... ... 47 18 *48 I'II 73 65PlymouthNottingham... ... 63 39 71 32 49 7366 ... 40 30 65 69 34Salford ... ... 74 5581 9768 86Oldham ... ... 78 1653 1.53 *48 66Sunderland ... 115 92 33 119 74 72Hull ... ... 117 25 27 84 83 48Newcastle-on-Ty 153 65 '30 119 67 55Sheffield ... ... 249 42 40 1.50 8566280...1,067PortsmouthNorwichWolverhampton ( no parks)This table indicates generally, that towns with thegreatest amount of park space have low small - poxdeath - rates, and vice versa. Liverpool appears to be anexception, but it will be noticed that in this town therates for the other zymotic diseases are also very high,52 38 62 75 40702655 52 5768 31 93 56 601 Fortieth and Forty-second Annual Reports of the Registrar- General .SALUTARY EFFECT OF OPEN SPACES.2563due to overcrowding and sanitary neglect. It must beremembered, that with regard to air supply, small townswould have the advantage of large ones. A singledwelling would be surrounded on all sides with air ; butsuppose we have a group of houses of equal sizesarranged symmetrically in the form of a square, withfive houses to a side, there will be sixteen outside houseswith twenty-five altogether, and the fraction willrepresent the external aerial supply ; with one hundredhouses to a side, this will be shown by the smallerfraction 396 and hence the difference in the externalventilation of the two groups of houses wouldbe very large, being represented by the differencebetween the two fractions and 1 Thus,independently of park space, a small town would havebetter external ventilation for its houses than a large one ;this may to some extent explain several exceptions inthe table.100006400 39610000It may be that there are other causes than theamount of park space to account for the difference inthe small-pox mortality in the several towns specified,but the figures, in comparison with those of theother zymotic diseases, appear to be so striking as tosuggest that external ventilation really exercises animportant influence on the prevalence and mortalityof this disease.The epidemic of 1871-72, which largely dominates thesmall -pox figures in the last table, was conspicuouslysevere in the mining districts, which, as a rule, are mostovercrowded. Durham was one of the most devastatedcounties, eleven of the thirteen registration districtshaving enormous small-pox death-rates .64 CAUSES OF DECLINE IN SMALL- POX .... ... 40,812... ... 99,705Registrationdistricts.DarlingtonStocktonPopulationin 1871.Deathsfromsmall-pox inthe 1871-72epidemic.Small-poxdeath-ratepermillion.152 3,724432 4,333Hartlepool ... ... 39,970 175 4,378Auckland ... ... 69,159 536 7,750Durham ... ... 91,978 835 9,078Easington ... ... 33,694 293 8,696Houghton-le-Spring .. 26,171 193 7,375Chester- le- Street ... 33,300 209 6,276Sunderland ... 112,643 1,011 8,975South Shields ... 74,949 744 9,927Gateshead ... ... 80,271 514 6,403Dudley, in Staffordshire, had a small-pox deathrateof 8,977, Newcastle one of 6,456, and Bedwellty,Pontypridd, Merthyr, Swansea, Abergavenny, rates of8,520, 7,492 , 6,380, 5,627, and 4,768 per million respeс-tively. Thus we see that small-pox picks out itsvictims from thickly - populated centres, and moreespecially towns which are imperfectly aerated, andwhere, as in mining districts, the industrial conditionspredispose to overcrowding.That our ancestors had a less plentiful supply of freshair in and around their houses goes without saying. Itis a well-known fact that our towns have increased inarea quite out of proportion to the increase in the population.Mr. John Timbs observes that the majority ofthe London squares were the growth of the last century,and that few of those in the western district existedbefore 1770, their sites being then mostly sheep-walks ,1 The epidemic was not limited to the years 1871 and 1872, in somecases it extended over several years ." " Curiosities of London, " pp. 746 , 747. John Timbs, F.S.A. 1867 .INCREASE OF METROPOLITAN AIR - SPACES. 65paddocks, and kitchen - gardens ; but we know thatseveral of the London squares existed in the seventeenthcentury, and there is a reference to BloomsburySquare in " Evelyn's Diary," under the date February 9,1665 :-" Dined at my Lord Treasurer's, the Earle ofSouthampton , in Blomesbury, where he was building anoble square or piazza, a little towne; his owne housestands too low, some noble roomes, a pretty cedarchapell, a naked garden to the north, but good aire. "At the beginning of the eighteenth century Grosvenor,Cavendish, and Hanover Squares were laid out, the lasttwo about the year 1718. Portman, Manchester, Finsbury,and Fitzroy Squares were constructed at the endof the last century ; and at the beginning of thepresent century, about 1804, Russell Square, one ofthe largest in London, was finished, and about thistime, also, Bedford and Euston Squares were opened.In 1829 a variety of important improvements weremade immediately around St. Martin's Church ;a whole labyrinth of close courts and small alleyswere swept away, a district including places knownas the Bermudas, the Caribbee and Cribbe Islands,and Porridge Island, notorious for its cook - shops ; ¹this wholesome and wholesale clearance prepared thesite for the construction of Trafalgar Square. Othersquares, such as Lowndes and Woburn Squares, weremade about 1836 ; while Blandford, Harewood, andDorset Squares are of more recent construction .Besides a deficient aeration of towns , our ancestorssuffered under an insanitary tax upon light and air,1 See Cassell's " Old and New London," vol. iii. , p. 141 .66 CAUSES OF DECLINE IN SMALL- POX .known as the window-tax. This was imposed in orderto make good the deficiencies of the clipped money.Its origin, in 1695, has been described by LordMacaulay :-" It was a maxim received among financiersthat no security which the government could offer wasso good as the old hearth -money had been. That tax,odious as it was to the great majority of those whopaid it, was remembered with regret at the Treasuryand in the City. It occurred to the Chancellor of theExchequer that it might be possible to devise an imposton houses, which might be not less productive nor lesscertain than the hearth-money, but which might pressless heavily on the poor, and might be collected by aless vexatious process. The number of hearths in ahouse could not be ascertained without domiciliaryvisits. The windows a collector might count withoutpassing the threshold. Montague proposed that theinhabitants of cottages, who had been cruelly harassedby the chimney men, should be altogether exemptedfrom the new duty. His plan was approved by theCommittee of Ways and Means, and was sanctionedby the House without a division. Such was the originof the window-tax, a tax which, though doubtless agreat evil, must be considered as a blessing whencompared with the curse from which it rescued thenation . " ¹The tax first fell largely on the landlord, but by the20th of George II . ( 1746) it was levied upon the severalwindows of a house at so much per window, and consequentlyfell more cruelly upon the tenants of the1 " History of England," vol . iv. , p. 641. Macaulay.THE WINDOW-TAX. 67tenement houses. By the 21st of George II . , cap. 10,all skylights, the lights of staircases, garrets, cellars , andpassages , were to count for the purpose of the tax ; andit was further enacted ( 11th section) that " no windowor light shall be deemed to be stopped up unless suchwindow or light shall be stopped up effectually withstone or brick, or plaister upon lath, etc. " The law wasenforced by a corrupt machinery of commissioners,receivers - general, and collectors , who were paid byresults , and thus could hardly fail to act injuriously.In 1803 the law was altered, the houses being rated as awhole according to the number of their windows, andat the same time the tax for tenement houses was maderecoverable from the landlord ; it thus became a sort ofmodern house-tax rated on windows.¹The great speculative builder of the Restoration wasNicholas Barbone, and his method of procedure maybe inferred from the following :-" He was the inventorof this new method of building by casting of groundinto streets and small houses, and to augment theirnumber with as little front as possible, and selling theground to workmen by so much per foot front, and whathe could not sell, built himself. This has made groundrents high for the sake of mortgaging ; and others, followinghis steps, have refined and improved upon it,and made a superfoetation of houses about London. " 2" In these mazes of alleys, courts or ' rents,' " Dr.Creighton says, " the people were, for the most part,1 For the above description of the window-tax, I am indebted to Dr.Creighton's " History of Epidemics. "* Quoted by Dr. Creighton from " Lives of the Norths." "A Historyof Epidemics in Britain," vol. ii. , p. 86.68 CAUSES OF DECLINE IN SMALL-POX .closely packed. Overcrowding had been the rule sincethe Elizabethan proclamation of 1580, and it seems tohave become worse under the Stuarts. On February24, 1623 , certain householders of Chancery Lane wereindicted at the Middlesex Sessions for sub-letting, ' tothe great danger of infectious disease, with plague andother diseases. ' In May, 1637, one house was foundto contain eleven married couples and fifteen singlepersons ; another house harboured eighteen lodgers. Inthe most crowded parishes the houses had no sufficientcurtilage, standing as they did in alleys and courts.When we begin to have some sanitary informationlong after, it appears that their vaults, or privies , wereindoors, at the foot of the common stair. In 1710,Swift's lodging in Bury Street, St. James's, for which hepaid eight shillings a week, had a ' thousand stinks init,' so that he left it after three months. The House ofCommons appears to have been ill-reputed for smells ,which were specially remembered in connection withthe hot summer of the great fever -year, 1685. "In the days of the Tudors and the Stuarts, the personalhabits even of the upper classes left much tobe desired. Fresh linen being a luxury, the clotheswere seldom changed, and the dyer was more often inrequisition than the laundress. Sir John Falstaff thusdescribes the contents of the buck or linen-basket :-" Foul shirts and smocks , socks, foul stockings, andgreasy napkins ; that, Master Brook, there was therankest compound of villainous smell that ever offendednostril . " ¹1 " The Merry Wives of Windsor," act iii. , scene v.DOMESTIC INSANITARY CONDITIONS. 69From a washing tally found behind some oakpanelling in the old chaplain's room at Haddon Hall ,in Derbyshire, it would appear that towels had notalways belonged to the domestic arrangements of thisestablishment, for in place of that word, which wasscratched out, " laced bands " had been written on thehorn of the tally.Some interesting relics called " scratch- backs " havecome down to us, the name sufficiently indicating thehabits of the aristocracy of the time. A scratch -backis a hand or claw set in a long handle, which was sometimesmade of silver elegantly chased, and there is oneinstance where a ring on the finger of the hand is setwith brilliants. At one time these implements were asindispensable to a lady of fashion as her fan or herpatch -box. They were kept in her toilet, and carriedwith her even to her box at the play. They belong toa period when personal cleanliness was not consideredessential, when the style of dress worn was anythingbut conducive to comfort and ease, and when ladieswore immensely high head -dresses, which, when oncefixed, were frequently not disturbed or altered for amonth, and not until they had become almost intolerableto the wearer and to her friends .In the sixteenth and seventeenth centuries, the stateof the public health in London was at a very low ebb.The town ditch was a receptacle for all kinds of rubbishand decomposing organic matter ; the streets were unpaved,and saturated with slops and other filth . Insteadof regular highways, the out- parishes were reached bya maze of narrow passages and alleys. The dwellingsof the poor were as bad as they well could be ; the70CAUSES OF DECLINE IN SMALL- POX.houses projected over the roadway, which was so narrowthat they almost met at the top ; there was no attemptat ventilation, and up to and even beyond the timeof Queen Elizabeth, the floors were strewn with rushes,and, if we may trust to an epistle from Erasmus tohis friend Dr. Francis, physician to Cardinal Wolsey,it would appear that these were seldom thoroughlychanged, and, the habits of the people being uncleanly,the smell soon became intolerable. He speaks of thelowest layer of rushes (the top only being renewed) assometimes remaining unchanged for twenty years, areceptacle for beer, grease, fragments of victuals, excrementaland other organic matter. To this filthiness ,Erasmus (one of the most actue observers ) ascribed thefrequent pestilences with which the people were afflicted.Even as late as the beginning of the present centurythings were very different to what they are now. Thus,Willan, writing of fever, says :-" Among the poor the mortality from this cause(contagious malignant fever) was nearly one in fourof all persons affected, notwithstanding the attentiveadministration of proper articles of diet, and of suitableremedies, with plenty of wine." The good effects of all these applications are almostwholly superseded by the miserable accommodations ofthe poor with respect to bedding, and by a total neglectof ventilation in their narrow, crowded dwellings. It willscarcely appear credible, though it is precisely true, thatpersons of the lowest class do not put clean sheetson their beds three times a year ; that, even where nosheets are used , they never wash or scour their blanketsand coverlets, nor renew them till they are no longerDOMESTIC INSANITARY CONDITIONS. 71tenable; that curtains, if unfortunately there should beany, are never cleaned, but suffered to continue in thesame state till they drop to pieces ; lastly, that fromthree to eight individuals, of different ages , often sleepin the same bed ; there being, in general, but one room ,and one bed for each family. To the above circumstancesmay be added, that the room occupied is eithera deep cellar, almost inaccessible to the light, and admittingof no change of air, or a garret, with a low roof andsmall windows, the passage to which is close, kept darkin order to lessen the window-tax, and filled not onlywith bad air, but with putrid, excremental, or otherabominable effluvia from a vault at the bottom of thestaircase. Washing of linen, or some other disagreeablebusiness, is carried on while infants are left dozing, andchildren more advanced kept at play whole days on thetainted bed ; some unsavoury victuals are from time totime cooked. In many instances idleness, in others thecumbrous furniture or utensils of trade with which theapartments are clogged, prevent the salutary operationof the broom and whitewashing brush, and favour theaccumulation of a heterogeneous , fermenting filth . Therooms do not change their condition till they changetheir tenants. Often, indeed, so little care is taken thatenough of the old leaven reinains to infect all theinmates who successively occupy the same premises.I recollect a house in Wood's Close, Clerkenwell,wherein the fomites of fever were thus preserved fora series of years ; at length a friendly fire effectuallycleared away the nuisance. A house notorious for dirtand infection, near Clare Market, afforded a furtherproof of negligence ; it was obstinately tenanted till the72 CAUSES OF DECLINE IN SMALL- POX.walls and floor giving way in the night crushed to deaththe miserable inhabitants. From all these causes combinedthere is necessarily produced a complication offoetor, to describe which would be as vain an attemptas for those to conceive who have been always accustomedto neat and comfortable dwellings." The above account is not exaggerated. For thetruth of it I appeal to the medical practitioners, whosesituation, or humanity, has led them to be acquaintedwith the wretched inhabitants of some streets in St.Giles's parish, of the courts and alleys adjoining LiquorpondStreet, Hog Island, Turnmill Street, Saffron Hill ,Old Street, Whitecross Street, Grub Street, GoldenLane, the two Brick Lanes, Rosemary Lane, PetticoatLane, Lower East Smithfield, some parts of UpperWestminster, and several streets of Southwark, Rotherhithe,etc." It cannot be wondered at, that in such situationscontagious diseases should be formed, and attain theirhighest degree of virulence. The inhabitants of thesecond storey in houses occupied by the poor areusually better accommodated, and therefore experience ,during sickness of any kind, the best effect from publicand private charities. But persons thus stationed sufferfrom contiguity, and from their friendly attentions tothose above them, or to the tenants of the cellars ; sothat in whatever part of the house a fever commences ,it is soon diffused among all the inmates and theiroccasional visitors, especially in seasons which favourits progress like the last autumn and winter.is a melancholy consideration that in London and itsvicinity hundreds, perhaps thousands of labourers , headsItEIGHTEENTH CENTURY PRISONS . 73of families, and in the prime of life, are thus consignedto perish annually, being often so situated that medicalapplications or cordial diet cannot in any wise alleviatetheir distress. " 1The sanitary condition of the prisons in the lastcentury, as discovered by the great prison reformer,John Howard, gives some indication of the ignorancethat prevailed in regard to the public health at thattime. In the Introduction to his book, he tells us thatin his inspection of gaols, he noticed a complication ofdistress, but his attention was principally arrested bythe gaol fever and the small-pox, which he saw prevailingto the " destruction of multitudes," not only offelons in their dungeons, but of debtors also. On page 8 ,in describing the air in prisons, he says :-" My readerwill judge of its malignity, when I assure him that myclothes were in my first journeys so offensive, that in apost-chaise, I could not bear the windows drawn up,and was therefore often obliged to travel on horseback.The leaves of my memorandum book were often sotainted, that I could not use it till after spreading it anhour or two before the fire ; and even my antidote, avial of vinegar, has, after using it in a few prisons ,become intolerably disagreeable. I did not wonderthat in those journeys many gaolers made excuses , anddid not go with me into the felons' wards ." From hence anyone may judge of the probabilitythere is against the health and life of prisoners, crowded1 Dr. Willan's " Observations on Diseases in London. " Medical andPhysical Journal, vol . iii . , pp. 298-300. (April , 1800. )" The State of the Prisons in England and Wales." (Second Edition . )1780. John Howard, F.R.S.674 CAUSES OF DECLINE IN SMALL- POX .in close rooms, cells, and subterranean dungeons, forfourteen or sixteen hours out of the four-and -twenty.In some of those caverns the floor is very damp ; inothers there is sometimes an inch or two of water,and the straw, or bedding, is laid on such floors ,seldom on barrack bedsteads. Where prisoners arenot kept in underground cells, they are often confinedto their rooms, because there is no court belongingto the prison, which is the case in most city andtown gaols."There was much overcrowding. On page 21 weread :-" Debtors crowd the gaols (especially those inLondon) with their wives and children . There are oftenby this means ten or twelve people in a middle-sizedroom , increasing the danger of infection. " John Howardobserves the effect of the window-tax (p. 9) :-" One causewhy the rooms in some prisons are so close, is perhapsthe window- tax, which the gaolers have to pay ; thistempts them to stop the windows, and stifle theirprisoners."Concerning the water supply and drainage, we read(pp. 8, 9) :-" Many prisons have no water. This defect isfrequent in bridewells and town gaols. In the felons'courts of some county gaols there is no water ; in someplaces where there is water, prisoners are always lockedup within doors, and have no more than the keeper orhis servants think fit to bring them. In one place theywere limited to three pints a-day each-a scanty provisionfor drink and cleanliness ! Some gaols have nosewers, and in those that have, if they be not properlyattended to, they are, even to a visitant, offensive beyondexpression. How noxious, then, to people constantlyAGE - INCIDENCE AND SANITATION . 75confined in those prisons ! " Under these conditions,is it to be wondered at, that typhus and small -poxprevailed to the " destruction of multitudes " ?Howard's attention was arrested by the insanitarystate of the prisons, but it is doubtful whether the poor,especially in the large towns, lived in a much healthieratmosphere than the prisoners. Dr. William Buchan ,in his work on " Domestic Medicine," says :-" Wheneverair stagnates long, it becomes unwholesome ; hence theunhappy persons confined in jails not only contractmalignant fevers themselves, but often communicatethem to others . Nor are many of the holes, for we cannotcall them houses, possessed by the poor in great townsmuch better than jails. These low, dirty habitations,are the very lurking-places of bad air and contagiousdiseases. Such as live in them seldom enjoy goodhealth, and their children commonly die young. " ¹Thus, Dr. Buchan connects the high mortality ofchildren in the last century with overcrowding and filth .From these facts we may infer, that sanitary reformwould tend to alter the age - incidence of zymotic disease.This has been fully recognised by the Registrar- General inthe following notable words :-" That the sanitary effortsmade of late years should have more distinctly affectedthe mortality of the young is only what might be naturallyanticipated ; for it is against noxious influencesto which the young are more especially sensitive thatthe weapons of sanitary reformers have been chieflydirected . " 21 " Domestic Medicine," p. 86. ( Tenth edition. ) 1788. WilliamBuchan , M. D.2 Forty- second Annual Report of the Registrar - General , p. xxiii. 1879.76 CAUSES OF DECLINE IN SMALL-POX.There is no reason to believe that small-pox is anyexception to this general law, and in this connection thefollowing table quoted by Dr. Collins and Mr. Picton isnot without interest.¹Fatal small-pox in Scotland, 1871.Small-pox PercentageSmall -poxdeaths atall ages.deathsunder fiveyears ofunder fiveyears ofage.age.Principal towns (population above ) 88625,000)19522.0... ... ..10,000 to 25,000)Large towns (population from 14332 22.3Small towns (population from 2,000 209 55to 10,000Mainland rural districtsInsular rural districts... 183 2526.313.6II 0 ΟΟThe larger proportionate small -pox mortality of childrenin the towns, compared with rural and insular districtsis certainly not due to any difference in the amount ofvaccination , and it is difficult to resist the conclusionthat the young are more injuriously affected by overcrowdingand other insanitary conditions associated withtown life than adults.2While discussing the subject of sanitation, it is necessaryalso to allude to the influence of burial-grounds onmortality. In the last century it was usual to establishthese in the midst of populous towns, and there can beno question, that the constant inhalation of effluvia fromdead bodies , had a deleterious effect on the living .1 Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 148.2 See Paper read by Mr. Alfred Milnes before the Statistical Society,June 15 , 1897 .BURIAL - GROUNDS AND MORTALITY. 77Buchan observes (p. 85 ) : " Certain it is, that thousandsofputrid carcases, so near the surface of the earth , in aplace where the air is confined, cannot fail to taint it ;and that such air, when breathed into the lungs, mustoccasion diseases. " With the growth of sanitary institutions,reforms have been made with regard to the disposalof the dead, and, in nearly all urban districts, the deadare now buried in outlying cemeteries. The nextgeneration will no doubt witness a great extension ofthe still more sanitary practice of cremation, alreadyintroduced in London, Glasgow, Manchester, Liverpool,and other places .Besides insanitation, other causes have probably hadtheir effect on the small-pox mortality.1A number of typhus and small-pox epidemics havebeen intimately associated with periods of scarcity andwant. The winter of 1683-84 was very severe. This wasfollowed by a long drought in the summer of 1684, andanother severe winter in 1684-85 , and not until the springof 1685 was there plentiful rain. In 1685-86 the countrywas visited by a terrible epidemic of fever, and in 1685small -pox was above the average, with 2,496 deaths inLondon, or a rate of 107 per 1,000 deaths from allcauses . The winter of 1708-09 was excessively severe,frost lasting all over Europe from October to March.This was followed by a bad crop of cereals in 1709, theprice of wheat per quarter running up from 27s. 3d. onLady- day, 1708, to 81s. 9d. on Lady-day, 1710.2 In1710, the proportion of small-pox deaths was 127 per 1,000" A History of Epidemics in Britain," vol. ii . , p. 23. Creighton.2 Ibid. , pp. 54, 55-78 CAUSES OF DECLINE IN SMALL- POX.1deaths from all causes ( 3,138 small-pox deaths). 2,810died from small -pox in 1714, or a rate of 106 per 1,000from all causes . This followed a rise in the price of wheat .In 1718 the harvest was a bad one ; and about thistime there was scarcity of employment amongst theweavers in the east end of London ; during the year1719, there were 3,229 deaths from small-pox in London,or a rate of 114 per 1,000 from all causes. Up to themonth of February, 1756, the season had been a forwardone, but the early promise of spring was blighted by cold.This was succeeded by a wet summer and autumn ; thefruit crop was ruined, and the corn harvest spoilt bylong, heavy rains ; dearth and bread riots followed.1757, the proportion of small- pox deaths rose to 155 per1,000 from all causes ( 3,296 small -pox deaths).InA bad harvest in 1794 raised the price of wheat to 55s.(January 1 , 1795 ) ; by August, 1795, it rose to 108s. , fallingin October to 76s. , owing to the action of the Government,in order to avert famine, causing neutral ships-bound to French ports with corn-to be seized andbrought to English ports. In the spring of 1796, theacme of distress was reached, wheat being sold for 100s.per quarter. Mr. Pitt admitted in Parliament that thecondition of the poor " was cruel , and such as could notbe wished on any principle of humanity or policy ; inthis year, the mortality figures showed the largestnumber of small -pox deaths of any year within theLondon Bills , being 3,548, or 184 per 1,000 deaths fromall causes. The harvest in 1816 proved deficient in14" A History of Epidemics in Britain, " vol . ii. , pp. 62 , 64. Creighton .2Ibid. , p. 125. $ Ibid. , pp. 158 , 159 .Eighth Annual Report of the Registrar-General , p. 12.COMMERCIAL DEPRESSION . 79quantity, and inferior in quality. Prices rose from 66s.a quarter in 1815, to 78s. in 1816, and 98s. in 1817. Thiswas succeeded by epidemics of small -pox, relapsingfever , and typhus in 1817-19 .From the Registrar-General's eighth annual report welearn that the year 1837 was one of great commercialdepression. In referring to joint stock banks, MajorGraham says :-" Many of the companies were got upby speculators, for the sole purpose of selling shares.The signal of collapse was given by the failure of theAgricultural Bank of Ireland in November, 1836. TheBank of England assisted the Manchester Northern andCentral Bank in December, the large American housesin February and March, 1837. It was in vain. Commercialcredit fell to its lowest point of depression inthe first half of the year 1837." 2 Again-" In 1837 theprice of bread rose rapidly, while trade was depressed,and speculation sat exhausted in the midst of ruin. " 3During the several years commencing in 1837, one ofthe most disastrous small -pox epidemics of the nineteenthcentury occurred , and also a very severe epidemicof typhus.Another cause of the diffusion of small -pox, as well asof typhus and dysentery, is probably war. Dr. , Guywrites :-" War is a special cause of that more generalcondition of overcrowding, so destructive to health, soproductive of disease. It consists in bringing one crowdof trained, armed, and disciplined men into collision withanother, under circumstances highly unfavourable tohealth . It reaches its climax in civil war, in prolonged1 Eighth Annual Report of the Registrar-General , p. 16 .2 Ibid. , p. 23 . Ibid. , p. 24.80 CAUSES OF DECLINE IN SMALL- PΟΧ .1siege operations, and when armies are quartered amongcivil populations. " The shock of battle also, with itsattendant anxiety, and the high tension of the organism ,are important and undeniable factors in the productionof epidemic diseases .Mr. Alexander Wheeler pointed out before the RoyalVaccination Commission (Q. 7,994) that during almostthe whole of the last century Europe was one hugebattle-ground, and wars continued on and off until theyear 1815. The fact that small -pox was decliningduring the opening years of the present century, doesnot exclude war as one of the causes of this disease .As to the effects of war. In a work by Mr. William F.Fox, entitled " The Losses of the American Civil War, " weread :-" 110,070 were killed , 249,458 died of other causes ,making 359,528 in all in the Northern army. " In speakingof the 249,458 who died from disease, Mr. Fox says :" One-fourth died from fever, principally typhoid ; onefourthfrom diarrhoea or other forms of bowel complaint ;one-fourth from influenza and lung complaints ; and onefourthfrom small-pox , measles, brain diseases , erysipelas,and various other forms of disease common to themasses . " 2With regard to the Franco- Prussian War, Mr. Wheeler,in his evidence before the Royal Commission, quotedsome of the commissioners sent to Eastern France to aidthe peasantry. One of these, Dr. Robert Spence Watson ,has published his experiences, from which the followinghave been extracted. I may state that in 1870 there1Journal of the Statistical Society, December , 1882 , p. 579.2 Third Report , Royal Commission on Vaccination, Q. 8,056 .3 " The Villages Around Metz. " Newcastle-on-Tyne. 1870.THE EFFECTS OF WAR. 81was not more small -pox than usual until the later monthsof the year. Its increase was at the time of the terribleslaughter following the invasion of France." November 6, 1870. Then I went to Lessy andChatel St. Germain, hearing everywhere the same stateof distress. All the crops gone, all the winter's firewoodgone, many houses destroyed, and numbers needing helpin every village. When the mare's hoofs sunk deep,she knocked up bits of flesh, and the stench was so sickeningthat I should have fainted but for my smelling salts.It was a strange and sad sight ; sometimes twenty- fiveheaps of graves within sight at once. These graves arein a bad state, many of them were too shallow to beginwith . The heavy rains have caused them to sink in, andthey are covered with an inch or more of black, oilywater, which has, when disturbed, a most disgustingstench " (pp. 22, 23)." November 7th. All men and officers alike speakof the terrible loss of blood. At Rezonville, and inits neighbourhood, the people say 18,000 Germans areburied . This I doubt, but the number must be enormous" (p. 25) ." November 9th. Metz was literally crammed withsoldiers. The Germans strong, hearty, conscious ofvictory ; the French-cowed, worn, starved, and miserable.In one place there were fifteen long streetsof railway vans, filled with typhus patients ; in anotheras many streets of canvas tents, also filled with sick. Ivisited these places, and found them in the filthiest state ;but the Germans had begun to put them into order. Atfirst , you might see soldiers, in full small -pox, walkingabout the streets, but this was soon forbidden " (p. 28 ).82 CAUSES OF DECLINE IN SMALL- POX.Dr. Watson concluded his last letter with the observationthat " unless England puts forth her hand liberallyand wisely, the coming winter must see in that beautifuland fertile land an amount of misery, famine, and plaguewhich it is too dreadful to contemplate " (p. 36).Another commissioner has kindly furnished me withthe following statement :-" Mr. William Jones, of Sunderland,was one of those who went out on behalf ofthe Society of Friends to relieve the sufferings of thepeople. He was present at Metz when Marshal Bazaine'sarmy surrendered. The main body were encampedoutside the walls of Metz , on low ground near theMoselle, the wetness of the season having convertedthe camping-ground into a morass. In some placesthe impress of the men's bodies was left as a cast in themud in which they had lain. Their clothes and theirblanket were saturated with mud. Their food for weekshad only been a biscuit and a bit of horseflesh withoutsalt. Dysentery was universal, and typhus and smallpoxraged. Over a wide area around the camp thecarcases of dead horses were left to rot and contaminatethe air. On the 29th of October, 1870, Mr.Jones and his companion, Mr. Allen, were permitted toenter the city, which had opened its gates to admit theGerman army, which marched through in triumph. Thenarrow streets were crowded with French soldiers disarmed, and looking diseased and hunger-bitten. Numbersof them were going about the streets with confluentsmall -pox fully out over their faces. Black typhusraged in the hospitals. Ultimately the worst cases wereremoved into 320 railway vans drawn up in the ' GrandePlace.' No one was allowed to pass the GermanMALTHUS DISCOVERS A NEW PRINCIPLE . 83sentries into the square, but the constant cry of thewretched sufferers for water was distinctly heard by Mr.Jones outside the square in which they were isolated.It was stated that all these black typhus patientsperished, and were buried in huge trenches outsidethe walls of the city." Mr. Jones's companion, Mr. Allen, who was vaccinated,and, he believes, re -vaccinated , took the small - pox,and his own sister, who came over to nurse him, caughtthe disease from him and died there, and was buried inthe cemetery at Plantières outside the walls of Metz." N.B.-Mr. John Bellows, of Gloucester, who followedMr. Jones to Metz , states in his pamphlet, ' The Track ofthe War round Metz,' that, of the twelve commissionersof the Society of Friends who were present in Metz, eightwere at one time ill, five being down with small -pox ,and one ( Miss Allen) died of small -pox . "There is, indeed, some reason to believe that this warwas the starting point of the great European pandemicof small-pox in 1871-72 .Another cause of the decline in small- pox during thepresent century, especially among children, remains tobe told. Malthus, in 1803, wrote :-" For my own part,I feel not the slightest doubt, that, if the introduction ofthe cow- pox should extirpate the small- pox, and yetthe number of marriages continue the same, we shallfind a very perceptible difference in the increasedmortality of some other diseases. " Malthus, thus early,clearly saw that even if cow- pox had possessed all the1 " An Essay on the Principle of Population," p. 522. T. R. Malthus.London. 1803.84 CAUSES OF DECLINE IN SMALL- POX .virtues that were claimed for it, the reduction in the mortalityfrom one zymotic disease would, other things beingequal , have no appreciable effect on the death- rate.This principle was first worked out experimentallyby Dr. Robert Watt, lecturer on the theory and practiceof medicine at Glasgow. He examined the Glasgowburial registers over a space of thirty years, from 1783-1812 , and divided the thirty years into five periods ofsix years each. The following table gives his figuresfor small-pox, measles, and whooping-cough, as percentagesof the deaths from all causes¹ :-Ofthe total deaths ,the percentageUnder tenFromTotal deathsPeriods.years offrom all causes .small-pox.Fromneasles .age.Fromwhoopingcough.1783-88 9,994 53.48 19.55 0.93 4.511789-94 11,103 58.07 18.22117 5131795-1800 9,991 54.48 18.70 210 5.361801-06 10,034 52.03 8.90 3.92 6.121807-12 13,354 55.69 3.90 10.76 5.57These statistics proved that while small-pox haddiminished, measles and to a lesser extent whoopingcoughhad increased, so that a child had no betterchance of reaching its tenth year in the last period thanin the first. Dr. Watt was somewhat staggered at theresult. He says (p. 6) :-" Taking an average of severalyears, I found that more than a half of the human species1 An Inquiry into the Relative Mortality of the Principal Diseases ofChildren , and the numbers who have died under ten years of age , inGlasgow, during the last thirty years ( p. 49) . Robert Watt, M. D. 1813 .2 Dr. Watt remarks that in Glasgow during the last period ( from 1807-12)vaccination may be said to have been pretty fully established , " perhaps,as much so , as in any other city in the Empire. "THE ZYMOTIC DISEASES REPLACE EACH OTHER. 85died before they were ten years of age, and that of thishalf more than a third died of the small - pox, so thatnearly a fifth part of all that were born alive perished bythis dreadful malady. I began to reflect how differentthe case must be now ! In eight years little more than600 had died of the small-pox ; whereas, in 1784, thedeaths by that disease alone amounted to 425, and in1791 to 607, which, on both occasions, exceeded thefourth of the whole deaths in the year." To ascertain the real amount of this saving ofinfantile life, I turned up one of the later years , and byaccident that of 1808, when, to my utter astonishment, Ifound that still a half or more than a half perishedbefore the tenth year of their age ! I could hardlybelieve the testimony of my senses, and therefore beganto turn up other years, when I found that in all of themthe proportion was less than in 1808 ; but still, on takingan average of several years, it amounted to nearly thesame thing as at any former period during the lastthirty years."Dr. Farr was a firm believer in Watt. He writes :-" The zymotic diseases replace each other ; and when oneis rooted out it is apt to be replaced by others, whichravage the human race indifferently wherever the conditionsof healthy life are wanting. They have thisproperty in common with weeds and other forms of life :as one species recedes , another advances. By improvingthe hygienic conditions in which men live, you fortifythem against infection ; and further, by isolating theinfected, the chances of attack are diminished. " ¹1 Thirty- fifth Annual Report of the Registrar-General , p. 224 .86 CAUSES OF DECLINE IN SMALL- POX .In this chapter, I have attempted to deal with some ofthe principal causes of the diminution of small-pox.Firstly, I have shown that a part of the decline, andespecially that part which has taken place in children , isnot necessarily a saving of life, but only a shifting of themortality on to some other disease, such as measles orwhooping - cough, which happens for the time being tobe more predominant .The residue of the diminution is a real gain, and isprobably due partly to the displacement of small-poxinoculation by a non-infectious malady ; and to thisextent was vaccination an advantage as compared withthe old variolous inoculation. Other causes have beendue to the more abundant air supply in and aroundhouses ; the greater cleanliness of the people in theirpersons, their houses, and their towns ; and last, but notleast, the greater material prosperity and freedom fromwar, which has been the lot of those who have beenfortunate enough to be born into the present century.CHAPTER IV.THE INCIDENCE OF SMALL- POX ON VACCINATED ANDUNVACCINATED COMMUNITIES.THE experience of Leicester has proved conclusivelythat small -pox can be kept from spreading in unvaccinateddistricts. In 1872 , Leicester was a wellvaccinatedtown, and had an epidemic of small -pox,with 346 deaths registered from the disease . Thisfailure to protect led to a revolt against the practice.The default commenced after 1874, and since 1885 thepercentages of vaccinations to births have been asfollows¹ :-Years. Births.Primaryvaccinations .Percentage of vaccinationsto births .1885 4,682 ... 1,842 39.31886 4,858 1,122 23.11887 ... 4,689 ... 474 ΙΟΙ1888... 4,787 ... 3146.61889 ... 4,789 ... 172 3.61890 ... 4,699 1312.81891 4,790 92 1.91892 5,816 ... 133 ... 2.31893 ... 6,006 249 ... 411894 ... 5,995 1332.21895 ... 5,962 ... 75 13As far as the children are concerned, therefore,Leicester is practically unvaccinated. Let us see what1 Report of the Medical Officer of Health for the year 1895 , pp. 31 , 38 .88 SMALL - POX INCIDENCE AND VACCINATION .has been their small -pox record since 1872, when thepopulation was about half what it is at the present time.Year.1872Small-pox deaths.346Year.1884Small -pox deaths .01873 2 18851874 Ο 18861875 I 18871876 Ο 1888 ...1877 6 ... 1889 0...1878 I ... 1890 Ο...1879 0 ... 1891 ..1880 0... 1892 6 ...1881 2 ... 1893 1518825 1894Ο1883 ... 3 1895 0 ...The above figures up to the year 1889 have been takenfrom a table handed in by Mr. Biggs, and published inthe Fourth Report of the Royal Commission (p. 438) .They include two deaths not given by Dr. Priestley inhis recent report, viz. , one in 1875 and another in 1877 .Over a period of twenty- two years, from 1874 to 1895,which embraces the recent epidemic in the town, in spiteof forty-nine separate importations from vaccinateddistricts, notably Sheffield, there were only thirty -ninedeaths from the disease, or an average annual small-poxdeath- rate of 12.6 per million, against 47 per millionduring the same period in better-vaccinated Englandand Wales.Certain objections have been raised to the Leicestersystem, but they are all totally irrelevant. One ofthese is given by Mr. Ernest Hart in his letter tothe Times of August 31, 1894 : " That wherever noncompulsionmakes head in the matter of vaccination , aTHE LEICESTER SYSTEM . 89great variety of forms of severe compulsion are thenecessary and accepted sequence and corollary-as, forexample, compulsory removal to hospital, compulsoryisolation and disinfection, compulsory quarantine anddetention from business of the persons in contact withthe small-pox patients prior to their removal. All theseforms of compulsion, and others connected therewith, arerampant in Leicester, the home and typical centre ofnon- compulsion and non-vaccination. "The answer to this is that there is no more interferencewith the liberty of the subject than the ordinarylaws allow. Alderman Windley, chairman of theLeicester Sanitary Committee, writing to the Times ofOctober 15 , 1887, says :-" Will you permit me to say :( 1 ) That the Sanitary Committee of this Corporation, intheir treatment of small-pox cases, when they occur, actunder the powers of the Public Health Act, 1875, whichapply to the country generally ; (2) that if the suffererhas not ' proper lodging and accommodation ' he is removedto the Fever Hospital, and the house in whichhe was found is disinfected and limewashed ; (3 ) that,whenever we can, we induce the persons found at thehouse, who have been in contact with the patient, to gointo the quarantine ward at the hospital for a fortnight,making their sojourn there as pleasant as practicable.In one instance we had a refusal, and in that case ourinspector made daily visits to the house, in order toascertain whether any other case had fallen of the disease.We have no power of forcible removal, and shouldhardly apply it if we had. " With regard to the power ofremoving quarantines, the Lancet of June 5, 1886 (vol. i . ,p. 1091 ) , admits that " actual legal powers do not exist ; "790 SMALL- POX INCIDENCE AND VACCINATION.-and in the recent epidemic it was not found necessary toremove them, for of 1,261 patients quarantined, 1,026, or81 per cent. , were quarantined in their own homes ; andthe medical officer adds : " I am satisfied that inan epidemic of small-pox, quarantining of persons whohave come into contact with the disease can be carriedout satisfactorily at their own homes-more efficiently,and at a much less cost, than in a special building orbuildings built for the purpose. " ¹The cost has been brought forward as an argumentagainst the system . The total expenditure on theepidemic was £4,500, which includes the cost oferection of new wards for the nurses. The amount ismodest in comparison with the £32,000 spent indealing with the epidemic in the well-vaccinated townof Sheffield, which sum, we learn, proved but a fractionof the total money loss caused to the inhabitants.Another argument is that Leicester, notwithstandingits widespread insurrection against the Vaccination Acts,owes its protection after all to vaccination, or ratherre- vaccination. Dr. J. G. Glover, in a letter to the Timesof September 11 , 1894, puts the case thus :-" The firstline of their defence is a cordon of re-vaccinated personsround every case that occurs in the town. The medicalofficer is re-vaccinated ; the sanitary inspectors are revaccinated;the nurses are re- vaccinated; and tell it notin Gath!-the other persons in the house of the small-poxcase are not only compelled (not by law) to keep themselvesto themselves , but are re-vaccinated. " With regardto the quarantines, the medical officer, on page 12 of hisreport, informs us that of 1,261 persons quarantined in the1 Report on the Epidemic of Small- pox, 1892-93 , p. 14.COMMENDED BY THE MEDICAL OFFICER. 911892-93 epidemic, 51, or 4 per cent., were vaccinated,and 72, or 5.7 per cent. , were re-vaccinated in quarantine.This disposes of the re-vaccination of the quarantines.On page 24, Dr. Priestley gives the hospital staff, allincluded, at 40 ; besides these, eight other sanitaryofficials must be added to make up the " cordon.”Among these, five took small-pox, or an attack -rate of104 per 1,000. Thus, this well-protected " cordon " hadan attack-rate fifty-five times that of the unvaccinatedpopulation among which they lived (attack-rate of population= 1.9 per 1,000), and it is not easy to understandhow it came to shield the town from small -pox.In defence of the Leicester system , I cannot do betterthan quote the words of the medical officer in the prefaceto his annual report for 1893 :-" You are entitledto great credit-more especially in the case of small -pox ,which, by the methods you have adopted, has been preventedfrom running riot throughout the town, therebyupsetting all the prophecies which have again and againbeen made. I need only mention such towns as Birmingham,Warrington, Bradford, Walsall, Oldham, and theway they have suffered during the past year from theravages of small-pox, to give you an idea of the resultsyou in Leicester have achieved, results of which I, asyour medical officer of health, am, justly I think, proud."The following are the attacks and deaths, with theirrespective rates, for the unvaccinated towns of Leicesterand Keighley in the recent epidemics :-Attack-rate Death-rateSmall-pox epidemics. Population. Attacks. permillion.Deaths. permillion.Keighley, 1893 ... 32,070 72 2,245 7 218Leicester, 1892-94 ... 184,547 355 1,924 21 11492 SMALL - POX INCIDENCE AND VACCINATION .If these be compared with epidemics that have takenplace in admittedly well-vaccinated towns, the result isvery striking.Small-pox epidemics.Willenhall , 1894Attack-rate Death-ratePopulation. Attacks. permillion.Deaths. permillion.... 17,684 842 47,614 47 2,658Sheffield, 1887-88 ... 312,793 7,066 22,590 679 2,171Warrington, 1892-93 674 12,481 65 1,2046,352 248 50454,000Birmingham, 1891-94 492,301 3,127At Short Heath, near Willenhall, in 1894, out of apopulation of 2,667, there were 90 cases and six deathsfrom small-pox, or an attack -rate of 33,746, and a deathrateof 2,250 per million. In the case of Sheffield ,Warrington, and Short Heath we have valuable evidenceabout the vaccination. At Sheffield, for a large numberof years previous to the epidemic of 1887-88 , over 80 percent. of the births had been vaccinated ; and in 1862, atan inspection of borough school children,¹ it was foundthat 86 or 87 per cent. were found " protected " in the likefashion. At Warrington, at the time of the epidemic, anexamination of 7,522 school children revealed the factthat 7,135 , or 94.9 per cent., were vaccinated ; and atShort Heath , in 1893, 89 per cent. were found to bevaccinated . But, in making an estimate of the vaccinationof the population, an allowance must be madefor the fact that school children would, if anything, beslightly better vaccinated than the rest of the population.At Willenhall and Birmingham, the large proportionof small -pox cases vaccinated is sufficient evidence thatthese towns were well " protected," being 89.3 and 88-8per cent. respectively ; for, as I have pointed out in a1A total of 1,409 school children were examined. ( Sixth Report of theMedical Officer of the Privy Council , p. 165. )SMALL- POX AND VACCINATION AT MOLD. 93letter to the British Medical Journal of November 9,1895, the population cannot very well be vaccinated toa lesser extent, or we should have to admit that smallpoxpicked out the vaccinated for its victims. In thecase of Willenhall, not only were a large proportion ofthe population vaccinated, but they were very efficientlyvaccinated, for 78 per cent. of the vaccinated cases exhibitedthree or four marks.Not only may well -vaccinated towns be affected withsmall -pox, but the most thorough vaccination of a populationthat it is possible to imagine may be followed byan extensive outbreak of the disease. This happenedin the mining and agricultural district of Mold, in Flintshire.On the 9th May, 1871 , Dr. Seaton informed theSelect Committee of the House of Commons, that from1853 to 1871 all the children born and remaining in thedistrict of Mold had been vaccinated, and he gave thefigures for thirteen years ending September 30, 1866.Of 6,601 births, 5,784 had been successfully vaccinated ;202 had left the district before vaccination ; 600 haddied previous to the operation ; 4 had had small-poxprevious to vaccination ; and II remained over for thenext year's vaccination. He added : " Of course it isa work of years to build up a district to the state inwhich Mold is." In 1871-72, fifty persons died ofsmall - pox , or on the population ( 13,834) a rate of 3,614per million.¹ Compare this with the immunity of1 The Registrar- General has courteously supplied me with the populationand deaths from small-pox, in the registration sub-district of Mold. Thenumber of small -pox deaths is slightly in excess of that given by the localregistrar ( see p. 53) , but even adopting the latter's figures, if calculatedon the population of the Registrar-General, the small-pox death- ratefor Mold in 1871-72 will be over 3,000 per million.94 SMALL - POX INCIDENCE AND VACCINATION .aLeicester in the late epidemic. Leicester, with thepopulation under ten years of age practically unvaccinated,¹ had small - pox death - rate of 114 permillion ; whereas Mold, with all the births vaccinatedfor eighteen years previous to the epidemic, had oneof 3,614 per million .Dr. Seaton informed the Committee that a greatdeal was done in Swansea to secure vaccination, andthe Lancet of August 6, 1870 (vol. ii. , p. 205 ), refersto the report of the medical officer of health, whereinit was stated that nine-tenths of the population wasvaccinated ; and this is borne out by the Local GovernmentBoard returns for 1872 , which give 91 per cent. ofthe births as vaccinated ; yet, in 1870-73 , there were 379deaths from small-pox, or, on the population of 1871(67,357), a death-rate of 5,627 per million. The followingtable specifies those towns which, in the epidemicof 1871-72 , had rates exceeding 6,000 per million .Registrationdistricts.South ShieldsHackneyNorthamptonDeathsfrom Small -pox Percentage of Percentage ofPopulation small-pox death-rate vaccinations vaccinationsin1871 . to births in to births in1892.per inthe1871-72 million.epidemic.1872.74,949 744 9,927 83.2 74.7124,951 1,231 9,852 78.6 43 250,743 467 9,203 79.7 6.2Durham 91,978 835 9,078 77.4 84.2Dudley 134,125 1,204 8,977 81.3 83.7Sunderland 112,643 1,011 8,975 85.2 84.0Easington 33,694 293 8,696 84.2 86.5Bedwellty 51,763 441 8,520 82.2 78.4Auckland 69,159 536 7,750 80.679.0Caistor 48,885 371 7,589 71.5 83.6Dover 35,249 265 7,518 84.9 74 IPontypridd 51,921 389 7,492 81.8 82.31 Medical Officer's Report for 1893 , p. 67.Registrationdistricts. inthe per1871-72 million.SMALL- POX AND VACCINATION IN 1871-72. 95Deathsfrom Small -pox Percentage of Percentage ofPopulation small-pox death-rate vaccinations vaccinationsin 1871. to births in to births in1872. 1892.epidemic.Houghton- le- Spring 26,171 193 7,375 87.2 84.4Walsall 71,834 527 7,336 83.1 60.9Bideford 19,506 141 7,229 86.4 917Norwich 80,386 562 6,991 81.5 26.2Southampton 48,055 312 6,493 750 78.4Newcastle 131,198 847 6,456 83.2 81.9Gateshead 80,271 514 6,403 75.2 64.5Merthyr 104,239 665 6,380 88.3 84.9Lambeth ... 208,342 1,324 6,355 77.6 69.8Chester-le- Street 33,300 209 6,276 85.8 83.7Llanelly 34,732 216 6,219 90°4 82.3Whitehaven 47,572 294 6,180 86.1 88.3In nearly all of the twenty- four towns, the epidemictook place in the years 1871 and 1872, but in several itcontinued over three or four years. The small -poxdeaths were distributed as follows :-Registration districts. 1870. 1871. 1872. 1873. 1874. Total .South Shields9 603 132 744Hackney 16 868... ... 313 2113 1,231Northampton 57 410 467Durham...30 43926234 70 835Dudley I ... 10 1,128 58 7 1,204Sunderland 2 ... 933 75 I 1,01 1Easington ... 183 110 293Bedwellty ... 172 265 3 I 441Auckland ... 9 150 371 I5 536Caistor ... 2 283 47 38 1 371Dover ... 16 .. ... 247 2 265Pontypridd ... 7 319 38 25 389Houghton-le -Spring ... 110 83 193Walsall 16 ... 502 2 7 527Bideford 36 105 141Norwich 245 316 I 56296 SMALL- POX INCIDENCE AND VACCINATION .Registration districts . 1870. 1871 . 1872. 1873. 1874. Total.Southampton 3 305 4 312Newcastle 8 702 132 5 847Gateshead ... I... 409 101 I 2 514Merthyr ... ... 2 32 538 58 35 665Lambeth 28 972 295 24 5 1,324Chester- le-Street ... I 106 93 7 2 209Llanelly ... 24 171 21 216Whitehaven... 3 294 7 163 105 16I have given the percentages of vaccinations to births forthe years 1872 and 1892 ; and it will be seen that most ofthe towns showed a higher rate of vaccination of infantsin the earlier than the later year ; some allowance must,however, be made for the epidemic of 1871-72 increasingthe vaccinations, but there is no reason to believe thatany of these towns were badly vaccinated.Gloucester has quite recently experienced an outbreakof small-pox exceeding the rates in any of these towns,enormous as they are, and as the town is one in whichvaccination has of late years been largely neglected, theoccurrence has been seized upon by the press all overthe country, with the result that numbers of Boards ofGuardians, which had allowed the Vaccination Acts tofall into abeyance, have been stimulated to reimposeproceedings. The attack- incidence of the epidemic isheavy, being 48 per 1,000, or about the same as that forthe well -vaccinated town of Willenhall in 1894 ; but it1 The rate for Gloucester is 10,548 per million .2 In 1895-96 611 per cent. of the cases of small-pox were vaccinated,and , therefore, the population must, on any theory of protection, havebeen vaccinated to this extent. The proportion is larger than at Leicester(55.7 per cent. ), and considerably larger than at Keighley (43.1 per cent. )in the recent epidemics in these towns.SMALL - POX AT GLOUCESTER . 97is the case-mortality of 21.8 per cent. of those attacked ,which has made it one of the most remarkable epidemicsof modern times. To explain this by want of vaccinationis merely to beg the question ; for at Chester, in1774 , where all the deaths were under ten years of age,and all , of course, unvaccinated, the fatality was 14.6per cent.; and recently in the unvaccinated towns ofKeighley and Leicester the fatality was 9.7 and 5.9 percent. respectively. From certain statistics, published bythe committee appointed by the Gloucester Board ofGuardians, it appears that the fatality at the hospitalwas much greater than among cases treated at home.Cases . Deaths . Fatality per cent .In hospitalAthome7301,30619924427.318.7These figures treat of the whole epidemic ; but it must beremembered that the hospital administration was takenover by Dr. Brooke, of the Thames Ambulance Service,towards the end of April, and, consequently, the casemortality( 27 per cent.) is considerably mitigated by theaddition of cases with a low fatality, due to the reformsinstituted under Dr. Brooke's regime. Dr. WalterHadwen has pointed out that the total number of completedcases under treatment for the twelve monthsprior to Dr. Brooke's arrival was 277, of which 151 ,or 54 per cent. , were fatal.¹ This tremendous hospitalfatality, when compared with the 59 per cent. atLeicester, where the cases were nearly all treated in thehospital , suggests certain influences at the hospitalwhich were deleterious to the vitality of the patients.The Dissentient Commissioners report (section 261 ) that1 An Address by Dr. Hadwen at Weston- super- Mare, October 22, 1896.98 SMALL- POX INCIDENCE AND VACCINATION .they learn from Dr. Coupland, that the following circumstancescontributed to the extension of the disease.1. "A main factor was the introduction of the diseaseinto some of the public elementary schools ."2. The large and increasing proportion of cases retainedat home ; especially as " quarantine, " which inthe early periods was under supervision, came to bemore a matter of advice than of control. Dr. Couplandbelieves that " the facilities of intercourse between neighbourswill account for a great deal-in other words, thefailure of isolation ."3. The hospital is situate within the city, and wascrowded to excess, there being at one time two and evenfour in a bed ; it is possible that the hospital contributedto the spread, but it is difficult to prove this. On theother hand, " there had been aroused a deep feelingagainst the hospital ; the mortality amongst the childrenadmitted into it had been very high, and this feelingcould not be eradicated , although the accommodationwas extended and the organisation improved. Thus ithappened that the majority of persons remained in theirhomes up to the last weeks. "4. The small sanitary staff was overtaxed ; and Dr.Coupland reports there were serious defects in hospitaladministration.5. The hospital accommodation was afterwards increased,and the administration improved. That theseefforts were not more immediately successful was owingto the unwillingness of the people to enter the hospital ,which had so suffered in reputation.6. Dr. Coupland, in comparing the experience ofGloucester with that of Leicester, points out thatDR. BROOKE'S REPORT ON THE HOSPITALS. 99Leicester has the advantage of being better organisedin its sanitary department, and its medical officer is not,as at Gloucester, engaged in private practice. There ismore " sanitary vigilance " at Leicester, and its sanitarystaff is more numerous .At the quarterly meeting of the Gloucester CityCouncil, held on Tuesday, January 26, 1897, the followingreport of Dr. Brooke was handed to the pressfor publication : -Gentlemen,-Stroud Road, Gloucester,May Ist, 1896.To the Sanitary Committee.In accordance with an arrangement made on the 20thult. with the Metropolitan Asylums Board, my services, undercertain conditions, have been temporarily lent to the SanitaryCommittee of the City of Gloucester, for the purpose of takingentire charge and control of the small-pox hospitals .In accordance with this arrangement I made a preliminary visitof inspection to the said hospitals on the 21st ultimo, and at asubsequent interview with the Chairman of the Sanitary Committeeand Mr. Alderman Powell, I made several suggestions ; one,which I deemed of the first importance, and which I suggestedfurther should be carried out at once, viz., the appointment of athoroughly experienced matron who must also be a trained nurse.Having obtained the consent of these gentlemen, I at once tooksuch steps as were necessary. I issued an advertisement in threedaily papers, The Lancet, and The Hospital, with the result thatamongst a great number of applications I was fortunate enoughto find the application of Miss E. Walker, late Assistant Matronat the London Hospital, and, more recently, Lady Superintendentof the Hill Road Infirmary, Liverpool, an infirmary with eighthundred beds. I engaged Miss Walker as matron, temporarily, at asalary of £4 4s. per week, with the usual allowances ; and I considerthat the city of Gloucester is to be congratulated on having100 SMALL- POX INCIDENCE AND VACCINATION .obtained the services of a lady who, from her past experience andtraining, is so eminently fitted to discharge the responsible dutiesand combat the difficulties attaching to her present post.Acting upon an instruction conveyed in an urgent telegramfrom the Chairman of the Sanitary Committee, asking that Mr.Pitt might be relieved from the great pressure of work, I engaged,temporarily, Dr. C. K. Bond, late Resident Physician, St. Georgeand St. James Dispensary, King Street, Golden Square, W. , at asalary of £5 5s. per week. Dr. Bond is a gentleman who has hadalready considerable experience in small-pox. I also engaged twocharge nurses-Nurses Wright and Wilkins, both of the HospitalShips, near Dartford.By the courtesy of the Clerk to the Metropolitan AsylumsBoard, I was allowed the use of the chief offices of the Board totransact all business and interview all candidates ; this was of thegreatest possible service and convenience to me.I came into residence at the house of Mr. M'Crea on the 28thult. I have since my arrival, and accompanied by Miss Walker,made a thorough inspection of the Stroud Road Hospital, and weare of opinion as to the absolute unsuitability ( 1st) of the site, assuch ; ( 2nd) of the structural arrangement, which is devoid of anyplan, system, or method, and renders the satisfactory working ofthe hospital an impossibility .The sexes, as perhaps you know, should in all hospitals beabsolutely separated in a separate building situated in a differentpart of the ground ; to separate them now with the existing buildingswould be practically impossible.We find also, that, from a sanitary point of view, the wholeadministration of the hospital has been shockingly neglected.One of the greatest defects is the deficient laundry accommodation,and the additional laundry which is in process of erectionwill not be nearly sufficient to meet the requirements. We areinformed at the hospital, that it is impossible to obtain a sufficientsupply of clean linen, and that they are already a month behindwith the washing.I considered it my duty, on visiting the hospital this morning,to direct Mr. Hall's attention to the fact that the gas stoves in thenew kitchen should be placed on iron plates, and that there shouldHOSPITAL DEFECTS IN GLOUCESTER . ΙΟΙalso be an iron plate over the match-boarding at the back, whichis scorched and browned by the heat, and there is great danger offire. This draws my attention to the fact, that there is, with theexception of a fire hose in centre of ground, a total absence offire-extinguishing appliances attached to the wards, and no firebuckets.Two additional men should be immediately engaged to clearthe grounds and the various nooks and corners throughout theplace, of the great accumulation of rubbish.The ambulance shed near the main block is very foul and dirty,and smells most offensively ; and round many of the wards I foundheaps of decaying animal and vegetable matter-bones, bread,vegetables, etc. and sometimes a heap of foul linen and soileddressings soaked in discharges. At any rate, in one of the wardswe found neither kitchen, scullery, nor pantry, and in the bathrooma miscellaneous collection of dirty dinner things, patients' clothing,and soiled linen .Our recommendations are :-( 1st) the appointment of two mento clear the ground of the refuse and keep it clean, and to performthe ordinary duties of a hospital porter ; ( 2nd) the appointmentof a gate porter at a salary of 25s. per week, and his board andlodging ; and that a gate book should be kept, and that no oneshould be admitted but those connected directly with the hospitalwithout a pass, to be obtained from the medical superintendent. Inotice that the gate is left open and that people are allowed inside .With regard to the Hempsted Hospital , I venture to say thatthe Sanitary Committee are incurring a great and serious responsibilityin continuing to keep this hospital open, and to allow patientsto be admitted. With regard to this, I state definitely that I havefound abundant evidence that both patients and staff are detainedthere at a grave risk.I can only add, that upon the whole question of the hospitalaccommodation, I am of opinion, in the interests of the inhabitantsof this city, and, perhaps, not only this city, but also in theinterests and welfare of the patients, that both hospitals should beclosed as soon as possible, and that immediate steps be taken toform a camp by means of tents at a considerably greater distancefrom the town .102 SMALL - POX INCIDENCE AND VACCINATION .At the present time, only the brick foundations have beenreached in the process of the erection of the building, which Isuggested ten days ago should be immediately put up for myaccommodation. I now suggest that this building, when completed,should, in at any rate a temporary way, be used for theaccommodation of the matron, as it is most essential that sheshould reside on the hospital grounds. I am, Gentlemen, yoursobediently,F. B. BROOKE,Medical Superintendent.These facts are of so serious a character, that it is to behoped there will be an official inquiry into the matter,as also into the sanitary condition of the city, regardingwhich there have been many complaints.Apparently the epidemic at Gloucester, although it hasbeen much commented upon in the press, is not by anymeans the most devastating epidemic of modern times.We have it on Dr. Edward Seaton's authority that,during the year 1885 , the inhabitants of Montreal sufferedto the extent of 3,000 deaths from small - pox, i.e. , on thepopulation ( 160,000), a small-pox death- rate of 18,750per million. It has been alleged that this epidemic wasoccasioned by the neglect of vaccination among theFrench Catholic population. In this connection, it issufficient to quote from the late Dr. W. B. Carpenter, who,in referring to the 1874-75 epidemic of small -pox, and theresistance exhibited towards the proposed vaccination1 The Times , December 10, 1886.2 The allegation has been revived quite recently ( 1896) by Dr. AndrewWhite, late President and Professor of History at Cornell University, inhis interesting work, entitled " A History of the Warfare of Science withTheology in Christendom " ( vol . ii . , p. 60. )THE MONTREAL EPIDEMIC. 103law, says :-" I made a point of enquiring during my staythere, in August last, as to what had been the subsequentcourse of affairs. I learned on the very best authoritythat the objections of the French Catholics had beencompletely overcome. Vaccination being now( 1883 ) as well carried out in Montreal by its officers ofhealth as in the other great cities of the Dominion,small-pox has become almost entirely extinct. " 1The causes of the epidemic in 1885 were not farto seek. Towards its close a member of the staffof the Montreal Herald interviewed Dr. Garceau, ofBoston, a supporter of vaccination, but who was declaredby the editor to be one of the best- informed sanitarianson the American continent. When asked to what causehe attributed the extent of the epidemic, Dr. Garceaureplied " One cause is the fact that the people havenot been properly vaccinated, but I attribute the chiefcause to the frightful system of cesspits which prevails ,and the insanitary condition of the place generally. Itis unclean ; and unless some action is taken to clean theprivy vaults and remove all garbage, the city will nextseason be in excellent shape for cholera, or any otherequally contagious disease. " The Secretary of theCitizens' Committee (Mr. Michaels) appointed to inquireinto the epidemic, said-" The streets and lanes are in adisgraceful condition. Not only in the distant portionsof the city, but within the most aristocratic quartersand in the heart of the commercial portion, the lanes,and even portions of the streets , are reeking with filth. "1A Letter to the Right Hon. Lyon Playfair, C.B. , pp. 13 , 14. 1883 .2 Vaccination Inquirer, vol. viii . , p. 179. ( February , 1887. )104 SMALL- POX INCIDENCE AND VACCINATION .In the present chapter, I have dwelt on the fact thatunvaccinated towns may, by means of personal andmunicipal sanitation, be kept comparatively free fromsmall-pox, and I have also pointed out, as in the caseof Mold, that the most complete vaccination of a districtpossible, may be followed by an epidemic, with a smallpoxmortality thirtyfold that of an unvaccinated community. On the other hand, recent experience has alsoproved, that towns where vaccination has been neglectedmay be seriously afflicted with the disease in preciselythe same way as well - vaccinated districts. The moral tobe derived from such occurrences is that small-pox, incommon with other zymotic diseases, is largely influencedby overcrowding and insanitation , and until theprofession awake to these important facts, we shall stillcontinue to pay a heavy price for our ignorance andmisdirected energy.CHAPTER V.DOES VACCINATION PREVENT SMALL- POX ?FOR a disease in the cow to afford protection against aradically dissimilar disorder in man, is a proposition sostrange, that we should demand the most completeevidence before subscribing to it. According to Jennera vaccinated person is for ever afterwards secure fromthe infection of small-pox, and this opinion was absolutelyendorsed by the Committee of the House of Commonsin 1802 ; 1 in fact, as Baron informs us, if cow-pox hadonly been a temporary security, " it would have deprivedthe discovery of nearly all its value. "2 Of course, nobodyat the present time believes in the life-long protection ofvaccination , or revaccination would not be so urgentlydemanded, but the statement was quite unwarranted even1 " The result, as it appears to your Committee, which may be collectedfrom the oral testimony of these gentlemen ( with the exception of three ofthem) is, that the discovery of vaccine inoculation is of the most generalutility, inasmuch as it introduces a milder disorder in the place of theinoculated small- pox , which is not capable of being communicated by contagion;that it does not excite other humours or disorders in the constitution; that it has not been known, in any one instance, to prove fatal ; thatthe inoculation may be safely performed at all times of life (which is knownnot to be the case with regard to the inoculation of the small-pox), in theearliest infancy, as well as during pregnancy, and in old age ; and that ittends to eradicate, and, if its use become universal , must absolutelyextinguish, one of the most destructive disorders by which the human racehas been visited " (pp. 3, 4).2 Baron's " Life of Jenner," vol. ii. , pp. 18, 19.8106 DOES VACCINATION PREVENT SMALL- POX ?in Jenner's day, and this no doubt explains the action ofthe Royal Society. When the subject was laid beforethe President, "Jenner was given to understand, that heshould be cautious and prudent ; that he had alreadygained some credit by his communications to the RoyalSociety, and ought not to risk his reputation by presentingto the learned body anything which appeared somuch at variance with established knowledge, and withalso incredible. " 1Baron informs us, that Jenner used to bring the subjectbefore the medical society to which he belonged. "Allhis efforts were, however ineffectual : his brethren wereacquainted with the rumour, but they looked upon it asone of those vague notions from which no accurate orvaluable information could be gathered, especially asmost of them had met with cases in which those whowere supposed to have had cow-pox, had subsequentlybeen affected with small-pox. " 2The celebrated Dr. Haygarth wrote and advised circumspection.He says : " Your account of the cow-poxis indeed very marvellous ; being so strange a history, andso contradictory to all past observations on this subject,very clear and full evidence will be required to render itcredible. You say that this whole rare phenomenon issoon to be published ; but do not mention whether byyourself or some other medical friend. In either case, Itrust that no reliance will be placed upon vulgar stories.The author should admit nothing but what he has provedby his own personal observation, both in the brute andhuman species. It would be useless to specify the doubts1 Baron's " Life of Jenner," vol . ii. , p. 168 . 2 Ibid. , vol. i . , p. 48.JUDICIOUS COUNSELS DISREGARDED. 107which must be satisfied upon this subject before rationalbelief can be obtained. If a physician should adopt sucha doctrine, and much more if he should publish it uponinadequate evidence, his character would materiallysuffer in the public opinion of his knowledge and discernment." 1 It is needless to remark that Dr. Haygarth'sjudicious counsels were disregarded by Jenner, as Baronand other authors repeatedly show.In the first chapter of this volume, I have alluded tothe fact that Jenner himself had instances of small-poxafter cow -pox, and also to the ingenious explanationsthat he invented to account for failures. This happenedin the following case, reported by Dr. Ingenhousz, whowas distinguished as a man of science as well as aphysician . He had made a particular study of smallpoxinoculation under Dimsdale, and had been summonedto the Court at Vienna, and appointed Physicianto the Emperor. Shortly after the appearance of the"Inquiry " he visited the Marquess of Lansdowne atBowood, and took the opportunity of writing to Jenneron the subject of cow- pox. Dr. Ingenhousz informedhim that the first person he addressed was a Mr. Alsop,practitioner at Calne. This gentleman introduced himto a farmer of the name of Stiles at Whitley, near Calne,who, thirty years before, had bought at a fair a cowwhich was found to be infected with cow-pox ; thedisease soon spread through the whole dairy, and Stileshimself caught the complaint in a very severe way.After he had recovered and the sores dried up, he was1 Baron's " Life of Jenner, " vol. i . , pp. 134 , 135 .Letter from Ingenhousz to Jenner, October 12, 1798. Baron's " Lifeof Jenner, " vol. i. , pp. 291-293 .108 DOES VACCINATION PREVENT SMALL- POX ?inoculated for the small-pox by Mr. Alsop. Stiles tookthe disease, had a number of eruptions, and communicatedit to his father, who died of it. Dr. Ingenhouszbesought Jenner to inquire further into the subject, beforedeciding in favour of a doctrine which might do greatmischief, should it prove erroneous.Jenner was in great trepidation, for in writing to hisfriend Gardner he said : " It is a matter of real moment ;a matter on which perhaps much of my future peacemay rest-indeed, my existence. " 1 But in reply toDr. Ingenhousz he takes a very lofty tone-" Truth,believe me, sir, in this and every other physiologicalinvestigation which has occupied my attention, has everbeen the object which I have endeavoured to hold inview. Should it appear in the present instancethat I have been led into error, fond as I may appear ofthe offspring of my labours, I had rather strangle it atonce than suffer it to exist, and do a public injury. " 2But what sort of explanation did Dr. Ingenhouszreceive of the case ? We read in " Further Observations "that the cows gave out " an offensive stench from theirudders, " that Jenner had heard of other cases of the sort ,and that he hoped the general observations he had tooffer in the sequel would prove of sufficient weight torender the idea of their ever having had existence, but ascases of " spurious " cow-pox , extremely doubtful.Dr. John Sims, a London physician of repute, contributedto the first number of the Medical and PhysicalJournal³ the experience of a Mr. Jacobs, a solicitor of1 Letter from Jenner to Gardner. Baron's " Life of Jenner," vol . i. , p. 296 .2 Ibid. , p. 294.* Medical and PhysicalJournal, vol. i . , pp. 11 , 12. ( March , 1799. )A LOATHSOME DISEASE. 109Bristol, who began life as a milker on his father's farm .Mr. Jacobs had twice suffered from cow -pox, and, onbeing inoculated for small-pox, had it in so greatabundance that his life was for some time despaired of.He described the cow- pox as the most loathsome ofdiseases, and added that his right arm was in a stateof eruption, both the first and second time, from oneextremity to the other ; the pain was excessive, and hisfingers so stiff that he could scarcely move them .Dr. Sims added :-" What this gentleman remarks of theloathsomeness of the disease, although a circumstanceentirely overlooked in Dr. Jenner's account, appears tobe in itself a formidable objection to its introduction,even should it be found to answer the purpose for whichit has been recommended . But, if in one case, and thatwhere the patient has been twice so severely afflictedwith it, it has already been found to be ineffectual inpreserving from the infection of the small-pox, it willsurely make us hesitate in recommending the introductionof a hitherto nearly unknown disease."When Jenner read this he remarked, in a letter to hisfriend Gardner :-" I am beset on all sides with snarlingfellows, and so ignorant withal that they know no moreof the disease they write about than the animals whichgenerate it. The last philippic that has appeared comesfrom Bristol, and is communicated by Dr. Sims , ofLondon . Sims gives comments on it in harsh andunjustifiable language." ¹ Sims appears to have lackedthe courage of his convictions, and afterwards admittedthat the case was " spurious," and in a year's time hisconversion was complete, for his name appeared near1 Baron's " Life of Jenner," vol. i. , p. 321 .110 DOES VACCINATION PREVENT SMALL- POX ?the top of a list of London physicians and surgeons whorecommended cow- pox to the public.There were other cases of the same description, andsome of these found their way to the medical journals.Thus Mr. Charles Cooke,¹ an apothecary of Gloucester,related the case of a Mrs. Carter, of Longney, aged50. At the age of eighteen, she lived in a dairy farm ;at that time the cows were affected with chapped andsore teats, and all the servants who stripped them hadinflammation and boils upon their hands. She was soill with fever and with these boils, that she could notwork for a week ; her hands and arms were dreadfullyswollen, and she kept her bed for two days. She wastold by a medical man that the disease she suffered fromwas a very bad attack of cow-pox. When inoculated forsmall -pox by Mr. Cooke, in December, 1798 , she tookthe disease, had " rather a burthen of pustules," andrecovered without any variation from the commoncourse of inoculated small-pox .Another case is reported by Dr. R. Hooper, of theMary- le- bone Infirmary. Thomas and William Pewsey,brothers, in the service of a farmer who lived nearDevizes , were seized with painful eruptions on differentparts of their bodies, and suffered very considerably ;they acquired the complaint in consequence of milkingcows affected with a pustular disease. Five yearsafterwards one of the brothers, Thomas, was taken illwith confluent small - pox and died. The usual form ofexcuse was forthcoming, this time from the Rev. T. D.1 Dr. Beddoes' " Contributions to Physical and Medical Knowledge,"pp. 387-392 . Bristol. 1799.* London Medical Review and Magazine, vol . i . , pp. 505-508. (July , 1799. )" SPURIOUS " COW- POX. IIIFosbrooke , M.A. , curate of Horsley, Gloucestershire,who, in a later number of the Review ( August, 1799,p. 628), said that the case appeared plainly to be oneof " spurious " cow-pox.Dr. James Woodforde,¹ of Castle - Cary, reluctantlypublished a case which seemed " to militate against thepermanent preventive influence of the variolæ vaccinæ."A patient-Mrs. Dredge, aged 55-took small-pox ofthe distinct sort ; she informed him that she did notexpect the disease, having taken cow-pox twenty-eightyears previously from milking cows affected with theShe observed that the cow-pox was very severe ;she had numerous pustules on her hands and fingers, losttwo nails, had considerable swelling in the arm-pit, andgreat fever.same.There is a case, given in the third volume of theMedical Observer, of a person who had cow-pox in thenatural way, accompanied by much constitutional affection.About nine months afterwards he took small-poxand died .So much for cases of small-pox after natural cow-pox.Jenner had a number of failures of this sort broughtto his notice, quite in the early days, and he and hisfriends attempted no sort of explanation, except thatthese cases had somehow or other managed to get inoculatedwith a " spurious " form of the disease ; theonly proof of spuriousness, however, being that they hadhappened to take small-pox afterwards.When vaccination came to be more extensively practised,there were a large number of instances recorded1 Medicaland PhysicalJournal, vol . v. , pp. 151 , 152. (February, 1801. )* The Medical Observer, vol . iii. , p. 200. (August, 1808. )112 DOES VACCINATION PREVENT SMALL- POX ?both of mild and severe small-pox, even within theshortest periods of the operation. Mr. E. Harrison, ¹ ofHorncastle , related the case of Fanny Allington, who,when exposed to variolous inoculation six months aftervaccination, was attacked with mild small-pox withmoderate eruption. Mr. Harrison remarks that severalwho were vaccinated from this case resisted the infection.Thus we are invited to entertain the strange notionthat " Fanny communicated a security against the smallpoxto others, although she herself remained liable to itsinfluence. "Mr. John Stevenson, of Kegworth, did not feel " perfectlysatisfied " that the cow -pox was " universally andinfallibly an antidote to the small-pox ; " and on readinghis case, it is quite evident that he had substantial groundsfor his heresy. Two children were vaccinated in June, 1800.According to the account given by Mr. Stevenson, thevaccination was perfectly correct. Six months afterwards,both these children were inoculated with recentvariolous matter, to remove all doubts in the minds ofthe parents about the efficacy ofcow- pox. Mr. Stevensonsays :-" You may conceive my confusion and chagrinwhen, on the eighth day, I received a message requestingme to visit my young patients, who complained ofheadache, chilliness, sickness, and the other precursorysymptoms of small-pox. On my arrival, I found, to mysincere regret, that there was little doubt of their havingthe genuine variolous fever; the pustules on the arms ofboth were fully distended with purulent matter, and considerablyinflamed around , their margins. In MasterMedical and PhysicalJournal, vol. v. , pp. 108-111 . ( February, 1801. )* Ibid. , vol . vi. , pp. 121-124. (August, 1801. )FATAL SMALL - POX AFTER VACCINATION. 113Edward, on the following day, a full crop of eruptionssupervened ; with respect to his brother, the eruptivefever was much milder. That this secondarydisease was the real small -pox, admits not of a doubt,since many children were inoculated successfully withmatter taken from Master Edward. "In the report on the cow-pox inoculation from thepractice at the Vaccine- Pock Institution during theyears 1800-02, we read (p. 66), " The distressing informationwas lately given of two children in one familytaking the small-pox casually, of which they died,although they were supposed to be in security, byhaving been inoculated for the cow-pox two yearsbefore."The following letter, dated March 27, 1802 , from Mr.John Grosvenor, of Oxford, to the Chairman of theHouse of Commons Committee, is printed in theAppendix to the Report 1 :-" I beg leave to informyou that, in the latter end of March, last year, twochildren were inoculated for the cow-pox by a younggentleman, a pupil of mine, and that I saw thechildren in the progress of the disorder, and theyappeared to have received the infection properly, andwere judged by us to be secure from the variolousinfection. A few months afterwards they were seizedwith the natural small-pox, of which one of them died.They were the children of a servant of Sir DigbyMackworth, of this place."From about 1804, as Baron² informs us, the reports of1 Report from the Committee on Dr. Jenner's Petition respecting hisdiscovery of Vaccine Inoculation. Appendix, p. 40. (Ordered to beprinted, May 6 , 1802. )" Baron's " Life of Jenner, " vol . ii . , pp. 13 , 14.114 DOES VACCINATION PREVENT SMALL- POX ?failures had begun to multiply, and one of Jenner'scorrespondents, who was seriously alarmed for hisreputation, wrote a long letter full of doleful anticipationsof the ill effects likely to arise from the " sinisterrumours propagated by the anti- vaccinists, " and advisedhim to come forward and vindicate his doctrines. Thecases which made the most stir were those communicatedby Mr. Goldson to the Portsmouth MedicalSociety. He wrote a pamphlet¹ on the subject, andconcluded with the following sensible remarks (p. 62) :-" It is far from my wish to provoke controversy. Ionly ask for further investigation. Vaccine inoculationmust stand by its own merits, or fall from its ownimmediate defects. To suffer zeal for the discoveryto shut their eyes to conviction, and, by deeming everyfailure spurious, to conceal it, is beneath the dignityof the profession. " The reviewer in the Medical andPhysical Journal observed, that " the objections of Mr.Goldson, if valid, would go to the entire abolition ofvaccine inoculation taken from the human subject. "These cases were the starting point of a very determinedopposition to vaccination, and even Jenner'sfaithful henchman, Dunning, admitted that some of thefailures looked " ugly, " and it required all Jenner'singenuity to keep him true to the cause. " But whileI am fighting the enemy of mankind, it will be vexatiousto see my aides-de-camp turn shy. Among the foremostin the field, I have always ranked Richard Dunning.1 " Cases of Small-pox subsequent to Vaccination. " William Goldson ,M.R.C.S. Portsea. 1804.2 Medical and PhysicalJournal, vol . xii . , p. 85. (July, 1804. )3 Letter from Jenner to Dunning, October 25, 1804. Baron's " Life ofJenner," vol . ii . , p. 341 .AN INGENIOUS EXPLANATION . 115No one has been more obedient to the commands ofhis general, or wielded the sword against the foe withgreater force and dexterity. But shall I live to seemy friend dismayed at the mere shadow of fortuneon the side of the enemy; will he who has led suchhosts into the field, and found them invulnerable, startif, in the continuation of the combat, he should see aman fall ? Enough of metaphor. The moral of allthis is, that I see you are growing timid. "The failures in Goldson's practice were such, however,as were beginning to be reported all over the country.Thus Mr. William Forbes,¹ of Camberwell, contributedthe case of Stephen Brown, a young man, who wasvaccinated in December, 1802. The vaccination, weare informed, must have been perfect, because mattertaken from his arm produced the same disease inanother case from whom two children were vaccinated,whose arms exhibited " beautiful" specimens of thecow-pox. Stephen Brown took the small-pox inFebruary, 1805, and had a considerable number ofsmall -pox eruptions, though of a mild kind. Mr.Forbes , who appears in ingenuity to rival Jenner himself,attributed the failure not " to a defect in thepreventive power of the vaccine virus, but to thecircumstance of his constitution not having undergonethat change which is necessary to secure it from thefuture contagion of the small-pox, notwithstanding theperfect appearance of the pustule upon his arm."In the same journal, Mr. John Ring mentioned a" clear case " of small-pox two years after one of his1 Medical and PhysicalJournal, vol. xiii. , pp. 517-520. (June, 1805. )" Ibid. , vol . xiv. , p. 6. (July , 1805. )116 DOES VACCINATION PREVENT SMALL- POX ?own vaccinations. On examination he found thatthere were the remains of a pustular eruption, whichappeared to be variolous, and was in some degreeconfluent ; he explained the case by saying, that whenthe child was vaccinated it was suffering from ringworm,which prevented the cow-pox from producing the fulleffect on the constitution.Mr. Blair, ¹ surgeon to the Lock Hospital , alsoreported the case of a child vaccinated on May 7, 1803 ;the vaccination left a cicatrix on each arm. On June 3 ,1805 , he was asked to see the child , whom he found" covered with a distinct variolous eruption, small in size,but fairly maturated." Dr. Adams, of the InoculationHospital , agreed that it was certainly a case ofsmall-pox.In the same number² (July, 1805), Mr T. M. Winterbottom,of South Shields, related four cases of small - poxafter supposed vaccination, as occurring in the practiceof Mr. G , surgeon in the town.John Gait was vaccinated on the 5th of December,1804. The arm inflamed regularly, and the pustuleswere full , leaving an indelible mark. He took confluentsmall -pox on March 3, 1805-that is to say, threemonths after vaccination-and died on March 14.Robert Thompson, vaccinated on March 5 , 1804.The inflammation and other symptoms were regular,On the 10th March, 1805 , he took discrete small -poxof a mild type,Richard Hall, vaccinated on December 17, 1804.The vaccination was regular, and he had four or fivepustules on other parts, caused by scratching. Small-1 Medical and PhysicalJournal, vol . xiv . , pp. 21 , 22. Ibid. , pp. 23, 24.MR. RICHARD DUNNING'S CASES. 117pox developed on February 24, 1805 ; he had a largenumber of pustules, but they were not confluent.Elder was vaccinated on December 20, 1804,and took small -pox of a confluent and bad kind inApril, 1805 .What failure could be more conclusive than thesefour cases ? One took the small-pox two months aftervaccination, and had a large number of pustules ; another,three months, and died of it ; a third, four months aftervaccination, with a confluent and bad kind of small -pox ;while the fourth, who had been vaccinated a year, had amild variety of the disease.In the Medical and Physical Journal for October ,1805 , are two cases reported by Mr. Richard Dunning.The first, two and a half years old, was vaccinated byMr. Dunning on October 8th, 1803, the cicatrix on onearm being distinctly if not strongly marked. In lessthan two years (29th July, 1805,) the patient wasattacked with small-pox, the pustules amounting tomany hundreds, and were situated principally on theface and extremities . In the other case he had vaccinatedthe child more than two years previously,and the patient had from fifty to one hundred pustules.In this case Mr. Dunning was not satisfied with thevaccination , as the child had torn both the vaccinevesicles on the seventh or eighth day with its nails ,although he observed that nothing could be moreregular and correct than the progress of the earlyvesicles, and the cicatrices on the arms were not unusuallysmall, and were in many respects satisfactory.In the November number of same volume (pp. 403, 404),1 Medical and Physical Journal, vol. xiv. , pp. 308-310.118 DOES VACCINATION PREVENT SMALL- POX ?Mr. John Ring mentioned the cases of two childrenvaccinated by him who had slight attacks of small-poxafterwards , and also a case in the practice of a Dr.Nelson ; and he explains : " I am now inclined tobelieve that these, and some other well-authenticatedcases of a similar kind, are to be ascribed to the greatersusceptibility of small-pox in some habits than inothers."In the Journal¹ for December, 1805 , Mr. Walter Drewrelated the case of a child whom he had vaccinated inthe spring of 1804. The arm , we are informed, exhibitedall those criteria by which vaccination is recognised,such as the hardened phlegmonic base, and inflammatoryareola encompassing the pustule from the ninth tothe eleventh day, and its gradual change to a dark brownprominent scab, which adhered a long time, and leftbehind an indelible impression on the arm, such as inappearance to " enable me to warrant safety from smallpoxinfluence. " In September, 1805 , however, the childwas seized with an eruptive fever to very high degree,and this was followed by a small-pox eruption of thedistinct kind.A number of cases are recorded in the eleventhvolume of the Medical and Chirurgical Review. Theeditors say " that late failures (real or supposed) ofthe vaccine inoculation to secure the constitutionagainst future small-pox have, as was to have beenexpected, excited a great sensation in the public mind,and which is not likely to be allayed till the subject hasundergone the fullest and most impartial investigation.Medical and PhysicalJournal, vol . xiv . , p. 537 .“ Medical and Chirurgical Review, vol . xi . , p. Ixii . (January, 1805. )FURTHER FAILURES OF VACCINATION . 119Speaking abstractedly, it is of no moment in whichway the question respecting the vaccine practice isultimately determined, but it is of infinite importancethat the true state of the case be made out, whether ittell for or against the practice."The following case, taken partly from the minutesof the Vaccine-Pock Institution, appears in pp. xxx.(September, 1804, ) and lxv., lxvi. (January, 1805, ) of theeleventh volume of the Review. The child, about fiveyears of age, was vaccinated on each arm in October ,1803 ; both places took well, and mahogany scabs wereformed, which, on separating, left pits. In July, 1804,nine months after vaccination, the child was taken illwith small -pox ; the pustules were distinct and attendedwith purple spots, and it died on the eighth day of thedisease. The two medical men who vaccinated thepatient saw it before death, and were satisfied that itwas a case of small-pox.The Review¹ gives two cases which were also verythoroughly investigated, viz., the children of Mr. Hodges ,stay- maker, residing in Fulwood's Rents, Holborn. Bothchildren were vaccinated by Mr. Wachsel , the residentsurgeon at the Small-pox Hospital. He witnessed theappearance of the vaccinated parts, and expressed himselfas perfectly satisfied of their regularity, and of affordingpermanent security against future variolous infection.In the younger child (two and a half years vaccinated),the small-pox was mild ; but in the elder (vaccinatedfour years previous to attack), the eruption was verygenerally over the body, face, and limbs, and proceededMedical and Chirurgical Review, vol. xi. , pp. liii. - lvi . ( November,1804) ; and pp. lxiii. -lxv. (January , 1805 ) .120 DOES VACCINATION PREVENT SMALL- POX ?in the customary manner of small-pox to maturationand scabbing. The patient was very ill, and for somehours delirious ; the eruption was exceedingly copious ,some of the pustules running together ; there was swellingof the face, occasioning temporary blindness, andthe patient was much pitted.The editors¹ also related five cases of small-pox aftervaccination, and pledged themselves for the accuracy ofthe statement in every material point (see opposite page).In the Medical and Chirurgical Review, further instancesare recorded, some of these being extractedfrom the minutes of the Vaccine- Pock Institution. Dr.Pearson, at the request of Dr. Benjamin Moseley, anopponent of vaccination, examined a case of small-poхin a patient who had been vaccinated fifteen monthspreviously, and on whom a distinct scar was left as theresult of the operation. There were several hundrederuptions, in greater proportion on the face, and Dr.Pearson had no doubt of its being a case of small -pox,although Mr. Griffiths, and Dr. Willan, who also saw thechild, supposed it to be chicken-pox ; it is to be noted,however, that another child was inoculated from thispatient, and the local result was described by Dr. Pearsonas " unambiguously variolous " (p. xxi. ). The editors³furnish particulars of seven instances of failure on theirown responsibility ; the disease was caught between twoand six years of vaccination. None of the cases weredescribed as mild, and several of the patients werevery ill ; one, who took the disease two years after1 Medical and Chirurgical Review, vol . xi . , pp. cxxv. -cxxviii. (May, 1805. )2 Ibid. , vol . xii . , pp. xvi. , xvii. ( July, 1805. ) * Ibid. , pp. xxiv. -xxvii .Name . Age .Thomas Bainbridge5Harriet Bainbridge3Mary Hart3Vaccination .Vaccinated intwo places onFebruary24th ,1800 ,by Mr. Wachsel ,atthe Small -pox Hospital .Thevaccination regular and satisfactory.Scabs fell off about thetwenty -sixth day and left "cicatricesasstrongly marked as.u"sualVaccinated atSmall -pox HospitalinOctober ,1802. Cicatricesstrongly marked ,and child declaredsecure from future smallpox.Vaccinated atSmall -pox HospitalinOctober ,1802. Wentregularlythrough thedisease with Nature ofthe small -pox .cD-sopMomenoanavxrflecllluheonptedM.,,11d2a98inant0eddrh5dchInoculated with variolous matter onMarch12th ,1805. Thirty or forty eruptionsappeared ,which ripened into pustules ,inevery respect resembling small -pox ,though ofsmall size .InMarch ,1803 (five months after vaccination),took small -pox inthe natural way .About forty pimples appeared ,several ofwhich maturated .Vaccinated when three months |Inoculated with variolous matter onMarch.sucsauraslJohn Kay4Jw,dMoRbelroiyh-.dhnongvcttbalhoecaecriendations. atisfactory16th ,1805. There was considerable constitutionaldisturbance ,with eruption ofpimples ,some maturating .The fifth case inthe practice ofMr. Forbes Surgeon ,ofCamberwell ,was that ofayoung man who took smallpox"inaconsiderable degree "when inoculated with variolous matter two years after vaccination .6122 DOES VACCINATION PREVENT SMALL- POX ?vaccination, " had it very full, so as to leave manymarks " (p. xxvii. ).The reports of failure at length became so numerous,that it was found necessary to take action. In a letterto Mr. Dunning in reference to Dr. Benjamin Moseley'spublication of failures, Jenner expresses the opinion thatnothing would " crush the hissing heads of such serpentsat once " but a general manifesto with the signatures ofmen of eminence in the profession, unless Parliamenthad a mind to take the matter up again. It was aboutLondon where the " venom of these deadly serpents "chiefly flowed. " I know very well," Jenner said, " theopinion of the wise and great upon it (vaccination) ; andthe foolish and the little I don't care a straw for ; " andtherefore he turned to those in authority. He had aconference with Lord Henry Petty (afterwards Chancellorof the Exchequer) at Hampstead, who expressedhis determination to bring the subject forward in theensuing session. Consequently, in 1806, an addresswas voted to His Majesty by the House, praying " thatHis Majesty will be graciously pleased to direct hisCollege of Physicians to inquire into the state of vaccineinoculation in the United Kingdom, and to report theiropinion and observations upon that practice, theevidence which has been adduced in its support, andthe causes which have hitherto retarded its generaladoption ; and that His Majesty will be graciously1 The progress of the vaccine pock was deemed regular by Mr. Nicholson ,apothecary at St. Bartholomew's Hospital , and it left the ordinary mark onthe arm.2 Baron's " Life of Jenner," vol. ii . , p. 354.3 Ibid. , p. 352. * Ibid. , p. 14.DR. ROBINSON'S ADMISSIONS.123pleased to direct that the said report, when made, maybe laid before this House.¹The College reported favourably, and Jenner wasawarded £20,000 (the sum total he received being£30,000), and the National Vaccine Establishment wasfounded with a Vaccine Board of eight, each having asalary of £ 100 a-year. Although the profession andParliament had been practically committed to vaccinationat the time of Jenner's Petition ( 1802) , this wasthe first instance of the establishment and endowmentof the practice, and the natural tendency was to stifleopposition ; indeed, it may be said that one of theprincipal functions of the National Vaccine Establishmentwas to explain away the failures of cow- pox toprotect from small - pox.In some towns the failures were such as to lead to adiscontinuance of the practice ; thus, in the appendix ofDr. Willan's book, is a report on vaccination by Dr.Rutter, physician to the Liverpool Dispensary, whogives Dr. Robinson's account of the state of vaccinationat Preston . " Vaccination was first practised in thistown by one or two gentlemen in the year 1798 or1799, soon after its introduction by Dr. Jenner. A fewchildren only were inoculated at that time, but theywere supposed to have gone through the disease in theregular way." The practice afterwards became more general, untilthe small -pox raged epidemically. It was then observed1 Hansard's Parliamentary Debates, first series, vol. vii. , pp. 883 and899. (July 2 , 1806. )" On Vaccine Inoculation. " Appendix, p. xxvi. Robert Willan ,M.D. London. 1806 .124 DOES VACCINATION PREVENT SMALL- POX ?that many of the children who had been previouslyvaccinated, and were supposed to be secure, caught thecomplaint ; some of whom died, and others recoveredwith difficulty. The frequent occurrence of theseuntoward events alarmed the public mind, and prejudicedthe vulgar against the practice so entirely, thatfor a time it was nearly laid aside, except among themore enlightened. " Thus, we have an early admissionof the fact, which can no longer be denied, that againstepidemic small - pox vaccination is of little or no avail.¹Sir Isaac Pennington, Regius Professor of Physic atCambridge, laid before the Royal College of Physiciansan account of twenty- five cases of small- pox after vaccination,which he had visited in the town of Cambridge.Most were strongly marked, six only being mild. Insome, the vaccination had been of seven or eight years'standing ; and in others, not of so many weeks. In all ,the cicatrix was very distinguishable ; and at the timethey were vaccinated, the inoculator declared they hadgone through the disease in a proper manner. Sir Isaacsaid he had not seen any fatal cases where he had reasonto suppose the vaccination had succeeded properly.In 1808, about ten years after the introduction ofvaccination, the opposition became very strong, theopponents being men of education, and many of thembelonging to the medical profession. Discussions onthe subject took place in public, and according to1 See extracts from recent official sanitary reports from India, quoted byDr. Collins and Mr. Picton . Royal Commission on Vaccination, DissentientCommissioners' Statement , section 227 .* Letter from Sir Isaac Pennington. Medical Observer, vol. iv. , p, 246.(December, 1808. )FATAL SMALL- POX AFTER VACCINATION . 125Jenner, many professional men, some holding importantpublic stations, were concerned in diffusing " wretchedand pernicious trash, " and we also learn from Baron that" the walls of London " were placarded with " falsehoods. " 1About a year later we find him writing that " Jennerand vaccination were again to be put upon their trial. " 2In the Medical Observer³ for November, 1809, theeditor selected cases of failure from those formerlypublished and known to be authentic. Of 113 instancesgiven, 16 died, or a case- mortality of 14.2 per cent. Thedetails given in fourteen of the fatal cases are asfollows :-1. A child was vaccinated by Mr. Robinson, surgeonand apothecary, at Rotherham, towards the end of theyear 1799. A month later it was inoculated withsmall-pox matter without effect, and a few monthssubsequently took confluent small-pox, and died.2. A woman-servant to Mr. Gamble, of Bungay, inSuffolk, had cow-pox in the casual way from milking.Seven years afterwards she became nurse to the YarmouthHospital, where she caught small-pox, and died.3 and 4. Elizabeth and John Nicholson, three years ofage, were vaccinated at Battersea in the summer of 1804.Both contracted small-pox in May, 1805, and died.They were attended by Dr. Moseley and Mr. Roberts.5. Mr. J. Adams, of Nine Elms, contracted casualcow- pox , and afterwards died of confluent small -pox.6. The child of Mr. Carrier, Crown Street, Soho,was vaccinated at the institution in Golden Square ,and had small - pox three months afterwards, and died.1 Baron's " Life of Jenner," vol . ii . , pp. 110, 111. 2 Ibid. , p. 128 .* Medical Observer, vol. vi. , pp. 387-398.* Two of the deaths have been described elsewhere in this chapter.126 DOES VACCINATION PREVENT SMALL- POX ?7. Mary Finney's child, aged one year, died of smallpoxin July, 1805, five months after vaccination .8. The child of Mr. Blake's coachman, living atNo. 5 Baker Street, died of small-pox after vaccination .9. Mr. Colson's grandson, at the " White Swan,"Whitecross Street, aged two years, was vaccinatedby a surgeon at Bishopsgate Street, in September,1803. He died of confluent small -pox in July, 1805 .10. Mr. Brailey's child, aged two years and eightmonths , was vaccinated at the Small-pox Hospital,and forty weeks afterwards died of confluent small-pox.11. Mr. Hoddinot's child, No. 17 Charlotte Street,Rathbone Place, was vaccinated 1804, and the cicatrixremained. In 1805 it caught small-pox, and died.12. C. Mazoyer's child, No. 31 Grafton Street, Soho ,was vaccinated at the Small-pox Hospital. Died ofsmall -pox in October, 1805 .13. The child of Mr. R died of small -pox inOctober, 1805. The patient had been vaccinated,and the parents were assured of its security. Thevaccinator's name was concealed.14. The child of Mr. Hindsley at Mr. Adam's office,Pedlar's Acre, Lambeth, died of small - pox a yearafter vaccination .In five of these fourteen deaths ( Nos. 2, 5 , 8 , 12, 13),the length of time which had elapsed since vaccinationis not given. In No. 2 the small-pox was contractedseven or more years afterwards; in No. 8 the patientwas a child ; and Nos. 12 and 13 were both children,and as they took small-pox in 1805, it is not possiblethis could have supervened more than five or six yearsafter vaccination. Of the nine remaining deaths, eight,OPINIONS OF BROWN OF MUSSELBURGH . 127with one possible exception ( No. II ), were affectedwith the disease within a year of vaccination, and theremaining death (No. 9) was within two years of theoperation .1In 1809, Brown, of Musselburgh, published notes offorty- eight cases of small -pox, all of which had occurredwithin nine years of vaccination, most of them withinmuch shorter periods. Brown was originally a convertto the Jennerian doctrine, but he says (pp. 279, 280) :—“ Іam also convinced, from what has passed under my ownobservation for the last three or four years, that we havebeen all guilty of rejecting evidence that deserved moreattention, in consequence of the strong prepossessionswhich existed, from the very persuasive proof of its(vaccination) resisting inoculation and exposure to theepidemic, and from our judgment being goaded andoverpowered with the positive and arbitrary opinionsof its abettors. I am now perfectly satisfied, from mymind being under the influence of prejudice, and blindto the impressions of the fairest evidence, that the lasttime the small-pox was prevalent, I rejected, and explainedaway many cases which were entitled to themost serious attention, and showed myself as violentand unreasonable a partisan as any of my brethren inpropagating a practice which, I have now but littledoubt, we must ere long surrender at discretion. " 2Brown allowed that it might keep off small- pox for atime, and that there was reason to believe it tended1 " An Inquiry into the Anti-variolous Power of Vaccination. " ThomasBrown, surgeon, Musselburgh. Edinburgh. 1809.* Brown somewhat modified his opinions in a later work published in1842.128 DOES VACCINATION PREVENT SMALL- POX ?to make the disease milder ; in fact, he held what wouldbe about the average medical opinion of to-day. Ofcourse he was hopelessly before his time, and came infor a great deal of abuse. Jenner, writing to Baron, andreferring to a letter written by Brown to one of theLondon papers, says :-" His letter, under the veil ofcandour and liberality, is full of fraud and artifice, forhe knows that every insinuation and argument he hasadvanced has been refuted both by the first medicalcharacters in Edinburgh and Dublin, and, indeed,by many others. " ¹ The more reasonable of Brown'sopponents, however, ultimately adopted his views, forin the Edinburgh Medical and Surgical Journal ofJuly, 1818, we read :-" Before we conclude, we must,in justice to ourselves, pay the amende honorable to Mr.Brown, of Musselburgh, whose opinions we strenuouslycontroverted in 1809, because we did not think themsupported by the evidence then brought forward, orconsistent with our knowledge of vaccination at thattime ; and to which we now, in 1818, confess ourselvespartly converts, in consequence of increased experienceand observation . "The Medical Observers for August, 1810, states thatat Witford, Hertfordshire, the poor of the parish werevaccinated some time previously by Mr. Farrow, apothecaryat Hadham, with matter procured from Dr. Walkerof the London Cow-pox Institution. During theprevalence of the variolous epidemic, of the sixty- ninevaccinated, twenty-nine contracted small-pox, nine of1 Baron's " Life of Jenner, " vol. ii . , p. 47 .2 Edinburgh Medical and SurgicalJournal, vol . xiv. , p. 387.3 Medical Observer, vol . viii . , pp. 81 , 82.MORTALITY AT WITFORD . 129whom died. The editor gives the names and ages ofthose who died, as follows :-Name.William BartonMary CatmoreAnn CatmoreEmma PriorMartha WrennWilliam CatmoreCharles WybrowJohn Fitstead... ... ...... ... ...... ... ...James Thoroughgood... ...Age.5 years .13 years .13 years .6months.6 years.3 years .6 months .1 year.2 years.Thus these vaccinated cases of small-pox in the parishof Witford had a fatality of 31 per cent. , and seven ofthe nine deaths (78 per cent.) were under ten years ofage. This can hardly be regarded as a successfulexperience of the protective or mitigating powers ofvaccination ; and to make matters worse, two of thechildren originally vaccinated were reported to havedied from the effects of the operation .The Edinburgh Medical and SurgicalJournal for July,1810, refers to the Third Report of the NottinghamVaccine Institution, in which it is stated, that " duringthe virulence of the epidemic, one of the subjects, whosecase was marked in the register as perfect or satisfactory,fell a victim to the small-pox. " ¹ The boy wasoperated on in September, 1806, the vaccination beingdismissed as satisfactory. On the 31st of January, 1809,he contracted small-pox, and died on the eighth day.About this time several failures took place in highlife, and consequently attracted much attention. Thecase of the Hon. Robert Grosvenor was an instance inEdinburgh Medical and SurgicalJournal, vol . vi. , p. 385.2 See Baron's " Life of Jenner," vol. ii. , pp. 155-158 .130 DOES VACCINATION PREVENT SMALL- POX ?point ; he took confluent small-pox and nearly died, tenyears after vaccination by Jenner's own hands. This wasvery awkward, especially as the case got noised abroad ;but the National Vaccine Establishment were quiteequal to the occasion, and issued a special report on thisand other cases, from which it appeared that the boywould have died outright had he not been vaccinated.The Grosvenor case evidently made some impression,for we find Jenner admitting, in a letter to a correspondent,that it was " a speck, a mere microscopic speck onthe page which contains the history of the vaccinediscovery, " ¹ and in a letter to Baron, about this time, wefind the following :-" The noise and confusion this casehas created is not to be described . The vaccine lancetis sheathed ; and the long concealed variolous bladeordered to come out. Charming ! This will soon curethe mania. The town is a fool, an idiot ; and willcontinue in this red-hot, hissing-hot state about thisaffair, till something else starts up to draw aside itsattention. I am determined to lock up my brains, andthink no more pro bono publico ; and I advise you, myfriend, to do the same ; for we are sure to get nothingbut abuse for it. It is my intention to collect all thecases I can of small-pox, after supposed security fromthat disease. The best plan will be to push outsome of them as soon as possible. This would not benecessary on account of the present case, but it will provethe best shield to protect us from the past, and thosewhich are to come. " 2Here we have a new doctrine which was broughtforward by Jenner to repel failures, viz., that cases of1 Baron's " Life ofJenner," vol. ii. , p. 158 . Ibid. , p. 161 .FURTHER PROOFS OF FAILURE . 131small -pox after small -pox were not uncommon, andthat vaccination could not be expected to do more thansmall -pox itself. In a letter to Mr. James Moore, wefind the extraordinary statement that " thousands ( ofsuch cases) might be collected, for every parish in thekingdom can give its case." It is important to notethat this admission-that small-pox takes place aftersmall - pox although undoubtedly true, was onlybrought forward when the failures of cow-pox to protecthad become so numerous and notorious that it wasimpossible to invent further excuses .Another case was that of the son of Sir Henry Martin.The medical man, Mr. Arthur Tegart, who vaccinatedand also attended the boy, gives a description of the casein the Medical and Physical Journal for September,1811. With regard to the vaccination , Mr. Tegart says,"A strong and marked eschar now remains on the armvaccinated, and Sir Henry Martin tells me, that aneminent professional gentleman saw the child during itsprogress through the disorder, and considered it as avery fine specimen of the complaint. " The diseaseattacked him ten years after vaccination ; at first theeruption conveyed to Mr. Tegart the idea of an aggravatedkind of chicken-pox, but afterwards he says, " Ibegan (reluctantly enough, I admit,) to consider thedisease as the small-pox. " There were upwards of ahundred pustules on the face, and about twice thatnumber on the extremities. Dr. Heberden, who wascalled into consultation, hesitated but little in pronouncingthe disease to be small-pox ; but Mr. James1 Baron's " Life of Jenner, " vol. ii . , p. 363 .* Medical and PhysicalJournal, vol. xxvi . , pp. 177-181 .132 DOES VACCINATION PREVENT SMALL- POX ?Moore, director of the National Vaccine Establishment,entertained " some doubts" on the subject.In February, 1812, opposition apparently ran ratherhigh, for we read that Jenner " was particularly annoyedby the atrocious falsehoods of the anti-vaccinists ; " ¹ andsome friends were inclined to urge him to seek redress ina court of law. Again, later in the year, in a letter to JamesMoore, we read that " the anti-vacks are assailing me, Isee, with all the force they can muster in the newspapers .The Morning Chronicle now admits long letters . "The Medical and Physical Journal for August, 1812(vol. xxviii. , pp. 111-114), gives extracts from the minutesof the Vaccine- Pock Institution regarding cases in onefamily who were vaccinated at the Institution, and visitedby Drs. Domeir and Pearson. (See opposite page.)Dr. Pearson remarks (p. 114), " It does not appear thatthe children had the subsequent small-pox mitigated inany proportion to the degree of affection by vaccination. "Apparently Dr. Pearson did not have a high opinion ofvaccination at this time, for Jenner, in a letter datedNovember 18, 1812, refers to his " insinuations thatvaccination is good for nothing. " 3In consequence of the revival of small-pox inoculation,Lord Borington, in 1813, at the instance of the NationalVaccine Board, brought in a bill to check this practice.Lord Ellenborough, the Lord Chief Justice, after ridiculingsome of the provisions of the bill, made someremarks on the subject of vaccination. " No doubt," heobserved, " it was of some use, but he did not concur inall the praise bestowed upon it in this bill ; but if the1 Baron's " Life of Jenner," vol. ii . , p. 181. 2 Ibid. , p. 383. 3 Ibid.N. ame A. geMAAnancrneyll12LAnucceyll-7V. accinationV.,31oM18anas0crt1ccihnatedvttWahhecerncoitungahtionirwomaeninagtenuhnlearrf.vlieansreigceleVS,3oarencdpctienmabteerd1scwH8ihea0xal5drl.acteri.,,vtveshiserzidecelesTwte.aheawrrecomehres.dsiucsbatbsisenqcutentonN.-tsophmafoeatxlulrep,-Ae2aSopr6opmnrutpaxiphelltaliroend1n,dvEb8ieruu1srutm2-ype.trioounsst."1tshOMi2hcananteavcyhbitsngftan,ioshotahfphanolfapesewlteeanrsvauldstfeicehrrpfsaerotmotryminnctv."accinationSa,-e2Apor9pmponutrapxphiletllairoend1lpoShna8aufhau1rsedm2g-.bererst,.htpwTiuehohhslraciteenkcesrshw,fctwoaaaoheenrncnerrmdefeesluentob,ivokaaneflrinsandiddcduelrayrslpobfheafaryuvrgomnetmspgrsahlst.tfewaTwhayhanhecoesedeelsmlenct.f1odauOMol2rwapnartooyhsyedvnstaf"cahrroacreowrecmseinationlpoautoaeehnnprfreetdomcneivablet.r"ihgehtJohn Ancell9V.,21Jo4a8ant0cnh4cuianraytedTdvfweioehsureitrercilnecestsa.stuahcsnteuadiabslsfactoryA.,-1s2Dpop8m7eon1atrvx2lhielllopedeN;itotmnhrthooiuhartrpentetryionsr."p1twMOer2heansetrlptyheletecytsdlstvfoaeichanrrfsaecotmtrcmisinncatt."asnireooeewnncyAuA,,icfftGasnhoeonanheganiunmaecvoemlrtireardedrlslcgaylcecitneadtedsa.-dpminoaexdldl134 DOES VACCINATION PREVENT SMALL- POX ?noble lord considered it a complete preventive of thesmall -pox, he differed with him in opinion. At thesame time he had shown his respect for the discovery,for he had had eight children vaccinated. He believedin its efficacy to a certain extent ; it might prevent thedisorder for eight or nine years, and was desirable ina large city like this, and where there was a large familyof children. " ¹ Lord Ellenborough also remarked thatvaccination was " perhaps, sometimes, apt to introducedisorders into the constitution . " The bill was withdrawn,but the remarks of the Lord Chief Justice, whichtended to damn vaccination with faint praise, wereannoying to Jenner, and it was also unfortunate thatthis was the opinion of one of the " wise and great, "and consequently Jenner felt the matter somewhatacutely. " I have seldom," said Baron , " seen Jennermore disturbed than he was by this occurrence, and notcertainly because he had any fears that the unsupportedassertion of his lordship would prove correct, but becauseit unhappily accorded with popular prejudices, and whenuttered by such a person, in such an assembly, wascalculated to do unspeakable mischief. " SMr. Thomas Hugo, of Crediton, in the Journal forDecember, 1814, said that at Crediton the cases offailure became at length so numerous and decisive thatthey could not fail to excite alarm, and to engage theserious attention of medical practitioners. He instancedtwenty- five cases of small -pox in persons who, from the¹ Baron's " Life ofJenner," vol . ii. , p. 196.2 Hansard's Parliamentary Debates, first series, vol. xxvi. , p. 989.(June 30, 1813. )3 Baron's " Life of Jenner," vol. ii. , p. 197.* Medical and PhysicalJournal, vol . xxxii . , pp. 478-481 .MR. HUGO'S CASES . 135regular progress of the vaccine vesicles, were consideredsecure. He alluded only to those cases attended bymedical practitioners, and where the evidence was consideredin all respects conclusive. The fever, we aretold, in its attack and progress was commonly violent ;the heat was excessive, the pulse very quick, universallanguor, pain in the head and loins, frequent vomiting ,occasional delirium in the night, and sometimes convulsions.These symptoms, after having occasioned considerablealarm for three or four days, were succeeded by adistinct and mild eruption, which dissipated all apprehensionof danger. Mr. Hugo adds (p. 480) , " I believethat vaccination has nowhere been practised with morescrupulous attention to the characteristic appearanceof the vesicle, and I have in no case which had beenentrusted to my own care, neglected to ascertain theconstitutional affection by the test of a second vaccination.It is impossible, I conceive, therefore, to explainthese unsuccessful cases on the supposition that thepreceding vaccination had been spurious and irregular. "In the London Medical Repository¹ for April, 1816, acase of failure is given in a girl , nine years of age, whowas vaccinated in Batavia, and, as far as could be judgedfrom the cicatrices on the arms as well as from theaccount of her mother, in a manner quite satisfactory.The eruptive fever was exceedingly violent, and theeruption, though distinct, was very considerable.In the MedicalandPhysicalJournal for January, 1817,Mr. Thomas Harrison, of Kendal, contributes some casesfrom the practice of Mr. M. Redhead, Ulverston (pp. 5-7).1 London Medical Repository, vol . v. , pp. 295, 296.2 Medical and Physical Journal, vol . xxxvii. , pp. 2-12.No. Name .wAhgeen.vaccinatedBywhom .AwgheeninfectedwithNature ofthe small -pox .s-.pmoaxllIJRtoownboeesr'tschildrenInfants Mr. Redhead2Elizabeth James Infant Mr. Harrison12J3Joasmeepsh RIMnref.dahntead154William James InfantMr.Carter5PWairlkleiram4Mr. Close ,Dalton 18FE6ellilzabeth3Mr. Briggs12c,1oShw8ap0oumhonotnairdxtlcnilhynuedsw;fsondiienreoavxeltryenyes.mbamchOehyaandidnelidcalcdffoeoaunvuryesrisrindgerableep.ttrrohueepvtiioouns8Very feverish .Pustules distinct .Awellmarkedcase ofsmall -pox .Very feverish ,and thought dangerouslyill for afew days .Eruption not sofull aswith Elizabeth .Had them (eruptions )milder than thetwo former .Continued out afew days .Delirious two days before the eruptionappeared .Pustules numerous ,andcontinued out seven oreight days .Considerable fever previous tothe eruption,which was ofthe distinct kind .7SMtaarbilae10Mr. Carter19Feverish before the eruption ,whichwas ofasmall horny kind ,and soondisappeared .w.,sewsaHlreoanaiulosdgpdlnhttionfahadBfoebaeturoygerusrattenen.sMiasrteirass,,dwFleuieilctvgichehrertieudmedpg.foanbiurfuynsemetabutleersAfew small horny pox ,which continuedout about five days .Small horny pox .p.itaShbBlobmooeeloarxgulnatlynafbT.haforehtroroettrnmhiaegrshtFeverish three days ,with delirium .Facefull ofpustules ,and many onher body ;small horny kind ,which disappearedinfive orsix days .Feverish .Not somuch indisposed asBetty ;had fewer pustules ,but larger .Very feverish .Had afull crop ofsmallhorny pox .Face swelled .Blind threedays .Much fever .Very full of pustules ,andismuch marked .Very feverish .Had large distinct pox .Has marks on the face .8Mary Stable InfantMr.Edmondson,Keswick149Charles Hodge InfantMr.Harrison91BJ0roihsncoe3Mr. Redhead 16IIThomas Briscoe Infant Mr. Redhead912 Mary A. Briscoe InfantMr.Redhead613Betty Turner Infant Mr. Redhead614 Alice Turner InfantMr.Redhead1215Rob .Braithwaite's Infant Mr. Carter14daughter16Mr. Rawlinson's son Mr. Briggs17Ellen Physaclea Infant Mr. Redhead1310No. Name .Awhgeenv. accinatedB.wyhomAwgheeninfectedwiths.-pmoaxll.-tsoNphmfaoeatxlulre1LM8oanrgy4CMarr.terΙΟ1BW9aiilnleisam IMRnref.dahntead3W2Mi0olnlkihaomuse2CMarr.ter21BCeltartky ICMnarfr.atnetr7NJ2io2chhnolson'sdaughter.2WR3ooobdhouse'sdaughterHMarr.rison'sassistant7wIoAnlonfdmanatn1324William Tyson2Mr. Briggs925 John Kirkby InfantMr.BriggsIIdM,,ftwdeehiauvlrtyceeihsrerhiumsh.sbpTumoyohcarxelcnleyededdp,fdtaoiihaonnfseyxdtahppeared.lltamaoeehrannfgemrdtssksillness ,succeeded by Hadthreedays'illh.,siedwpinnoahoxcryixrnscuyhstedN.Ptiomuhnfousedtctiushlpeossedh.ifokBnoroiefunrcerdncaytmeedfv.awifaevtceeeckrisnationFE,.ftbduehrualvrutyleepsertiisohndrw,ttaiehhensgerndtuotilunagcrthsp-.sotmfoaxglelsS.fodoSnlefefmuivgamgerlbhrelteerip..FnaodvxiosuproasbeldydV.fsfBeeaeeuvvywrteesyrriaslhps,.rauepnscedtoeuvdleyersysA.ihtdneehativeygeshntI.tdotHnharwordyoreisnesyposede.,iddfanriaeusywpastpipoenared.||5TC3M2BaaW.ar6ennrm.nddtjearminKirkby2JK7oisrekpbhy RIMnref.dahnetad528 Sarah Bond InfantAtLiverpool1229 Jane Ellis InfantMr.Lodge,IngletonII,leWowaTarinanhrulsdegpletiriaomn.rtlctTehoohhsennaetgtnseiernuedifctwwnohweefuioreerlekcdstreedna.vPtofauhftcseectriunlaetsionh.koinrdnyt.etcGahhoosermtioplulygahintw,.fdmHMeieaauvtlnecdihrryhium,ptoskhwuhfoiohseonritndncuyhlesd. isappeared;,fficraHuanrealcomltdparkably.ioccownfoanacmkesrpeulsettaetionR,ipwbmserueueltccltothvyered..acammWobaoanornsfuktitehndedWB3ae0lttseyrs HIMnarfr.arnitson14dpc.soaHiumrfassaottdlpiulnlcets31 IDsiaxboelnla HIMnarfr.arnitsonΙΟ,.frIbcmaHuesuraal-torldpkedc.weolvleredMD3ai2rxgoanret RIMnref.dahnetad12B3Ge3atrtnyet CIManrrf.taenrt1434 Christ .Troughaire's Mrs.Dixonfour children Mr. CarterP..fdpvNuieueolsrsrlttftyieunclctetlsyR.weelcloveredW.iapDthntuiheasseisttguihlntecstwrd.,eaeieanlgcydlhostveredf)(etotHarhfhauveepodmtuiroanbslyf..dckahOuirianlsonldetpdinctMr. Briggs140 DOES VACCINATION PREVENT SMALL- POX ?Although there are no deaths in this list, the casesare by no means all of the mild variety, and in five ofthe number the patients were pitted. Again, they donot support the theory that the severity is in proportionto the length of time elapsed since vaccination. Let uscompare cases in the same family which would probablybe under much the same conditions.William James ( No. 4), who had been vaccinated abouteight years, had a milder attack than the other twoJames's (Nos. 2 and 3), vaccinated twelve and fifteenyears . In the case of Maria Stable, however, vaccinatedonly nine years before attack, the small -pox wascertainly not milder than that of her sister Mary,vaccinated fourteen years before attack (Nos. 7 and 8).Then, in the three children, John, Thomas, and MaryBriscoe ( Nos. 10, II , and 12) : in John, who had beenvaccinated thirteen years, the disease was as mild, if notmilder than the other two, vaccinated nine and sixyears. Also Betty Turner (No. 13), six years aftervaccination, took small-pox more severely than hersister ( No. 14) , vaccinated twelve years previously.the four Kirkbys ( Nos . 25 , 26, and 27) : although Josephand John had been vaccinated five and eleven years, theeruptions were larger and continued longer in William,who was infected four weeks after vaccination. Lastly,there were the two Dixons (Nos. 31 and 32). Isabella,ten years after vaccination, had a full crop of pustules ,and was marked ; whereas, in the case of Margaret,vaccinated twelve years prior to attack, the disease wasnot so severe.InTaking all these cases in conjunction, they afford nosupport to the theory that the disease is modified inMR. REDHEAD'S CASES. 141proportion to the proximity of the vaccination ; nordoes the incidence of small-pox seem to be regulatedin this manner, for the National Vaccine Board says : -" It appears to us to be fairly established, that the dispositionin the vaccinated to be thus affected by thecontagion of small-pox, does not depend on the timethat has elapsed after vaccination ; since some personshave been so affected who had recently been vaccinated ;whilst others, who had been vaccinated eighteen andtwenty years have been inoculated, and fairly exposed tothe same contagion with impunity. " This evidence is ,I venture to suggest, more valuable than present -day experience,for these theories of prevention and mitigationhad not then obtained the same hold on the medical mind.Mr. Redhead also gives several instances of small - poxbeing taken by means of inoculation after vaccination .One of these, James Shepherd, was vaccinated at fiſteenmonths of age by Mr. T. Carter, and when a year and ahalfold, i.e. , three months after vaccination, was inoculatedwith matter from Elizabeth James, above - mentioned .Mr. Redhead notes that the patient was very feverish ,the arm much inflamed, but the pustules not very large.Mr. Harrison, in referring to Mr. Redhead's cases, says(p. 10) :-" We cannot but feel our confidence in thepreventive power of the cow-pox to be somewhatshaken . " He also relates three instances in one family ;these excited considerable interest among medical men,from one of them having been vaccinated at a publicinstitution in London by Jenner himself, who, afterhaving inspected the vaccination, pronounced the childsecure from small -pox .1 Report of the National Vaccine Establishment for 1819.142 DOES VACCINATION PREVENT SMALL- POX ?There is every reason to believe that about this timevaccination was rapidly falling into disrepute. Thus,Jenner's old friend, Gardner, writing to him fromFrampton, on May 21 , 1817, says :-" From some unaccountablecauses, the fame of vaccination seems todecline in this part of the country : I find my offers ofgratuitous service very frequently rejected even by thosewhose former children have undergone the operation. " ¹In the London Medical Repository for July, 1817, theeditors, Dr. G. M. Burrows and Mr. A. T. Thomson, intheir observations on prevailing diseases, say : " Variola,above all , continues and spreads a devastating contagion .However painful, yet it is a duty we owe to the publicand the profession to apprise them, that the numberof all ranks suffering under small-pox who havepreviously undergone vaccination, by the most skilfulpractitioners, is at present alarmingly great. This subjectis so serious , and so deeply involves the dearestinterests of humanity, as well as those of the medicalcharacter, that we shall not fail in directing our utmostattention to it . " 2In the August number the editors remark : " Generally,the diseases of last month partake of that nature usualto the season ; hence there is nothing but variolaparticularly demanding notice. Small-pox, however,still forces itself upon our observation. It has, webelieve, been more prevalent than for many years past,and has assumed a more than usually virulent character ;many of the cases having been of the confluent kind.This may in some degree account for so many, whoBaron's " Life of Jenner, " vol . ii. , p. 203.2 London Medical Repository , vol . viii. , p. 95.1OFFICIAL EXCUSES FOR FAILURE . 143had previously undergone vaccination, being infectedby small -pox, as we remarked in our last report ; andwe are concerned to find, from the increasing testimoniesof medical practitioners, that these instanceshave been much and widely extended. So little modifiedhas the disease in some cases appeared to have beenby the influence of the vaccine inoculations, that deathhas ensued ; an effect which, as far as our informationgoes , was never before produced by small- pox, after thepatient had been subject to the action of the vaccinevirus . " ¹Baron informs us that in 1818 " there was greatclamour about the prevalence of small-pox after vaccination,"and that "the greatly exaggerated statements onthe subject of the vaccine failures, and the hesitatingmanner in which respectable individuals spoke on thesubject, threatened to lead to a considerable abandonmentof the practice. " 2About this time we even find failures recorded bythe National Vaccine Establishment, coupled withingenious but far-fetched explanations. Thus, in thereport of 1818 , we read :-" Five cases have been reportedto the Board, of vaccinated persons who havesubsequently died of small -pox. In one of these cases,it was clearly ascertained, that the only vaccine vesiclewhich had been excited, was disturbed and broken inits progress, which there is great reason for believinghas been a frequent cause of the insecurity of vaccination:in the other cases, no detail respecting thevaccination could be obtained, and they were, moreover,1 London Medical Repository, vol . viii . , p. 183 .2 Baron's " Life of Jenner, " vol. ii . , pp. 237, 238 .144 DOES VACCINATION PREVENT SMALL- POX ?all vaccinated at a period of time when the mode ofvaccination , and the management of the vesicle, werenot well understood . "In the report of 1819 it is stated :-" The testimoniesof some of our correspondents in this country, are byno means so favourable. They concur in showing, thatgreat numbers of persons who had been vaccinated,have been subsequently seized with a disease presentingall the essential characters of small-pox ; but that inthe great majority of such cases, the disease has been ofcomparatively short duration, unattended by symptomsof danger. In several of these cases, however, themalady has been prolonged to its ordinary period ; andin eight reported cases it has proved fatal. "In the London Medical Repository for August, 1819,Mr. William Gaitskell, surgeon of Rotherhithe, was" truly sorry to report two cases of malignant smallpoxsubsequent to vaccination." The first, a stoutyoung man, eighteen years of age, contracted small -poxtwo years after vaccination , and died on the twelfth day,a mass of putrefaction . The second, about twenty-twoyears old, took small-pox of a very malignant description,twelve years after vaccination , but recovered .Both patients were supposed to have gone through aregular vaccination ; they were pronounced safe (accordingto their own statement), and presented distinctimpressions of the disease on their arms .In the Medical and Physical Journal for July, 1820,Dr. Macleod, physician to the Westminster GeneralDispensary, contributed a communication, entitled1 London Medical Repository, vol . xii . , pp. 113, 114.2 Medical and PhysicalJournal, vol . xliv . , pp. 1-12DR. MACLEOD'S EXPERIENCES . 145"Remarks on the Small-pox, as it has occurred inLondon subsequent to Vaccination." He gives thefollowing cases (pp. 10-12) illustrating some of theappearances assumed by small-pox after vaccination.(See next page.)Dr. Macleod says (p. 6) :-" I have seen too manyinstances of small -pox in children vaccinated in London,where that process was carried on in the way whichthe National Vaccine Establishment has recommendedas the most efficacious, to retain much faith in itspreventive powers, in whatever manner conducted. "Again he remarks (pp. 8 , 9) :-" The history of vaccinationaltogether forms a severe satire upon the mutability ofmedical doctrines. In the first ardour of discovery, notcontented with its blessings to mankind, its benefitswere also extended to the brute creation. It was toannihilate small- pox, prove an antidote to the plague,to cure the rot in sheep, and preserve dogs from themange. These good-natured speculations , however ,were soon abandoned ; and more recently all hadagreed in acknowledging its anti-variolous powers,which, we were told , were as well established as anythinghuman could be."But the present epidemic shows too clearly the mortifyingfallibility of medical opinions, though foundedon the experience of twenty years, and guaranteed bythe concurring testimony of all the first physicians andsurgeons in the world. "In 1820 we have also further official admission ofvaccine failures. " It is true, indeed, my Lord, thatwe have received accounts from different parts ofthe country of numerous cases of small -pox havingN. ameAwgheen.infectedLTuhcoamsas5SDeolviena9OHlednfireyld7SLtuicllywell22William Pyrhe 8Robert Page.Vaccination.soaVmwifgaohxecnectnihnsatedV,ayosawtefeaghavceerecsnninatedt.IiJHnnheosenltnbieotruritnaionnHV-aStpoatmhoscaexpcliiltnaaltedw,pofamhaeleoahrdwndeftenchts.ctoaihnrcematrix,tapyV1otrea4teacavrccisikonuasted.cptaahoaiehnanrcreddmaftercitxV-aHtSptoahmosecaxpcliiltnaaltedw,ofmahaleonahdwnddetnhsp.ctoaeihnrcremaftercitx2,tVshmah1oauaoancpvndcpetiohnssaetdedm.sidtaanihatseniensafesaerctory-Page3h,tVsahoaaunacpvddcpeionsaetdeds.idtamanihatseniesnafseaerctoryN.-stopmhafoaetxlulreS,fpecfbeuroomyvsuplaetpilrrutootliuwaoserndlo.,,fcnaahienncemcdesbktsh,.fdwACaeeietonvltatpdeihdairracickuhemedo,pcfeeaouahurxnnsceutsdtespruttelimaoirntc..pftEoiaahrrnerceuostepwitcdiuelodanrlyp,feCtaouerohnnsvunedtepsrutilidaoernrsable.,,fcbaahancecdeskt,-fcbiuwSpeounsimovnthtaxesehlrirldeedrable.iotpwnnfhoaucecsmokbnsseirderable,,fdVhaaeeiecnvloacdeildorreamincputhameniedb.fresoaAiexcfnytsstrdtreleaemsmseinnegsscdpeaoiourpnfspupftipeeutoarliueraosnerntdp.fettowbOaarhhefonrcueerdetpeystions,cetturamoyhhnononeeedudufsentlrdhuent.ipcotopaMnahotfonarehcdnteksrysentftwsnwoaohiuaenretrrehreraooruwmnsded,apgptaoruihupfesverpotipelunlaalgereasnce.acSptoofreeehffrinvteosteemirrcneahgliæf.ftpawpwilhuioeluertcrliphekdedlse,fdifuwaTeinosinhvslhtdeeelehraorsweeedds.rrmdabTeaeeayhvssayeehessrmlabellsingc,rfvcaaeeehonnsvsinddteiltlrcdieiunsslsuhaerde,cdwaoreeipnnuptptprherteaaisrlosenidosns.fvpatowbaTieehpfeahrsa-esrceitrekcllyes.,apoabmfepneotaadcrerqaeraumwneaecredsa,cndsaToboiynhnatdmdsetpteittoumtsional;otcsbchouecenpcasveaseurmilvoseeninaoelndsm,sctttadaehehhbionvineeoerdeltuderdhte.itodlhfaleynesss,haitbbamWiifnoruaamsfotnietslnchateererrddisease milder .COW- POX FAILURES EXTENSIVE. 147occurred after vaccination ; and we cannot doubt thatthe prejudices of the people against this preventiveexpedient are assignable (and not altogether unreasonablyperhaps) to this cause. These cases the Boardhas been industriously employed in investigating ; andthough it appears that many of them rest only onhearsay evidence, and that others seem to have undergonethe vaccine process imperfectly, some years since,when it was less well understood, and practised lessskilfully than it ought to be, yet, after every reasonablededuction, we are compelled to allow that too manystill remain on undeniable proof, to leave any doubtthat the pretensions of vaccination to the merit of aperfect and exclusive security in all cases against smallpox,were admitted at first rather too unreservedly. " ¹It was the small-pox epidemic of 1817-19 which,however, demonstrated the failure of vaccination on alarge scale, for a majority of the cases were admittedly" protected . " Dr. John Thomson writes :-" It is tothe severity of this epidemic, I am convinced, that weought to attribute the greatness of the number of thevaccinated who have been attacked by it, and not toany deterioration in the qualities of the cow - pox virus ,or to any defects in the manner in which it has beenemployed. Had a variolous constitution of the atmosphere,similar to that which we have lately experienced ,existed at the time Dr. Jenner brought forward hisdiscovery, it may be doubted whether it ever could haveobtained the confidence of the public. " *1Report of the National Vaccine Establishment for 1820." Historical Sketch of Small-pox, " p. 394. John Thomson, M.D. ,F.R.S.E. London. 1822 .148 DOES VACCINATION PREVENT SMALL- POX ?Dr. Thomson's publications on the subject called forthan article in the Edinburgh Review, which opens thus :-" Vaccination, we are perfectly persuaded, is a very greatblessing to mankind ; but not quite so great a blessing,nor so complete a protection, as its early defendersconceived it to be. The proof of this has been admittedwith great reluctance ; but it has unfortunately becometoo strong for denial or resistance. The first answersgiven to the instances of failure, with which the friendsof vaccination were pressed, were, either that the diseasewhich had occurred after vaccination was chicken-pox,and not small-pox ; or that the process of vaccinationhad been unskilfully or imperfectly conducted ; or thatit was one of those very rare cases which occurred inthe times of inoculation , and from which vaccinationitself did not pretend to be wholly exempt. " ¹This does not appear to be strongly condemnatory ofvaccination, but apparently Jenner was much disconcerted." I have an attack," he says, " from a quarterI did not expect, the Edinburgh Review . These peopleunderstand literature better than physic ; but it will doincalculable mischief. I put it down at 100,000 deaths,at least. Never was I involved in so many perplexities." About two weeks after writing this, the unhappyman died in the midst of his difficulties.Dr. William Maxwell, in a paper read before theDumfries Medical Society, remarked that " it must beallowed, that the world has been grievously disappointed,Edinburgh Review, vol. xxxvii . , pp. 325 , 326. ( November, 1822. )* Letter from Jenner to Gardner, dated January 13, 1823. Baron's " Lifeof Jenner, " vol . ii. , p. 433.FAILURES ON H.M.S. " PHAETON." 149in the hope that this discovery (vaccination) would beperfect security against variolous disease." 1In a communication from the Admiralty, which wasprinted with the Report of the National VaccineEstablishment for the year 1825 ( pp. 10-13), is areport by Dr. W. Burnett, one of the Medical Commissionersof the Victualling Board, relating to an outbreakof small -pox on His Majesty's ship " Phaeton " in herpassage to America. Amongst other cases is one of apatient, J. Munns, aged twenty- seven, who was vaccinatedon June 24, 1825, attacked with small-pox onJuly 8, i.e. , fourteen days after vaccination, and whonearly died of the disease.Two others , J. Sutton and T. Avenall, aged twelveand thirteen respectively, who were vaccinated in May,1825 , presented perfect cicatrices , and contracted smallpoxon the 7th of July, i.e. , about two months aftervaccination ; but they " completed the stages in a verymild manner."In the case of John Reid , A.B. , aged nineteen, vaccinatedon the 24th of June, who was attacked withsmall-pox on the 4th of July, and who died on the30th of the same month, it may be objected that thepatient was vaccinated during the incubation of smallpox; but no possible objection can be raised to thethree instances previously mentioned.The Sunday Times of February 12 , 1826, furnishes anaccount of a meeting of the Governors of the LondonSmall -pox Hospital, with the Duke of York in the chair.The number of admissions in 1825, and the particulars of1 Edinburgh Medical and SurgicalJournal, vol . xxii . , p. 9. ( April , 1824. )150 DOES VACCINATION PREVENT SMALL- POX ?each case were read . The account stated that in thelast year twelve persons had died of small - pox whosedeaths were presumed to be subsequent to vaccination.The Duke of York here interposed, and observed thatthe fact of the cases having previously been vaccinatedwas distinctly stated in copy of the report sent to him ;and the Home Secretary, Mr. Peel, who was alsopresent, said that, after reading his copy of the report,he became uneasy about his own children, all of whomhad been vaccinated .Dr. Gregory, the physician to the hospital, stated thatthe copies alluded to by his Royal Highness had beensent before they had been finally settled by him . Hewished to add notes, but finding that the copies hadbeen made, and that the words could not be introducedwithout the making of fresh copies, he did not think theomission of any great consequence, and therefore he letthem go as they were. He regretted he had not inscribedthe word "presumed," but one reason was that itwas not a term generally used by the profession .It is fairly evident what Dr. Gregory thought of thecases . They were, however, the subject of inquiry bythe National Vaccine Establishment, ¹ and, as we mighthave expected, the result was so satisfactory, " as toleave no cause to doubt that these individuals had notbeen properly vaccinated. "From this time onwards medical criticism becameless acute, but neither then nor at any other time hasit subsided, and there was a strong undercurrent ofscepticism amongst able and trustworthy observers atBaron's " Life of Jenner," vol . i. , pp. 273, 274.UNMITIGATED BY PREVIOUS VACCINATION. 151the period with which we are engaged. Thus, in a letterfrom Mr. Edward Greenhow, of North Shields, to theLondon Medical Gazette of February 2, 1833 , vol. xi. ,p. 590, we read :-"And not only is the small -pox aftervaccination becoming much more frequent, but it isbecoming also much more virulent. It is true, in thegreater number of cases, the disease is modified , oftenturning on the fifth and sixth day ; but cases are by nomeans rare where the disease is confluent, and runs itsfull course, unmitigated by the previous vaccination,and death occasionally ensues." From what I have above stated, it would appearthat vaccination is losing its protective influence ; andit becomes a matter of serious consideration to ascertainto what causes we are to attribute this failure. Is itthat its protective power wears out after a certainnumber of years, and that it becomes necessary torepeat the operation ? Or is it that the vaccine virusloses wholly, or in part, its virtues, by passing so repeatedlythrough the human system ? The latter isthe opinion that has forced itself upon my conviction,because the disease has principally attacked youngpersons, and such as have been vaccinated within thelast ten or twelve years, and by far the largest portionhave been done much within that period, so that thenumbers attacked are in the inverse ratio to thenumber of years which have elapsed since they werevaccinated. " I may observe that the age- incidence ofthis disease did not begin to alter very much untilafter the epidemic of 1837-38, which would account forthe large proportion of young persons attacked at anearlier date. The same fact was noticed by one of Dr.152 DOES VACCINATION PREVENT SMALL- POX ?John Thomson's correspondents, Mr. William Gibson, ¹in his experience at New Lanark, where, of 251 vaccinatedcases of small-pox, 191 , or 761 per cent. , took thedisease at intervals up to ten years after vaccination.In 1837 the reviewer in the " British Annals of Medicine,"in criticising certain statements about vaccination,pertinently inquired, " Will it not be better to collectfacts patiently, and to remain a little longer in suspense,than assume a dogmatical tone, or assert a blind belief,and thus silence inquiry ? " *Sir Henry Holland, in his " Medical Notes andReflections, " writes (p. 401 )-" Not only in GreatBritain, but throughout every part of the globe fromwhich we have records, we find that small-pox has beengradually increasing again in frequency as an epidemic ;affecting a larger proportion of the vaccinated ; andinflicting greater mortality in its results. " Again , hesays ( p. 414)-" It is no longer expedient, in any sense,to argue for the present practice of vaccination as acertain or permanent preventive of small- pox. Thetruth must be told, as it is, that the earlier anticipationson this point have not been realised. "Dr. George Gregory was also known to be somewhatsceptical as to the merits of vaccination, and this factcomes out clearly in his writings. In 1823 he wrote,1 Letter from Mr. William Gibson to Dr. John Thomson, datedJanuary 11 , 1819. " An account of the varioloid epidemic which haslately prevailed in Edinburgh, and other parts of Scotland," pp. 251-258.John Thomson, M.D. , F.R.S.E. London. 1820." British Annals of Medicine , Pharmacy, Vital Statistics , and GeneralScience, " vol . i. , p. 235. (February 24, 1837. )3 " Medical Notes and Reflections." Henry Holland, M.D. , F.R.S.London. 1839.OVER -SANGUINE PATHOLOGISTS. 153" The acknowledged frequency of cases of small-pox,subsequent to vaccination, in all parts of the country, issuch as to have excited, in no inconsiderable degree, thefears of many, and the anxieties of all. No one canlook back upon the history of the last few years withoutfeeling sensible that these unpleasant occurrences areon the increase. " ¹ In 1837 he says, " Many of thephysicians and surgeons who flourished at the commencementof this century, and to whose generousefforts in behalf of vaccination the world is deeplyindebted, are passed from this scene. A few stillsurvive, who when they call to mind the strong hopeswhich were held out, in their day, of the ultimateextermination of small -pox, will probably be surprisedto find that, after the lapse of thirty-six years, smallpoxstill prevails ; that the same necessity exists nowas formerly for studying its various aspects ; and thatthe benevolent anticipations of 1800 receive no countenancefrom the facts of 1836. It is impossible to deny,and useless to conceal, that these bright prospects wereoriginally built upon very slender foundations. Thewish was father to the thought. " 2In 1840 Dr. Gregory writes :-" It is often noticedthat persons (vaccinated persons, for instance,) who .resist small - pox in common years, though fully exposedto the contagion, are attacked by it in years ofepidemic prevalence. These and other facts, whichbear on the epidemic origin and diffusion of small -pox,were overlooked by those sanguine pathologists, who1 " Medico- Chirurgical Transactions , " vol . xii. , p. 324. ( 1823. )2 " British Annals of Medicine, Pharmacy, Vital Statistics, and GeneralScience ," vol . i. , p. 193. (February 17 , 1837. )11154 DOES VACCINATION PREVENT SMALL- POX ?imagined that in vaccination nature had provided uswith means adequate for the complete exterminationof small -pox from the earth. " ¹Increased experience does not appear to have modifiedDr. Gregory's views, for twelve years later we findhim writing, " When we look around us, when we observethe quantity of small-pox, now (at the close ofthe first half century from the promulgation of vaccination)diffused through this and other countries,-when we see the practice of re-vaccination almostuniversal on the continent of Europe, and greatlyincreasing in this country, we are led irresistibly to theconclusion, that these broadly-urged claims in favourof vaccination have not been substantiated. Small-poxdoes invade the vaccinated, and the extirpation of thatdireful disorder is an event as distant now as when itwas first heedlessly (and, in my humble judgment, mostpresumptuously) anticipated by Jenner. " *In the Report of the Vaccination Section of theProvincial Medical and Surgical Association, it isstated-" It will be observed in subsequent parts of ourReport, that failures are noticed at all periods, froma few weeks after vaccination up to thirty or moreyears. It has been supposed that they are mostcommon at and after the age of puberty ; but this iscertainly not the opinion of our correspondents ingeneral. Some, it must be admitted, do affirm thatsmall -pox has more frequently occurred in personsArticle by Dr. Gregory on " Small-pox " in Tweedie's " Library ofMedicine, " vol . i. , p. 310. London. 1840.* Medical Times and Gazette, new series, vol. iv. , p. 633. ( June 26,1852. )ADMISSIONS OF THE " LANCET." 155recently vaccinated, than in those at a remote period,while others assert that time makes no difference. " 1Even the Lancet, which has generally been known asa thorough-going advocate of vaccination, reluctantlywrites : " In the public mind extensively, and, to amore limited extent, in the profession itself, doubtsare known to exist as to the efficacy and eligibility ofthe practice of vaccination. The failures of the operationhave been numerous and discouraging. It hasfailed frequently by producing no effect at all ; it hasfailed by producing a vesicle by no means clearlyindicative of the existence of the vaccine disease ; andit has failed in protecting persons so vaccinated froma future attack of small-pox. " 2Thus, in the early epidemics, the cases of smallpoxafter vaccination were numerous ; but, in estimatingthe number, we must take account of some of thecases which have been ascribed to chicken-pox. SirThomas Watson, writing in 1848, said, " These mildand irregular forms of variola, both parents and medicalmen, wishing, I suppose, to believe nothing in disparagementof the protecting power of vaccination, arevery apt to consider, and to call chicken-pox. " 3 In theearly days, however, it was by no means only the mildcases that were thus designated .In a report on the cow- pox inoculation from thepractice at the Vaccine-Pock Institution, during the" Transactions of the Provincial Medical and Surgical Association, "vol. viii . , pp. 35, 36. ( 1840. )2 The Lancet, vol . i. , p. 476. (May 21 , 1853. )3 " Lectures on the Principles and Practice of Physic," vol . ii . , p. 805 .(Third edition. ) 1848 .156 DOES VACCINATION PREVENT SMALL- I'OX ?years 1800-02, we read (pp. 19, 20) :-" It may bealso useful to notice that we have been alarmed two orthree times with the intelligence of the small-poxoccurring several weeks or months after our patientshad undergone the cow- pock. We thought it our dutyto visit and examine these patients, and also to inquireinto their history among their attendants, and by thesemeans we obtained the completest satisfaction that thepretended small-pox was generally the chicken-pox. "They gave the following instance as an illustration inwhich the eruptions were, by their resemblance, mistakenfor small-pox by the friends of the patient, andeven by a medical practitioner, " who accordingly gavea representation of the case by no means advantageousto the Institution. " The child was vaccinated on April1 , 1800 ; a genuine vaccine scab was formed, whichfell off and left a cicatrix. Four months afterwards thechild was attacked with fever, followed by an eruption,which , when seen at the Institution, presented over onehundred eruptions of blackish scabs and red spots," apparently the chicken -pox, in the scabbing state. "Small pits were observed some months afterwards .Dr. John Walker, the resident vaccinator of theRoyal Jennerian Society, related that a father called onhim and informed him that, of two children he hadvaccinated the previous spring, one was now coveredwith small-pox, and the other sickening, and that he(the father) was advised to advertise it. On consultingthe register, Dr. Walker found both the cases markedperfect, and he told the father that it was impossible forMedical and PhysicalJournal, vol . xii . , p. 543. (December, 1804. )CASES ATTRIBUTED TO CHICKEN - POX . 157either of the children to be infected with small-pox ; hethen called on the vice- president, Mr. John Ring, andchallenged him to come and detect his (Dr. Walker's)failure. " He had the goodness to accompany me,and on our seeing the child, he immediately declaredit chicken -pox."Dr. William Farquharson, Mr. James Bryce, and Mr.A. Gillespie, of Edinburgh, in a joint letter to Dr.Walker, remark on many children who had passedregularly through the process of vaccination, but onwhom eruptions appeared at different periods afterwards,which by some ignorant people were supposedto be variolous ; but which, upon investigation, uniformlyturned out to be chicken-pox. In some of these casesthe eruptive fever was very severe, sometimes evenattended with convulsions ; and the consequent eruptionsvery numerous, and in a few cases the last ofthe pustules did not disappear until the fifth or sixthday. " These cases," they add , " were repeatedly visitedby many medical practitioners of this place, as well asby ourselves, and none of them entertained any doubtof the disease being chicken -pox.2A case is recorded in the Medical and ChirurgicalReview. A child was operated on by Mr. Ring inMay, 1804, who expressed himself as perfectly satisfiedwith the progress of the vaccination, saying that " hewould forfeit a hundred guineas if the child ever tookthe small -pox afterwards. " A distinct scar was lefton each arm as the result of the operation. In October or* Medical and PhysicalJournal, vol. xiii . , pp. 286, 287. ( March, 1805. )* Medical and Chirurgical Review, vol. xi . , pp. cvi . - cviii. ( March,1805. )158 DOES VACCINATION PREVENT SMALL- POX ?November of the same year it was taken ill, and thepustules were pretty numerous, particularly on thescalp, two of them leaving pits; the patient was seenrepeatedly during the progress of the eruption by Mr.Ellis, apothecary, of Drury Lane, who asserted it to besmall -pox. The child was next taken to Mr. Soley,apothecary , in Bloomsbury Square, about the ninth day.He declared immediately, and without hesitation, that itwas undoubtedly small-pox, and he chided the motherfor not having taken means to prevent it by vaccination .She replied that she had done all in her power byhaving the child vaccinated by Mr. Ring. " Then," saidMr. Soley, " it cannot be small-pox, for small-pox neveroccurs after cow-pock. It must be a rank kind ofchicken-pox ; " and he sent her to Mr. Ring. Oncalling at Mr. Ring's house, she first saw his assistant,who declared it to be small-pox, and upbraided themother for not having had the child vaccinated. WhenMr. Ring was informed of this unusual circumstance,and on seeing the child, he remarked that it could notbe small-pox, for this disease was never attended byitching, nor did it appear in clusters, as in this case.He told the mother she might rest satisfied that it wasnot small - pox , and he begged her to say nothing aboutit, as it might excite alarm. In a foot-note on p. cvii . ,the editors remark on the above case :-" This attemptto conceal everything that appears unfavourable, sofrequently resorted to by certain pretended friends ofvaccination, cannot be too much reprobated. It showsthe business to have got into very bad hands.truth their only object, they would court investigation,not endeavour to suppress it.WereCASES OF CONFLUENT CHICKEN - POX . 159Mr. John Ring, in the Medical and Physical Journal,gave a description and drawing of a case of confluentchicken-pox in a boy four years of age, who had beenvaccinated some time before. He added : " When thechicken - pox broke out in so formidable a manner, it wasmistaken for the small -pox. "In the Medical and Physical Journal for November,1805 , Mr. R. Hall, of Clement's Inn, related instances inthe family of a Mr. Ross. An eruption appeared ontwo of his children, one of whom had been vaccinatedabout a year before. In both cases, the eruption wasextremely copious, but the pustules were much largerand more confluent in the one which had not beenvaccinated. Mr. Hall says : " In both, the pustules soexactly resembled in form, figure, and other circumstances-those of small-pox, that, had we founded ouropinion on the external character alone, we should mostunquestionably have deemed them both cases of genuinesmall -pox ; but, as they neither went through theregular course, nor were attended with any of thosesymptoms which uniformly accompany violent cases ofsmall -pox , we did not hesitate to consider themas cases of confluent varicella . "In the twentieth volume of the Medical and PhysicalJournal, on pp. 257, 258 (September, 1808), Mr. ThomasHardie relates the case of a patient who, four yearsafter he had vaccinated her, was much indisposed, andhad a considerable eruption, which he supposed to bethe chicken-pox, until the fourth day of the eruption,1 Medical and PhysicalJournal, vol . xiv. , pp. 141 , 142. ( August , 1805. )Ibid. , pp. 410-412 .160 DOES VACCINATION PREVENT SMALL- POX ?when the phenomena, both local and general, inducedhim " reluctantly " to alter his opinion.Mr. Richard Pew, of Sherborne, ¹ also saw a postvaccinalcase, in which the pustules " bore so general aresemblance to real small-pox, that anyone acquaintedwith the subject must immediately acknowledge themto be a branch of the same family."In 1818 there was published the Substance of aCorrespondence between the Directors of the Cow-pockInstitution , Sackville Street, Dublin, and their subscribersor other medical practitioners ; and also with the IrishMedical Staff and Militia Surgeons, being replies tocertain queries circulated by the Directors, occasioned byalleged failures in vaccination. A number of thereplies testified to the occurrence of chicken - pox aftervaccination.Mr. Heron, of Lucan , remarked "that in the summerand autumn of 1810 a very bad kind of pustular eruptionmade its appearance among the children about Banagherand its neighbourhood, which many of the practitionersin these places took for small- pox , and inoculated withmatter from it as such. From observations, however,then made, it appeared to Mr. Heron to be nothingmore than a malignant chicken-pock, of which somedied." 2Dr. Little, of Ballina, stated that, " about three yearsago, the regiment to which he belonged, being quarteredin Tuam, a very severe form of confluent varicellaprevailed epidemically, and he was repeatedly calledMedical and PhysicalJournal, vol . xxi . , p. 250. ( March , 1809. )* " Historical Sketch of Small -pox," p. 252. John Thomson, M.D. ,F.R.S.E. London. 1882.DR. P. MUDIE'S EXPLANATION. 161upon to see children as well of the townspeople as thesoldiers, whom he had vaccinated, and who were markedin his journal as having gone regularly through thedisease ; but in no instance could he hesitate as to thenature of the disease, which, though often of a mixednature, was genuine, and of the conoidal form , asdescribed by Dr. Bateman. " 1Dr. P. Mudie, in a letter to Dr. Thomson, datedOctober, 18 , 1818, freely acknowledges a bias in hisown mind with regard to the prevalence of small -poxafter vaccination. " Of late years," he says , " I haveremarked, that the disease called chicken -pox has beenmuch more severe than it used formerly to be, andmany of the cases, occurring after vaccination, so muchresembled small-pox, that if my mind had not beenprejudiced against the possibility of such an occurrence,I would have pronounced the eruption to have been of avariolous nature. " 2Thus there were a large number of vaccine failuresin the early years of the century; and, if we includesome of the chicken-pox patients, there must have beenthousands of such cases in the epidemic of 1817-19.Secondly, these failures took place at all periods aftervaccination , even within a few weeks or months of theoperation. Thirdly, post- vaccinal small - pox, accordingto these early records, did not seem to be an especiallymild disease ; and lastly, there did not appear to be any1 " Historical Sketch of Small - pox , " pp. 252, 253. John Thomson,M.D. , F.R.S.E. London. 1822 .•An account of the varioloid epidemic which has lately prevailed inEdinburgh and other parts of Scotland, p. 240. John Thomson, M.D. ,F.R.S.E. London. 1820.162 DOES VACCINATION PREVENT SMALL- POX ?relation between the severity of the disease and thelength of time which had elapsed since the operation .Vaccination was first made compulsory in 1853. Itis difficult at this day to understand how the promotersof vaccination managed to get this Act on our StatuteBooks, except on the assumption that the overwhelmingevidence of the early failures of vaccination had beenoverlooked or forgotten.Mr. George Canning declared, in. 1808, that althoughhe considered the discovery (vaccination) to be of thevery greatest importance, he could not figure any circumstanceswhatever that could induce him to followup the most favourable report of its infallibility, whichmight be brought forward, with any measure of a compulsorynature.¹2We have it on the authority of Mr. T. S. Duncombe,M.P. for Finsbury, that in 1840, Sir Robert Peel, beingurged to make vaccination compulsory, expressed hisopinion that such a course would be repugnant to thehabits and feelings of the British people, and to thatfreedom of opinion and action to which they were wellaccustomed. Mr. Duncombe quotes Sir Robert assaying that " The proposal to make it compulsorywas so contrary to the spirit of the British people, andthe independence in which they rightly gloried, that hewould be no party to such compulsion. " 3 Sir RobertPeel , however, died in 1850, and in 1853 a measureinvolving an enormous curtailment of the liberty of the1 Hansard's Parliamentary Debates, first series, vol. xi . , p. 844.(June 9 , 1808. )* Ibid. , third series, vol. cxliii. , p. 552. (July 10, 1856. )3 Ibid. , vol . clxiv. , p. 674. (July 10, 1861. )VACCINATION MADE COMPULSORY. 163subject, without any demand for such legislation, andwithout previous inquiry, was passed through bothHouses of Parliament with very little discussion.Lord Lyttelton introduced the Bill into the House ofLords, and, on the motion to go into Committee,explained that, having no scientific knowledge of thesubject himself, he was indebted for almost all hisinformation to some able and learned members of theEpidemiological Society. " It was unnecessary, " heinformed the House, " to speak of the certainty ofvaccination as a preventive of the small-pox, that beinga point on which the whole medical profession hadarrived at complete' unanimity. " 1If we refer to the Return on " Small-pox andVaccination," prepared by the Committee of the EpidemiologicalSociety, and from which Lord Lytteltonobtained his information, we find certain extraordinaryand wholly unwarrantable statements (p. 4). " Smallpoxis a disease," say the authors, " to which everyperson is liable, who is not protected by a previousattack or by vaccination." Again : " Every case of itis a centre of contagion, and every unvaccinated orimperfectly vaccinated population is a nidus for thedisease to settle in and propagate itself."1 Hansard's Parliamentary Debates, third series, vol . cxxv. , p. 1002.(April 12 , 1853. )* Copy of " Letter from Dr. Edward Seaton to Viscount Palmerston,with enclosed Copy of a Report on the State of Small - pox and Vaccinationin England and Wales and other Countries, and on Compulsory Vaccination,with Tables and Appendices, presented to the President and Councilof the Epidemiological Society by the Small-pox and Vaccination Committee,the 26th day of March, 1851. " ( Parliamentary Paper, No. 434.Ordered, by the House of Commons, to be printed, 3rd May, 1853. )164 DOES VACCINATION PREVENT SMALL- POX ?The two latter propositions, we are seriously informed," do not admit of being controverted. " Wewill suppose, for the sake of argument, that none ofthese propositions are capable of refutation. We thenread : " If it admit of doubt, how far it is justifiable inthis free country to compel a person to take care of hisown life and that of his offspring, it can scarcely bedisputed that no one has a right to put in jeopardy thelives of his fellow-subjects."Here the question presents itself, If vaccination is apreventive of small-pox, as asserted by Lord Lyttelton ,how could the unvaccinated put in jeopardy the livesof their protected fellow- subjects ? Thus, there is noargument for compulsion, even if it be admitted thatvaccination protects for life ; if vaccination does notprotect for life, and it is evident, from the numerouscases I have quoted, that it does not do so, then theprofession should show how long its protective valuelasts. Of the various medical experts who have beenexamined before the recent Vaccination Commissionit is important to remember that none have endorsedthe opinion of Jenner, Sir John Simon, and others,that vaccinated persons are for ever afterwards securefrom the infection of small -pox. Although some havemaintained that vaccination protects for considerableintervals, one prominent official expert, Dr. WilliamGayton, thinks that " primary vaccination is a veryfleeting protection indeed. As to the time that thatprimary protection lasts, I do not know, but I think it isa very short time" (Q. 1,755). Another authority , Dr.R. A. Birdwood, with an experience of 12,000 casesof small -pox, emphatically stated that vaccination cannotDR. JAMES COPLAND'S VIEWS. 165be relied on as an absolute protection up to any agewhatever (Q. 31,191 ) . And lastly, there have beenwitnesses of the very highest professional standing andscientific attainments, who have maintained that vaccinationexerts no specific protective influence at all. Whenthe profession are agreed on this important point,then the vaccinated will be able to make themselvessecure by periodical re-vaccinations, and their lives willnot be placed in peril by anti- vaccinists .It is interesting to note that the first compulsoryAct of Parliament entirely failed to remove the honestdoubts of some distinguished members of the medicalprofession. Thus Dr. James Copland expressed theopinion that vaccination " will never be generallyadopted, and that, if it were so adopted, it could neveraltogether banish small -pox, nor prove a complete orlasting preventive of variolous infection. " ¹Again he writes (p. 829) :—“ At the time of my writingthis , just half a century has elapsed since the discoveryand introduction of vaccination ; and after a quarterof a century of most transcendental laudation of themeasure, with merely occasional whisperings of doubt ,and, after another quarter of a century of reverberatedencomiums from well-paid vaccination boards , raisedwith a view of overbearing the increasing murmuringsof disbelief among those who observe and think forthemselves, the middle of the nineteenth century findsthe majority of the profession, in all latitudes andhemispheres, doubtful as to the preponderance of1 " A Dictionary of Practical Medicine," vol . iii . , part ii . , p. 831 .James Copland, M.D. , F.R.S. London. 1858.166 DOES VACCINATION PREVENT SMALL- POX ?advantages, present and prospective, to be obtainedeither from inoculation or from vaccination . "I now propose to show that the unvaccinated whenexposed do not necessarily take small-pox, and also ,that since the population has been more largely" protected," it is the vaccinated who form not only anoverwhelming proportion of the sufferers, but in a largenumber of instances they are the means of propagatingthe disease.Some very remarkable cases are recorded by Dr.William Baylies in his little book entitled, " Facts andObservations Relative to Inoculation in Berlin " ( 1781 ,pp. 132-144) . The King of Prussia having given hissanction to inoculation in February, 1775 , eight orphanchildren were chosen to commence the series , and onlythose were selected who were perfectly free from allmarks or signs of their having gone through the smallpoxbefore ; a thread was used, which had been chargedwith fresh variolous matter at the London Small- poxHospital ; the matter was inserted into both arms ofthe patients, and Dr. Baylies had not the least doubtthe disease would come on as it ought to do ; yetwe are informed that " neither fever nor any othersymptom followed in consequence of it, though thearms of two of them, on the third or fourth dayfrom the operation, had a degree of inflammation fora day or two " (p. 138).He then used a thread of much older matter, andre- inoculated these eight children, and also inoculated ,for the first time, four others, with a similar result ; andlastly, having learnt that the child of a baker was downwith the disease, he resolved to inoculate them with freshDR. MICHAEL UNDERWOOD'S OPINIONS. 167variolous matter. The twelve children before-mentioned,with seven others, were conducted to the baker's house,and they were all inoculated with warm fluid matterfrom ripe pustules, and for nearly an hour the childrenwere kept in the infected atmosphere, and " not one ofall the nineteen children manifested the least symptomof the disease in consequence of it" (p. 143 ) .As Dr. Baylies was a practised inoculator, we areforced to the conclusion that either the children had hadsmall-pox before-the conclusion arrived at by Dr.Baylies himself-or that they were naturally immune tothe disease ; but, considering that the most careful examinationwas made for marks of small-pox, the latterview appears to be the more probable.In this connection some remarks made by Dr.Michael Underwood, in his work on the diseases ofchildren, are not without interest. Dr. Underwoodobserves :-" Though the small-pox is a complaint soincident to the early part of life, that comparativelyfew children living to the age of eight or ten years,are found to escape it, yet it is not so readily communicatedin the state of early infancy, as hath beengenerally imagined, unless by immediate infection.The poor furnish frequent instances of the truth ofthis observation. I have attended where children bornin an air, saturated, as it were, with the miasma (orinfectious particles) of this disease (as well as of themeasles), and even lying continually in a cradle inwhich another child has died a few days before, have,nevertheless, escaped the disease, and sometimes, whenthey have slept together in the same bed with oneloaded with it. Hence it appears, that highly tainted168 DOES VACCINATION PREVENT SMALL- POX ?air, and even personal contact, are often insufficient tocommunicate the poison. Yet we know that infantsare very easily infected, receiving the small-pox byinoculation as readily as adults ; though neither are atall times equally susceptible of it. "¹In the Medical and Physical Journal for April, 1803 ,Mr. C. Dennett, of Soho Square, related the followinginstances :-In August, 1800, Mr. had two childrenwho were laid up with confluent small-pox, one of whomdied ; an infant, three weeks old, was exposed to theinfection the whole time, being always in the same room,and sometimes in the same bed. Mr. Dennett says hecould not persuade the parents to have the baby inoculated,and to vaccination they positively objected. Itdid not take the infection ; later in the year, the childwas inoculated with fresh variolous matter withouteffect, and this was repeated three times with no bettersuccess .Another child in the same family, born later, escapedthe disease, although it had slept in the same bed withthe former child, who had now contracted confluentsmall-pox . Mr. Dennett inoculated the infant on fourseparate occasions with small-pox matter without effect.These cases were evidently not very uncommon, for Mr.Dennett remarked that "every practitioner must havemet with cases when, under some peculiar constitution,the habit is not susceptible of the disease, either byinfection or inoculation" (p. 394).1 " A Treatise on the Disorders of Childhood, and Management ofInfants from the Birth," vol . i. , pp. 299-301 . Michael Underwood, M.D. ,Physician to Her Royal Highness the Princess of Wales. London. 1797.2 Medical and Physical Journal, vol . ix. , p. 365.DR. COUPLAND'S REPORT. 171Two other persons, aged fourteen and twenty, who hadnever been vaccinated, and who slept with the others,did not contract small-pox."The above instances appear to show that immunityin the unvaccinated, even when strongly exposed tosmall-pox, is not nearly so rare as has been generallybelieved . It is also instructive to note that Dr.Coupland, in his report on the Leicester outbreak,shows, with regard to 193 invaded households, that atseveral specified age-periods, the small-pox attack-rateswere much the same, although, according to his censusof the inmates, the proportion of the unvaccinated atthese age-periods vastly differed. The figures cited areas follows :-Ofthe total inmates ,the percentage.Age-periods.Totalinmates. 2 Unvaccinated. Attacked.Under 1 year 33 910 2121-10 years 328 740 28.910-30 years 534 15.5 28.130 years and upwards ... 330 2.7 20.5With these figures before him, it is not surprising thatDr. Coupland should have come to the conclusion that"the natural liability to small-pox, unaffected by vaccination,was not so great as has been supposed."To resume our inquiry into the question as towhether vaccination prevents small-pox, the followingcases, extracted from the Sheffield Report, are of importanceas showing that recent vaccination of the mostapproved fashion will not secure immunity from thisdisease. ( See next page.)1 Final Report, Royal Commission on Vaccination, Appendix vi. , p. 3 .2 In nineof the inmates the age was not ascertained .Page ofReport .District.No. Name .Age whenattacked .Vaccination.Results of vaccination .c,foFionocveuae-trartiecdesh.iaisnanrqceluahfare,cpoFilnocaeuai-trnricesh.iisananqrlcuefhaare41Brightside.27 Mary H.iinnfancy10months Vaccinated Five foveated cicatrices ,twothirdssquare inch inarea .41Brightside-41 Sarah C. 6months Vaccinatediinnfancy42 Brightside -102SLA.anrnah V1ma0ocnctihnsatediinnfancy62 North Sheffield 79ErnestC.. 9months VaccinatediinnfancyS9Sho7euftfhield 2Ge9rtrudeHoskins M.150NHeatlhlearm 1SF.8rank150Nether Hallam 57HedleyV.H.c,.fFoiooncvueaetrartiecdesh.isainaqnrlucefaahreCharacter-.spomofaxllVery slight ,notpitted .,snVloeitrghytp.ittedV, eryslightindeed.pniotttedV,moienlerdyp. itpS,-,.cpenVom2Oilliioanoncaitgtcenaeitghcttenhtirdhthinsxatedwhenow6ledekss.iainqrneucahare,cfVtFm6ioawoocvcounaec-trtairhtinescadetsedwhen .tisaihnqrniuecraahdrseow6ledeksiinnfancyc,fVmT8ioaohcvcnraectteairhetinsecadetsedo-tiishnnqnicuerhadrea. rea,spVlleiargyyh-teatalhbdleout,.pntioittmteed,inmVloieltlrdya,.apnltioltttedFATAL SMALL- POX IN VACCINATED CHILDREN . 173Examples of more absolute failure to protect couldhardly be imagined than these seven cases contractingsmall -pox from a fortnight to seven or eight monthsafter vaccination of the most correct type. Altogetherthere were about 450 vaccinated cases under ten yearsof age at Sheffield in the 1887-88 epidemic, and yet aprominent defender of compulsory vaccination deliberatelymaintained that " vaccinated children under tenyears of age are wholly and entirely immune fromsmall - pox , and cannot be infected . " ¹Since writing the above, it appears that the editorof the British Medical Journal has somewhat shiftedhis ground, for in a recent article on "Vaccinationas a Branch of Preventive Medicine," he maintainsthat in certain epidemics (referred to) "vaccinatedchildren under ten have been almost immune fromdeath by small-pox," which I venture to suggest is aconsiderable modification of his original statement. Itis a pity that Mr. Ernest Hart did not have an opportunityof consulting Dr. John MacCombie's article on" Small-pox " in the same volume (Allbutt's " System ofMedicine," vol. ii.), for he would then have discoveredthe following figures (p. 221 ) : -Age -periods.Under 5 years5-9 yearsVaccinated.Cases. Deaths.Fatalitypercent.3851,46830 7.859 40It must also be presumed that Mr. Hart's attention hasnot been arrested by the following experience of the1Letter ofMr. Ernest Hart to the Times ofAugust 31, 1894.*Allbutt's " System ofMedicine," vol. ii. , p. 664. London. 1897.174 DOES VACCINATION PREVENT SMALL- POX ?Metropolitan Asylums Board in the epidemic of1870-72 :-Age-periods.Under 5 years5-10 yearsVaccination .Numberadmitted.Number ofdeaths.Fatalityper cent.195 38 19.5786 60 7.6These two tables prove that " vaccinated children "under five years of age (let alone ten years ) are noteven " almost immune from death by small-pox. "What could be more emphatic than the followingexperience of Mr. T. Massey Harding ? " " Allpractitioners are acquainted with cases disproving theimmunity of the vaccinated, such as the following :-Iattended a man, aged 40, with confluent small- pox, ofwhich he died. He had been vaccinated twice, accordingto his own statement. In the house were his sister,her husband, and two children, all unvaccinated. Ivaccinated them all, and it took effect. In threeweeks from the day of vaccination, the woman, Mrs.G. , and one of her children had small-pox, distinct, butslight. "Nor can it be truthfully said that epidemics originatewith the unvaccinated , for in a number of notableinstances the first unvaccinated case is a long waydown the list. Thus, at Neuss , in Germany, from1865-73 , there were 247 cases of small-pox, all of1 " Report of the Committee appointed on the Ist June, to collate andreport upon the Returns obtained from the several Hospitals of theManagers, with regard to the cases of Small-pox treated therein. " Presentedto, and adopted by, the Managers of the Metropolitan AsylumsDistrict , at their meeting on the 13th July, 1872. P. 5 ; Table 2.2 British MedicalJournal, p. 974. ( November 21 , 1857. )STATISTICS OF VACCINATED SMALL- POX. 175them vaccinated ; at Bromley, in 1881 , 43 cases, allvaccinated ; and in the 1870-72 epidemic at Bonn,the first unvaccinated case was forty-second on thelist.¹The following table shows the large proportion ofvaccinated cases in some well-vaccinated districts : -Vaccinated Percentageattacks.Small-pox epidemics . Years. Attacks." ofattacksvaccinated.Bavaria 3 1871 30,742 29,429 95.7Berlin 4 1871-72 20,391 17,038 83.6Cologne41871-73 2,282 2,248 98.5Neuss4 ... 1865-73 247 247 1000London Small -pox Hospital5 1852-67 13,581 10,661 78.5Hospitals "Metropolitan Asylums Board) 1870-86 50,668 41,061 810Bromley 7 188143 43 1000Sunderland 8 1884 100 96 96.0Sheffield 1887-88 7,066 5,891 83.4Warrington 1892-93 674 601 89.2Birmingham 1893-94 2,945 2,616 88-8Willenhall 1894 828 739 89.3In an epidemic, it is not possible, on any theory ofprotection, for the population to be vaccinated to any1 " Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung,"p. 143. Berlin . 1888 .2 Cases in which there was a doubt about the vaccinal condition of thepatient have been excluded .Second Report, Royal Commission on Vaccination . Q. 1,489.4" Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung,"pp. 152, 154 , 168. Berlin . 1888.Report from the Select Committee on the Vaccination Act ( 1867 ) ,p. 237. 1871 .6 Third Report , Royal Commission on Vaccination , Appendix, p. 204,Table L.7 Lancet , vol . ii . , pp. 372, 373. (August 27 , 1881. )8 Lancet , vol . i . , pp. 363 , 364 . ( February 23 , 1884. )176 DOES VACCINATION.PREVENT SMALL- POX ?lesser extent than the cases of small -pox , or it wouldshow that small-pox picked out the vaccinated for itsvictims. The figures for Bavaria and Cologne, with95.7 and 98.5 per cent. of the cases vaccinated respectively,hardly leave any margin for the population to bevaccinated to a greater extent. Considering that inthese two instances the proportions approximate soclosely, there is every reason for scrutinising very carefullyany estimate of the vaccination of the populationwhich differs largely from the ratio of the vaccinatedcases of small -pox.Such estimates have been made for Sheffield by Dr.Barry, and for the houses invaded by small-pox atWarrington, Dewsbury, and Leicester, by medical menappointed by the Vaccination Commission. As, in thelatter instances, there was no opportunity for examinationof these experts, it will be more satisfactory if Iconfine myself to the case of Sheffield.In his report on the Sheffield epidemic, Dr. Barryestimated that 97.9 per cent. of the population wasvaccinated. It was pointed out to him before the RoyalCommission, that the house-to- house inquiry, on whichhis estimate was based, was taken after the epidemichad reached its height, during the course of which atransfer had been taking place from the unvaccinatedto the vaccinated class. A new estimate was thereforemade, which is included in the Report of the RoyalCommission, at 97.3 per cent.; but even this cannotbe justified. In his examination before the RoyalCommission, Dr. Barry admitted that in the SheffieldUnion, the house-to-house inquiry was enumerated bymen under the supervision of the vaccination officersTHE SHEFFIELD “ CENSUS. " 177(Q. 2,389), and that its primary object was to secure,as far as possible, the discovery of all unvaccinatedchildren (Q. 2,390). These were reported to the vaccinationofficers, whose duty it was to take steps tosecure their vaccination (Q. 2,391). The " census, " Dr.Barry informs us, was a " secondary affair " ( Q. 2,390) .This inquiry, therefore, was instituted in order to huntup the unvaccinated , and it is obvious that a censusconducted on these lines could not have the slightestpretension to accuracy. It would have been thesimplest matter in the world for the householder toomit the mention of the unvaccinated, and, as theinquiry lasted nearly six weeks , to evade the enumerators,who , in the Sheffield Union, were not evensupplied with the names of the occupiers. Moreover ,in 764 houses, information was altogether refused, and11.8 per cent. of the population, or over six timesthe " unvaccinated enumerated," were left out of thecalculation altogether, For these and other reasons,it is impossible that the population could have beenvaccinated to the extent that was claimed ; and, therefore,the calculations that are based on this estimateare misleading.It has been shown that the unvaccinated may beexposed to small -pox without taking the infection, andalso that the most recent and efficient vaccination ofindividuals will not prevent the complaint, and consideringthat such a large proportion of sufferers areamong the vaccinated, who, in most instances, startand spread the epidemic, the statement so often promulgatedthat an unvaccinated individual is a sourceof infection and a danger to the community, is178 DOES VACCINATION PREVENT SMALL-POX ?It has also been pointed out, that evenif vaccination was a complete protection against smallpox,this would be no argument for legislation ; for, inthe words of Dr. J. H. Bridges, " non-vaccinated peopleare not a source of injury to their neighbours ; for theirneighbours can get themselves vaccinated. " ¹ It follows,therefore, that the law, which was first passed on theassumption that the unvaccinated are a danger tosociety-even if there were no other evidence againstvaccination-should be immediately abrogated. "erroneous .¹ Positivist Review , vol . iv. , p. 226. (November, 1896. )* If vaccination mitigates small- pox , as maintained by some, it is noargument for compulsion. The Medical Officer of Health for the City ofBirmingham ( Report for 1893 , p. 45) alleges that one of the causes of therapid spread of small-pox in the recent epidemic was due to " the mildnessand modification of the attacks in vaccinated persons, making it mostdifficult in some cases to decide the nature of the illness , and causing it tobe mistaken for chicken-pox and other trivial affections , and arousing nosuspicion of its being small- pox until severer forms of the disease subsequentlyappeared in the same family."CHAPTER VI .THE MITIGATION THEORY.WHEN it was discovered, in the epidemic of 1817-19 ,that small -pox attacked such a large number of thevaccinated, the theory of mitigation was promulgated.From the cases detailed in the last chapter, it doesnot appear that small-pox was very conspicuouslymitigated by vaccination in the early years , nor doesthere appear to have been any relation between theseverity of the attack and the length of time whichhad elapsed since the operation. It will be profitableto proceed to enquire whether the later experienceshows results more favourable to the mitigation theory.Dr. George Gregory has indicated the measure of themodifying powers which, in his opinion, may be attributedto vaccination. " Vaccination," he says , “ does notappear to lessen the violence, or shorten the duration, ofthe first or eruptive stage of fever, which is generally assevere, and even sometimes severer and longer in itsduration than that of the casual confluent small-pox.It does not appear in like manner to influence thequantity of eruption upon the skin, so much, at least, ashas been generally imagined. It is true, that, in manycases of small-pox, subsequent to vaccination, the eruptionhas been very scanty; but, in a large number also,I have seen it very copious, more particularly about the180THE MITIGATION THEORY.face, breast, and upper extremities, and occasionallyfully equal, in point of quantity, to what is seen in theworst kinds of confluent or coherent natural small -pox. " 1The great power of vaccination, he thought, consisted inmodifying the progress of inflammation in the variolouseruption on the skin and in the throat; but he added :" It is curious to observe that it does not always affectthe course of the disease, when the variolous poisonfixes itself on other parts, more particularly on thebrain. It is in this manner that small-pox, after vaccination,occasionally proves fatal. "2 In a foot- note onp. 331 , he explains that " the eruption on the skin andthroat is only one of the effects of the poison. Another,at least equally important, both with reference to pathologyand practice, is that which is excited upon thebrain and nervous system ; the chief evidences of whichare delirium, inflamed eyes, stupor or restlessness, anddisposition to erysipelas and gangrene. "There are several ways of testing the mitigationquestion, one of which would be to compare the casemortalityor fatality of small-pox before and after theintroduction of vaccination. In the Appendix will befound a table taken from Dr. Creighton's " History ofEpidemics. " It consists of censuses of small -pox epidemicsduring the years 1721-30, the fatality rangingfrom 9.1 to 36.4 per cent. , there being in all 13,192cases, with 2,264 deaths, or an average fatality of 17.2per cent.The principal objection that has been raised to these1 " Medico - Chirurgical Transactions, " vol. xii. , pp. 328 , 329. ( 1823. )2 Ibid. , pp . 330, 331 .JURIN'S STATISTICS. 181statistics is, that in the censuses of small-pox epidemicspassing under the name of Jurin, which largely dominatethe figures in Dr. Creighton's list, Jurin is said tohave " not knowingly set down any deaths under twoyears old as due to small -pox, and that someof his correspondents, in furnishing him with statistics ,followed the same rule." 1The ostensible grounds for this assertion are :-( 1 ) That the Aynho census, to which I have referredin a previous chapter (pp. 43, 44), contains no casesunder two years of age.The Aynho census, a copy of which is to be found inthe archives of the Royal Society, was made by therector of the parish, and the cases are given in theorder of time, just as they occurred over a period ofsome fifteen months, three in one family, two inanother, and so on . There is no suggestion of infantsbeing excluded, and the fact that there were only threeaged two years, and four aged three years , out of atotal of 132, makes the absence of cases in infants notonly credible, but probable. The epidemic was mainlyamong young people and adults , and was quite intelligiblefor a country place where epidemics took placeinfrequently.(2) The other ground of objection is founded on anargument used by Jurin in his letter to Dr. Cotesworth.2 " It is notorious, that great numbers, especially“1Article on Small -pox and Vaccination," by John C. M'Vail, M.D. ,in Stevenson and Murphy's " Treatise on Hygiene and Public Health,"vol . ii . , p. 399. London. 1893 .2 A Letter to the learned Caleb Cotesworth , M.D. , p. 11. James Jurin ,M.D. , Secretary to the Royal Society. London. 1723 .182 THE MITIGATION THEORY.of young children, die of other diseases, without everhaving the small-pox, " etc.The statement that a number of young children diedof other diseases, without ever having the small -pox;has no reference to the censuses which were taken toshow the fatality -rate of natural small -pox as contrastedwith the inoculated. It was part of an argument toshow that the real hazard of dying of small-pox inLondon was greater than the Bills of Mortality showed ,inasmuch as the excessive London infantile mortalitycut off an immense number from other causes (such asconvulsions, infantile diarrhea, etc.,) before small -poxcould attack them. But Jurin admits (p. 12) that inall probability some infants, " very young children, or atmost not above one or two years," went through thesmall -pox, which is sufficient evidence that he had nointention of counting them out, or ignoring them, in thepercentages of fatalities to attacks. His argument,such as it was, applied only to London, but there wereno statistics for London in the censuses, which are allfrom the provinces, many of them made by Nettletonof Halifax, and none of them made, nor even controlled, by Jurin himself.aThe incidence of small-pox in the eighteenthcentury, as pointed out in former chapter, wasalmost entirely on the young ; for instance, at Chester, ¹in 1774, of 1,385 cases, 202 died, or a fatality of14.6 per cent. , the ages at death being as follows(p. 150 ; Tables II . and IV. ) :-1 " Philosophical Transactions," vol . lxviii. , p. 151. ( Dr. Haygarth'sObservations on the Population and Diseases of Chester in the year 1774. )OPINION OF THE ROYAL COMMISSION .Under 1 month ΟBetween I and 3 months ... 3" 3 and ود 6... ... 46 and 12 ..... 44" I and 2 years ... ... ... 38" 2 and 3..... ... 42" 3 and 5 " 495 and 10 22Over 10 yearsTotal 202183The contention, therefore, that the last century fatalityof 17 or 18 per cent. is lower than it should be, becauseof the deliberate omission of young children from thecensuses , is groundless, and ought never to have beenraised.¹Let us now see what is the fatality of small -pox sincea large proportion of the cases have been vaccinated.Dr. Collins and Mr. Picton quote the experience of theMetropolitan Asylums Board's Hospitals, where, from1870 to 1874, 60,855 cases were treated , with a fatalityof 167 per cent. , and among 50,668 of these admissions,the vaccinated were 41,061 , or 81 per cent.During this period the figures have varied considerably.In the year 1896, the fatality was 401 percent.; whereas, from December 1 , 1870, to February 3 ,1 The Royal Commission say ( section 53)--" It has been urged that thedeaths of those dying under two years of age were excluded from Jurin'sstatistics , and that this must have led to the omission of many deaths , asthe mortality in that class was high. The evidence relied on to show thatcases under two years of age were excluded certainly cannot be regardedas establishing it."* Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 97 .184 THE MITIGATION THEORY.In1871 , it was as high as 20.81 per cent. This highfatality in the earlier years may in part be due to thelimited accommodation at the hospitals, when the tendencywould be to admit the more serious cases.this epidemic ( 1870-72), however, the fatality was high ,for the Lancet of July 15, 1871 (vol. ii., p. 94) , estimatedthe fatality of small-pox at 17.5 per cent.; and hence,the large proportion of vaccinated cases¹ does notappear to have diminished the severity of the disease,as compared with the last century.The other method of testing the question is to comparethe fatality in the two classes. Dr. Davies, theMedical Officer of Health for Bristol, in the BristolMercury of April 2, 1896, states the case thus : " Theunvaccinated die at the rate of thirty or forty deathsper hundred cases, the vaccinated at something lessthan five per hundred cases. " This agrees approximatelywith Mr. Ernest Hart's figures in his summary ofdifferent towns during recent epidemics. The claim isthat vaccination mitigates small-pox in the bodies ofthose who have taken the disease, and this is practicallythe whole case for the observance of the operation ; andthe evidence is chiefly to be derived from the reports ofmedical officers of health and others in official position,from which the following have been taken : -1 In the epidemic of 1870-72, a total of 14,808 cases of small-pox wereadmitted into the hospitals of the Metropolitan Asylums Board. Of these ,11,174 , or 75.5 per cent. , were in vaccinated persons .* British MedicalJournal, vol. i. , p. 487. (March 2 , 1895. )FATALITY STATISTICS .Unvaccinated Fatalities-1836-96.Report of Hospital or MedicalOfficer of Health .185Years. Cases. Deaths.Fatalityper cent.Highgate 1836-51 2,654 996 37.5Highgate¹ ... 1871 74 4966.2Dublin ( HardwickeHospital )Feb. 1871 toMarch 1872 )70 55 78.6Homerton 1871-77 1,243 570 45.9Hampstead 1876-78 847 397 46.9Dublin ( Cork Street ) 1876-80 448 288 64.5Fulham .. 1877-79 374 176 47.1Deptford ... 1878-79 258 121 46.9Sheffield..1887-88 1,173 392 33′4Birmingham 1893-94 329 107 32.5Gloucester 1895-96 781 317 40.6Hence, in these instances, the proportion of deaths toattacks among the unvaccinated is stated to have rangedfrom 78 to 32 per cent. Most of these figures are,however, impossible, for the simple reason, that in thelast century, as already shown, before the introductionof vaccination, the average fatality of small-pox wasonly about 17 or 18 per cent.In making a critical examination of the fatalitystatistics in the two classes, it is obvious that theiraccuracy would depend on whether the statementas to vaccination could be absolutely relied upon ;and secondly, on whether the two classes were perfectlycomparable in every respect ; and to do thisit is necessary to say a word or two about thedifferent types of small-pox, and also the method ofclassification.British Medical Journal, vol . 1. , p. 171. ( February 10, 1872. )2 Ibid. , p. 682. (June 22, 1872. ) These figures include four doubtful cases.13186 THE MITIGATION THEORY.A prominent feature in medical and official publicationsadvocating vaccination¹ has been to paint thehorrors of small-pox in its natural state in the mostvivid colours. I have already dwelt on the fact that,in the last century, the average fatality of small-poxwas only about 17 or 18 per cent. of those attacked,and in many epidemics the proportion was much less.Different forms of small-pox have been distinguishedfrom the time of Rhases, and it may be said thatSydenham's main success in his treatment of thedisease was due to the fact that he recognised adiscrete and confluent variety, in the former of whichthe patient, if left alone to Nature, invariably recovered .The following quotations from Sydenham bear onthis point :-" As it is palpable to all the world, howfatal that disease (small-pox) proves to many of allages, so it is most clear to me, from all the observationsthat I can possibly make, that if no mischief be done,either by physician or nurse, it is the most slight andsafe of all other diseases . " 3Sydenham observes that in 1669 small -pox " appeared1 See Mr. Ernest Hart's " Truth about Vaccination," pp. 2-8 ( 1880) ,and also " Facts concerning Vaccination for Heads of Families, " a tract" revised" by the Local Government Board, and " issued with theirsanction," in which it states (p. 4)-" The disease (small-pox) used torage unchecked, killing a very large proportion of those whom it attacked,and maiming, blinding , and disfiguring those whose lives it spared. "" A Treatise on the Small-pox and Measles. " Translation from theoriginal Arabic by Dr. W. A. Greenhill, and printed for the SydenhamSociety, 1848 , pp. 71-73 .3 Letter to Mr. Robert Boyle, dated Pall Mall, April 2, 1688. TheWorks of Thonias Sydenham , M.D. Translation from the Latin Editionof Dr. Greenhill, with a life of the author , by R. G. Latham, M.D.Printed for the Sydenham Society , 1848, vol . i. , pp. lxxii . , lxxiii .SYDENHAM'S CLASSIFICATION OF SMALL- POX . 187in some few places, but in a mild and manageableform." 1"Now, the confluent small-pox is as much worse thanthe distinct, as the plague is worse than the confluent. " ?" As for the distinct sort, even if it can be seenbeforehand, bed is so much out of the question, thatinjunctions against it are superfluous. The scantynumber of the exanthemata makes matters safe eitherway." 3" With few pustules, and those of the distinct sort,the treatment is immaterial ; provided there is no grosserror. The disease is a slight one. The ignorance ofthe physician, who aims at nothing so much as thepromotion of heat, can alone make it dangerous.Dangerous , too, it has been made ; since in such casesthe doctor, though unconsciously, helps the disease. " 4In referring to the treatment of small-pox, " all thisapplies to the confluent small-pox only. With thedistinct sort, they have nothing to do. Those whoboast about curing cases where the rash has beenscanty, deceive themselves and others. If they reallywish to test their skill, let them take a confluent casein a young subject who has drunk hard ; and not so farblunder as to fancy that, in their easier practice, theyhave saved the lives of patients whom it would havebeen a hard matter to have killed. " 5Other authorities testify to the mildness of someforms of the disease. Thus Wagstaffe, in a letter to1 " Medical Observations."vol . i. , p. 160.Printed for the Sydenham Society , 1848 ,2 Letter to Dr. Cole . Ibid. , vol. ii . , p. 58.3 Ibid. , p. 65. * Ibid. , p. 71 . 5 Ibid. , p. 79.188 THE MITIGATION THEORY.Dr. Freind, observes-" There is scarcely, I believe, sogreat a difference between any two distempers in theworld, as between the best and worst sort of small -pox,in respect to the danger which attends them . Sotrue is that common observation, that there is one sortin which a nurse cannot kill, and another which even aphysician can never cure. " 1 Sir Richard Blackmore, inhis remarks on the treatment of small-pox, says :-" Inthe most favourable sort of the distinct small-pox,which are few in number and mild in quality, Natureherself, as I have before observed, is able to cure the distemper,and needs not call the physician in aid. " 2 IsaacMassey, the apothecary to Christ's Hospital, thus giveshis experience :-" Here is the natural small-pox, but onein forty-nine died, and, I can assure the reader, that upona strict review of thirty years' business, and more, notone in forty small-pox patients of the younger life havedied, i.e. , about five, and under eighteen. " Mr. JohnMudge, a surgeon of Plymouth, writing in 1777, says-" There is not perhaps a disease to which the human raceis exposed, that differs more from itself at different timesthan the natural small-pox. We soinetimes see thisdisorder so mild and benign, as scarcely to expose thepatient to more danger than a common cold ; and atothers, exasperated by a degree of malignity and1 A Letter to Dr. Freind showing the danger and uncertainty ofinoculating the Small-pox, pp. 9, 10. W. Wagstaffe , M.D. , F.R.S.London . 1722 .2 " A Treatise upon the Small-pox," p. 42. Sir Richard Blackmore,M.D. , F.R.C.P. London. 1723.3 " Remarks on Dr. Jurin's Last Yearly Account of the Success ofInoculation ," p. 7. Isaac Massey. London. 1727 .CONFIRMED BY JENNER. 189virulence, little, or perhaps not at all, inferior to theplague itself. " 1The matter has also been alluded to by Jenner.Of course Jenner never dreamt in the first ardour ofhis discovery, that the advocacy of vaccination wouldbe reduced to a mere plea for mitigation, and thuswe obtain the following interesting confirmation ofthe painstaking and carefully recorded experience ofSydenham. " There are certainly more forms thanone," he says, " without considering the common variationbetween the confluent and distinct, in which thesmall -pox appears in what is called the natural way.-About seven years ago a species of small -pox spreadthrough many of the towns and villages of this partof Gloucestershire : it was of so mild a nature, that afatal instance was scarcely ever heard of, and consequentlyso little dreaded by the lower orders of thecommunity, that they scrupled not to hold the sameintercourse with each other as if no infectious diseasehad been present among them. I never saw nor heardof an instance of its being confluent. "More recently also we have the corroboration ofMr. Marson, who says " The death- rate from distinctsmall-pox among the unvaccinated is only four percent. , and even those four per cent. die of convulsions,or some other disease to which children are liable." 31 " A Dissertation on the Inoculated Small - pox, " pp. 1, 2. JohnMudge, Surgeon . London. 1777 ." An Inquiry into the Causes andp. 54. Edward Jenner, M.D. , F.R.S.3Q. 4,316, Report from the SelectAct ( 1867 ). 1871 .Effects of the Variola Vaccine,"London. 1798.Committee on the Vaccination$190 THE MITIGATION THEORY.And Dr. William Gayton, medical superintendent ofthe North- Western Fever Hospital, has admitted thatdiscrete small- pox is a comparatively mild disease evenin the unvaccinated .Another variety of small- pox, viz. , malignant orhæmorrhagic, is of a different type. Regarding this,Dr. MacCombie² states ( 1 ) That it is by no meansrare ; ( 2 ) that the majority of attacks occur in vaccinatedpersons ; and (3 ) that recovery does not takeplace. This last statement accords with the experienceof Dr. Gayton, who informed the Royal Commission(Q. 1,818), that malignant or hæmorrhagic small -poxwas almost uniformly fatal whether the person hadbeen vaccinated or not. The following table, compiledfrom the hospital reports by Mr. Wheeler, 3demonstrates the point conclusively :-Malignant Small-pox.Vaccinated. Unvaccinated.Attacks. Deaths. Fatality Attacks. Years. Deaths. Fatalityper cent. percent.Homerton 1871-77 163 139Hampstead ... 1876-78 127 10585.3 153 15382.7 127 115100090.6Fulham 1877-79 26 18 69.2 44 3988.6Deptford 1879 21 21 1000 10 10 1000Dublin ( Cork )Street)1876-80 163 113 69.3 103 93 90.3Total ... 500 396 79.2 437 410 93.81Q. 1,816, Second Report , Royal Commission on Vaccination .* Allbutt's " System of Medicine," vol . ii . , pp. 203, 204. London.1897.3 Third Report, Royal Commission on Vaccination, Appendix, p. 206(Table Q. ) .VARIETIES OF SMALL-POX. 191As vaccination apparently has no influence on thisform of the disease, Dr. Grieve, medical superintendentof the Hampstead Small-pox Hospital, was probablycorrect when he stated that it was " but too commonin people who had lived in defiance of all sanitarylaws, or who by intemperance have debilitated theirconstitutions. " 1Another particularly fatal, but rare variety, termedcorymbose small-pox, has been observed. This wasdescribed by Mr. Marson as presenting two or threepatches or clusters about the size of the palm of a hand,upon which the eruption is as thickly set as it possiblycan be, while the skin around for 'some distance isalmost, if not entirely free. Mr. Marson gives thefigures for 104 cases of this variety, which came underhis observation : 29 were unvaccinated, of these 13 or44.8 per cent. died ; and 74 were vaccinated, of which32 or 43.2 per cent. died. Thus, the fatality in thetwo classes of this variety of the disease, is practicallyidentical .The only remaining type of the disease for us toconsider is the confluent, and from the above it will beevident that the huge difference in the rates of thevaccinated and unvaccinated must take place in casesof this description. In this variety of the disease, thepustules coalesce, so as to render the features hardlyrecognisable, and it can easily be understood that marksof vaccination may be and are readily obscured, so that1 " An Analysis of eight hundred cases of Small -pox. " The Lancet,vol . i . , p. 371. ( March 18 , 1871. )*Article on " Small- pox, " by Mr. J. F. Marson.of Medicine, " vol. i. , p. 438. London. 1866.Reynolds' " System192 THE MITIGATION THEORY.it is impossible to determine from an examination ofthe arm whether they exist or not.This difficulty has been recognised by the leadingauthorities. Thus, Dr. Gregory says-" Great difficultieswere necessarily experienced in determining whohad been really vaccinated, of those who assumed tohave undergone that process . The cicatrix was ourchief guide, but this often failed us, from the swollen andpock-covered condition of the arm at the time of thepatient's admission. " Dr. James B. Russell remarks-" Sometimes persons were said to be vaccinated, but nomarks could be seen, very frequently because of theabundance of the eruption. In some of those caseswhich recovered, an inspection before dismissal discoveredvaccine marks, sometimes ' very good.' Thosewho died, or who were not so examined, are placed ina separate column as ' said to be vaccinated, but V.M.not visible . ' I do not observe in the reports on smallpox,as observed in London and Dublin, any allusion tothis difficulty. Even the best vaccine mark is readilyobscured, or even hidden, by a copious eruption, andunless such special means, as I have described, areadopted, it is impossible accurately to ascertain thefacts of small - pox in the vaccinated . " 2Not only may the scars be obscured by eruption, butthere is no doubt also that they may wear out. Dr.George Gregory says-" The absence of a cicatrix is notdecisive against either the present or prior existence ofvaccine energy in the system, because in many cases," Medico - Chirurgical Transactions," vol. xxii . , p. 97. ( 1839. )* Glasgow MedicalJournal, vol. v. , p. 6. (November, 1872. )CLASSIFICATION OF SMALL- POX PATIENTS . 193the specific inflammation is moderate, and the resultingscar wears out in the progress of life, as other scars dowhich are not the result of a specific poison. " 1 In his" Observations on the Variola Vaccina, " Mr. RobertCeely, of Aylesbury, says-" Inspection of many scars,caused by this lymph, shows that in a few months littleis to be learned in many subjects, with thin skins, ofthe degree to which the vaccine influence has beenexerted on them. " 2A Committee appointed by the EpidemiologicalSociety (" Epidem. Soc. Trans. , " vol. v. , p. 153 , 1885-86)recognised that " not every cicatrix which is oncefoveated will always retain its condition of foveation,and, further, that not every cicatrix will permanentlyexist. " Dr. Savill in his report on the Warringtonoutbreak has also called attention to the fact thatvaccination scars tend to become obliterated with age,and to alter in character with time.3Let us now see what has been the practice withregard to the classification of small - pox patients.Mr. Francis Vacher, Medical Officer of Health forBirkenhead, candidly observes-" The mere assertionsof patients or their friends, that they were vaccinated,counted for nothing, as about 80 per cent. of thepatients entered in the third column of the table( ' unknown ') were reported as having been vaccinatedin infancy. " Mr. Marson informs us-" Patients were1 London Medical Gazette, vol . xxv. , pp. 289 , 290. (November 15, 1839. )" Transactions of the Provincial Medical and Surgical Association ,"vol . viii . , p. 416 , foot- note. ( 1840. )* Final Report, Royal Commission on Vaccination, Appendix v. , p. 42.+ " Notes on the Small-pox Epidemic at Birkenhead in 1877," p. 9 ..:194 THE MITIGATION THEORY .never entered in the register as vaccinated, unless theaccount of the vaccination was a tolerably clear one. " ¹And Dr. William Gayton, in the Homerton Reportfor 1875 , observes ( p. 58)-" I have always classed as' vaccinated ' those upon whom any mark supposed toresult from vaccination has existed, and as ' unvaccinated' when no scar presumably arising from theeffects of vaccine lymph could be discovered. Individualsare constantly seen who state that they havebeen vaccinated, but upon whom no cicatrices of anydescription can be traced. In a prognostic and statisticpoint of view it is better, and, I think, necessary,to class them as unvaccinated . "The fallacies of this method of classification havebeen pointed out by Dr. Birdwood and Dr. Ricketts.Dr. Birdwood, with an experience of twelve thousandcases of small-pox, stated, before the Royal Commission,that in his opinion the evidence of primaryvaccination , collected in small-pox hospitals , shouldnot be relied on . Because-" ( 1 ) On the outbreak of an epidemic there isnecessarily much administrative confusion, and manyuntrained observers. The early observations are incompleteand faulty." (2) In the worst instances the eruption may be sufficientto, and does obscure the scars." (3) The statement of parents as to primary vaccination,and of adult patients as to re-vaccination, shouldbe accepted even when scars are not seen ." Medico - Chirurgical Transactions," vol. xxxvi. , p. 374. ( 1853. )2 Sixth Report , Royal Commission on Vaccination. Q. 31,221 .DRS. BIRDWOOD AND RICKETTS ' EVIDENCE. 195" (4) Scars produced in infancy grow with the growthof the body ; as was pointed out, I understand, by SirJames Paget." (5) In such statistics insufficient allowance is madefor other circumstances, such as occupation, intemperance,and the existence of other diseases. An altogetherdifferent death -rate might be anticipated if small -poxbroke out in a public school, or in the infirm and agedwards of a workhouse. A typhoid fever patient, or anill - fed baby, catching discrete small -pox and dying,would be counted a death from small-pox, obviouslyneither vaccination nor its neglect having anythingto do with it." (6) The accurate observation and record of clinicaldetails is one of the most difficult duties requiredof medical men employed in hospitals for infectiousdisease."Dr. Ricketts ' says-" In some of the earlier statisticson vaccination only two classes of cases were considered,viz. , those vaccinated and those unvaccinated ; apparentlythe only evidence as to vaccination that wasaccepted being the presence or absence of scars. Anabsolute reliance, however, ought not to be placed onthis evidence. There is no doubt that cases occur inwhich vaccination has been successfully performed,although cicatrices are not present when the attackof small - pox supervenes . There is a small class, too,but naturally a very fatal class, in which the rash istoo abundant over the upper part of the arm for anassertion to be made that scars are absent. " On Table1 Report of the Metropolitan Asylums Board for 1893 , p. 136 .196 THE MITIGATION THEORY.B. pp. 144, 145, he gives twenty-six cases, with thirteendeaths, in which the absence of scars could not beasserted because of the abundant eruption ; and intwenty- five of these, the patient was stated to havebeen vaccinated ."noLet us see how Dr. Ricketts' figures work out. OnTable II.c, pp. 185-188 of the same report, there areforty-two vaccinated deaths, and forty-four in whichthere is " no evidence " as to cicatrices. On p. 138 , hedescribes an age-distribution he has made of theevidence " cases. He puts it in the form of a diagram ,and on comparing it with similar diagrams for thevaccinated and for cases in which the vaccinationcicatrix was " absent," he finds that the diagramcorresponds much more nearly with the former thanthe latter. There were ninety- four deaths in whichthe vaccination cicatrix was " absent," but it will benoticed that forty- four of these are in the first threeyears of life, in which there are no cases or deaths inthe other two classes . In all fairness these shouldbe therefore struck off ; we then get fifty deaths inthis class, and if we add the " no evidence " deaths tothe vaccinated ( I am aware that I am slightly overstatingthe case), we have eighty-six vaccinated deaths,and fifty in which the cicatrix was " absent. " Thus,over three years of age, there are, if we include the" no evidence " cases with the vaccinated, 63.2 per cent.of the deaths vaccinated .But there are further allowances to be made, for, onp. 134, Dr. Ricketts says of his class, in which thevaccination cicatrix was " absent," that he is not ableto describe these cases as all " admittedly unvacSOURCESOF FALLACY. 197cinated." Another source of fallacy is pointed outin the British Medical Journal of October 23 , 1880(vol. ii. , p. 672). The editor says-" It is probable thata larger proportion of unvaccinated persons is to befound among the ignorant, dirty, and wretched inhabitantsof the slums of London, and very few indeedamong the educated and better fed members of society."And Dr. Gayton admitted before the Royal Commission(Q. 1,843) that this would be likely to operate detrimentallyby way of raising the unvaccinated mortality.This applies to all places vaccinated up to the usualaverage. When allowance is made for these fallacies,it will be found that the proportion of deaths vaccinatedwill not be very largely different from that of thevaccinated population, which in London, from theamount of default that has taken place in recent years ,would not be very high .It is only fair to mention that other reports agreein not assigning such a large proportion of deaths tothe unvaccinated. In the Glasgow Medical Journal ofNovember , 1872 (vol. v., p. 12), Dr. Russell classifieshis cases according to the eruption. He found thatin discrete cases the fatality in both classes was nil,and in confluent small-pox the fatality of the vaccinatedexceeded that of the unvaccinated. Thus,among seventy-one vaccinated confluent cases therewere forty - nine deaths, or a fatality of 69 per cent. ,and of one hundred and sixteen unvaccinated confluentcases, sixty- four, or 55.2 per cent. , died.But the most striking figures come from Prussia,and they show that up to ten years of age there ispractically no difference in the fatality in the two198 THE MITIGATION THEORY.classes. The following table gives the figures for Berlin'in the 1871-72 epidemic :-Vaccinated. Unvaccinated.Ages. Cases. Deaths.Fatalityper cent.Cases. Deaths.Fatalityper cent.O- I 259 136 52.5 977 570 58.32-5 1,244 437 35 1 1,359 564 4156-10 737 163 22 I251 77 30.7If the difference between 52 and 58 per cent. is allthe mitigation that can be fairly claimed on behalfof vaccination within a year of the operation, even themost enthusiastic champions of vaccination will agreethat we must look to other and more scientific methodsfor the extirpation of small- pox.To recapitulate the facts briefly :-Figures have beenput forward showing an enormous difference in therates of the vaccinated and unvaccinated . It has beenshown that these are open to suspicion, because therates in the unvaccinated considerably exceed thoseof the last century before vaccination was discovered .When we come to analyse them, we find that thedisparity obtains principally in cases of confluent smallpox,in which, according to the leading authorities, thevaccination marks are readily obscured ; and when it isremembered that it has been the practice to classify thecases according to marks, whether discernible or not, itis evident that the results have been largely fallacious.Other sources of fallacy are the different conditionsunder which the two classes labour, and also the age.Of course, when the different ages are separated as" Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung, "p. 168. Berlin. 1888.INVESTIGATION BY THE REGISTRAR -GENERAL. 199in the reports of the Metropolitan Asylums Board, thisobjection would not hold, but in the majority ofinstances , all ages are taken together, or separatedonly into those under and over ten ; and consideringthat the unvaccinated more largely consist of younginfants, who normally have a high small-pox fatality,this method naturally raises the rates for this class.The Government returns of small - pox deaths wouldappear to be one way of settling the question, but herewe are met with the difficulty that in death - certificatesof cases of small -pox, medical men in a large proportionof instances make no statement about thevaccination, although they have been repeatedly urgedto do so by the Registrar-General, and also by themedical press . In England and Wales, in 1892-95 ,there were 2,931 deaths from small -pox, of which 391,or 13.3 per cent. , are reported in the vaccinated ; 596, or20.3 per cent. , in the unvaccinated ; whereas, in 1,944,or 66.3 per cent. of the whole, there is no statement asto whether the patient was vaccinated or not. Thefollowing from the British Medical Journal of March17, 1877 ( vol. i. , p. 330), appears to throw some lighton the matter :-" It may not be generally known thatthe Registrar-General, during the epidemic of smallpoxin London in 1871-72, attempted to obtain morecomplete information as to the vaccination of personsdying of small-pox than was furnished in medicalcertificates. Then, as now, no information as to vaccinationwas given in a large proportion of medicalcertificates." The Registrar-General, therefore, requested the localregistrars, in cases where the medical certificate was200 THE MITIGATION THEORY.silent on the point, to endeavour to ascertain from theinformants of the deaths (almost invariably relatives),and to insert in the Register, whether the deceased hador had not been vaccinated." Information derived in this way certainly yieldedresults very similar to those obtained by the antivaccinationiststhemselves ; relatives almost invariablyasserted that the deceased had been vaccinated ; but, asinquiries of the medical attendants in a large numberof these ' not stated ' cases elicited the fact that thedeceased, the statements of relatives notwithstanding,bore no marks of vaccination, registrars were subsequentlyinstructed to insert in the Register no facts asto vaccination unless certified under the hand of aregistered medical practitioner. "It need hardly be said that this inquiry of theRegistrar- General is very important. In these " notstated " deaths, the medical men presumably are unableto decide the fact of vaccination. The difficulty nodoubt is great, for as Dr. Savill has pointed out in hisreport on the Warrington epidemic, " in nearly all fatalcases the eruption is profuse and tends to hide thevaccination scars if they exist. " Dr. Birdwood, as Ihave shown, is also alive to the difficulty, and recommendsthat the statements of parents as to primaryvaccination should be accepted. The relatives in thecases I am referring to almost invariably asserted thatthe patients had been vaccinated, and thus I cannothelp thinking that the most important part of the casefor vaccination has been given away, for if in the recent1 Final Report , Royal Commission on Vaccination, Appendix v . , p. 34.CLASSIFICATION BY MARKS . 201cases epidemic ( 1892-95), we add the " not stated "to the vaccinated, nearly 80 per cent. of the totaldeaths from small-pox will be found in the vaccinatedclass.It seems a pity that the vaccinal condition of patientssuffering from small-pox has not more often been determinedby reference to the vaccination register.Dr. Birdwood informed the Royal Commission (Q.31,250-51 ) that the Metropolitan Asylums Board usedto forward a list of patients to the Local GovernmentBoard for this purpose, but that he knew of nopublished results of their inquiries. If the LocalGovernment Board would undertake investigations ofthis nature, they would doubtless receive the cordialco-operation of both parties in the vaccination controversy,and the results would prove interesting, if notinstructive.It has been urged that the protection afforded byvaccination is in proportion to the number and thequality of the marks. In the first place, cicatricesresulting from the same lymph of good quality varyconsiderably. They may be smooth, striated, puckered,pitted, and so on ; in fact, a French observer, Decanteleu,has figured no less than seventy different varieties ofscars. Dr. Savill points out that " the foveation ofvaccination scars does but follow the same laws whichgovern other lesions involving only the superficial layersof the skin ; " and he figures the arm of a girl to show1 Professor Crookshank's Evidence. Fourth Report , Royal Commissionon Vaccination. Q. 11,892.2 Final Report, Royal Commission on Vaccination , Appendix v. ,p. 42.14202 THE MITIGATION THEORY.the similarity of foveate texture in a scar resulting froma superficial burn on the shoulder, and in some primaryvaccination cicatrices. Thus, it would appear that thetexture of the vaccination cicatrix depends on theamount of the local inflammation, on the method ofperforming the operation, on the age, surroundings,and general health of the individual, and on otherfactors.It is also worthy of notice that in classifying casesof small-pox according to vaccination marks, differentmethods are adopted by different observers. Thus Dr.Gayton informed the Royal Commission (Q. 1,700-06)that when he found one good mark and three imperfectones, he might class them as a case of two good marks,or he would ignore the three imperfect marks, and classthe case as one of a single good mark. Of 10,403 casesof small-pox admitted to the hospitals of the MetropolitanAsylums Board during 1870-84, Dr. Gayton 1classified 2,085, or 20 per cent. , as " vaccinated with goodmarks ; " whereas, at another hospital of the same Board,during the years 1880-85 , Dr. Sweeting placed only39 out of 2,584, or 1.5 per cent., in the category of" good vaccination. " The Dissentient Commissioners,Dr. Collins and Mr. Picton, observe (section 129)-" Itis evident that such a difference indicates a wide marginfor personal discrimination as to what is and what isnot ' good vaccination. " It is, therefore, not altogethersurprising to learn, on the authority of Dr. M. D.Makuna, when medical superintendent of the Fulham1 Second Report, Royal Commission on Vaccination, Appendix, p. 245.2 Ibid. Q. 3,689." GOOD " AND " BAD " MARKS.203Small -pox Hospital, that " what one will call an indifferentmark, another will call fair, a third moderate,and a fourth bad, and so on, till the confusion is worstconfounded." 1،،The following testimonies appear to show that even" good vaccination " is far from securing a perfect immunityagainst small -pox. Thus, Dr. J. J. Bigsby, in anepidemic of small -pox at Newark, found that someof the worst cases (of small-pox) had remarkably goodscars ." 2 In the British Medical Journal of April 1 ,1871 , Dr. Atthill is reported to have stated that " hedid not think that a good mark insured protectionmore than an ill - defined one. "Dr. B. Browning, Medical Officer of Health to Rotherhithe,gives particulars of 469 cases of post-vaccinalsmall - pox, of which 100, or 21.3 per cent. , died."Many of these sufferers, " he says, " showed goodvaccine marks of the kind that would be deemedworthy of an extra grant from the GovernmentInspector (at least I used formerly to receive suchgrants for doing similar looking work), and yet theytook small -pox-some within six days, some withinsix months, and some within six years of their vaccinationdate. " And lastly, I may quote the valuabletestimony of Dr. John MacCombie, who, on June 12,1878 , stated before the Epidemiological Societythat " the evidence afforded by the cases admitted1 Report of the Fulham Small -pox Hospital for the year 1878 , pp. 11 , 12 .2 London Medical Gazette , vol . xxv. , p. 18. (September 28 , 1839. )3 British MedicalJournal, vol . i. , p. 352 ." Transactions of the Society of Medical Officers of Health ( Session1881-82 ), " p. 29.204 THE MITIGATION THEORY.into the Asylum Boards Hospitals goes to showthat the good and bad marks are equally protectiveagainst attacks of small-pox," ¹ and he further remarksthat " good vaccination protects absolutely against noform of small-pox. " 2In considering the theory that the protection is inproportion to the number of marks, it may be mentionedthat, if we are to be guided by Jenner, " a single cowpoxpustule is all that is necessary. " But this, as wellas other theories promulgated by Jenner, has beendiscarded, and the orthodox number of marks at thepresent time is four. It is not pretended that thistheory has any scientific basis, but it appears to restmainly on certain figures compiled by Mr. Marson,surgeon to the London Small-pox Hospital . Theresults he obtained are given in the following tables :-Cases. Deaths.Fatalitypercent.UnvaccinatedVaccinated ( no scars)Vaccinated ( scars)... 2,883 1,006 34.89... 259 102 39.38... 10,293 685 6.66I scar ... 2,584 357 13.822 scars 3,138 242 7.713 scars ... 2,139 65 3.044 scars ... 2,432 21 861 Paper on " Comparison of Small-pox Statistics, Epidemics 1871 and1876, " by John MacCombie, M.A. , M.B. , Medical Superintendent tothe Deptford Small-pox Hospital. Transactions of the EpidemiologicalSociety ( Sessions 1877-78 and 1878-79 ) , vol . iv. , part 2, p. 190.2Ibid. , p. 192.3 " Further Observations on the Variola Vaccina, or Cow-pox. " p. 38.London. 1799.* Report from the Select Committee on the Vaccination Act ( 1867 ) ,pp. 236, 237. 1871 .MR. MARSON'S STATISTICS.Good scars . Indifferentscars .Scars. Cases. Deaths.FatalityCases. Deaths .per cent.Fatalitypercent .I1,530 328 21 44 1,054 29 2.752 1,838 224 12.19 1,30018 1.383 1,151 55 4.78 988 10 ΙΟΙ4 1,179 20 170 1,253 I 08627 1100 4,595 58 1.26205Total ... 5,698To obtain the above figures, Mr. Marson deducteddeaths for superadded disease, thus :-Totaldeaths.Deathsdeducted.Percentage ofdeaths deducted.UnvaccinatedVaccinated ( scars)Indifferent scars.... 1,043 37 3.5790 105 13'3Good scars .Total Deaths Percentage Total DeathsPercentageScars . ofdeaths ofdeathsdeaths. deducted. deaths. deducted.deducted. deducted.I 353 25 71 34 5 1472 25228 III 24625.03 65 10 15′4 14 428.64 37 17 45.9 II IO 90.9Total 70780113 83 25 301This shows that he deducted a larger proportion ofdeaths for the vaccinated than for the unvaccinated,for good scars than for indifferent scars, a larger proportionfor two scars than one scar, for three scarsthan two scars, and for four scars than three scars ,the climax being reached with four good scars, inwhich class, with eleven deaths altogether, he deductedten before making his calculations, and these, forsooth,are the figures on which the notorious marks theorylargely depends !206 THE MITIGATION THEORY.Mr. P. M. Davidson, the Medical Officer of Health toCongleton, has drawn attention to the strange conclusionsto which we should be driven were we toaccept some of the figures in Dr. Barry's SheffieldReport. Table CXIV. (p. 212) shows the fatality andtype of disease with one, two, three, and four or morescars in cases treated at the Borough Hospital, WinterStreet.Under 20 years of age . Above 20 years of age .Conditions as tovaccination .Cases. Deaths. Fatality Cases. Deaths . Fatalityper cent. per cent.No visible primarycicatrix, or I cica- 22 Ο 00 73 13 17.8trixonly ...2 primary cicatrices 94 3 3.2 165 21 12.73 primary cicatrices 187 316 185 18 974 or more primary)cicatrices67 00 32 2 6.2With regard to the type of disease under twentyyears of age, there was one confluent case, and thathad four marks. The only conclusion to be deducedfrom these figures is, that under twenty years of age,no visible mark, or one mark only, secures the greatestimmunity from death and severe disease ; whereaswhen a person reaches the age of twenty and upwards ,one-mark cases have the greatest fatality, the fatalitygradually diminishing with two, three, and four marks,and thus twenty years must elapse before the influenceofplurality of marks comes into play. Dr. Barry surelydid not intend us to believe that this was the case,but it is unquestionably what his figures tend to show.Again in Table CXV. (p. 214), Dr. Barry gives statisticsfor the Ecclesall Bierlow Union Workhouse Hospitalat all ages , as follows :-MR. DAVIDSON'S CASES. 207Scars. Attacks. Deaths.I or 23 or more1411872Fatality per cent.50017These percentages are seriously set forth to show thealarming difference in fatality between one or two andthree or more marks, Dr. Barry and those who suppliedhim with the statistics apparently forgetting that thefatality he gives for one or two marks is nearly threetimes the average fatality of the unvaccinated in thelast century, and even much larger than the figureshe himself gives for his own unvaccinated class, andif they show anything at all they show that the onemarkvaccination which was fashionable during the firsthalf of the century was provocative of a fatal issue ifattacked, and that most of the private vaccination atthe present time is in the same plight, and that Mr.Ernest Hart is giving the best of advice when he says-" Better by far let such applicants (for one or two smallinsertions ) depart with their children unvaccinated thanplace them in a state of false security. " ¹Mr. P. M. Davidson, besides criticising Dr. Barry'sfigures, has given us the result of his own painstakingand valuable experience of a small outbreak he hadto deal with at Congleton, and the following has beenextracted from a table he gives of these cases, onp. 27 of his report.2 ( See next page. )1 Allbutt's " System of Medicine," vol. ii. , p. 676. London. 1897 .2 Special Report on the Recent Outbreak of Small -pox in Congleton.1889.No. Name . Age . Resultsofvaccination.Character of small -pox .IGT.eorge 182HB.enry43S,.,-,ppcsosdFonaiiocneeienunttnaevevemmdstfr-epeieelsrlrdueyeonutsi.itsanhnqricuerhaadresDw;,,-,ptsvsmnoOuihiceqionnptisarulreeetrcryadrkidrrfneeiegdtciealinch in area . throughoutillness.3GeorgeW.26 Three scars (one deeply pitted ,two Semi -confluent ,very few pits .q,-)psoauiqnntauedtraetrdeer.iiannrceha-B4E.mma40s;,-sptDovmstnhTuichineiqwoawptiaslrluodetrrocyydaridsrrfnseigetcieal.iiannrceha .;istanbnpwbeeoeovdtneustrty5Annie S.25 p,)(ssttFiucwwoptaoouetrrresfdiciali.-hisaonanqrnlcueefhaare.,pDvmniieiotsrltcydirnegteBR6.andel32 ,(pstdoFichenotareeutrepreseldyi,-.)tpisathninqrwictueorhtaadersdeC,,pesdixoeettvneteefpenrlld-euyentc;sfp,aiaeonvcrmdeem-laynently.pcloevteerleyd7Harry B. 26PJ8.ohn19sc.,(),sppsCEtiuiiocoiwxpttanngoettrsfhreesiltfddduiecerinaatlbly.iiasonnrqnceuehaarep,-,tespCdaoThxcioeennwitatnredeorertfpmdnsellasduynieevnnetltylys.iianqnrcuehaare .pitted-CD9.aniel2710J-C.ames20IICJ.ohn192555Three scars (one pitted ,two superficial ),|Discrete ,very mild ,no pitting .one -fifth square inch inarea .Four scars (two deeply pitted ,one Discrete ,some pitting .sqt,-,)pouhuinparteeterreetfdeircsiala.iisnrnqceuhaare.,,,p(spsCdotFmieicoenwoutvtaneeouctetrfperrheslldeduyent,),spsouiqnptueetarerfdeicial.aiinrnceahssD.-,,pptsfaoFliciihqenotiatisuweusgrtrcahresdrrtdeetea.iinrnecahpcS.,,(sps-dooTlioicenenhitntaeeemrgtftrphieelesltdudelyeynt,,-)stpoouhinnpiteeertrdefdicialsquare inch inarea .Three scars (one deeply pitted ,twosuper- Discrete ,very mild ,two orthree pits .ficial ),four -fifths square inch inarea .Two deeply pitted scars ,three -quarters Discrete ,severe slightly .square inch inarea .1812TW.illiamS1T.3homas1PA.4nnieC1M.5rs.431TM6.argaret40sively ;the most severe case .1AS7.arah27One deeply pitted scar ,one -third square Discrete ,very mild ,no pitting ;mildestinch inarea . of all except Cases 2and 4.Four deeply scars ,three -quarters Confluent ,hæmorrhagic ,pitted extensquareinch inarea .210 THE MITIGATION THEORY.Thus five of the cases (Nos. 6, 7, 8 , 11 , and 16) wereconfluent, three semi-confluent (Nos. 1, 3, and 13 ), andnine discrete (Nos. 2, 4, 5, 9, 10, 12, 14, 15, and 17).All the confluent cases, except No. 7, had well-pittedvaccination scars . One of them (No. 7) had eightscars, three (Nos. 6, 11 , and 16) had four scars, and theremaining one (No. 8) two scars ; the average numberof scars being four and one half, and the average superficialarea three-quarters of a square inch.Of the three semi-confluent cases, No. I had fivescars, and this was the most severe ; and the remainingtwo (Nos. 3 and 13) had three scars each ; theaverage number of scars being three and two-thirds,and the average superficial area one square inch.Of the nine discrete cases, three (Nos. 5 , 10, and 12)had four scars, two (Nos. 9 and 14) three scars, two(Nos. 4 and 15) two scars, and the remaining two(Nos. 2 and 17) one scar each ; the average numberof scars being two and two-thirds, and the averagesuperficial area one half of a square inch. The followingtable gives a summary :-Average numberofscars.Average superficial areain square inches .5 confluent cases ...3 semi -confluent cases9 discrete cases ... ... 25533034324535..IMr. Davidson adds (p. 15)-" Comment on this issuperfluous, and I leave it to anyone caring to considerthe matter to judge for himself what he is toexpect from scars and superficial areas in this part ofthe country. If they teach anything, it is that themore you have of them, and the larger and deeperthey are, the more severe will be your small -pox. "THE SHEFFIELD EXPERIENCE . 211The best way to test the question is to compare theincidence of small-pox following vaccination by publicand private practitioners, for the public vaccinators arebound by their regulations to work up to a certainstandard. In the Sheffield epidemic ( 1887-88) it wasfound that 358, or 79.4 per cent. , of the 451 vaccinatedcases of small-pox under ten years of age hadbeen vaccinated by public vaccinators, who had onlyperformed 63 per cent. of the successful primary vaccinationsfor the ten-year period up to the epidemic ; ¹hence it follows that small-pox picked out the workof the public vaccinators , whose skilful and successfulperformances had qualified each operator for a Governmentgrant. Again, Sheffield Park, North Sheffield,and West Sheffield-the districts of the borough whichwere the most seriously afflicted with small-pox-hadthe largest percentage of their successful primary vaccinations,for the ten years previous to the epidemic,performed by public vaccinators ; whereas Ecclesall andUpper Hallam, with the smallest percentage, came offthe lightest of all the districts of Sheffield.The large proportion of three or four-mark cases ofsmall-pox in very efficiently vaccinated towns, as in thecase of Willenhall, strongly condemns the theory. Ofthe 681 vaccinated persons attacked in which thenumber of scars was known, 374, or 54.9 per cent. , hadfour marks , and 536, or 78.7 per cent. , had three or fourmarks, while the one-mark cases only amounted to 24,or 3.5 per cent. of the whole.1 Report on an Epidemic of Small- pox at Sheffield ( 1887-88 ) , pp. 185 ,187 ; Tables xcvii. , xcix .212THE MITIGATION THEORY.Before concluding the chapter, the opinion of Dr.George Gregory, the distinguished predecessor of Mr.Marson at the London Small-pox Hospital, is worthrecording. In the twenty-fourth volume of the " Medico-Chirurgical Transactions " ( 1841 , pp. 23, 24), after detailingseveral cases, he says :-" It follows, I think, fromthese cases, that the cicatrix cannot be relied on asaffording any certain test of the degree to which theconstitution has imbibed an anti-variolous influence. "Another authority (Dr. Fleetwood Churchill) observes:-" For some years I have only made one(puncture), on account of the severe inflammationwhich sometimes results from two or more, nor haveI had any reason to suppose that my object was notas completely attained. " ¹The more recent authorities also deprecate the " marktheory. " Thus, Dr. Birdwood observes that, in regardto primary vaccination, he advocates " the productionof one vaccine vesicle only ; " 2 and Dr. Ricketts writes-" Considering that scars vary in size and in appearancein the course of years , and that vaccinia must beregarded as a specific fever, it is not at first sightapparent what the characteristics of the inoculationcicatrices have to do with the amount of protectionafforded. But, after all, it is a question of fact, which,provided proper observations are made, ought to be,and can be settled in course of time by such statistics. "1 " The Diseases of Children," p. 821. ( Third edition. ) FleetwoodChurchill, M.D. Dublin. 1870.2 Sixth Report, Royal Commission on Vaccination. Q. 31,221 .3 Report of the Metropolitan Asylums Board for 1893 , p. 134.DR. COUPLAND'S FIGURES. 213Some observers, besides those already mentioned,obtained equivocal results. Dr. Dalton' gives thefollowing experiences :-Marks.I2345 or moreCases. Fatality per cent.126 24171 5'3177 2.8140 07932.2Also Dr. Coupland, who gives the following for theDewsbury epidemic :-Marks.I234 or moreCases. Deaths. Fatality per cent.3400175 10 5.7210 0042 I 2.4There is thus very slender evidence to show that theprotection depends upon the number or character ofmarks, and the little that exists is mainly affordedby the earlier statistics, such as Marson's, which it isobvious are inaccurately founded.From the foregoing facts it is evident that themitigation attributed to vaccination depends largelyupon the elimination of cases from the vaccinated lists,rather than to any real modification of the disease, andthis is borne out by the fact that the fatality of smallpoxin 1871-72, when a large proportion of the caseswere admittedly vaccinated, was as great as the averagefatality of the last century.1 " Small-pox in its Relation to Vaccination," p. 23. J. H. C. Dalton,M.A. , M.D. , B.C. ( Reprinted from the Medical Chronicle, October, 1893. )2 Final Report , Royal Commission on Vaccination, Appendix iii. , p. 115 .CHAPTER VII .RE -VACCINATION .THE admission that re-vaccination is necessary, is adeparture from the original position taken up by theprofession. It was not only Jenner who was so positiveabout the lifelong protection afforded by vaccination ,but his opinion has been endorsed by the highestauthorities at a later period. Sir John Simon says :-" On the conclusion of this artificial disorder (vaccination),neither renewed vaccination, nor inoculation withsmall-pox, nor the closest contact and cohabitation withsmall-pox patients, will occasion him (the vaccinatedperson) to betray any remnant of susceptibility toinfection. " "When this theory, upon which all vaccinationlegislation was initiated and justified, was discovereduntenable, that of re-vaccination was introduced.Instances of both mild and severe attacks of smallpoxtaking place at all periods after re-vaccinationare numerous. I propose to give a few of these. Mr.Badcock, the celebrated small-pox cow-pox vaccinator,relates his own personal experience : " Towards1 " Papers relating to the History and Practice of Vaccination, " p. xiv.1857.FAILURE OF TRIPLE VACCINATION . 215the end of the year 1836, I suffered severely from adangerous attack of small -pox, which happened buta few months after re- vaccination. " ¹ We also havethe experience of Mr. Justice Grantham :-" He impressedon the anti-vaccinators the peril they wereincurring to themselves and their neighbours by theiropposition to inoculation, and in support of his argumentsas to the effect of vaccination, stated that he,after having been twice inoculated, had an almostmiraculous recovery from an attack of small - pox ,which, in its incipient stages, was as bad as itcould be. " 2The following case shows the complete failure ofthree successful vaccinations to prevent a severe attackof small-pox. It is recorded by Dr. T. C. Wallace inthe American Medical Times of March 1 , 1862 (vol. iv. ,p. 122). The patient, Charles Nichols, aged thirty - fivehad an " extraordinarily severe " attack of confluentsmall-pox, and Dr. Wallace observed that he hadnever seen anyone so completely covered with pustules.The man had a large scar on the right arm,resulting, he informed Dr. Wallace, from vaccinationwhen a child, and a similar one on the left arm, dueto vaccination three years prior to attack. He wasagain vaccinated on the 24th of December, 1861 , thevesicle being " fully formed, large, and well filled," thevaccination being accompanied by some slight constitutionalsymptoms. He was attacked with small-pox1 " A Detail of Experiments confirming the power of Cow- pox, etc. ,"p. 11. John Badcock, chemist . Brighton. 1845 .2 Sussex Daily News, April 9, 1896 .216 RE - VACCINATION .on the 8th of January, 1862 , just fifteen days afterthe third vaccination .The British Medical Journal of December 7, 1872(vol. ii. , p. 643 ), reports a meeting of the Medical Societyof the College of Physicians in Ireland, when Dr. Darbyfurnished statistics of small-pox cases treated in theRathdown Union Hospital ; thirteen of the cases werere- vaccinated, with one death. At the same meeting,Dr. Grimshaw alluded to three re- vaccinated cases ofsmall-pox admitted to the Cork Street Hospital, oneof which was fatal .In a letter to the British MedicalJournal of December9, 1876 (vol. ii. , p. 774), Mr. R. G. Kellett wrote that,during an epidemic at Bilston, Staffordshire, in 1871-72 ,he re- vaccinated himself, his wife, and his two servants .Although the vaccination took well in all, each in turndeveloped small-pox, " certainly of a most abortive form ,not more than a dozen spots or so appearing on any ofus, but still it was small-poх."The same journal¹ also reports some cases of smallpox,which came under the observation of the HealthDepartment of Brooklyn, the statistics being furnishedto the Brooklyn Eagle, by Dr. J. H. Raymond, theHealth Commissioner. Among these is that of a child,aged three, who died of small - pox notwithstandingthat she had been well vaccinated in infancy and oncelater.In the Homerton Hospital Report for 1878 (pp. 23-25),Dr. Gayton gives six cases of small -pox after re-vaccination,with the following particulars :-1 British MedicalJournal, vol . i. , p. 749. ( May 20, 1882. )DR. GAYTON'S CASES. 2171. " Kate King, aged twenty, admitted February 18 ,1878 , three imperfect marks ; eruption very discrete;was placed on ' Full Diet ' February 22 , 1878 , and dischargedMarch 14, 1878. The re-vaccination wasstated to have been performed five years ago, withsuccess . The patient did not remember upon whicharm it was done, therefore the cicatrices observedmay have been due to either the primary or thesecondary operation, as no others were visible . "2. " John Wist, aged twenty - seven, two good marks ;admitted March 7, 1878, with discrete small -poxThe patient reported that he had been vaccinatedthree times in the course of his life; the first ininfancy, the operation succeeding ; the second at thetime of joining the Metropolitan Police, at twenty- twoyears of age, and that this took ' very slight ; ' thethird and last time, six months before becoming apatient, by a medical man in Whitechapel, but withouteffect. He was also positive that the two cicatricesseen upon the left arm were the result of the primaryoperation, as the sore left by the secondary one soonhealed up and left no marks. "3. " Samuel Fish, aged twenty-three, admitted March21 , 1878 , three imperfect marks ; eruption confluent,general symptoms very severe. Discharged cured June17, 1878. Was vaccinated in infancy, and again whenten years old. The certificate of re-vaccination in thiscase was produced, but it could not be satisfactorilydetermined to which operation the cicatrices were tobe attributed."4. " James Connelly, aged thirty-nine ; admittedMarch 30, 1878, with five marks, three good and two15218 RE - VACCINATION .imperfect, the eruption being discrete. He was puton ' Full Diet ' on April 1 , and transferred April 13 ,1878. The patient, an old soldier, stated that he wasre- vaccinated when in India about four years ago, andthat the operation was very successful. There werethree well foveated cicatrices close together, the extentof surface being about the size of a shilling. "5. " Ellen Clark, aged twenty- one, with one imperfectmark, admitted April 10, 1878, with small- pox of thehæmorrhagic form, and died April 12, 1878. Was saidto have been re- vaccinated, and arm to have beenslightly sore for three or four days, but no cicatrix,except the one referred to , could be traced. "6. " E. Williams, aged three years, admitted April 25 ,1878 ; eruption discrete. On April 27 had ordinary diet,and on May 18 discharged. Was stated by parents tohave been ' vaccinated when an infant,' one imperfectmark being now visible as the result. Six weeks ago ,in consequence of small-pox having occurred in thehouse, she was again vaccinated in four places, all ofwhich were attended , apparently, by some result. Themarks seen , reddish- brown in colour, were small in size,and not indented."In the Deptford Report for the period from April,1878 , to December, 1879, Dr. John MacCombie detailsthe following experience ( pp . 7, 8 ) :-I. " William W. , at. nineteen ; admitted May 13 ,1878. Three imperfect marks of primary vaccination ;re- vaccinated at. sixteen, two re-vaccination marks ;discrete attack ; discharged June 10."2. " Matilda B. , at. twenty ; admitted May 31 , 1878 .Two imperfect marks of primary vaccination ; reDR. MACCOMBIE'S CASES. 219vaccinated at. sixteen, three re-vaccination marks ;discrete attack ; discharged June 20. "3. " Caroline P., at. twenty-three ; admitted July 11 ,1878. Five imperfect marks of primary vaccination ;re -vaccinated at. ten and sixteen. She stated that shehad a ' sore arm ' on both occasions, but there wereno re-vaccination marks ; discrete attack ; dischargedAugust 22."4. " Emma S., at. twenty- one ; admitted July 25 ,1878. Two good marks of primary vaccination ; fourmarks of re-vaccination performed at the age of nineor ten ; discrete attack ; discharged August 31. "re-5. " Lucy H. , at. forty- two ; admitted August 5 , 1878 .Two imperfect marks of primary vaccination ;vaccinated at. twelve ; one re -vaccination mark ; discreteattack ; discharged August 22."6. " Sarah H. , at. thirty-six ; admitted August 13.1878. Three imperfect marks of primary vaccination ;three marks of re- vaccination performed at the ageof sixteen ; attack confluent ; discharged July 23 ,1879."7. " Fanny C. , at. thirty- three ; admitted March 11 ,1879. One imperfect mark of primary vaccination ;re - vaccinated at. twenty -one, on left arm in two places.There were no re-vaccination marks, but patient statedthat her arm was sore, and that the medical man towhom she showed it a week after the operation wasperformed said ' it was doing all right.' She died ofblack small -pox on March 14. "8. " Sarah P. , at. twenty- one ; admitted April 18, 1879 .Said to have been vaccinated in infancy, but therewere no marks. Has three marks of re- vaccination220 RE - VACCINATION .performed at the age of eighteen ; discrete attack ;discharged May 5. "9. " Fanny L. , at. thirty - six ; admitted October 13 ,1879. Three imperfect marks of primary vaccination ;two marks of re-vaccination performed at the age ofthirty- one ; discrete attack ; discharged November 8 ,1879."10. " James H. , at. twenty- seven ; admitted November8 , 1879. One good mark of primary vaccination ;re - vaccinated at. fifteen. Stated that he had a ' sorearm ' after re- vaccination. No marks ; discrete attack ;discharged December 12. "1Elsewhere Dr. John MacCombie says-" For myself,I am inclined to believe that small-pox after successfulre-vaccination is not infrequent. " Apparently anextended experience has not modified his views, forquite recently he says-" Some persons who havebeen successfully re-vaccinated do, however, contractsmall- pox. Of such cases observed by me the timeintervening between the re-vaccination and the attackof small -pox varied from one to twenty - five years ;the average being ten years." * And further on inthe same work he makes further admissions when hesays " it is impossible in all cases to promise immunityfrom attack or even from death after vaccination andre -vaccination. " "In the Homerton Hospital Report for 1881 (p . 11 ), Dr.Collie gives details of three cases after re -vaccination.1 " Transactions of the Epidemiological Society , " vol. iv . , part ii . , p. 193 .(Sessions 1877-78 and 1878-79. )Allbutt's " System of Medicine, " vol . ii . , p. 207. London. 1897.3 Ibid. , p. 222.DR . COLLIE'S CASES. 2211. " Henry P. , at. nineteen, admitted November, 11 .Primary vaccination in infancy ; re- vaccination sixyears ago ; three marks on right arm, two on left, butpatient cannot differentiate them ; all imperfect. Transferredto ' Atlas ' December 7. Mild discrete attack .(Admitted from City and sent in City ambulance. ) "2. " Emma P. (sister of above), at. twenty-two,admitted November 26. Primary vaccination in infancy; five imperfect marks ; re-vaccination six yearsago ; no marks, but said to have taken well ; againre - vaccinated on morning of November 5 ( firstsymptoms of small-pox on November 21 ) , seems tohave taken well. Transferred to ' Atlas ' December 7 .Mild discrete attack. ( Admitted from City and sent inCity ambulance. ) "3. " Ada J. , at. twelve, admitted December 12.Primary vaccination in infancy ; two imperfect anddoubtful marks ; re-vaccination six months ago ; patientsays it took well ; one imperfect and doubtful mark .Mild discrete attack. ( Sent by Hampstead in Hampsteadambulance . ) "These cases, together with those recorded by Dr.Gayton and Dr. MacCombie, have, through the courtesyof the Clerk, Mr. Duncombe Mann, been copiedverbatim from the reports of the Metropolitan AsylumsBoard. I wish to commend them to those who affirmthat compulsory re-vaccination would effectually extinguishsmall-pox.The following cases of small - pox, within shortperiods of re-vaccination, are given in the SheffieldReport.No. .NameAwgheena. ttackedVaccinationandr.-veaccinationi.innfancyEAH6l..5izabeth2912 Elizabeth J. 1872NShoerftfhield FW4.i5lliam2771 -SNhoerftfhield SG5a.rah12ΙΟΙSouth Sheffield 8FannyC.7PageofReport .District .1Ec3c9lesallPS8ha7erfkfieldΙΟΙSShoeuftfhield J3Wo.seph29VaccinatedovRafaencsdcuilntastionv.-reaccination-,cwTmiehaclrraletkreeidces-qtisuhnqarcurehatereers.airneas--,csvoORiiqannecxuceaetacthirrneiaxted,.1O8c8t7oberVaccinated.iinnfancy-vRaeccinated.,S1e8p8t7.Vaccinated.iinnfancy-vRaeccinated.i1n886Vaccinatedin infancy .v-Raeccinated1.i8n84Vaccinatedininfancy ..ianrceha,ccgTilohcaorastdsereicesa.isoornqvnecueeaharre,-cwmTieawclraoltkreidces-tsiohqnniucerahdre.area-lcwTmaiehar-lrrglekeeed,-chooaaannntleedrfices.iiasnnrqceuhaares.cTimwcaaoltlricescm-,wTieahclrraltekreeidces-iqtsnuhqcaruhreatereers.airneao-cssOiiqnncxueateathrreix.iainrnecah-fcwFmaieoaiclurrallr-kyed,-ttisorhnqniicuecrhaedrse.airnea.-cvsORiamneccaaecltilrniaxted.1i8n85Vaccinated.iinnfancyc-wTdmieheaclreralepkeeds,tqtruqhiarucreaeterseers.aiinrnceah.-cwvmRTieaaewclcraolctkireniadctesed.1i8n82C.-ospfmhoaaxlrlacterstAhuolaflvfeeegreedd-isfDpnmreoaocxlm-le;,1er8mu8bp7etrion:rtoohihnnagelnhytd.esanlpnosoyetwshereF,-iSpnemobaxrlularym,;av1ite8tlr8ady8ckf.,istdnlepeioleondtltsa-sopMtmfoitaxlaldclk1,;iN8no8v7ember.pniotttedmEaotifxtltadrcekmelyO,-ispnmcoatxlolber,;ipn1lio8ltt8t7ed.fdoauyrsteensaomVmtfieatlrladylc-kp,ia1nb8oo8xu8t,.pstnipwotoettnistnygsSoefmvaelrlepaotxtack1D;,in8e8c7ember.pbiatdtleydDR . DALTON'S CASES. 223In the Report of the Metropolitan Asylums Board for1890 (pp . 55-57), we learn that, during the year, twentysixpatients were admitted for small-pox, and two ofthese died. The first, aged twenty- six, had been unsuccessfullyvaccinated at nine months of age, andsuccessfully vaccinated when about ten years of age,and the scars were obscured by the eruption. Theother death was in a man aged forty-four, who hadbeen three times successfully vaccinated, once ininfancy, and again at seven and twenty-one years ofage. Five of the twenty- six patients were unvaccinated, and none of these died.Dr. Dalton, ¹ in his critical examination of 1,000 casesof small -pox, gives a list of sixty -one persons taking thedisease from one to forty years after re-vaccination. Ofthese, seven, or 11.5 per cent. , died, or a higher fatalitythan that for his 1,000 cases (8.5 per cent. ) .If any further evidence were required to demonstratethe futility of re- vaccination, it is furnished by theArmy and Navy Reports. Staff- Surgeon T. J. Prestoninformed the Royal Commission (Q. 3,270) that in 1883" three cases occurred in the ' Audacious,' which werecontracted at Shanghai. All three men had been successfullyre -vaccinated-one in 1880, one in 1881 , andthe third in 1882. The disease was of a very mildform , and the men were but slightly marked. "On p. 63 of the " Statistical Report of the Health ofthe Navy for the year 1881 , " dated 1882, there is areference to nine cases occurring on the " Eclipse," on1 " Small - pox in its Relation to Vaccination, " p. 25. J. H C. Dalton ,M.A. , M.D. , B.C. ( Reprinted from the Medical Chronicle, October, 1893. )224 RE - VACCINATION .the East Indies Station. " The first case, in the personof a leading seaman, aged thirty- one, was contracted atRangoon, where small-pox had been lately prevalent,and proved to be a severe case of the confluent form ofthe disease. The patient had been re-vaccinated twoyears before. He was taken ill on the 19th April ; therewas a copious confluent eruption, with high fever anddelirium. On the arrival of the ship at Trincomalee, hewas landed at a bungalow on Sober Island, where hedied on the next day, 28th April. On the 29th April,a second case appeared, in the person of an able seaman ,aged twenty-seven, who was at once landed in thetemporary hospital ; in his case the eruption was alsoconfluent, and he died on the eleventh day of thedisease. He is said to have been successfully re-vaccinatedfour years previously. " There were seven othercases, several of which were severe, and all of themvaccinated and re- vaccinated.¹With regard to the army, the tract before alluded toinforms us that the men are always re-vaccinated onentering the force, and it states (p. 7) that " officialexperience in England and abroad has shown thatsoldiers who have been re-vaccinated can live incities intensely affected by small-pox without themselvessuffering to any appreciable degree from thedisease."Brigade - Surgeon Nash, when examined before theRoyal Commission, also agreed ( Q. 3,559) that in the( Revised by the1Second Report , Royal Commission on Vaccination. Q. 3,284.2 Facts concerning Vaccination for Heads of Families.Local Government Board, and issued with their sanction. )RE - VACCINATION IN THE ARMY. 225army vaccination and re-vaccination was as perfect asendeavours could make it, and yet he handed in a listof 3,953 small -pox cases, with 391 deaths, for the years1860-88 . In 1889, among the troops in Egypt, therewere 42 cases of small-pox, with 6 deaths. These, onthe strength (3,431), give an attack - rate of 12,241 ,and a death-rate of 1,749 per million ; the attack-ratebeing six times that of Leicester, and five timesthat of Keighley, and the death - rate fifteen timesthat of Leicester and eight times that of Keighley inthe recent epidemics in these notoriously unvaccinatedtowns.The Army Medical Report for 1889 states (p. 190) :—" A detachment of the Ist Battalion Welsh Regiment wasstationed at Assouan during the latter part of 1888 andthe early part of 1889 ; during that time an outbreak ofsmall -pox occurred among the native population, andthe disease broke out among the troops ; two cases alsooccurred on the voyage from Assouan to Cairo. Notwithstandingall the precautions taken in Cairo, anddue regard having been paid to vaccination and revaccination,the disease kept on the increase, and in themonth of May presented signs of doing so still further.The Welsh regiment, which suffered most, was inKasr- el - Nil barracks, which are situated near a crowdedthoroughfare and on the banks of a navigable river. Itbeing more than probable that the disease was derivedfrom natives, the Welsh regiment, on the recommendationof the Principal Medical Officer, was removed toAbbassiyeh , where the situation is healthier and intercoursewith the natives could be prevented. Small-pox,the Principal Medical Officer, Deputy- Surgeon General226 RE -VACCINATION.Jameson, remarks, is always more or less prevalentamong the natives in Cairo, and, indeed throughoutEgypt, and as there exists no means of segregatingaffected cases, it is certain that patients in various stagesof the disease are permitted to walk about, and tofrequent bazaars and streets to the great danger ofthe public."If we take the figures over a long period, the resultsare the same.¹ Thus, in Egypt, in the fourteen years,1882-95 , there were 233 cases and 25 deaths fromsmall-pox among the troops, or an average annualattack- rate of 3,004, and a death- rate of 322 per million .The Indian army, during the same period, furnished691 cases and 68 deaths, the rates being 768 and 76 permillion respectively ; while in Leicester the rates wereonly 204 and 13 per million (446 cases and 29 deaths) .I may mention that the comparison is unfair to Leicester ,for the army consists of picked men living at a comparativelyinsusceptible period of life.The following cases extracted from a report bySurgeon I. Boulger, of the Army Medical Staff, relateto the small-pox which prevailed among the troops atCairo in 1885 :-" Private A. W-, 2nd East Surrey Regiment, agetwenty- three ; service, three years. Marks, three right(good). Re-vaccinated on enlistment ; modified. Admitted,4th December, 1884 ; discharged, 8th January, 1885-thirty-six days. This was a mild case ;See Appendix.2 " Report of a series of cases of smallpox which occurred amongst theBritish troops in Cairo from January to October, 1885. " Appendix to theArmy Medical Report for 1885, pp. 443-450.RE - VACCINATED SMALL- POX IN CAIRO. 227symptoms preceding eruption were well marked, suchas lumbar pain, vomiting, pyrexia ; but the eruptionwas scanty ; discrete throughout ; slight secondaryfever ; no pitting. "" Private F. A-, 2nd East Surrey, age twenty- three ;service, three and a quarter years . Marks , one right(good), three left (fair). Re-vaccinated on enlistment ;modified. Admitted, 2nd February, 1885 ; discharged,15th May, 1885-one hundred and three days. Patienthad been under treatment in hospital for a month withsecondary syphilis, when symptoms of small-pox appeared.The attack was most severe , of the confluenttype. Convalescence was delayed by large boils onlegs, and for a long time he was in a very anæmicstate. Skin much pitted. "" Private J. K-, 2nd East Surrey, age twenty- eight ;service, five and a half years. Marks, two right (good) ,one left ( faint). Re-vaccinated on enlistment ; modified.Admitted, 2nd February, 1885 ; discharged, 22ndMarch , 1885-forty-nine days. Was of the confluentvariety. Temperature before eruption appeared, 103 °Fahr. Patient very robust ; there was a large quantityof eruption, and it went on to maturation, though withoutmuch secondary fever. No complications ; throatwas sore ."Sapper J. H-, Royal Engineers, age twenty- five ;service, three years. Marks , two right (good). Revaccinatedon enlistment ; modified. Admitted, 2nd.February, 1885 ; discharged, 22nd February, 1885-twenty - one days. Very mild ; discrete ; eruptionscanty, but went on to maturation ; no complications ;no pitting ; desquamation rapidly completed. "228 RE -VACCINATION ." First -class Staff-Sergeant E. F-, Medical StaffCorps, age thirty-two ; service, fourteen years. Marks,two left (good), two right (fair). Re-vaccinated, 18thAugust, 1870 ; failed. Re-vaccinated, 2nd March,1876 ; perfect. Admitted, 2nd February, 1885 ; discharged,21st February, 1885-nineteen days. Verymild case ; very little eruption, and it never wentbeyond the vesicular stage ; had most severe initialsymptoms . The lumbar pain was intense, and twentyfourhours before eruption appeared, he had a wellmarkedattack of dry pleurisy on the left side ; thefriction sound was very marked, and the temperature,103 ° Fahr. "" Private F-, 2nd Royal Sussex, age twenty- two ;service, three years . Marks, two right and two left(faint). Re-vaccinated, 2nd February, 1882 ; perfect.Admitted, 22nd February, 1885 ; discharged, 13thMarch , 1885-eighty- two days. Very severe ; initialsymptoms, vomiting, lumbar pain, pyrexia very marked ;eruption preceded by a scarlatinous prodromal rashover pubes, and at flexures of joints. Eruption copious,confluent on face and forehead ; went on to suppuration,but there was not much secondary fever. Large,soft crusts formed on face when the pustules ruptured,and convalescence was long delayed owing to theadherence of these crusts."" Private P , 2nd Royal Sussex, age twenty-one ;service, two years. Marks, two left (fair). Revaccinated24th May, 1883 ; modified. Admitted 21stMarch , 1885 ; discharged, 4th May, 1885-forty - fivedays. Severe case. Eruption confluent, with markednervous symptoms ; eruption went on to pustulation ;RE -VACCINATED SMALL- POX IN CAIRO . 229secondary fever high ; extensive crusts formed on face ;desquamation was long delayed ; slight pitting. "" Private C-, 2nd Royal Sussex, age twenty-three ;service, four and a third years. Marks, two left (good ).Re-vaccinated, 2nd December, 1881 ; modified. Admitted24th March, 1885 ; discharged, 2nd May, 1885-forty days . Case of average severity ; semi-confluent.Eruption plentiful, and went on to pustulation. Nocomplications ; desquamation slow."" Lance - Corporal S-, 2nd Royal Sussex, agetwenty - three ; service, three and a quarter years .Marks, two right (good) , four left (fair). Re-vaccinated, 1881 ; modified. Admitted, 25th March, 1885 ;discharged, 21st April, 1885-twenty-eight days. Verymild case ; eruption scanty ; no secondary fever of anyconsequence ; pustules formed and soon dried up ;desquamation rapid. "" Private M-, Ist Yorkshire Regiment, age twenty ;service, two years . Marks, three right (good) . Revaccinatedon enlistment ; modified. Admitted, 16thApril, 1885 ; discharged, 16th May, 1885-thirty- onedays. Case of average severity. Eruption copious,but discrete ; went on to suppuration. No complications,except severe sore throat. "" Private O-, 2nd Royal Sussex, age twenty ; service,two years . Marks, three left (good). Re-vaccinated,25th August, 1883 ; modified. Admitted, 29th April,1885 ; discharged, 5th June, 1885-thirty-eight days .Case of average severity ; initial symptoms severe.Eruption copious, but discrete ; went on to pustulation ;not much secondary fever. No complications or pitting ;desquamation tedious. "230 RE - VACCINATION ." Private A-, 2nd Royal Sussex, age twenty ; service,two years. Marks, three right (good). Re-vaccinated,25th May, 1883 ; perfect. Admitted, 11th May, 1885 ;discharged, 22nd June, 1885-forty- three days. Case ofaverage severity. Eruption copious, but discrete ; wenton to formation of pustules ; very little secondary fever.No complications ; desquamation much prolonged. "" Private MacF-, Ist Gordon Highlanders, agetwenty- six ; service, five and two-thirds years . Marks,three left (very faint). Re- vaccinated, 10th October,1879 ; modified. Admitted, 20th May, 1885 ; died28th May, 1885-nine days. " ( Man contracted smallpoxwhile under treatment for syphilis at the hospital. )" Private J-, 2nd Duke of Cornwall's Light Infantry,age twenty- four ; service, four years. Marks, two left(good) . Re-vaccinated on enlistment ; modified . Admitted,24th June, 1885 ; discharged, 21st July, 1885-twenty - five days. Very mild case ; but the eruptionwent on to pustulation. Eruption scanty and discreteeverywhere ; no secondary fever ; desquamation rapid."" Private S-, Ist Royal West Kent, age twentytwo; service, three years. Marks, three left (good).Re- vaccinated , 1882 ; modified. Admitted, 27th June,1885 ; discharged, 12th August, 1885-forty - sevendays. " ( Muscular pains, followed by vomiting andrise of temperature. Copious discrete eruption all overbody, rapidly going on to pustulation ; desquamationtedious.)" Private F-, 2nd Oxford Light Infantry, age twenty ;service, two years . Marks, two left (good). Revaccinated, July, 1883 ; perfect. Admitted 15th July,1885 ; discharged, 12th August, 1885-twenty-nineRE - VACCINATED SMALL- POX IN BERLIN . 231days. Mild case; usual initial symptoms, and whichwere well marked. Eruption appeared on 17th ; wasscanty, and principally on forehead and face ; discreteeverywhere. Papular became vesicular on 19th,and then proceeded no further, but rapidly desiccated.No secondary fever. Case was complicated with slightsore throat ; desquamation rapid."" Lance - Corporal G-, Mounted Police, age twentysix; service, six years. Marks, four left (faint). Revaccinated,25th September, 1879 ; modified. Admitted30th July, 1885 ; died, 3rd August, 1885 - five days. "(Surgeon Boulger here gives details of the case, whichappeared to be of the hæmorrhagic variety. )In the 1870-72 epidemic at Berlin ' we have figureson a still larger scale. There were 1,036 re-vaccinatedcases of small- pox, and of these 162 are reported tohave died . This is a fatality of 15.6 per cent. , or verylittle less than the average fatality of small-pox duringthe last century in England, and over two and a halftimes that of unvaccinated Leicester in the recentepidemic.A statement which is always quoted as indisputableevidence of the special protective power of re-vaccination,is the alleged immunity of small-pox hospitalattendants.If re- vaccinated nurses do not take small -pox, asaffirmed, abundant evidence has been adduced to showthat this is not the case with re-vaccinated soldiers ;and hence it is clear that the nurses' immunity1 " Zeitschrift des Königlich Preussischen Statistischen Bureaux," p. 119.Berlin . 1873 .232 RE -VACCINATION.(such as it is) is rather a function of being nurses, thanof being re-vaccinated. Moreover, unre-vaccinatedattendants have had a like immunity, as shown bythe experience of M. Colin at the Bicêtre Hospitalanimmunity, it may be noted, which was not sharedto so marked a degree by the re -vaccinated. He foundthat out of nearly two hundred attendants on thehospital staff, almost all of whom had been re- vaccinatedunder his own eyes, fifteen were attacked with smallpox,with one death ; while among the forty doctors andchemists attached to the establishment, and among theforty nuns who took care of the patients night and day,and who lived in the centre of the hospital, none wereattacked, in spite of the fact that the greater numberof the staff, and a large number of the nuns neglected.to get themselves re-vaccinated. 'Examples of immunity, even when strongly exposedto small-pox, have also been observed in the unvaccinated; these have been alluded to in an earlierchapter. The following personal experience, detailedin a letter , dated March 10, 1897, from one of theManagers of the Metropolitan Asylums Board, is acase in point :-" In answer to yours of the 2nd inst. I was elected asManager to the Metropolitan Asylums Board in March,1892 , and placed on the Small-pox Hospital ShipsCommittee at once. This Committee meets at theShips every fortnight, except during holidays ; a surprisecommittee visits the ships in the intervalsbetween the Committee meetings. I generally visit1 La Variole, pp. 84, 114. Léon Colin. Paris. 1873 .IMMUNITY OF PLAGUE ATTENDANTS. 233the wards, speak to the patients, examine the bedcardsto ascertain the vaccinal state of the patients.The number of patients, according to the AnnualReports , admitted to the ships from 1802 to 1896inclusive is 4,952 ; and I have no doubt that I haveseen from 3,000 to 4,000 patients suffering from smallpox,and some of these cases twice or thrice. Mycase is stronger than you put it. I have not evenbeen vaccinated, or had small-pox to my knowledge ;the reason I was not vaccinated, I understand, beingthat I was too delicate in my young days to besubjected to the operation. "Apparently small-pox is not the only zymotic diseasein which an immunity of hospital attendants hasbeen observed, for Dr. James Cantlie, in his interestingreport on the recent outbreak of bubonic plague inHong Kong, specially alludes to the fact, that " nonurse, male or female, concerned in attendance at thehospitals devoted to plague, contracted the disease.""It is not quite manifest why persons frequentlyexposed to contagion should be immune. M. Colin,a strong advocate of vaccination, felt called upon togive some explanation of the cases coming under hisnotice, and he suggested that a certain tolerance wasacquired by repeated exposures. Of course, this mayor may not be true ; but whether the theory beaccepted or not, it is clear that some other explanationof the alleged immunity of the hospital attendants,than the one usually given, must be sought forto meet all the facts of the case.1 British Medical Journal, vol. ii. , p. 425. (August 25, 1894. )16234 RE - VACCINATION.Reference is often made to the German army. SirJoseph (now Lord) Lister, at the annual meeting ofthe British Association in 1896, is reported to have saidthat small-pox " is absolutely unknown in the hugeGerman army, in consequence of the rule that everysoldier is re-vaccinated on entering the service. " ¹In a letter to the Times of September 23, 1896, Mr.Trobridge pointed out that the ordinance enforcing revaccinationon all recruits, came into force on June 16,1834, and that it provided for at least ten insertionsbeing made in each arm ; and he quoted the evidenceof Dr. Arthur F. Hopkirk, who informed the RoyalCommission that he believed the law was alwaysobeyed ; and those men who refused were tied downand vaccinated by force ( Q. 6,799).The following are the figures for small-pox in theGerman army since 18252 :-Small-pox.Year. Cases . Deaths . Year.Small-pox.Cases. Deaths .1825 ? ... 12 1836 ... 130 91826 ? 16 ... 1837 ... 94 31827 ?23 1838 III ... 71828 ?... 35 1839 ... 89 21829 ?... 33 1840 ... 74 21830 ? 27 1841 ... 59 31831 ? 108 ... 1842 ... 99 21832 ?... 96 1843 ... 167 31833 ? 108 ... 1844 ... 69 31834 ... 619 38 1845 ... 30 I1835 ... 259 5 1846 ... 30 I1 The Times, September 17 , 1896 .2 " Beiträge zur Beurtheilung der Nutzens der Schutzpockenimpfung,"pp. 23 , 24. Berlin. 1888.SMALL- POX IN THE GERMAN ARMY.Small-pox.Cases. Deaths .235Small-pox .Cases. Deaths . Year. Year.1847 5Ο 186897 I1848 22 I 1869 108 ... I1849 62 I ... 18701 41 01850 ... 176 I 1870-712 ... 2,879 1641851 246 3 18713 828341852 87 I 1872 ... 389 121853 138 I 18734 26 2...1854 121 3 1873-745 22 1 ...1855 12 1874-75 26 0...1856 21 Ο 1875-76 20...1857 ... 35 I 1876-77 ... 19 Ο1858 64 Ο 1877-78 12 Ο...1859 58 2 1878-79 ... 15186044 3 1879-80 ... 701861 ... 56 4 1880-81 ... 230186225 I 1881-82 16 Ο...1863 90 Ο 1882-83 ... 9Ο1864 120 I..1883-84 ... 7 Ο1865 69 I 1884-85 ... 7 161866918 1885-86 6 Ο1867 188 2 1886-87 ... 7 ΟIt will thus be seen that since the year 1834, therehave been 7,505 cases and 291 deaths from small-pox inthe German army, and hence Lord Lister's statement isobviously inaccurate. On March 31 , 1897, at a meetingpresided over by the Duke of Westminster for theFrom January to June, 1870.2 From July , 1870, to June, 1871 .3 From July to December, 1871 .4 From January to March, 1873 .From April 1 , 1873 , to March 31 , 1874.The above death was of a man who was twice unsuccessfully revaccinatedwhen recruited.236 RE -VACCINATION.purpose of raising a fund for a national memorial toEdward Jenner, Lord Lister took occasion to modifyhis original statement. He excused his previous utteranceby saying that he had " quoted from memory afterreading an authority on the subject," and added that" if he had stated that ' fatal ' small-pox was absolutelyunknown in the German army he should have beenspeaking the literal truth. " With an exception in1884-85 , it is quite true that there have been no deathsfrom small -pox in the German army since 1874-75 ;but Lord Lister must be aware that " in consequenceis usually held to imply an effect following on a cause,and that it is scarcely clear, without further explanation,why we should wait for half a century for the allegedeffect of something which commenced to operate as analleged cause in 1824. In other words, Lord Listerin order to make good his case, even as amended,should account for the small - pox deaths in theGerman army since 1834, and more particularly the210 deaths in 1870-72, for whatever the vaccinalcondition for some years subsequent to the enactmentin 1834, all authorities agree that the Germanarmy was a thoroughly well re-vaccinated body in1870-72. The decline of small-pox and other zymoticdiseases in recent years in the German army is dueno doubt, as Mr. Trobridge has suggested, to the" great wave of sanitary reform which spread throughoutthe newly-formed German Empire in 1872, andwhich has reduced the general death- rate from 29 per1,000 living in that year to 24 per 1,000 in 1887. "1 The Times, April 1 , 1897 .SMALL - POX IN THE FRANCO-PRUSSIAN WAR. 237Another statement which is frequently appealed to is,that during the Franco- Prussian War, 23,469 died fromsmall-pox in the French army, whereas the Germanarmy only lost 263 from this disease, the differencebeing attributed to want of re-vaccination in theFrench army. In 1883 Dr. W. B. Carpenter refers tothe subject thus : " In Germany, vaccination is compulsoryin children under a year old ; and everyman on his entrance into the army is re-vaccinated.In France, on the other hand, vaccination is notcompulsory, and re-vaccination is not enforced onarmy- recruits. During the Franco-German War of1870-71 the total number of deaths from small-pox inthe German army was 263, while in the French army itwas 23,469, or very nearly ninety times as great. " ¹On June 19, 1883 , Sir Lyon, now Lord Playfair,triumphantly reproduced the statistic with greateffect in the House of Commons, in a speech whichis reputed to have influenced more votes than anyspeech ever made in Parliament. Mr. Ernest Hartgives us the authority for the statement. " Totaldeaths from small-pox in German army (where revaccinationwas rigorously enforced), 263 ; in theFrench army (where re-vaccination was neglected),23,469. Cf. Colin : La Variole."Now, there does not appear to be any authority forsaying that re-vaccination was not enforced in theFrench army, and exception must also be taken to1A letter to the Right Hon. Lyon Playfair, C. B. , M.P. , F.R.S. , p. 8.William B. Carpenter, C.B. , M.D. , F.R.S. London. 1883.* British Medical Journal, vol. i. , p. 1217 , foot-note. (June 23, 1883. )238 RE -VACCINATION.the 23,469 French soldiers reported to have died ofsmall -pox. Mr. Alexander Wheeler followed up thisstatement as soon as it was uttered, and he receivedassurances from the French War Office that there wereno official medical statistics taken out during the periodof the war in 1870-71 .According to the " Wiener Medizinische Wochenschrift,"¹ this figure (23,469) would appear to havebeen taken from a French source of information ; andDr. Hopkirk informed the Royal Commission that ithad been recently confirmed from Paris (Q. 1,543),that he believed the confirmation was official (Q. 1,654) ,and, moreover, an " absolute fact " (Q. 6,774) ; but whenhe was confronted with the French official records, inwhich it was stated that the medical statistics in 1871-72 were wanting (Q. 6,778-6,782), he was obliged toadmit that he was not aware of any figures on whichthe calculation was based ( Q. 6,787) .It appears that the statistic rests on certain figuresgiven by M. Colin for the garrison at Paris. Heestimated that there were about 1,600 small -pox deathson an effective strength of 170,000 men, indicating asmall-pox mortality of 94 per cent. The number23,469, it is said, was obtained by applying this ratioto the whole army of France .When Dr. Carpenter found that the statement he hadmade was incorrect, he most honourably retracted it1 " Wiener Medizinische Wochenschrift ," p. 896. (August 31 , 1872. )* See also " Rapport sur la Vaccine," p. 47. Proust. 1889.* La Variole, p. 58. Léon Colin. Paris. 1873 .* Letter from Dr. Jeunhomme to Dr. Collins. Sixth Report, RoyalCommission on Vaccination, Appendix, p. 727 , foot - note.SMALL- POX IN THE FRANCO - PRUSSIAN WAR. 239in the Daily News of August 7, 1883. He says, " Irequested Earl Granville to obtain what information hecould on this point ; and after considerable delay, I havereceived through Colonel Cameron (military attaché tothe Embassy in Paris) an explicit statement that thearmy medical returns of the Franco-German War areso incomplete as not to supply the total for whichI asked."Mr. Ernest Hart, whom I have also mentioned asgiving currency to the statement, has reproduced thediscredited statistic quite recently ( 1897). He refersto " the following utterances of M. de Freycinet whenMinister of War in 1890," and then quotes him asfollows :-" One now sees, not only in France, but inAlgeria, in Tunis, and in Tonquin, the army protectedby the strict application of compulsory vaccination.I cannot forget that, in 1870-71 , the Germanarmy, counting a million vaccinated and re-vaccinatedmen, only lost 459 men from small-pox in the twoyears, whereas our army, far less numerous, had, fromthe same cause, a loss of 23,400 men whom theprescient application of re - vaccination might havesaved for the service of France." This quotationfrom a report by M. de Freycinet, dated June 16,1882, is apparently taken from the sixth volume ofthe Royal Commission Evidence (Appendix, p. 727),which was published subsequently to Mr. Hart's article,and Mr. Hart has omitted to notice an asterisk at theend of the quotation ; this refers the reader to a footnotecontaining a letter from Dr. Jeunhomme to Dr.1Allbutt's " System of Medicine," vol. ii. , p. 662. London. 1897.240 RE - VACCINATION .Collins, in which Dr. Jeunhomme states that no officialdocuments exist, and he proceeds to explain how thestatistics for the whole army have been arrived at bycalculation from the estimate given by M. Colin ofthe small -pox mortality of the army in Paris .Even if the 23,469 statistic were true, it would beabsurd to compare the small-pox mortality of thestrong, resolute Germans, conscious of victory, withthat of the cowed, worn, starved , and discomfitedFrench. As it happens, the figure is a pure assumption;but no statement has probably ever been quoted withmore telling effect, or done such service to the causeof compulsory vaccination .CHAPTER VIII .INFLUENCE OF SANITARY MEASURES ON THEINCIDENCE AND MORTALITY OF SMALL- POX .THE influence of sanitation as regulating the attackand death-incidence of small-pox has already beenalluded to in various parts of this work, more particularlyin the third chapter, dealing with the causesof the decline of the disease. Since that chapter waswritten, a resolution has been adopted by the JennerSociety, signed by a large number of medical officersof health, denying the sufficiency of sanitation as apreventive of small -pox, and affirming that " the onlytrustworthy protection at present known against smallpox,alike for the individual and the community, isefficient vaccination in infancy and subsequent re-vaccination,and that the only effective way of stampingout epidemics of this disease lies in the free use of theseagencies." It is necessary, therefore, to deal with thisimportant branch of the subject more fully.The views of the Royal Commission may be gatheredby the following quotations extracted from their FinalReport."The question how far the behaviour of small-pox in theeighteenth century and earlier was influenced by sanitary conditions,is one rendered difficult by the lack of exact information .We may distinguish between overcrowding as one insanitary242 INFLUENCE OF SANITARY MEASURES.condition and all other insanitary conditions, such as lack ofcleanliness and the like. A priori we should expect that a densepopulation, especially one of great internal movement, and onein continual interchange with surrounding populations, by offeringgreater facilities for the conveyance of contagion, would leadto a greater amount of small-pox. " ( Section 78. )" We might a priori expect the other acknowledged imperfectsanitary conditions of the eighteenth century to increase thefatality of, and so to a corresponding extent, the mortality fromsmall-pox; but there is no exact evidence to confirm this supposition." ( Section 78. )" In general both the incidence of, and mortality from, smallpoxseem to have been far less affected by sanitary conditionsthan might à priori have been expected." ( Section 78. )" Admitting à priori that crowded dwellings tend to increasethe liability to contagion, and so the prevalence of the disease,while other insanitary conditions tend in addition to increase thefatality among those attacked, so that insanitary conditions asa whole must tend to increase the mortality from small-pox ; noevidence is forthcoming which distinctly shows that the dependenceof the prevalence of, or the mortality from, small-pox, on thelack of sanitary conditions, was a feature of the history of smallpoxduring the eighteenth century. " ( Section 79. )" Whatever may have been the sanitary improvements duringthe first quarter of this century in England and some othercountries, there seems no ground for supposing that throughoutWestern Europe the period was marked by great changes in thedirection of improved sanitation. Indeed, in many countries downto a recent period, in some it may perhaps be said even to thepresent time, insanitary conditions have continued to prevail ."(Section 81. )" There is no proof that sanitary improvements were themain cause of the decline of small -pox under discussion. Andno adequate evidence is forthcoming to show to what extentsuch improvements may be considered as a subsidiary cause."(Section 82.)" We have already pointed out that small-pox tends at timesto become epidemic, i.e., to spread more readily than at otherVIEWS OF THE ROYAL COMMISSION. 243times. The occurrence of the conditions, whatever they may be,which cause the disease to be thus epidemic has of course norelation to the state of the population as regards vaccination,even conceding to the full that it has a protective effect. Theonly result of widespread vaccination, in a case where small-poxbecame epidemic, could be to render the extent of the epidemicmore limited, and its fatality less than it would otherwise be."(Section 144.)" It is beyond doubt that an infectious disease like small -poxis, other things being equal, more likely to spread in towns thanin country districts, and more likely to spread in crowded towndistricts than in others not so densely populated ; so that weshould expect a lessened proportion of overcrowded dwellings,by diminishing the opportunities for contagion, to check the prevalenceof the disease and consequently to render its mortalityless. " (Section 147.)" We have already pointed out that on à priori grounds it isreasonable to think that improved sanitary conditions would tendto diminish the fatality of, and so to a corresponding extent themortality from, small -pox. And there can be no doubt that theperiod with which we are dealing has been characterised by animprovement of this description. There has been better drainage,a supply of purer water, and in other respects more wholesomeconditions have prevailed. " ( Section 151. )" We do not mean to indicate an opinion that sanitary improvementshave been without an effect on small-pox mortality, but onlythat, when all the changes which have occurred are considered, itcannot be asserted that they afford an adequate explanation of thediminished mortality from small-pox. " (Section 153. )" We fully recognise that sanitary improvements have had aneffect in reducing the mortality from small-pox as from the otherdiseases to which we have just been referring." ( Section 166. )If these various quotations and fluctuating opinionsare summed up, they amount to this. The Commissionstate ( 144) that the occurrence of the conditionswhich cause small-pox to be epidemic has no relation244 INFLUENCE OF SANITARY MEASURES.to the state of the population as regards vaccination.They also imply (481¹) and admit (494¹ ) that someother reason than vaccination must be sought for toexplain the decline of small-pox. They allow thatovercrowding, which is distinctly an insanitary condition,accentuates the disease (78 , 79, 147). Theyalso admit that other insanitary conditions have someinfluence (78, 79, 151 , 153 , 166). They say that sanitaryimprovements act especially in the direction ofdiminishing fatality (79, 151), although there is noproof that they are the main cause (82), and thatthey cannot be asserted to form an adequate explanationof the diminished mortality from small -pox ( 153) .I am not at all sure that those who favour the viewthat sanitary measures are responsible for the diminutionof small-pox will be disposed to quarrel with theseconclusions ; my own reading of the Report is that theCommissioners, in their desire to state the case fairly,have been obliged, somewhat reluctantly, to admitsufficient to seriously discredit the point of view forwhich they are arguing. I do not know that it hasever been seriously maintained that the amelioration ofinsanitary conditions is the only cause of the decline ofsmall-pox, as others have been suggested, to which Ihave alluded in my third chapter, but that insanitaryconditions are among the principal causes of the prevalenceand mortality of this complaint must, I think,1 In section 481 the Commissioners refer to the experience of Leicester ;and in section 494 to the recent decline in small-pox in the Metropolis,and they add-" We think it is impossible to attribute this change tovaccination ."OPINION OF LORD SHAFTESBURY . 245be allowed. The purport of the present chapter is tosupply further evidence under this heading.A prominent feature of small-pox is that it has beenconfined almost exclusively to the lower stratas ofsociety, or among those who live in the least favourablesanitary conditions. In Austria, small-pox is calledthe " beggars' disease," and in this country it is largelyspread by tramps, who not only live under unhealthycircumstances, but are frequently deprived of thecommon necessaries of life .Mr. John Cross found that at Norwich, in 1819, thesmall-pox epidemic was " confined, almost exclusively,to the very lowest orders of the people. "'In the Provincial Medical and Surgical Journal forDecember 22 , 1852, in an article entitled, " Report onSmall-pox, as it occurred during three Epidemics inthe practice of the Canterbury Dispensary between theyears 1837 and 1848," Mr. Rigden says, concerning thethird epidemic (p. 682), that " The most severe cases,and the greatest number, existed, generally speaking, inthe districts most thickly populated by the lower orders,and most badly drained. "In the debate on the Compulsory Vaccination Bill of1853 , Lord Shaftesbury confessed that it was perfectlycorrect " that the small-pox was chiefly confined to thelowest class of the population, and he believed thatwith improved lodging- houses the disease might beall but exterminated. "1 " A History of the Variolous Epidemic which occurred in Norwich inthe year 1819, " p. 7. John Cross, M.R.C.S. London. 1820.Hansard's Parliamentary Debates, third series, vol. cxxv. , p. 1012 .(April 12 , 1853. )246 INFLUENCE OF SANITARY MEASURES.The Medical Times and Gazette of February 11 , 1871(vol. i. , p. 159), in referring to mistakes in diagnosis,indicates very plainly the class of people and themiserable environment of those who took small-poxin the 1871-72 epidemic, and observes :-" Medicalmen cannot be too cautious in such a matter ; butwhen it is considered that the diagnosis has often tobe made under most unfavourable circumstances, indark corners of ill- lighted rooms, amidst the discomfortsof squalid surroundings, chattering women, andsqualling children, often by candle-light, and uponindividuals where the dirt upon the skin is apt toobscure otherwise distinct signs, while the patientsare too stupid to reply clearly to questions, thedrift of which they are at a loss to comprehend ,one cannot altogether wonder at occasional occurrenceof error."Likewise at Birkenhead, in 1877, Mr. Francis Vacher ,the Medical Officer of Health, noted that " an overwhelmingmajority of the sufferers in this epidemic(consisting of 603 cases of small-pox) were derivedfrom the labouring class, and the remainder-six onlyexcepted-from the artizan class. " The six exceptionsalluded to were two professional men, two clerks ,an insurance agent, and a shipbroker.Dr. Savill, in his report on the Warrington epidemicfor the Royal Commission, has pointed out that all buteleven of the 455 infected houses were rated at lessthan £ 16 per annum, and 406 of them at £8 or lower ;1 " Notes on the Small -pox Epidemic at Birkenhead in 1877 , " p. 16 .2 Final Report, Royal Commission on Vaccination , Appendix v. , p. 87.RESULTS OF SANITARY IMPROVEMENT. 247and Dr. Coupland found that at Dewsbury the incidenceof the disease with but few exceptions fell uponmembers of the working class community.On the other hand, it has been observed that inindustrial dwellings, where the poor are aggregatedunder strict sanitary supervision, there has been amarked immunity from small-pox. Thus Dr. SouthwoodSmith observed that " There has been in theimproved dwellings complete exemption from typhus,cholera, and it may be added small-pox ; yet it mustbe admitted, that other forms of zymotic diseasescarletfever, measles, whooping-cough, and diarrhoeahaveoccurred, though rarely, and these maladies havein no instance spread." 2 Dr. Collins and Mr. Pictonalso report that they learn from the secretary ofthe Improved Industrial Dwellings Company that in1880-82 there were but 2 deaths from small - poxamong more than 15,000 tenants, while there were3,268 small -pox deaths in those years in London witha population of 3,800,000.3In the Fifth Annual Report of the Registrar- General ,dated 1843 , will be found replies from MetropolitanRegistrars relative to the sanitary state of their districts.A number of these testify to the occurrenceof small -pox and other zymotic diseases in the poorestand most filthy parts of their districts, from which Ihave taken the following :-1 Final Report, Royal Commission on Vaccination, Appendix iii. , p. 28.2 " Results of Sanitary Improvement," p. 17. Southwood Smith, M.D.London. 1854 .3Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 231 .248 INFLUENCE OF SANITARY MEASURES.The Registrar of the north-east district of Chelsearemarked that the crowded buildings in his districtare more fatal to the first four classes of cases (smallpox,measles , scarlatina, and whooping -cough) than toany of the others (p. 486).The Registrar of the Hanover Square district ofSt. George, Hanover Square, reports (pp. 487, 488) thatthe districts which suffered most from contagious andepidemic diseases were Oxford Buildings, Brown Street,Hart Street, Toms Court, George Street, GrosvenorMarket, Grosvenor Mews, and Thomas Street. " TomsCourt," he says , " contains eight houses ; inhabitantsin a wretched state in many cases, partly from wantof employ, partly intemperance. Small-pox and epidemicshave raged here. "The Registrar of the Rectory division of Marylebonestated (p. 498) that the greatest number of deaths fromsmall -pox , measles , and scarlet fever occurred in YorkCourt and Calmell Buildings. He further stated thatYork Court , Calmell Buildings, and Gray's Buildingsappeared to be the unhealthiest portions of the district.He added that the drainage of York Court was bad,that of Calmell Buildings " good ; or rather middling ; "the inhabitants complained of the inefficiency of thewater supply, and the districts were anything butcleanly. According to the previous year's census, theinhabitants of one house ranged from fifteen to seventy,the greatest number known to sleep in one room beingeleven . He remarked that Calmell Buildings, which wasprincipally inhabited by the Irish poor, was a narrowcourt about twenty- two feet in breadth, and the houses,three storeys high, were surrounded and overtopped byINSANITARY CONDITIONS. 249the adjacent buildings ; the drainage was carried on bya common sewer running down the centre of the court,and the lower apartments, especially the kitchens, whichwere underground, were damp and badly ventilated,light and air being admitted through a grating on alevel with the court. At all times, but especially inwarm weather, most offensive effluvia were perceptibleeverywhere. According to the previous year's censusthere were 944 inhabitants, and the number of personsin one house varied from two to seventy (p. 499).The Registrar of the St. Mary division of Marylebonestated (p. 501 ) that " the few cases of small -pox whichoccur in my district are invariably amongst the poor,"but that the other zymotic diseases named were notconfined disproportionally to any parts or class ofinhabitants.The Registrar of the Gray's Inn Lane division ofSt. Pancras remarked that the small-pox, measles, andwhooping-cough had been most prevalent in certaindistricts, which included Battle Bridge, comprisingBritannia, George, Charlotte, Field, and ParadiseStreets, with many small courts and places leadingtherefrom. He stated that in the Battle Bridgedistrict' the condition was extremely bad, the streetsbeing unpaved and impassable, occasioned by quantitiesof rubbish and filth thrown thereon. The watersupply was generally very good, but drainage verybad in many places, and great want of cleanlinessuniversally.1 The district known as Battle Bridge formerly occupied the site onwhich King's Cross Station now stands.17250 INFLUENCE OF SANITARY MEASURES.He forwarded the accompanying statement, whichbears upon the subject under consideration (p. 506)." I beg to state," he says, " that I adopted the plan ofsearching all the register books from November , 1837 ,to the present time. I made columns, headed by thenames of the several diseases, and as they appeared inthe books, placed the names of the streets in whichdeaths occurred ; this plan gave me at once the meansof ascertaining amongst what particular classes theseveral diseases most prevail. I found between 50 and60 cases of small -pox, the whole of which, with twoexceptions only, are confined to the occupants of thelowest habitations ; between 15 and 20 cases of typhus ,occurring only amongst the lower classes ; 60 or 70cases of measles, in the proportion of about two to oneamongst the lower classes ; of whooping- cough between80 and 90, occurring in about the same proportion asthe measles ; of scarlatina between 70 and 80, whichappeared to prevail without regard to circumstances orplace; very few cases of diarrhea, dysentery, cholera,and influenza, and those not confined to any particularpart. The population of my district is 22,149. "In the St. Anne division of the Strand the Registrarobserves ( p. 523)-" Of small-pox in 1838 there werethirty - one cases ; in 1839, none ; in 1840, two ; in 1841 ,five ; and in 1842, eight. Of those in 1838, three werein Falconberg Court, three in St. Anne's Court, andfour in Crown Street. These are poor places , anddensely peopled ; in Falconberg Court and CrownStreet there are some Irish. The remaining cases aredispersed over the parish. "The report of the Registrar of the Goswell StreetSALUTARY EFFECT OF OPEN SPACES . 251division of Clerkenwell is of interest as illustrating theeffect on small -pox and other zymotic diseases of agood system of drainage, combined with abundant openspaces. The Registrar found that there had been noepidemic prevalent in his district since the commencementof registration (July 1 , 1837). This is the moreremarkable as the opening years of registration wereoccupied with one of the most disastrous small -poxepidemics of the present century. " The whole district,"he remarks, " with the exception of about a hundredhouses, has been built on since the year 1806 ; it isbounded on the south and west by spacious streets ;on the north and east by two great roads, and throughits centre runs the high road to Islington. It containsthree large squares, with the vast area occupied by theNew River- head. The whole district belongs to fourgreat proprietors, namely, the Marquis of Northampton ,the New River Company, the Brewers' Company, andthe Skinners' Company, who secured by their buildingleases as perfect a system of drainage as can probablybe found in any part of the Metropolis " (p . 527) .The Registrar of the north-west division of the Cityof London observed that at " Christ's Hospital (occupiedby eight hundred Blue-coat boys) there are not morethan one or two deaths in a year, the diet and hoursbeing regular, and the wards lofty and cleanly " (p. 542).The Registrar of the St. Leonard's division of Shoreditch,reported (p. 547)-" The whole of my districthas been particularly healthy during the last twelvemonths , except in the winter of 1840 and 1841 , whensmall -pox prevailed with great fatality in New Courtand Old Court, Hackney Road. They were the only252 INFLUENCE OF SANITARY MEASURES.unhealthy parts of my district, the small-pox havingbeen introduced into the place by travelling gypsiesand other vagrants occupying the huts in these courts :since which time they have been well cleansed andpurified by the parish authorities , and have sincebeen in a very healthy state, and are well suppliedwith water. "In the Church division of Bethnal Green the Registrarstated that the greatest number of deaths in theunhealthy parts of his district took place from smallpox, measles, scarlatina , whooping - cough, diarrhea ,influenza, and typhus ; these places were entirely withoutdrainage ; there was a great want of cleanliness,and with regard to the water supply there was butone hand-cock to many houses. He observes that inmany cases six persons occupied a room of ten feetsquare by eight feet high (p. 551 ).The Registrar of the Borough Road division of St.George, Southwark, observed that there was scarcely astreet or court in his district which had not been visitedby small -pox, measles , or whooping-cough. The supplyof water was plentiful, but drainage very deficient ;cleanliness little attended to by a great number, andthere was extreme overcrowding ( p. 580) .The Registrar of the Kennington district of Lambethstated that small-pox was most rife in WandsworthRoad, Spring Place, and the poor streets of SouthLambeth. The water supply was good, but drainagebad and the district dirty, and in winter frequentlyinundated. The neighbourhood was also thickly populated,from three to five persons sleeping in a room.In Hamilton Street in the Wandsworth Road was aINSANITARY CONDITIONS. 253filthy open ditch called the Corporation CommonSewer, which the Registrar considered to be veryunhealthy (pp. 586, 587) .The Report of the Registrar-General on the state ofthe public health in different parts of England andWales, during the year 1856, shows how the minds ofotherwise sensible people may overlook facts and beunconsciously warped by the vaccination dogma. TheRegistrar of Bury South ascribes the entire absence ofsmall-pox " to the attention paid to vaccination, " andthe freedom from other zymotic diseases " to the greatimprovement which has taken place in the last tenyears in the sewering, paving, and cleansing the streets ,and to the regulations under the Improvement Bill forcommon lodging- houses. " ¹In the Twentieth Annual Report of the Registrar-General, it is stated (p. xxiv.) that " the deplorableneglect of sanitary measures, and the extent to whichthe lives of the poor people of Dudley are sacrificed,may be inferred from this one appalling fact : ' smallpoxwas fatal in fifty- one cases. " The Twenty-secondReport (p. xxiv.) states that " In the South- Westerndivision, Wilts, Dorset, and Devon suffered an unusuallyhigh rate of mortality; scarlatina, diphtheria,and small - pox have proved fatal in many cases.' Sanitary arrangements are far from good in manyhouses,' not only of Abbotsbury, where three deathsoccurred in one house over drains in the worst possiblecondition, but it is to be feared in many other parts ofthese great counties."1 Nineteenth Annual Report of the Registrar- General, p. xxxiv.254 INFLUENCE OF SANITARY MEASURES.In 1864 the Registrar of the St. Helen's sub-districtof Prescot writes to the Registrar-General thus :-" The deaths exceed the average considerably. Themortality has been greatest among children in consequenceof the prevalence of scarlatina and small-pox.One hundred and twenty deaths occurred from scarlatina,and twenty- four from small-pox. Small-pox ismost prevalent in that part of the town noted for itsdefective sanitary arrangements, and inhabited principallyby the Irish. In this portion of St. Helen's, theevils arising from want of sewers, unpaved streets, smalland unhealthy dwellings, are still further increased bythe crowding of several families in one house, and anentire absence, apparently, of all ideas of cleanliness. " ¹In 1855 , or about two years after vaccination wasmade compulsory, we have the following notable wordsfrom Dr. Southwood Smith :-“ Overcrowding, for example,we can prevent; the accumulation of filth intowns and houses we can prevent ; the supply of light,air, and water, together with the several other appliancesincluded in the all-comprehensive word Cleanliness, wecan secure. To the extent to which it is in our powerto do this, it is in our power to prevent epidemics.The human family have now lived together in communitiesmore than six thousand years, yet they havenot learnt to make their habitations clean. At last weare beginning to learn the lesson. When we shall havemastered it , we shall have conquered epidemics. " ?1 Twenty- seventh Annual Report of the Registrar-General, p. Ixiv.2 Two Lectures delivered at Edinburgh in November, 1855 , entitled,"Epidemics considered with relation to their common nature, and toclimate and civilisation ," p. 23.HOW SMALL- POX IS PROPAGATED . 255In 1871 , during the great small-pox epidemic, severalimportant testimonies crop up in favour of the viewthat small-pox is controllable by sanitary measures.Mr. Henry Carr, in a letter to the Times of February 9 ,1871 , under the heading, " How small- pox is propagated," writes-" I pray your insertion of the followingreport of one visit of inspection among the habitationsof the poor in Westminster :-St. James's Court, St.Ann's Street. This is a blind court, no thoroughfareand no through ventilation ; the entrance a narrowarchway, three feet wide ; the houses, two rooms each,opposite ; the space between the opposite houses notmore than five feet; at the end of the court a dead wall,dust-heap, etc. No back windows or doors . Only onecloset for the whole court, and that at times in mostfoul condition. At present in this court there aresixteen families-sixty- five persons." Then follows aminute description of insanitary horrors, coupled withabounding small -pox as the natural result. From alater issue of the Times (February 15, 1871 , ) it appearedthat the authorities inspected St. James's Court,and that the whole court was condemned as unfit forhuman habitation .In the Lancet of January 14, 1871 ( vol. i. , p. 63 ), underthe heading of " Small-pox in Belfast," is the following:-" From a circular lately issued by the Poor-lawCommissioners of Ireland relative to the spread ofsmall -pox in Belfast, we find that seventy-nine caseshave occurred there, resulting in nine deaths, sinceMarch, 1870. The Commissioners point out to theGuardians of the Belfast Union that, when the diseasehad been imported into other parts of Ireland, it has256 INFLUENCE OF SANITARY MEASURES .either not spread or quickly died out, and that itsbreaking out into an epidemic at Belfast is probablyowing to two causes-namely, the dangerous sanitarycondition of parts of the town, and the very defectivestate of the vaccination ."In the same volume, under the date March 18, isan article by Dr. Grieve, medical superintendent tothe Hampstead Small -pox Hospital. In some concludingremarks Dr. Grieve observes (p. 372)-" Badas this epidemic when upon us may appear to be, letus hope that it will bear fruits of good results. Alreadyunder its pressure our sanitary reformers are on themove ; and the report of the Sanitary Commission justcomes in time. It is to be hoped that this epidemicof small -pox will be the last of its kind ; that it willprove to be, as it were, the boundary-stone placed tomark the place where the old rule of complete localself-management was replaced by that of a propercentralisation under a competent head ; and that thereign of confusion, in which Boards of Guardians,Vestries , Local Boards, and other intractable bodieshave to be coaxed and wheedled into doing theirduty, is fast drawing to an end. We look forwardwith pleasurable anticipation to that time when, underthe firm rule of a Minister of Public Health, sanitarymeasures will be judiciously and vigorously enforced ,and zymotic diseases-small-pox among the numberwillbe driven out of our island as effectively as St.Patrick banished reptiles from Ireland."Even from the writings of so pronounced a vaccinepropagandist as Mr. Ernest Hart is the following admissionregarding an epidemic of small-pox at Douglas,DR. FARR'S TESTIMONY.1257Isle of Man, in 1877 :-" The disease spread veryrapidly, especially in the filthy purlieus of the old town,until, between July 8, 1877, and March 11 , 1878, no lessthan 257 cases occurred." It is true that Mr. ErnestHart observes that there was no system of compulsoryvaccination in the Isle of Man, and thus a number ofthe sufferers may well have been among the unvaccinated,which only shows from what class theunvaccinated are usually drawn, and how absolutelyunfair it is to compare their small-pox incidence andmortality with that of the better fed, better housed, andmore cleanly vaccinated population .One of the greatest sanitary reformers, Dr. WilliamFarr, has said that " healthy sanitary condition as tofood, drink, and cleanliness of person, house, and city,stands first in importance ; after it, but surbordinately,come quarantine, vaccination, and other preventives, asmeans of subduing mortality ; for the mere exclusion ofone out of many diseases appears to be taken advantageof by those other diseases, just as the extirpationof one weed makes way for other kinds of weeds in afoul garden. " 2Another eminent sanitarian, Sir Edwin Chadwick,mantained " that cases of small-pox, of typhus, and ofothers of the ordinary epidemics, occur in the greatestproportion, on common conditions of foul air, fromstagnant putrefaction, from bad house drainage, fromsewers of deposit, from excrement-sodden sites, fromfilthy street surfaces, from impure water, and from overBritish Medical Journal, vol. ii. , p. 78. (July 17, 1880. )2 Supplement to the Thirty- fifth Annual Report of the Registrar -Generalp. xli. ( 1875. )258 INFLUENCE OF SANITARY MEASURES.crowding in foul houses. That the entire removal ofsuch conditions by complete sanitation and by improveddwellings is the effectual preventive of diseasesof those species, and of ordinary as well as extraordinaryepidemic visitations . " 1The two following statements, printed within aboutsix months of each other, if taken together, almostentirely concede the case. The British Medical Journalstated that " all sanitarians are agreed that insanitaryconditions greatly favour the spread of small - pox , " andDr. W. B. Carpenter admitted " that in the generalmitigation of the type of this disease (small -pox), andin the enormous reduction in its mortality which havetaken place during the last hundred years, the improvedsanitary condition of our population (evinced by areduction in the general death-rate) has had a largeshare. " 3Another authority, Dr. August Hirsch, maintainedthat " small-pox, as well as typhus, takes up its abodemost readily in those places where the noxious influencesdue to neglected hygiene make themselvesmost felt . " 4With reference to sanitation in Europe generally,the reader who is interested in the subject may with1 Printed copy of addresses on " Prevention of Epidemics," pp. 22, 23.Delivered by Mr. Edwin Chadwick, C. B. , at Brighton Health Congress ,December 14 , 1881 .* British Medical Journal, vol. ii . , p. 801. ( October 21 , 1882. )The Nineteenth Century, p. 527. (April , 1882. )4 " Handbook of Geographical and Historical Pathology," vol . i . , p. 481 ,by Dr. August Hirsch. Translation by Dr. Charles Creighton. London.1883.BERLIN PREVIOUS TO 1872 . 259advantage consult a work by Dr. T. M. Legge on the" Public Health in European Capitals. " ¹It is claimed by Dr. Edwardes, Dr. Charles Drysdale,and Mr. Ernest Hart, with endless reiteration, that thenotable reduction of small-pox in Germany during thelast two decades is due to vaccination and compulsoryre-vaccination. On page 38 Dr. Legge observes that,prior to 1872, the drainage in Berlin was of the mostprimitive description ; privies were in nearly everyhouse ; open drains, badly built, and with insufficientfall, ran through many of the streets , and dischargedtheir contents into the Spree, the pollution of whichbecame well-nigh intolerable. On page 10 he informsus that between 1871 and 1892 the Corporation ofBerlin spent on buildings connected with publichealth, including waterworks, drainage, sewage farms ,hospitals, asylums, abattoirs, disinfecting stations, nightshelter, infirmary, and public baths, nearly £9,500,000,or, on an average, about £450,000 a-year. This largeoutlay appears to have been judiciously expended, foron page 41 Dr. Legge says that, since the introductionof the drainage works, the total mortality has declinedfrom 32.9 per 1,000 in 1875 to 20.2 in 1892, and he alsopoints out the enormous reduction in the mortality fromtyphoid fever during the period under review.From the foregoing it is evident that neglect of sanitarymeasures is very largely responsible for the prevalenceand mortality of small-pox as well as of otherzymotic diseases. As the late Sir B. W. Richardson1 " Public Health in European Capitals." Thomas Morison Legge,Μ.Α. , Μ.Ι) . ( Oxon. ) , D.P.H. London. 1896 .260 INFLUENCE OF SANITARY MEASURES.most aptly puts it-" If by some magic spell , Englandcould wake up to- morrow clean, she would wake up purealso in spirit and godly in the comprehensiveness ofgoodness. Cleanliness covers the whole field of sanitarylabour. It is the beginning and the end. Practised inits entirety it would banish all disease from the world."Another cause of the lessened fatality of small -pox isthat better methods of treatment are now in vogue thanthose which prevailed formerly. Anyone reading thepages of Sydenham cannot fail to have been struckwith the distressing results of the treatment practised inhis time. This was known as the hot regimen. Thepatient was put to bed, the blankets were piled up overhim, every breath of fresh air and all light was carefullyexcluded from his room, and he was plied withhot cordials.This distinguished medical reformer protests againstthis treatment, and says-" We must take especial care,lest the ebullition rise too high. This it may do underthe weight of blankets, under the over-heated state of theair in the apartment of the patient, or under the use ofheating medicines and cordials."" " From the use ofyourvaunted cordials, and from your hot treatment," he says ," the pustules may be crowded together and renderedconfluent. " 2 Again he observes-" Had they (pustules)been left to their own pace they would merely havebeen discrete, and the chances would have been better. " 3" Medical Observations. " The Works of Thomas Sydenham, M.D.Translation from the Latin edition of Dr. Greenhill, with a life of theauthor, by R. G. Lathom, M.D. , vol. i. , p. 134. Printed for the SydenhamSociety . 1848 .Ibid. , p. 135 . Ibid. , p. 139.SYDENHAM'S TREATMENT OF SMALL- POX. 261In speaking of his own more rational method oftreatment :-" This is the true and genuine methodof treating this sort of small-pox, and however muchit may be opposed by the great and unfounded prejudiceof the partisans of an opposite practice, it is themethod which will prevail when I am dead. I willnot deny that many have been treated on a differentprinciple, and that under such treatment they haverecovered . On the other hand, it must be confessedthat many have died under it. And this, when we considerthat the disease of the distinct sort is in no wisedangerous of itself, is a sad reflection . " ¹Sydenham must have felt saddened at the prevailingignorance when he wrote " Considering thepractices that obtain, both amongst learned andignorant physicians, it had been happy for mankind,that either the art of physic had never been exercised,or the notion of malignity never stumbled upon. " *Sydenham was greatly in advance of his age,and consequently was subjected to the unmeasuredopprobrium of his contemporaries.1 " Medical Observations ,” vol. i. , p. 142. Printed for the SydenhamSociety. 1848 .Letter to Mr. Robert Boyle, vol. i., p. lxxii .3 Sydenham's writings are full of appeals to his colleagues to trust moreto Nature in the cure of disease . " Frequently, however, it is less fromthe character of the morbific virus than from the effects of unskilful treatmentthat such severity has occurred. We often attend too little to theintentions of Nature in the cure of disease, and set up on insufficientgrounds some different method of cure. From this arises a perturbationof the whole bodily economy, and, this being upset, a melancholy stateof things , worse than that of the original disease, is induced. " ( Vol. i. ,p. 98. )In referring to the pleasant sensations produced among his patients by3262 INFLUENCE OF SANITARY MEASURES." To crown my misfortunes," he observes, " it hassometimes happened that, after the standers-by hadrejected my advice throughout the whole disease, Ihave still been held answerable for the loss of thepatient ; and this has happened after I have talkedmyself hoarse against the heating treatment of thefriends and nurses. For reasons like this, I have oftenthought that it would be better for me never to undertakea case of small-pox, than to oppose the insuperableprejudices of the οι πόλλοι.”In spite of the teachings of Sydenham, these barbarousmethods of treatment continued to prevail, forin the eighteenth century we find much the same statethe cool regimen, he observes-" This has often made me draw a differencebetween the deceptions of reason (so-called) and the realities of oursenses ; from whence I infer that-provided that they be not absolutelyunreasonable, and deadly-much more than is usually given should beallowed to the appetites and sensations of the patients themselves. Theseare better than the treacherous rules of art. E.g. , a fever-patient ardentlylongs for cooling drinks freely bestowed. Art denies them. Art hasa theory of its own. Art has an end and aim of its own. Art assumesthat cool liquors are adverse to its doctrines : and so starves an appetite,giving a cordial instead. The same patient loathes all food , unless accompaniedby diluent drinks. Art - the art of nurses and lookers - oncontends that he must eat . After a long languor, he probably asks forsomething absurd , or prejudicial , and asks earnestly. Art is again in theway, and threatens death in case of disobedience-unless, indeed, theartist be wise enough to remember Hippocrates :-more bad than good,whether food or drink, if palatable, is preferable to more good than bad,ifunpalatable. A man of moderate medical practice, but ofdiligent observation, will freely own, that many patients who have spurnedphysic and followed their own inventions, have been the better for doingso." (Vol . ii . , pp. 67 , 68. )1 Letter to Dr. Cole. The Works of Thomas Sydenham, vol. ii ,p. 66.A PARALLEL. 263of things recorded. Buchan,' in his " Domestic Medicine,"remarks on the practice of confining the patienttoo soon to bed and plying him with warm cordials andsudorific medicines, thereby increasing the number ofpustules and tending to make them become confluent." The good women," he says, " as soon as they see thesmall -pox begin to appear, commonly ply their tendercharge with cordials, saffron, and marigold-teas, wine,punch, and even brandy itself. All these are given witha view, as they term it, to throw out the eruption fromthe heart. " Buchan also comments on the practice ofcrowding patients together, which reminds us of thedisgraceful state of things which prevailed at theGloucester Hospital in the recent epidemic. He says-" Laying several children who have the small-pox inthe same bed, has many ill consequences. They ought,if possible, never to be in the same chamber, as theperspiration, the heat, the smell, etc. , all tend to augmentthe fever, and to heighten the disease. It is commonamong the poor to see two or three children lying inthe same bed, with such a load of pustules that eventheir skins stick together. One can hardly view a sceneof this kind without being sickened by the sight. Buthow must the effluvia affect the poor patients, many ofwhom perish by this usage ? "In a foot - note he remarks " This observation is likewiseapplicable to hospitals, workhouses, etc. , wherenumbers of children happen to have the small-pox atthe same time. I have seen about forty children cooped1 " Domestic Medicine," pp. 241-244 . William Buchan, M.D. ( Tenthedition. ) London. 1788 .264 INFLUENCE OF SANITARY MEASURES.up in one apartment all the while they had this disease,without any of them being admitted to breathe the freshair. No one can be at a loss to see the impropriety ofsuch conduct. It ought to be a rule, not only in hospitalsfor the small-pox, but likewise for other diseases,that no patient should be within sight or hearing ofanother. This is a matter to which too little regard ispaid. In most hospitals and infirmaries, the sick, thedying, and the dead are often to be seen in the sameapartment. " On the other hand, Buchan had seen poorwomen travelling in the depth of winter, and carryingtheir children afflicted with small-pox along with them,and had frequently observed others begging by thewayside, with infants in their arms covered with thepustules ; yet, he says, " I could never learn that one ofthese children died by this sort of treatment." He alsoobserves-" A very dirty custom prevails amongst thelower class of people, of allowing children in the smallpoxto keep on the same linen during the whole periodof that loathsome disease. This is done lest they shouldcatch cold; but it has many ill consequences. The linenbecomes hard by the moisture which it absorbs, andfrets the tender skin. It likewise occasions a bad smell,which is very pernicious both to the patient and thoseabout him ; besides, the filth and sordes which adhere tothe linen being resorbed, or taken up again into thebody, greatly augment the disease. "Writing in the early part of the present century, Mr.John Cross, in his history of the Norwich small-pox11 " A History of the Variolous Epidemic which occurred in Norwich inthe year 1819," pp. 11 , 12. London. 1820.THE EFFECTS OF FRESH AIR. 265epidemic, stated that the disease was often aggravatedand made to assume its worst characters by the mostinjudicious treatment. This was as follows :-" At thecommencement, to set the object before a large fire,and supply it plentifully with saffron and brandy tobring out the eruption ; during the whole of the nextstage, to keep it in bed covered with flannel, and even thebed-curtains pinned together to prevent a breath of air ;to allow no change of linen for ten or more days, untilthe eruption had turned ; and to regard the best symptomto be a costive state of the bowels during the wholecourse of the disease."The effect of fresh air-which the current practiceexcluded in the treatment of small -pox is illustratedby the following singular incident. In 1731 a fire tookplace in Blandford, in Dorset. This was so violent andrapid that few had time to save much, and many couldsave nothing. " The calamity," we are informed, " washeightened by the small-pox raging in about sixtyfamilies ; none of the sick perished in the flames, butwere removed under hedges in the fields, gardens , andunder the arches of the bridge, and but one died ;-astrong argument for the cool regimen ." ¹I should here like to quote the words of a lady whohas probably done as much for the mitigation of diseaseand human suffering as any person now living. I referto Miss Florence Nightingale, and the axiom I wishto impress is contained in the following notable words :-" The very first canon of nursing, the first and the last1 " The History and Antiquities of the County of Dorset," vol. i. , p. 76 .John Hutchins , M.A. London. 1774 .18266 INFLUENCE OF SANITARY MEASURES.thing upon which a nurse's attention must be fixed, thefirst essential to the patient, without which all the restyou can do for him is as nothing, with which I hadalmost said you may leave all the rest alone, is this : tokeep the air he breathes as pure as the external air, withoutchilling him."There cannot be the shadow of a doubt that the displacementof the obsolete and deadly methods describedby Sydenham and others, by the fresh air and judiciousnursing which accompany the modern treatment ofsmall-pox, and in which Miss Florence Nightingale wassuch a distinguished pioneer, has had a potent influenceon its mitigation in recent years, although for someoccult reason, vaccination (which, by the way, has beensensibly diminishing) has managed to obtain all thecredit.One word with reference to the blindness producedby small-pox. We have always been taught to believe,and statistics are ingeniously arranged to show, that thediminution has been brought about by vaccination.Apparently this is not so. One of the greatest authoritieson small -pox informs us-"As to corneal ulceration,this affection is probably not a part of small -pox, but isaccidentally associated with it. It occurs late in thedisease, both in the vaccinated and the unvaccinated, theprevention of permanent eye mischief resulting morefrom altered methods of treatment, improved nursing,and hospital hygiene than from vaccination. " 21 " Notes on Nursing," p. 8. Florence Nightingale. London. 1876.2 Dr. Birdwood's Evidence. Sixth Report, Royal Commission on Vaccination.Q. 31,146.CHAPTER IX.THE INJURIOUS RESULTS OF VACCINATION.VACCINATION has been advocated and its enforcementrecommended not only as an absolute protection againstsmall-pox, but as a safe and even benign operation, andattended with no more danger than " the scratch of apin," or, as a well - known authority would have usbelieve, " it is not more harmful than piercing the earsto place rings in them. " ¹In his petition to the House of Commons ( 1802),Jenner claimed that cow- pox " admits of being inoculatedon the human frame with the most perfect easeand safety, and is attended with the singularly beneficialeffect of rendering through life the persons so inoculatedperfectly secure from the infection of the small -pox. " 2In the Report of Small-pox and Vaccination 3 preparedby the Committee of the Epidemiological Society,the Report, it may be added, on which the first compulsoryAct of Parliament was based, it is stated(p. 4)-" We are ourselves satisfied, and it is the concurrentand unanimous testimony of nearly two thousand1 " A Manual of Animal Vaccination," p. 153. E. Worlomont. Translationby Dr. Harries. London. 1885 .2 Baron's " Life of Jenner," vol . i . , p. 490.* Parliamentary Paper 434. ( Ordered by the House of Commons to teprinted, 3rd May, 1853. )268INJURIOUS RESULTS OF VACCINATION .medical men, with whom, as we have already stated, wehave been in correspondence, that vaccination is aperfectly safe and efficient prophylactic against thisdisease."Sir John Simon has identified himself with thisposition when he says that against the " vast gain " byvaccination " there is no loss to count. Of the variousalleged drawbacks to such great advantages the presentstate of medical knowledge recognises no single trace. " 1Again, he says-" I must say that I believe it to beutterly impossible, except under circumstances of grossand punishable misconduct, for any other infection thanthat of cow-pox to be communicated in what pretendsto be the performance of vaccination . " 2 Elsewhere, SirJohn candidly gives it as his opinion that, " If Governmentcould not reasonably guarantee that it gave purevaccine lymph, it should not force the public to accept it." 3Now, if it can be shown that there is no such thingknown or obtainable as pure lymph, setting on one sidethe question of its supposed protective value, compulsoryvaccination is totally unjustifiable.Let us see what precautions the Government take tosecure the purity of lymph. Mr. Farn, of the NationalVaccine Establishment, when under examination beforethe Royal Commission, furnished some interestingdetails, as follows :-Q. 4,130. You are not a medical man, are you ?-No.1 " Papers relating to the History and Practice of Vaccination, " p. lxvii.1857.* Ibid. , p. Ixiii.* Report from the Select Committee on the Vaccination Act ( 1867) .Q. 3,458 . 1871 .SOME DAMAGING ADMISSIONS. 269Q. 4,133. Have you made any special study ofmicrobes ? No.Q.4,154. With such (microscopic) power as you are ableto employ would you be able to recogniseor distinguish any micro-organisms whichmight be present ?-No, I should not.Q. 4,155. Have any micro-organisms been identified ,or stated to have been identified, for sucha disease as erysipelas and so on ?-I amafraid you are going rather out of mydepth as a non-medical man.Q. 4,159. Is there any disease within your experiencewhose cause you can identify with suchmicroscopical power as you employ ?Not that I am aware of.Q. 4,173. Having regard to what you have told us, doyou think it would be possible, from themicroscopical examination you made, toguarantee that any lymph was pure ?-No ; I should not undertake to say whetherit would be a guarantee that the lymphwas pure. I do not know that you coulddo it.Q. 4,200. Are we to understand that, as a matter of fact,you have ever guaranteed lymph ?-No.It seems , therefore, that there is no such thing knownor obtainable as pure vaccine lymph, and it is verysignificant that as long ago as 1883 the Grocers'Company, by reason of the numerous disasters followingvaccination, offered a prize of £1,000 for the discoveryof any vaccine contagium cultivated apart from an270 INJURIOUS RESULTS OF VACCINATION .animal body, but up to the present time the award hasnot been made. The matter has, however, been settledbeyond all dispute by the Royal Commission itself. Theysay:-" It is established that lymph contains organisms ,and may contain those which under certain circumstanceswould be productive of erysipelas " (section 410).With regard to the dangers attending vaccination ,in the official tract, entitled, " Facts concerning Vaccinationfor Heads of Families," is the following (p. 3) :-"Asto the alleged injury from vaccination, all competentauthorities are agreed that, with due care in the performanceof the operation, no risk of any injurious effectsfrom it need be feared."That vaccination produces injurious results of adefinite kind can be shown from a very early periodin the history of vaccination. The disease cow -poxitself, as Dr. Edward Ballard has pointed out, is onethat is not to be " trifled " with. In describing thecomplaint in milkers, Jenner says :-" The systembecomes affected-the pulse is quickened ; and shiverings,with general lassitude and pains about the loinsand limbs, with vomiting, come on. The head ispainful, and the patient is now and then even affectedwith delirium. These symptoms, varying in theirdegrees of violence, generally continue from one day tothree or four, leaving ulcerated sores about the hands,which, from the sensibility of the parts, are very troublesome,and commonly heal slowly, frequently becomingphagedenic, like those from whence they sprung. " ¹ And,1 " An Inquiry into the Causes and Effects of the Variola Vaccina,"p. 5. London. 1798 .IMPLANTING THE SEEDS OF A DISEASE. 271in referring to the case of Sarah Wynne, he remarks :-" She caught the complaint from the cows, and wasaffected with it (cow-pox) in so violent a degree thatshe was incapable of doing any work for the spaceof ten days. " 1Again, in the case of Thomas Edinburgh, describedby Dr. Pearson :-" He was so lame from the eruptionon the palm of the hands as to leave his employ, inorder to be for some time in a public hospital.According to the patient's description, the disease wasuncommonly painful and of long continuance. " 2That vaccination is, indeed, a serious matter has beenfully recognised by the late Dr. Ballard, one of HerMajesty's Inspectors of Vaccination. " Medical menand parents alike should drive from their minds theidea so prevalent, that vaccination is but a trivialoperation at the most. They should keep inmind that in the act of vaccination they are not merelyimparting a protection, not merely performing a sort ofmagic rite, but that they are engaged, in very truth,in implanting the seeds of a disease." The resultshave been described by the Royal Commission asfollows :-" The introduction into the system of evena mild virus, however carefully performed, is necessarilyattended by the production of local inflammation and1 Taken from Jenner's original paper, which was forwarded to theCouncil of the Royal Society, and afterwards returned to him. SeeCrookshank's " History and Pathology of Vaccination," vol . i. , p. 275 .2 " An Inquiry concerning the History of the Cow- pox," p. 15. London.1798.3 " On Vaccination : Its Value and Alleged Dangers," p. 362. A PrizeEssay. London. 1868.272 INJURIOUS results OF VACCINATION.of febrile illness " (section 409) . Elsewhere in theReport the Commissioners affirm that " it is not opento doubt that there have been cases in which injury anddeath have resulted from vaccination " (section 399),and that the admission that some risk attaches to theoperation is one " which must without hesitation bemade " ( section 379).InSir James Paget wrote in 1863 :-" The progress of thevaccine or variolous infection of the blood shows usthat a permanent morbid condition of that fluid is establishedby the action of these specific poisons uponit. And although this condition may, so far at leastas it protects the individual from any further attackof the same disease, be regarded as exercising abeneficial influence upon the economy, yet it is notthe less to be looked upon as a morbid state.forming an estimate of the persistent changes producedin the blood by these and similar infectiousdiseases, we must not lose sight of the influencewhich the tissues, themselves altered by the inoculation,exercise upon the blood. They will necessarilyre-act upon it, so as to assist materially in preservinga permanent morbid, though beneficial condition. " 1It is not altogether clear how a permanent morbid conditionof this vital fluid can be beneficial to the animaleconomy, but it is worthy of notice that one of ourgreatest living English surgeons has put it on recordthat the principle of inoculation involves an unhealthyas distinguished from a healthy state of the system .1 " Lectures on Surgical Pathology," pp. 39, 40, foot-note. JamesPaget , F.R.S. London. 1863 .SYMPTOMS ACCOMPANYING VACCINATION . 273،،The general symptoms accompanying vaccinationhave been given in some detail by Dr. Acland in hisvaluable contribution on vaccinal injuries to Allbutt'sSystem of Medicine." Dr. Acland says :-" These arecommonly unimportant ; sometimes a slight rise oftemperature is noted about the third day after inoculation; this may be followed by remissions, and thepyrexia, if any occur, reaches its maximum generallybefore the eighth day. These slight disturbancesare often the only evidence of a general diffusionof the virus, although eruptions such as erythema,roseola, or urticaria, may accompany even the mildestand most favourable cases of vaccination. Theserashes, which may develop early in children who areunusually susceptible to the vaccine virus, may occurwithin four or five days of inoculation , or they maydevelop during the period of maturity and subsidenceof the pocks ; they have no special significance, and,as a rule, are not harmful except in SO far asthey produce irritation and consequent restlessness.Amongst the more usual complications which occur ator about the period of the full development of the pocksare those which are common in all the acute exanthems :they consist in headache (in adults and in elder children),lassitude, irritability, sleeplessness, disturbances of thedigestive system-such as anorexia, vomiting, catarrhaldiarrhoea; and possibly, during the onset of the vaccinalfever, rigors may occur in adults and in the re-vaccinated,and convulsions in children . In relation to these indicationsof a general infection, in some instances there willbe evidence of a corresponding disturbance of the circulatoryor respiratory apparatus, as shown by increased274 INJURIOUS results OF VACCINATION .rapidity of pulse and respiration, bronchial catarrh, orslight temporary albuminuria. " ¹I wish especially to draw attention to the possibilityof convulsions in children supervening on vaccination, towhich Dr. Acland has alluded; and though it is difficultto prove in all cases that this condition is the directresult of vaccination, the occurrence, and that not unfrequentlyafter vaccination, has led to a belief that theyare often in some way related to the operation. (Seefatal cases in Appendix ix. to Final Report of the RoyalCommission, more especially Nos. vi. , lv. , cii. , clviii. , clxx. ,45, 119, 123 , E.G. (p. 334), 216, and 223.)Another result of ordinary vaccination is enlargementof glands, sometimes giving rise to an abscess in thearmpit. According to Dr. Louis Frank, " Adenitis isquite a common complication of an otherwise normalcourse of vaccination, and needs but a passing mention."2 As this condition appears to be of such frequentoccurrence, one would like to feel a little more certainthat scrofulous affections do not sometimes arise in thisway, as they are admitted to do in connection withglandular enlargement associated with other diseases,such as measles.Although it appears to be thought by many that injuriousresults from vaccination are only of comparativelymodern occurrence, a study of the older writings on vaccinationproves that this is very far from being the case.In the year 1800 some cases of injury with oneAllbutt's " System of Medicine," vol. ii . , pp. 562, 563. London. 1897 .Journal of Cutaneous and Genito- Urinary Diseases, vol. xiii . , p. 144.(New York , April , 1895. )THE CLAPHAM CASES. 275death were reported as having taken place in ThunderboltAlley, Clapham.¹ According to the narrative, theparents of some of the children were " much prejudiced ,full of invective, and refused to converse reasonably."In a report signed by certain medical men, the symptomsproduced were extensive erysipelas rapidly spreadingfrom the inoculated parts, accompanied in manyinstances by considerable constitutional disturbance,and followed in most cases by an immediate ulcerativeprocess, and in some cases even a tendency to gangrene.Then, as now, vaccination had its apologists. On thisoccasion Dr. Lettsom , a leading London physician ,undertook the office. " The disease," he said , “ wasnot the cow-pock, but morbid ulceration, originatingfrom the purulent matter formed under the scab ordried pustule of the cow- pock. "Mr. B. Maddock, of Nottingham, in bringing forwardcases of injury, wrote that he would be sorry to exciteprejudices against the introduction of vaccinationas a substitute for small-pox inoculation, but hehad to lament that its advantages were somewhatoverrated when it was said, on respectable authority,that it was a disease free from danger. " It is a greatmisfortune," he said, " that proselytes to new systems donot always carefully examine into opinions handed downfrom high authority, but give them implicit credit ; andit is equally unfortunate, that, in the recommendation ofany new doctrine, the unfavourable symptoms are too1 London Medical Review and Magazine, vol . v. , pp. 276-289.(January, 1801. )* Medical and PhysicalJournal, vol . v. , p. 161. ( February, 1801. )276 INJURIOUS RESULTS OF VACCINATION.frequently placed in the background, and only the morepleasing ones exposed to public view. "In November, 1805, the editors of the Medical andChirurgical Review, in referring to the cases of injuryrecorded in the minutes of the Vaccine-pock Institution,observe :-" This case, with others to be found in thesereports , serves to show that constitutional affectionmakes an essential part of the vaccina as well as ofvariolous inoculation ; it proves also that the disorderis occasionally severe, contrary to what some haveasserted."Dr. Robert Willan, a supporter of vaccination, in anearly work on the subject, also noticed that the resultsof the new inoculation were occasionally severe. Hewrites :-" There may also be a few in which theinoculation excites a new mode of action, terminatingin erysipelas , phagedenic ulcer, or other morbid appearancesnot necessarily connected with the specific disease.Several of these anomalies or exceptions to the generalrule have occurred, but certainly not so often as wasexpected by those who considered the subject, from thefirst , dispassionately, nor have they been in sufficientnumber to form any serious objection to the practicefounded on Dr. Jenner's discovery." 2On December, 15 , 1806, the Royal College of Surgeons³Medical and Chirurgical Review, vol. xii . , p. lxxvii . , foot- note.2 " On Vaccine Inoculation," pp. 20, 21. Robert Willan, M.D.London. 1806 .3 Report of the Royal College of Physicians of London on Vaccination ,with an Appendix, containing the opinions of the Royal Colleges ofPhysicians of Edinburgh and Dublin, and of the Royal Colleges ofSurgeons of London, of Dublin , and of Edinburgh, pp. 10, 11. ( Orderedto be printed , 8th July, 1807. )THE COLLEGE OF SURGEONS' REPORT. 277addressed a letter to their members on the subject ofvaccination, among other questions asking them for thenumber of vaccinations they had performed, and forinformation about any injurious results in their practice.The replies, when summarised, showed that out of164,381 vaccinated there were 66 cases of skin eruptionsand 24 cases of inflammation of the arm, of which 3proved fatal. The College reported that in theMetropolis vaccination was on the decrease, and theyassigned the following reasons :-(1 ) Imperfect vaccination .(2) Instances of small- pox after vaccination.(3) Supposed bad consequences.(4) Publications against the practice.(5) Popular prejudices.Sir John Simon, in his classic " Papers relating to theHistory and Practice of Vaccination," while printingthe College of Physicians' report, which was stronglyfavourable to vaccination, omitted any reference to theappendix containing the report of the Royal College ofSurgeons.In 1808 Dr. Richard Reece wrote " Even if thecow -pox did afford a certain security against small -poxinfection, as Dr. Jenner has represented it, it wouldstill remain a question whether the human race wouldreally be benefited by its universal adoption, since thecutaneous eruptions that have followed have in manyinstances proved more fulsome than even small -poxitself. That those eruptions do occur after cow infectionmust be allowed by its most strenuous advocates ,being perfectly novel, of a nature unknown before the278 INJURIOUS RESULTS OF VACCINATION.introduction of vaccination, and peculiar to those whohave been vaccinated, and often so inveterate as morethan to counterbalance the trivial advantages that wewere first led to expect from its introduction. " Again,he says " It must be allowed that the local inflammationexcited by the inoculation with this matter, is ofa very unfavourable nature, and often ends in a deepsloughing, frequently producing such an adhesion of themuscles of the arm, as very much to confine its motions ;and some instances have occurred of the mortificationspreading, so as to destroy the life of the child ; aninstance of which happened in St. George's Fields.The child was inoculated at the Cow-pox Institution,Salisbury Square, Fleet Street ; the inflammation of thearm exceeded its usual boundary ; on the sixth daymortification ensued, which proved fatal to the child." ¹In the Medical Observer for September, 1810, Dr.Charles Maclean gives a list of sixty cases of vaccinalinjuries , with the names and addresses of ten medicalmen, including two professors of anatomy, whosefamilies had suffered from vaccination. In the LondonMedical Gazette for December 21 , 1833 , Mr. CharlesFluder reported that " five children were recentlyvaccinated from the arm of a healthy child, whichhad been vaccinated about a week previously. Eachof these children became the subject of much constitutionaldisturbance almost immediately ; their armswere enormously swollen and ædematous ; one childhad convulsions ; in two of them abscesses formed ;1 See Article on " Cow-pox," in " A Practical Dictionary of DomesticMedicine." Richard Reece, M.D. London. 1808.* Medical Observer, vol . viii . , pp. 195-197 ." THE LANCET " IN 1854. 279• and in all there was an alarming degree of febrileexcitement. " 1The Lancet for July 15, 1854 (vol. ii. , p. 35 ), remarksin a leading article :-" There is a belief-it may bedenounced as a prejudice, but it is not the less a deeplyrootedconviction, and one not confined to the poor or theignorant-that if the vaccine disease may be transmittedby inoculation, other diseases less beneficial may be propagatedin the same manner, and by the same operation .Many a parent of high and low degree dates constitutionaldisease in her offspring to vaccination with ' badmatter. ' Who shall say that this etiological conclusionis always false ? " In the number for October 28, 1854(vol. ii. , p, 360), it is stated :-" The poor are told thatthey must carry their children to be vaccinated bymedical men who may be strangers to them. Theyapprehend-and the apprehension is not altogetherunfounded, or unshared by the educated classes-thatthe vaccine matter employed may carry with it the seedsof other diseases not less loathsome than the one it isintended to prevent. " On November 11 , 1854 (vol. ii. ,p. 404), it says :-" So widely extended is the dread,that along with the prophylactic remedy somethingelse may be inoculated, lest the germ of future diseasesmay be planted, that few medical practitioners wouldcare to vaccinate their own children from a source ofthe purity of which they were not well assured. "In 1869 Dr. Felix von Niemeyer writes :-" It cannotbe denied that it (vaccination) sometimes endangers life ,and in other cases leaves permanent impairment of1 London Medical Gazette, vol. xiii. , pp. 440, 441 .280INJURIOUS RESULTS OF VACCINATION .health , especially cutaneous eruptions, and other scrofulousaffections . " 1In 1880 Dr. Benjamin Bell writes as follows :-" Everyman," he says, " who has seen much of the kind ofpersons who apply to dispensaries and vaccine institutionsmust have an impression, perhaps indefinite, butstill reasonable, that hereditary disease may be communicatedby the channel of vaccination. Children arebrought very properly to such institutions, manifestingdistinct indications of syphilitic and scrofulous disease.Are these indications always recognised ? And is lymphnever taken from the arms of such children ? My ownbelief is, that many mothers speak correctly when theytell us that their child was poisoned when it took thecow-pox. I have seen such cases, and their existencecannot be doubted since the publication of Mr. JonathanHutchinson's valuable series of cases. " ?In 1880 a Select Committee of the LegislativeAssembly of the Colony of Victoria was appointed toinquire into the subject of vaccination. After recordingthe " conflicting and contradictory " testimonies ofmedical men examined by them with regard to lengthof time vaccination protects, the requisite number ofmarks, etc. , the Committee came to the conclusion that" Greater unanimity prevailed on the question of thecommunication of extraneous diseases, such as syphilisand scrofula, by vaccination ; although some of the1 Dr. Felix von Niemeyer's " Text- Book of Practical Medicine," vol . ii. ,p. 557. Translation by George H. Humphreys, M.D. , and Charles E.Hackley, M.D. New York. 1869.2* Edinburgh Medical Journal, vol . xxv. , p. 976. (May, 1880. )VACCINATION OF YOUNG INFANTS. 281witnesses maintained that there would be no liability tosuch transmission unless blood were drawn during theoperation . Dr. Beaney and Dr. Sparling, however,mentioned instances that came under their observation ,of syphilis and erysipelas being communicated tochildren from purely colourless vaccine matter whichcontained no trace of blood. " 1That the disease-cow-pox in itself is sufficient tocause death to a weakly child, is shown by the fatalitydue to calf lymph recorded by Dr. Farrar, in the BritishMedical Journal of October 13, 1894 (vol. ii . , p. 807).After describing the case, Dr. Farrar says :-" I considerher death to have been due to a constitutional malaise,induced by vaccinia in a poorly nourished child. " Dr.Farrar very rightly publishes the case as a warning tovaccinators to avoid vaccinating weakly children ; and ifit be dangerous to vaccinate weakly children, it is surelyso in the case of the newly- born ; and yet this objectionablepractice is in vogue in workhouses, and moreover,it is encouraged by the Local Government Board ,as will be seen from the following letter." Local Government Board, Whitehall, S.W.," 27th January, 1881 ." Sir, I am directed by the Local Government Board to statethat their attention has been called, in connection with the stateof vaccination and the present prevalence of small-pox in theMetropolis, to the large proportion of children who, having beenborn in workhouses, are discharged with their mothers before1 Report from the Select Committee upon Vaccination Law, togetherwith the Proceedings of the Committee, Minutes of Evidence, and Appen.dices . ( Ordered by the Legislative Assembly to be printed, 24th March ,1881. )19282 INJURIOUS RESULTS OF VACCINATION.being vaccinated, and many of whom escape vaccination altogetherbecause the vaccination officer has no means of tracing them ." 1. The Board are desirous of being informed, as regards theseveral workhouses and poor law infirmaries in the Metropolis,how many children were born in each during the year 1880, andhow many of those so born were discharged before being vaccinatedor before the vaccination has been ascertained to be successful,and I am to request that you will have the goodness to furnishthe Board with this information as respects any such poor lawestablishments under the control of the Guardians ."2. I am at the same time to state that some Boards ofGuardians have passed a resolution requiring the medical officer,subject to the exercise of his judgment as to making exception inparticular cases, to secure the vaccination of all children born inthe workhouse as soon as possible after birth, and it has beenfound practicable as a rule to vaccinate the children when sixdays old, and to inspect the results on the thirteenth day, as themothers in such cases rarely leave the workhouse within a fortnightafter their confinement. The Board would be glad to learn whetherthe Guardians have directed the adoption ofthis practice." 3. The Board also request that they may be informed whethera specific fee is paid to the medical officer of each workhouse orinfirmary for every vaccination or re-vaccination successfully performedby him." I am, Sir,"Your obedient Servant,"JOHN LAMBERT, Secretary."The following is a case in point. At an inquestheld on December 8, 1882, on the body of Lilian AdaWilliams, born in St. Pancras Workhouse, and vaccinatedon the seventh day after birth, the jury found " thatthe death was caused by suppurating meningitis , followingulceration of vaccine vesicles on the arm, and theywere of opinion from the results of the post-mortemexamination that the vaccination of the child oughtto have been postponed."VACCINATION OF YOUNG INFANTS. 283mous.""Such instances are by no means rare, as disclosedin Appendix ix. to Final Report of the Royal Commission,one of the most flagrant cases there reportedbeing a fatal one of pyæmia in a puny and probablysyphilitic seven months child weighing 4lbs. 2ozs., andvaccinated when less than two days after birth. (No. cxxi. )With regard to the most suitable age for vaccination ,the profession does not appear to be altogether unani-The following from one of the leading authoritiesof the last century, with reference to the best age forinoculation , may possibly be of interest in guiding usat the present day. Dr. Percival, in citing argumentsagainst the inoculation of children in early infancy,remarked that " Nature, weak and feeble as she then is,can scarcely struggle with the diseases to which sheis ordinarily exposed ; it is therefore equally cruel andunjust, to add to the number with which she is alreadyoppressed. " 1 It is also interesting to notice that ina communication from the Government of Norwayappended to Sir John Simon's " Papers, " it is stated :-" Experience has taught us that in the great majorityof cases vaccination may be performed without dangerin the earliest infancy ; but the experience of theCommittee, as well as that of several other medicalmen, has also shown, on many occasions, that infants,after vaccination, do not unfrequently become sicklyin various ways. As it hardly ever happens that thefirst case of epidemic small- pox occurs in a child, the"Article on the Arguments against the Inoculation of Children inEarly Infancy," by Thomas Percival, M.D. , F. R. S. Gentleman'sMagazine, vol. xxxviii. , p. 162. (London, 1768. )284 INJURIOUS RESULTS OF VACCINATION.Committee (particularly on account of the difficultyof control), in their proposal for a new law on vaccination,have not hesitated to recommend deferring ituntil school-time begins . " 1The Vaccination Commissioners are not quite soaccommodating, but their recommendations are in thesame direction, and it is certainly rather significantthat after forty- two years with a compulsory age- limitof three months the Commission recommend extendingthe time to six months. The reasons they give areunassailable. " Looking at the circumstance that thetenure of life in children of a very early age is frail,and that where a disease supervenes upon vaccinationthe ability to battle against it may determine whetherthe result is fatal or not, or to what degree injurious ,we should à priori think that the chances of death orinjury from such a cause would be less, looking atthe matter as a whole, when the age of the child wasmore advanced. " (Section 438.) And they further thinkthat, provided the children coming within the range ofthe present compulsory law could be vaccinated on theoccasion of the introduction of small-pox into the district,the " age might be advantageously extended to oneyear from the date of birth, and that the number of casesin which death was, whether correctly or not, attributed tovaccination would then much diminish. " (Section 440.)Vaccine Généralisée.This name has been given to a widely- spread eruptionof vaccine vesicles on different parts of the body, the" Papers relating to the History and Practice of Vaccination,"Appendix, p. 187. 1857 .VACCINE GENERALISEE. 285lesions being identical in character with the typicalvesicle, and containing an inoculable fluid. Some ofthese are doubtless cases of auto- inoculation from theoriginal sore, but the remainder are examples of true,specific generalised cow-pox eruption. A case is relatedby Dr. Martin, of Boston, in the Medical Record¹ ofApril 15, 1882, where there were four hundred clearlydefined, perfectly circular, invariably umbilicatedvesicles. According to Dr. Prince A. Morrow, numerousexamples of generalised eruption have been recordedby experienced vaccinators, and we also have it on hisauthority that " French vaccination literature, especially,abounds in cases of this character." 2In this country, apparently, the complication is not socommon, but a few cases are given in Appendix ix. toFinal Report of the Royal Commission. (See Nos. li. ,clxii. , cxciv. , 109, 173, and 214.) Anyone wishing to seehow serious this disease may really be will do well toconsult the coloured drawings of the fatal case figured byDr. Acland in the " Transactions of the Clinical Society. "(No. 214 of Vaccination Commission Cases. )Skin Diseases.Of the various diseases alleged to be induced byvaccination, skin disease takes an important place.How common is the mother's remark that the childnever had a blemish until it was vaccinated ! And,1 Medical Record, vol . xxi . , p. 393. ( New York. )Journal of Cutaneous and Venereal Diseases, vol. i. , p. 173. (NewYork, March, 1883. )3 " Transactions of the Clinical Society," vol. xxvi. p. 114. London. 1893.286 INJURIOUS RESULTS OF VACCINATION.according to Dr. Robert Lee,¹ it appears that there issome foundation for the allegation. He found froman experience of three thousand cases of skin diseasetreated at Great Ormond Street Hospital, that in threehundred, or 10 per cent. , the mothers attributed therash to vaccination, and Dr. Lee thought that we werenot justified in pooh-poohing the notion ; and therecan be but very little doubt that Dr. Lee is correct in hissurmise, and for this reason, viz. , that a secondary rash,as in syphilis, is not unfrequently part and parcel of thedisease cow-pox. Mr. Robert Ceely, in describing thecasual disease in milkers, says :-" Papular, vesicular, andbulbous eruptions, are occasionally seen attendant oncasual cow -pox, especially in young persons of sanguinetemperament or florid complexion, at the height orafter the decline of the disease. They are generally ofthe same character as those known to attend the inoculateddisease. " 2 Again, in writing about the inoculateddisease when primary lymph is used " about thisstage of the areola, especially on children, small supernumeraryvaccine vesicles in miniature often appearwithin its limits, sometimes on the shoulder, and stillmore rarely on the face and body. The well-knownpapular, vesicular, and bulbous eruptions, occurring insuch subjects are frequently observed. "-With regard to cutaneous affections, the VaccinationCommissioners say (section 418)-" It is to be freelyadmitted that vaccinia, like varicella, does occasionally1 Sixth Report , Royal Commission on Vaccination, pp. 564, 565." Transactions of the Provincial Medical and Surgical Association,"vol . viii . , p. 337. 1840.Ibid. , p. 346.SKIN ERUPTIONS. 287cause an irritable condition of the skin, which may lastlong."The complication of skin disease, and that not unfrequently,was noticed very early in the history ofvaccination. Thus, Mr. Thomas Wainwright, in theMedical and Physical Journal for November, 1805 (vol.xiv. , p. 435), in reviewing a vaccination experience ofthree thousand cases, observes that " Various kinds ofobstinate cutaneous eruptions are not unfrequently consequentto the vaccination of young children ; but theyvery rarely take place in those who have the cow-pockat the age of ten years or at any later period. " Wealso have it on the authority of Dr. Robert Willan that" during the progress of the vesicle some disorder takesplace in the constitution, and there is frequently on thearms and back a papulous eruption resembling someforms of the lichen and strophulus. " 'Mr. Ross in a paper read before the Medical Societyof London, on February 7, 1857, drew the attention ofthe profession to the occurrence of secondary eruptionsfollowing vaccination. These generally appear afterthe eighth day. " No experience," Mr. Ross concludes,66on this matter can be worth much that is limited to anobservation of the pock on the eighth day, as is theordinary practice in public institutions. Hence I donot regard as of any weight the objections of thosegentlemen who, with such an experience, have denied" On Vaccine Inoculation," p. 10. Robert Willan, M.D. , London.1806.2 See also remarks by Dr. Hugh Thomson at the Birmingham meetingof the British Medical Association. British Medical Journal, vol. ii. ,p. 1231. (November 29, 1890. )288 INJURIOUS RESULTS OF VACCINATION .the existence of a special secondary eruption. BeingPublic Vaccinator for an extensive district, I vaccinatea considerable number of children every week, at thepresent time, yet from never watching the cases afterthe eighth day, I rarely hear of instances of secondaryeruption ; but I have not the slightest doubt that Ishould discover them, as frequently as heretofore, if Ifollowed the cases up as I did when I was conductingthese investigations. I think that I have now adducedevidence sufficient, if not to convince absolutely, at leastto induce a strong presumption in the mind of an unbiasedman, that vaccinia, under certain circumstances ,is followed by a secondary eruption, special in its nature,though various in forms, which observes fixed periodsof evolution, and is an integral part of the originalaffection." ¹A considerable discussion followed the paper , and, inreply, Mr. Ross observed that the " external character ofthe eruptions differed, but in their nature he believedthey were specific-in fact, sui generis ; that they weredirectly caused by the vaccination, and were evolved bythe actions going on in the economy, though it mightbe difficult to explain those actions. " 2 Dr. Louis Frankhas testified that " the skin diseases attributed to vaccinationare exceedingly numerous," and he adds, " therecan hardly be any doubt in the minds of those who havehad great experience in vaccination that there exists anintricate connection between vaccination and cutaneouseruptions as a sequel thereof. "3 Dr. William C. Cutler,Lancet, vol . i. , p. 166. ( February 14, 1857. )*Medical Circular, vol . x. , p. 68. ( February 11 , 1857. )Journal of Cutaneous and Genito- Urinary Diseases, vol . xiii. , p. 142.(April , 1895. )MR. HUTCHINSON'S OPINION . 289in discussing the various forms of injury incident tovaccination , remarks that " vaccine roseola or lichen isso often met with in the practice of all physicians thatit hardly needs to be mentioned in this connection. " 1Indeed, Mr. Jonathan Hutchinson has probably notoverstated the case, when he says that " the wonder isnot that vaccination should sometimes produce anexanthem, but that it should ever be without one. " 2Dr. P. A. Morrow, in alluding to the frequency ofvaccinal eruptions, quotes the experience of Behrend,who only observed them six times in three hundredsuccessive cases, and says-" From the unusually largenumber of cases reported in the various medicaljournals within the last few years, I should judge thatthe proportion was much greater. " 3 He remarks thatpreceding and accompanying erythematous eruptions,there may be slight febrile reaction, headache, malaise,and other evidences of constitutional disturbance. Dr.Acland has also testified that vaccinal eruptions are" often attended with much irritation, considerablegeneral disturbance, and some pyrexia. " 4 Now, if theseeruptions are an integral part of the vaccine disease,and often attended with constitutional disturbance andmuch irritation, even if they are usually characterisedby a temporary duration, as stated by Dr. Acland, I1 Annual Report of the Health Department of the City of Baltimore , forthe year 1883 , p. 62.2 " Lectures on Clinical Surgery, " vol . i. , p. 18. Jonathan Hutchinson,F.R.C.S. London. 1879.Journal of Cutaneous and Venereal Diseases, vol. i. , p. 176. (NewYork , March, 1883. )*Allbutt's " System of Medicine," vol. ii. , p. 564. London. 1897.290 INJURIOUS Results OF VACCINATION .cannot help thinking that all this offers a somewhatserious objection to the practice of vaccination.Occasionally these eruptive disorders may prove morevirulent. Thus, Professor Hardy, of Paris, at the InternationalMedical Congress held in London in 1881 ,related an unpleasant reminiscence of which he was thesubject in 1870. Three days after being re-vaccinatedhe was attacked by an intense urticaria, developed onthe skin and in the bronchial mucous membrane, in thelatter situation exciting attacks of suffocation so seriousas to put his life in danger. We have it on the highauthority of Drs. Colcott Fox and Louis Frank thatthis complication of vaccination (urticaria) is not at alluncommon.21With regard to eczema, there can be but little doubtthat quite a large number of cases are attributable tovaccination. In an article on " Vaccinal Skin Eruptions "Dr. George Thin says-" All practitioners of any experiencemust be able to recall cases in which obstinateeczema in infants has first shown itself after vaccination,and other ailments of a general character are probablysometimes produced by the effect of the vaccine viruson the system in delicate persons. During the lateepidemic of small-pox in London I had occasion to meetwith several cases in which patients attributed a temporarycondition of depressed health to re-vaccination.3The following gives the age-distribution of eczemacases during the first year of life coming under the care1 " Transactions of the Seventh Session of the International MedicalCongress, " vol. iii. , p. 158. London. 1881 .* British Medical Journal, vol. ii. , p. 1235 (November 29, 1890) ; andJournal of Cutaneous and Genito- Urinary Diseases, vol. xiii. , p. 145(April , 1895) .Edinburgh MedicalJournal, vol . xxvii. , pp. 523, 524. ( December, 1881. )EXPERIENCE OF DR. COLCOTT FOX. 291Cases.... 33of Dr. Colcott Fox ' at the Paddington Green Children'sHospital :-0-1 monthCases.6 7 months ... 10I 2 months 22 7- 8 months ... 42 3 months ... 258 9months 233 - 4 months ... 39 9 10 months I4 - 5 months ... 2310 II months I5 6 months ... 7 11 12 months 3The large proportion under three months of ageseems to afford ground for believing that vaccinationis not to be held responsible for the majority of casesof infantile eczema. At the same time, as Dr. Acland2says, it must be noted that there is definite increase inthe numbers in the fourth and in the ninth months, atperiods when the irritation of vaccination and teethingrespectively might be expected to come into play. Forcases recorded in Appendix ix. to the Commissioners'Final Report, see Nos. xcix., cxi. , 14, 15 , 25 , 95, 98, 101 ,B. S. and J. W. (p. 282), 120, 130, 140 (three cases ) , 192 ,B. R. ( p. 389), 225 , A. H. and A. G. (p. 444).Adisease of the skin which has been especially referredto by the Vaccination Commissioners is impetigo contagiosa.The frequent occurrence of this malady aftervaccination has been remarked on by the late Dr.Tilbury Fox³ and others. An extensive epidemic ofimpetigo contagiosa was occasioned by vaccination in theIsle of Rügen in 1885 ; 79 children were vaccinated on1 British MedicalJournal, vol. ii. , p. 1235. ( November 29, 1890. )* Allbutt's " System of Medicine," vol. ii . , p. 580. London. 1897 .British MedicalJournal, vol. i . , p. 553. ( May 21 , 1864. )Q. 9,797-9,834, Third Report , Royal Commission on Vaccination .292 INJURIOUS RESULTS OF VACCINATION .June II with humanised thymos-lymph obtained froma Government establishment at Stettin ; all, with threeexceptions, were attacked with impetigo contagiosa, and,by infection, the disease was spread to 320 out of apopulation of 5,000 inhabitants. A Commission ofInquiry was appointed by the German Government,who reported that they were unanimously of opinionthat the outbreak of the disease had been a directconsequence of vaccination.2Skin eruptions from vaccination are not unfrequentlycomplicated with intense irritation. A case of thisnature is recorded by Mr. Jonathan Hutchinson. Thepatient (aged 13) was vaccinated when nine months old,and the eruption began within a fortnight, and had beenincreasing ever since (twelve years). Mr. Hutchinsonwas told that the patient would sometimes lay awakemost of the night scratching herself. Weather andseasons made no difference, and " the eruption itchedintolerably and incessantly." Mr. Hutchinson addsthat the vaccine eruption and that of varicella appearto be alike in their proneness to evoke prurigo.year, " he says, " passes but brings before me freshexamples of the causation referred to. "" No1 Extensive outbreaks are also reported by Protze ( see " Viertelgahresschriftfür Dermatologie und Syphilis, " vol. xx. , pp. 478, 479, Vienna, 1888 ) ;by Melichar in Allgemeine Wiener Medizinische Zeitung, December 10 ,1889 , vol . xxxiv. , pp. 581 , 582 ; by Perron, Pourquier, and others. Seealso Nos. cx. , 9, 12 , 19, 20, 29, 82, 129, 180, М.С.В. (p. 368), 196, and 230in Appendix ix . to Final Report of the Royal Commission on Vaccination ,and cases at St. Pancras Workhouse in 1890-91 , reported in " Archives ofSurgery, " vol. iii. , pp. 206-215 , January , 1892 .2 " Archives of Surgery, " vol . i. , pp. 161 , 162 ( October, 1889) . JonathanHutchinson , LL.D. , F.R.S.M. RICORD ON VACCINATION .Syphilis.293With regard to the communication of syphilis byvaccination , Professor Ricord declared in a lecture atthe Hotel Dieu that " if it be true that vaccinationcan transmit syphilis, then vaccination is done for .For who, pray, will run the risk of being affected withthe great to escape the small pox." 1These ominous words from the greatest authorityon the subject of syphilis may well have occasioneddismay among the promoters of vaccination, and thuswe find that medical literature was, and up to quiterecent times has been, full of denials of the possibilityof such an occurrence . The official tract before referredto informs us (p. 4) that " The fear that a foul diseasemay be implanted by vaccination is an unfounded one.Such mischief could only happen through the mostgross and culpable carelessness on the part of thevaccinator. The alleged injury arising from vaccinationis, indeed, disproved by all medical experience." 2To illustrate the sceptical attitude of the medicalpress on this subject, the British Medical Journal ofDecember 21 , 1861 (vol. ii. , p. 666) , in referring to areport in an Italian medical journal of childrensyphilised by vaccination at Rivalta, heads thearticle " An Absurd Tale," and says in conclusion-" We need hardly add, that our main object in referringto this matter is not so much to warn the profession1 Lecture delivered at the Hotel Dieu. Translation by Dr. HeronWatson. Edinburgh Medical Journal, vol. vii . , p. 859. ( March, 1862. )2 " Facts concerning Vaccination for Heads of Families. " ( Revised bythe Local Government Board, and issued with their sanction. )294 INJURIOUS RESULTS OF VACCINATION.against such a tale, as to enable our brethren to give ananswer concerning it to those of the ignorant publicwho may be frightened by it. It is unfortunately truethat there are only too many strangely-minded peoplewho will be glad to make capital against vaccinationout of such a tale. "But, in spite of all denials in the past, the matter hasnow been placed beyond dispute by the leading authoritieson this subject.Mr. James G. Beaney, of Melbourne, in his work on" Constitutional Syphilis," says "And I at onceannounce at the outset my firm belief that syphilis isin very many instances communicated by means of' child's vaccine lymph.' This opinion I have deliberatelyformed, and as firmly defend. The evidences ofsuch being the case have, in my practice, been numerousand well -pronounced ; so distinct, indeed, that no doubtwhatever could exist as to the nature of the eruptions ,and the certainty of transmission . " 'M. Fournier, Professor of the Faculty of Medicine ofParis, in discussing the subject, remarks-" From thatwhich precedes, it results in the first instance, and quiteclearly, that in a general way a real and serious dangeris contained in vaccination. But that danger, surely, isquite of a nature to evoke our solicitude for a numberof reasons . For ( 1 ) every individual is destined toundergo, one or several times in his life, the vaccineinoculation. The danger then of vaccinal syphilis isencountered by all the world once or several times inthe course of existence ; ( 2 ) the excessive and ever-1 " Constitutional Syphilis," p. 373. James George Beaney, M.D. ,F.R.C.S. Melbourne. 1880.MR. BRUDENELL CARTER'S OPINION . 295increasing diffusion of syphilis in modern societies willonly increase numerically the risks of that danger ;(3 ) the syphilis which attacks subjects quite young(that is to say, which invades the organism at theusual age at which vaccination is practised) is particularlygrave, everyone knows it, and grave to the extentof terminating it in a fatal manner on many occasions. " ।Dr. Edward Ballard, in his " Prize Essay " (p. 344) ,informs us that " the thing has happened over and overagain in cases which may now be counted by hundreds ;so that this disposes for ever of the cry of ' impossible,' "and therefore Dr. Charles Drysdale was probably notvery wide of the mark when he said " I think there canbe no doubt in the minds of instructed and unprejudicedmedical men that syphilis has occasionally been ratherwidely propagated by means of vaccination. " 2One of the most serious charges which has ever,probably, been made against vaccination was made byMr. Brudenell Carter, the well-known oculist. Hesays-" I think that syphilitic contamination by vaccinelymph is by no means an unusual occurrence, and thatit is very generally overlooked, because people do notknow either when or where to look for it. I think thata large proportion of the cases of apparently inheritedsyphilis are in reality vaccinal ; and that the syphilis inthese cases does not show itself until the age of fromeight to ten years ; by which time the relation betweencause and effect is apt to be lost sight of." 31 " Leçons sur la Syphilis Vaccinale," pp. 17, 18. Alfred Fournier.Paris. 1889.2 Medical Press and Circular, vol. i . , p. 194. (March 8 , 1876. )3 Mr. Carter's statement was communicated to the North London MedicalSociety by Dr. Kesteven in a paper read on May 8 , 1877. MedicalExaminer, vol . ii. , p. 409. ( May 24, 1877. )296 INJURIOUS results OF VACCINATION .The following is a list of alleged cases of vaccinosyphiliswhich have been reported from time to time :-Year.Alleged Cases of Vaccino- Syphilis.Place. No.1814 Undine 301821 Cremona 401830 Frederiksborg 71841 CremonaSaône)641843 Quers (Haute- About1845 Constantine1849 Piedmont1849 Coblentz1852 Freienfels (Oberfranken)1852 Paris30321984I 1855 Lyons1855-7 Czomad ( near 34Pesth)1856 Lupara 341858 Cherbourg 2Authority and Reference .Marcolini . " Annali Universali diMedicini ," vol. xxix. , pp. 146-150,Milan , January, 1824 .Cerioli . See " Revue Médicale Françaiseet Etrangère," vol. iii. , pp.54, 55 , Paris , September , 1845 .Ewertzen . " Notizen aus dem Gebieteder Natur und Heilkunde" ( Froriep'sNotizen) , vol . xxxiv. , p. 303 , September,1832 .Cerioli . Ibid.Aliès. " La Revue Médicale Françaiseet Etrangère, " vol. i. , pp. 29-33, January 15, 1865.See Layet . Traité pratique , de la VaccinationAnimale, p. 70, Paris, 1889.Viani . " Gazette Médicale de Paris ,"3S . , vol . iv . , p. 874, November 10,1849.Wegeler. "Medicinische Zeitung," vol .xix. , pp. 69, 70 , Berlin, April 3 , 1850.Hübner's Cases . See " AerztlichesIntelligenz -Blatt," vol. i. , pp. 166-168 , Munich , May 27, 1854 ; also" Gazette Hebdomadaire de Médecineet de Chirurgie, " IS . , vol . ii . ,pp. 176-178 , Paris, March 9, 1855 .Auzias-Turenne. See " Bulletin del'Académie Impérialede Médecine,"IS. , vol. xxx. , p. 467, 1864-65.Rodet. See "Bulletin de l'AcadémieImpériale de Médicine, ” IS . ,vol . xxx. , pp. 466 , 467 , 1864-65.Glatter . See Bohn's " Handbuch derVaccination," p. 322, Leipzig , 1875 .Marone. See " Lancet," May 31 ,1862 , vol. i. , pp. 567 , 568 ; alsoLancereaux on " Syphilis,"p.641.Lecoq. " Gazette de Hôpitaux," vol .xi . , p. 598, Paris , December 24, 1859 .ALLEGED CASES OF VACCINO-SYPHILIS. 297Year. Place. No.1860 Rufina (nearFlorence)141861 Rivalta1861-2 Paris46I1862 Torre de' Busi51863 Paris I1863 Paris I1863 Paris1863IBéziers I1863 BergamoFranceAuthority and Reference.Galligo . " Gazette Hebdomadaire deMédecine et de Chirurgie, " IS. , vol .vii . , pp. 519 , 520 , August 10, 1860.Coggiola. See Cerise in " L'UnionMédicale, " 2S. , vol. xii . , pp. 259-264, Paris, November 9, 1861 ; also" Gazette Hebdomadaire de Médecineet de Chirurgie," IS. , vol. viii . ,pp. 779-782 , December 6, 1861 ;and " Lancet, " November 16, 1861 ,vol. ii . , pp. 485 , 486.Trousseau. See Depaul, “ Bulletinde l'Académie Impériale de Médecine, " IS. , vol . xxx. , pp. 144, 145 ,1864-65.Adelasio. " Gazzetta Medica ItalianiLombardia, " 5S. , vol . iv. , pp. 158-161 , Milan , May 1 , 1865 .Chassaignac. " Bulletin de la Sociétéde Chirurgie de Paris," 2S. , vol .iv. , p. 361 , 1864. For drawingof case by R. Druitt, see Trans.Obstet. Soc. Lond. for 1863, vol .v. , p. 196 , 197.Devergie. " Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxviii . , pp. 664-669, 1862-63.Hérard. Ibid. , pp. 1189, 1190.Sébastian. " Gazette des Hôpitaux,"vol . xvi . , p. 493, October 22 , 1864 ;also " Gazette Hebdomadaire deMédecine et de Chirurgie," 2S. ,vol. ii . , p. 41 , January 20, 1865.Adelasio . " Gazette des Hôpitaux,"vol. xvi . , p. 494, October 22, 1864.2 or 3 Auzias-Turenne. " Bulletin de l'AcadémieImpériale de Médecine ," IS . ,vol . xxx. , pp. 322, 323, 1864-65 .Laroyenne. Ibid. , pp. 470, 471 .2I12 or Depaul. Ibid. , vol . xxxii. , pp. 1048-moreParis1865 Paris1866 Argenta (Fer- 27rara)1866 Rosheim ΙΟ1056, 1866-67 .Gamberini. " Gazette des Hôpitaux, "vol . xxi . , p. 505, November, 1869.Schuh. See Depaul in " Bulletin del'Académie Impérialede Médecine, "IS . , vol . xxxii. , pp. 1058-1061 ,1866-67 .20298 INJURIOUS results OF VACCINATION.Year. Place. No.1866 Auray ( Morbihan)50 ormoreIII35Depaul.Authority and Reference ." Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxxii . , pp. 201-224 and 1033-1038.Fuqua. See Joseph Jones' " Medicaland Surgical Memoirs, " p. 472 ,New Orleans, 1890.Depaul. See " Bulletin de l'AcadémieIn périale de Médecine , " I S. ,vol . xxxii . , pp. 1039-1043 , 1866-67 .Verfasser. See Köbner in " Archivfür Dermatologie und Syphilis , "vol . iii . , p. 159, Prague , 1871 .Guérin . "Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxxiv. , p. 512, 1869 .Zallonis. See Depaul, Ibid. , pp.1017, 1018 .Vicherat. Ibid. , pp. 1103-1106.Kocevar. " Allgemeine Wiener MedizinischeZeitung," vol. xv. , pp.266-268 , May 24, 1870.1866 Florida 521866 Cardeillac ( Lot ) 131869 Prussia1869 ParisSyra (Greece) 2Villemaréchal1869 Schleinitzand St.Veit ( Styria)1869and218701875 New YorkKöbner. " Archiv für Dermatologieund Syphilis," vol. iii. , p. 133 ,1871 .I Taylor . " Archives of Dermatology,"vol. ii. , pp. 203-209, New York,April , 1876 .1876 Lebus ( Prussia) 15 Appendix to Report of German VaccinationCommission , 1884. ( SeeQ. 9,961 , Third Report, RoyalCommission on Vaccination. )58 Journal D'Hygiène, vol . vi. , pp. 399,I400, Paris , August 25, 1881 .Moré. " Bulletin de l'Académie deMédecine, " 2S. , vol. xiii. , p. 1240,1884.Layet. Traité pratique de la VaccinationAnimale, p. 74, Paris, 1889 .Perrin . " Annales de Dermatologieet de Syphiligraphie," 3S. , vol. i. ,pp. 654-657 , Paris, 1890.Hervieux. " Bulletin de l'Académiede Médecine," 3S . , vol . xxii . , pp .116-125, 1889.Hervieux. Ibid. , pp. 230, 496 , 517 .Rosenthal . " Deutsche MedicinischeWochenschrift, " vol. xviii. , p. 121 ,Leipzig and Berlin, Feb. 11 , 1892.1880 AlgiersFrance I1885 Turin 351889 Marseilles I1889 Oise 51889 Motte- aux-Bois1891 Germany43DR. JAMES WHITEHEAD'S CASES. 299Thus we have a total of over 700, without includingEnglish cases to be mentioned hereafter.The cases which first attracted serious attention tothe subject in this country are those of Dr. JamesWhitehead. He made a systematic examination ofchildren brought to the Hospital, and 1,435 out of 1,717were found to have been vaccinated. In a considerablenumber of instances the mothers blamed vaccinationas the cause of the disease from which the childrensuffered, and in thirty-four cases Dr. Whiteheadthought that the evidence appeared to be sufficientlyconvincing to warrant the belief that a taint had beencommunicated ; in fourteen he considered the diseaseto be of true syphilitic character, as shown by thesymptoms and by the mode of its derivation ; and inthe remaining twenty, although the history was lessclear, the symptoms so precisely resembled constitutionalsyphilis that the treatment employed was that commonlyused in syphilitic disease, and was in most cases attendedwith satisfactory results. In the four following cases,described by Dr. Whitehead, the local vaccine vesiclesdeveloped into sores, and thus, in these instances atany rate, there can be but very little doubt thatthe syphilitic symptoms were actually produced byvaccination .Case 2. An infant, aged nine months, of a bad habitof body. Copper-coloured blotches appeared aftervaccination. When seen, there was a mixed eruptionon the face and scalp and extreme irritability of the1 Third Report of the Clinical Hospital , Manchester. James Whitehead,M.D. London. 1859.300 INJURIOUS RESULTS OF VACCINATION .whole surface; the vaccinated spots remained unhealedat the end of five months, presenting a well-formedrupia with excavation. The father and mother aredescribed as apparently healthy.Case 11. An infant, aged eleven weeks, of mediumhabit of body. When seen, there were two deep ulcerswith hardened bases where the vaccine vesicles wereformed three weeks previously ; copper-coloured roseolaon the nates and chin, sallow complexion, mucoustubercles round the anus, eruptions and intertrigobehind the ears, coryxa, atrophy, and dysentery. Thehistory of the case is that roseola appeared from twelveto fourteen days after the vaccination, at the age oftwo months ; the mucous tubercles nine weeks after,while under treatment, and atrophy four months after.Father said to be healthy ; mother feeble, but apparentlyfree from taint.Case 56. An infant, aged seven and a half months,of good habit of body. After the subsidence of thevaccination, the vesicles degenerated into ulcers ,surrounded by erythema. When seen, there wereerythematous blotches of a copper colour on the chestand neck, eczema auris, arthritis of the left elbowjoint, and syphilitic pallor. Father said to be healthy ;mother apparently healthy.Case 57. A child, aged three years and three months,of good habit of body. She was healthy up to thetime of vaccination, three months previously. The threevaccinated spots degenerated into three deep ulcerationswith hardened bases, which remained open for twomonths. When seen, there were all over the trunk andlimbs flat herpetic-like crusts, with large erythematousMR. HUTCHINSON'S CASES. 301areolæ of copper tint, most numerous on the thighs ; thecicatrices of the first-formed patches being of a deepcopper colour. The patient suffered from great prostration,inappetence, eneuresis, and dysuria, erythema ofthe vulva without discharge, chronic blepharitis, photophobia,and syphilitic pallor. The first symptoms wereulceration of the vaccinated spots with copper-colouredblotches. Father and mother apparently healthy.Mr. Jonathan Hutchinson, on April 25, 1871 , madehis first communication to the Royal Medical andChirurgical Society on the subject. Twelve persons(mostly young adults ) were successfully vaccinated withlymph from a healthy- looking infant. In all excepttwo, indurated chancres developed in the vaccinationscars .Shortly afterwards, Mr. Warren Tay, one of Mr.Hutchinson's colleagues, came across another series ofcases. Two children of the same family, aged fouryears and sixteen months respectively, had been vaccinatedseven weeks before they came to be treated forskin eruption ; the vaccination spots were unhealed andindurated at the base. By means of the vaccinationregister, twenty- four others vaccinated with the samelymph were traced. It was found that nine children ,counting the two previously mentioned, had unquestionablesymptoms of constitutional syphilis, and therewere suspicious symptoms in six others , a certainnumber entirely escaping. It is important to note thatnothing had occurred to excite the vaccinator's suspicions,none of the children having been taken back tohim on account of the unhealthy condition of the arm .Two of the patients, however, had been under medical302 INJURIOUS RESULTS OF VACCINATION .care, but in not a single instance had the real nature ofthe disease been suspected.Mr. Hutchinson's third series consisted of one caseonly. The patient, aged forty- six, came under his careat the Moorfields Eye Hospital for acute iritis. Hehad been vaccinated three months previously, and thevaccination spots were the seat of chancrous induration.Mr. Hutchinson called on the vaccinator, who said hehad never seen such sores as were displayed on thisman's arm , but had not, however, suspected the realnature of the disease. About twelve other personswere vaccinated at the same time, and from the samechild, and with the exception of a little trouble in thehealing of the sores in one or two of the patients, theyhad shown nothing peculiar.In the fourth series, the patient was a woman agedforty-six. Neither the patient nor the surgeon whovaccinated her had suspected she had been syphilised.The fifth series was brought under Mr. Hutchinson'snotice by Mr. Warren Tay in April, 1876. A motherand her two children, one an infant and the other achild of two, were found to be suffering from secondarysyphilis. The children were vaccinated in September,1875, and their vaccination sores had re- opened and fora long time remained unhealed. The mother had contracteda sore on her nipple from the younger child,and her symptoms were two months behind those ofthe children. The husband subsequently contractedsyphilis from his wife.Mr. Hutchinson also relates a case of vaccino - syphilishe had seen in a lady recently arrived from India. Thevaccination did not take, but a little spot like aMR. MAKUNA'S " INQUIRY.” 303mosquito - bite resulted ; this healed, and six weeksafterwards a sore formed. When seen by Mr. Hutchinsonshe had two indurated and dusky chancres on thearm, and was covered with a syphilitic eruption .When we consider that in a number of these casesthe nature of the complaint had been unsuspected (insome, even by the medical men) until they had comeunder the care of Mr. Hutchinson or Mr. Warren Tay, itseems more than probable that a large number of casesof vaccino - syphilis remain unrecognised as such, andnever come to light at all .In 1883 questions were addressed to medical men onthe subject of vaccination . Among others, it wasasked, " What diseases have you, in your experience,known to be conveyed or occasioned or intensified byvaccination ? " Three hundred and eighty- four replieswere received, and they are published in Mr. M. D.Makuna's " Transactions of the Vaccination Inquiry."The following testimonies have been extracted relativeto the occurrence of syphilis after vaccination :-5. " Syphilis once only."18. " I have only seen one case of syphilis which I attributed25.to vaccination from a syphilitic infant. "" A certain amount of syphilis, in rare instances. "40. " I have known syphilis in aggravated forms .... to followvery speedily the operation ."51. " I only remember one case in my practice in whom syphiliswas intensified."52. " I have seen one case of syphilis apparently conveyed. "64. " I have known syphilis occasioned by it ."93. " I have seen syphilis more than once."96. " Syphilis once with an incrustated rash."112. " Syphilis."304 INJURIOUS RESULTS OF VACCINATION .114. " Syphilis .... having previously been dormant."120. " I remember one case of syphilis" (intensified by vaccination).130. " Syphilis."139 and 140. " Syphilis in two cases."162. " Occasionally in rare instances it has appeared to conveyI cannot recall any syphilitic ...disease.such cases in my experience as absolutely proved,although I have had my suspicions aroused."164. " I cannot quite assent that I have seen syphilis conveyedby vaccination, but I firmly believe I have seen three orfour such cases ."175. " One case of death from syphilis in a boy about two yearsold, who was found afterwards to have been vaccinatedfrom a child born with symptoms of syphilis. "190. Had seen syphilis in other medical men's practice.192. Had seen syphilis "perhaps once."211. " Syphilis and death occasioned."231. "Three cases of syphilis." (Notes of cases lost.)238. " I have also on two occasions seen among children inLondon what I thought to be syphilitic eczema, whichyielded to mercury."262. " I have seen syphilis .... produced by vaccination."271. " Syphilis conveyed twice, once by primary, and once byre-vaccination."274. " Syphilis " (conveyed).277. "Only one case in which syphilis was suspected."281. " Very rarely syphilis conveyed by impure vaccination."282. " I have seen one child die of syphilis, I believe fromvaccination."288. "When a student I have seen syphilis conveyed, but havenot details of cases."291. Two cases, one of which doubtful. (Notes of cases given.)299. "One case at St. George's Hospital, when I was a pupiltwenty years ago, in a young woman, ofsyphilis."318. "Secondary or probably tertiary syphilitic symptoms."326. " I have known two cases where there were good groundsfor supposing syphilis was conveyed by vaccination."FURTHER CASES OF VACCINO- SYPHILIS.331. " Syphilis once."305340. " I remember a case of syphilitic sores on the arms of a boyfrom vaccination, five years ago. "353. " One case of syphilis . "383. " I have known lymph taken from a syphilitic or scrofulouschild communicating analogous disease to the childrenvaccinated with it ."384. " One case of syphilis ."Quite recently, and before the Royal Commission(Sixth Report, pp. 218, 219), Mr. E. Ward mentionedthree cases which had come to his knowledge, two inthe practice of Mr. Holmes, of Leeds, in 1871 , and thethird a very sad case in a young woman of twenty-two.She was vaccinated in 1888, and about four or fiveweeks afterwards the points of vaccination becameindurated. This was followed by the usual phenomenaof syphilis, and the case terminated two years afterwardsby death with cerebral symptoms.For further British cases, see next page :-306 INJURIOUS RESULTS OF VACCINATION.Alleged Cases of Vaccino- Syphilis.Year. Place. No.1839 I1843 Bodmin 2| 1863 Glasgow ILondon 31866 London I1866 London I1870 London I1872 Belfast I1873 London I1883 London IAuthority and Reference .Whitehead. " On the Transmissionfrom Parent to Offspring of someForms of Disease and of MorbidTaints and Tendencies, " pp. 174-176. 1851 .Haydon. Medical Times and Gazette,March 29, 1862, vol. i. , p. 316 .Buchanan. Glasgow MedicalJournal,April, 1865 , vol . xiii. , pp. 60-65.Nayler. " A Practical and TheoreticalTreatise on the Diseases of theSkin," pp. 279-281 . London, 1866 .Drysdale. British MedicalJournal,April 25 , 1868 , vol. i. , p. 396.Pollock. Lancet, April 21 , 1866, vol .i. , p. 424.Smith . " Transactions of the ClinicalSociety, " vol. iv. , pp. 53-59. 1871 .Scott. Medical Press and Circular,January 29, 1873 , vol . i. , pp. 84,85.Hulke. Medical Times and Gazette,February 8 , 1873 , vol. i. , p. 153 .Collins . 1 " Transactions of the VaccinationInquiry," p. 63. 1883 .For some time after the publication of Mr. Hutchinson'scases, although the communicability of syphilis byvaccination was admitted, it was stated that this couldonly take place if the blood of the vaccinifer was takenwith the lymph. In this connection it may be mentionedthat a committee consisting of Dr. Bristowe, ProfessorHumphry, Mr. Hutchinson, and Dr. Ballard, in reporting1 These cases are also alluded to in the list on pp. 303, 304, and areumbered 18 and 291 respectively.ALL LYMPH CONTAINS BLOOD CELLS. 307on a well -known case,¹ said-" It is conclusively provedthat it is possible for syphilis to be communicated in vaccinationfrom a vaccine vesicle on a syphilitic person,notwithstanding that the operation be performed withthe utmost care to avoid the admixture with blood . "All lymph, however, contains blood cells, and thisapparently was known as long ago as 1862. Dr. HeronWatson writes-" There is no vaccine matter, howevercarefully removed from the vesicle, which, on microscopicinvestigation, will not be found to contain bloodcorpuscles. " 2 This has been corroborated by Drs.Barthélemy³ and Husband, the latter's statement beforethe Royal Commission being accepted as final. Thusthe Commissioners say (section 430)-" The evidencegiven by Dr. Husband, of the Vaccine Institution ofEdinburgh , established the fact that all lymph, howeverpellucid, really does contain blood cells. "There is nothing necessarily in the appearance of thevaccine vesicle to lead one to suspect syphilis ; and Dr.Ballard informs us that " The perfect character of thevesicle is no guarantee that it will not furnish both vaccineand syphilitic virus." 5Again, a vaccinifer may exhibit no signs of the disease.1 See Supplement, containing the report of the Medical Officer , to theTwelfth Annual Report of the Local Government Board, pp. 46-51 ,1882-83 , and for subsequent history of case Allbutt's " System of Medicine,"vol. ii . , p. 608. London. 1897 .2 Edinburgh MedicalJournal, vol . vii. , p. 859, foot-note. (March, 1862. )3 See " Leçons sur la Syphilis Vaccinale," pp. 112-114 , foot-note. AlfredFournier. Paris. 1889.* Sixth Report , Royal Commission on Vaccination. Q. 27,327-9." On Vaccination : Its Value and Alleged Dangers." A Prize Essay.P. 345. London. 1868 .308 INJURIOUS RESULTS OF VACCINATION .Mr. Hutchinson, referring to a discussion on the subject,before the British Medical Association at Birmingham,in which he had taken part, observes " In reference tothe possibility of conveying syphilis from a vacciniferwho did not reveal the taint by any visible symptoms orany degree of cachexia , I felt bound in honesty to saythat I felt sure of it. No surgeon in his senses wouldever vaccinate from a child which showed obvioussymptoms. The fact is, however, that a certain numberof syphilitic infants look perfectly healthy whilst yet veryefficiently contagious. There is no use, and much danger,in denying this important clinical fact. " ¹He then mentions that the child from which the lymphwas taken to vaccinate his first series of cases, onlyrevealed a little sore ; this was seen by several medicalmen, including Sir John Simon, who questioned whetherit could be considered proof of taint. In the secondseries , the vaccinifer did not present a single visiblesymptom, and Mr. Hutchinson concludes that " It isabsurd to assert that inherited syphilis is always to bedetected, and it is a cruel injustice to imply that allaccidents have been the result of carelessness," indeed ina large number of cases, the vaccinifer has presented notrace of syphilitic disease. This brings us face to facewith the terrible thought that there may be some relationshipbetween the two diseases-cow-pox and syphilis.In the first chapter of this volume, I have alluded to themisleading name of variola vaccina or small -pox of thecow, given to the disease by Jenner. It is this misleading1 " Archives of Surgery," vol. ii. , p. 104 ( October, 1890) . JonathanHutchinson , LL.D. , F.R.S.:TRAMMELS OF JENNERIAN PATHOLOGY. 309name that has been, and is, even at the present time,largely responsible for the misunderstanding of the cardinalsymptoms of cow-pox, and this has been pointed outby none more forcibly than by the great Dr. Gregory :-" The more I reflect on the phenomena of small -pox aftervaccination, the more convinced I am that, so long asthe notion of the identity of cow-pox and small -pox thusobstinately prevails in our minds, so long will all justviews of vaccine pathology be embarrassed. " 1In a letter to Stewart, of Kelso, Dr. Gregory writes-" I have never yet addressed anyone in writing on thesubject, and I now write to you upon it, because I seethat you have considered it well-that you have thrownoff the trammels of Jennerian pathology, and think foryourself. Observe, I say, Jennerian pathology, notJennerian practice. I feel assured you do not viewvaccination as a kind of small -pox. The term variolavaccina was incorrect in pathology. Cow-pock is asomething that alters the human blood, and indisposesit to take small-pox. But it is not small-pox. A coatingof gold secures our salt spoons from the action ofchlorine ; but gold is not chlorine. Small -pox, aftervaccination, is not on a par with double small-pox. " 2The disease that cow-pox most resembles is notsmall -pox, but syphilis. This view of the analogyof cow- pox with syphilis was held by Auzias- Turenne,and in this country it has been advocated by Dr.Creighton. Auzias -Turenne says-" Between syphilis1 London Medical Gazette, vol. xxix. , p. 193. (October 29 , 1841. )2 " An Investigation of the Present Unsatisfactory and Defective State ofVaccination," p. 106 , 107. Thomas Brown, formerly medical practitionerin Musselburgh . Edinburgh. 1842 .310 INJURIOUS Results OF VACCINATION .and cow-pox the analogy may be a long way followedup. The inoculation of cow-pox-a malady with afixed virus sufficiently well-named pox of the cow(vérole de vache) may, for example, give rise to polymorphicvaccinides, and sometimes to disseminatedpathognomonic vesico-pustules, just as the contagion ofthe mucous patch, symptom of a malady with anequally fixed virus, gives rise to various secondaryeruptions, and sometimes to the appearance of disseminatedmucous patches. But, happily for the vaccinated,cow -pox passes through a rapid evolution, anddoes not leave virulent remains for so long a time or sofrequently as syphilis. " ¹The difficulty of distinguishing some cases of cowpoxfrom syphilis has been recognised by the bestauthorities. Mr. George Berry, ophthalmic surgeon tothe Royal Infirmary, Edinburgh, in a communicationon cow- pox of the eye-lids, says that the main interestin these cases " consists in the possibility of the inoculationtaking place at all, and in the differential diagnosisbetween vaccinia and a primary syphilitic sore. " 2Dr. Seaton has also alluded to this difficulty : " Amongthe sources of fallacy against which we have to be onour guard in cases in which syphilis has been said tohave been produced by vaccination, one is an erroneousdiagnosis. Persons talk very glibly about sores beingsyphilitic, and eruptions being syphilitic, as thoughthe characters of syphilitic sores and syphilitic eruptionswere so made out that there could never be any mistake1 " History and Pathology of Vaccination , " vol. ii . , p. 552. Edgar M.Crookshank , M.B. London. 1889.2 British MedicalJournal, vol. i. , pp. 1483, 1484. (June 28, 1890. )SYMPTOMS OF NATURAL COW- POX . 311about them. Yet such mistakes are daily being made bypractitioners in general, and are occasionally made by thevery highest authorities. About four years ago one ofthose amongst us most conversant with syphilis, Mr.Henry Lee, announced to the Medico - Chirurgical Societythat he had a case under his care in which a syphiliticchancre had been produced on the arm of a child byvaccination. The case was seen by many membersof the profession, some of whom agreed with Mr. Lee,while others saw nothing but a sore arm, the result of adegenerated vaccine vesicle. The subsequent progressof the case quite satisfied Mr. Lee that he had beenmistaken in his diagnosis, as he publicly acknowledged. " יThe accounts of cow- pox in milkers and in the earlyremoves from the cow describe it as consisting of corroding,hard, and painful sores with small disposition toheal, accompanied by enlargement of the neighbouringlymphatic glands. There appeared also considerableconstitutional disturbance and secondary eruptions. Acontagious disease presenting these characteristics cannotbe very far removed from syphilis, and there seemsnothing improbable in the suggestion that cases of socalledvaccinal syphilis are merely the reversion ofcow-pox to a former type. What is known as the Leedscase is an instance in point.Emily Maud Child was vaccinated on March 26, 1889,and died at the Leeds Infirmary on July I of the sameyear. At the inquest on July 10, four members of theinfirmary staff-Messrs. M'Gill, Ward, Littlewood, and1 " Handbook of Vaccination, " p. 322. Edward C. Seaton, M.D.London. 1868 .312 INJURIOUS results OF VACCINATION .Dr. Barrs-gave evidence that the child died from vaccino-syphilis , and the verdict of the jury was that she" died from syphilis acquired at or from vaccination."The case was shortly afterwards made the subject ofinquiry by Dr. Ballard, one of the medical inspectors ofthe Local Government Board, and his conclusions wereas stated in Parliament by the President of the LocalGovernment Board, Mr. Ritchie, who used the followingwords:-" An inquiry has been made by an Inspector ofthe Board with regard to the case. His conclusions arenot the same as those arrived at at the inquest. Hestates that the child in question was the only suffererfrom subsequent syphilis among all the children hereached and whom he saw that had been vaccinated withthe same or any other lymph in the whole course of thevaccinator's March vaccinations ; and further, that theentire family to which the alleged vaccinifer belongedwere, as far as he could discover by examination of them,free from any syphilitic taint or suspicion of such taint.The Report of the Inspector will be at the disposal ofthe Royal Commission on Vaccination. "¹This implies that the child died from hereditarysyphilis , and I would direct my readers' attention tothe following from Mr. E. Ward's evidence before theRoyal Commission :-Q. 23,688 . ( Dr. Collins.) Did you examine the twoelder children, the brother and sister ofEmily Maud C.?-Yes, on several occasions.1 Hansard's Parliamentary Debates, third series , vol. cccxli . , p. 1330,1331. ( February 27, 1890. )THE LEEDS CASE. 313Q. 23,689. Did you find them " stunted in growth " ?-No, they struck me, the girl particularly,as being remarkably fine children.Q. 23,690. Did you find the central upper permanentincisors of Eva, the eldest child, notchedin the characteristic syphilitic manner ?I do not think it was at all characteristicof syphilis ; and I do not think Mr.Hutchinson thinks so.Q. 23,691 . (Chairman.) Do you know what was referredto as the " notching " ?-Yes, perfectly.Q. 23,692. (Dr. Collins.) Did you get any history of" prolonged snuffles " in the second child,the boy ? No, that is nothing ; when Isaw the boy he was a little stuffy in thenostrils, but so many children are thatnothingthat I should attach any importanceto-it was long after any snufflesfound in the ordinary course even of congenitalsyphilis would have disappeared.Q. 23,701 . Would it be true to say that the familywas in any sense a " syphilitic family " ?-I should say certainly not.The words within quotation marks were presumablyquoted by the Chairman and by Dr. Collins from Dr.Ballard's report to the Local Government Board, andhence there can be no possible doubt of the nature ofthis report.The matter would probably have been left at thisstage were it not that a Royal Commission was then21314 INJURIOUS results OF VACCINATION .sitting. An independent inquiry was, therefore, madeby Dr. Barlow on behalf of this body, and he reportedthat there was no evidence of syphilis in either parentof the child, no evidence of inherited or acquiredsyphilis in either of the two elder children, nor did thehistory of the third (deceased) child suggest to himthat it was the subject of inherited syphilis. Mr.Hutchinson has also testified to the fact that there isno evidence of syphilis in any of the family. It maybe mentioned that Dr. Ballard's report containing thisaccusation was refused to the parents, but handedover to the Royal Commission, who, for some reasonor other, have omitted to publish it in their reports.The conclusion of the Commissioners on the case isthat it " may probably be classed with a few others asexamples of gangrene and blood poisoning, the directresult of vaccination, which are not to be explainedby supposing the introduction of any syphilitic orother poison . " (Section 427.) Considering that thecase was taken for syphilis by the four members ofthe infirmary staff, and also by Dr. Ballard, it appearsthat symptoms presenting all the characteristic phenomenaof syphilis can be produced by the vaccine diseaseitself.Mr. Hutchinson, in alluding to this and other similarcases , says, " Lastly, the question has to be entertainedwhether the cases are examples of syphilis in any form .To many I am aware it will seem undue scepticismto doubt this. When such symptoms as snuffles, thrush ,1 Hansard's Parliamentary Debates, third series, vol . cccliii . , p. 881 .(May 22, 1891. )RELATIONSHIP OF COW- POX TO SYPHILIS. 315the eruption on the genitals in infancy are mentioned,not a few will hold that the suspicion is rendered verystrong, if not actually proven. In the same way, nodeson the head, bubo in the armpit, phagedænic sores,abscesses and eruptions on the genitals occurring inconnection with a vaccination sore which has gonewrong, will be held by many as conclusive proofs thatsyphilis has been introduced. I cannot but freelyadmit that they bring with them much suspicion, andthat this suspicion is strengthened by the fact thatwell - experienced surgeons, who saw these varioussymptoms and examined them carefully, thought thatthey could be none other than syphilis. Further, thereis the fact that two of the infants were thought to havebeen much benefited by mercurial treatment. " ¹ Mr.Hutchinson also observed that if syphilis were conclusivelyproved in any one he would admit it in theothers.On the next page is a list of cases presenting featuressimilar to the Leeds case ; in some the symptomswere not so well marked as in others, but the casesmay all be said to come under the same category." Archives of Surgery," vol . i . , pp. 114 , 115. ( October , 1889. )316 INJURIOUS RESULTS OF VACCINATION .Authority. Number. Reference .Taylor and Fyson ILucas IHutchinson IHutchinson ( Dr. E.'s case) ISixth Report , R.C.V. , pp. 196-198.Guy's Hospital Reports , 3 S. ,vol. xxvii . , pp. 31-37 . 1884.Illustrations of Clinical Surgery ,vol. i. , p. 141 , plate xxv. , fig. 3 .London, 1878 .Archives of Surgery, vol . i. , pp.98-104. October, 1889.Hutchinson ( Dr. W.'s case) I Ibid. , pp 193, 194 Jan. , 1890.Hutchinson ( Dr. H.'scases ) Several Ibid. , pp. 194, 195.HutchinsonHutchinsonHutchinsonParsonsI Ibid. , pp. 197, 198 .I Ibid. , vol. ii , pp. 23, 24. July,1890.ILocal Government Board,Nos. xix. , xlii. , lix. ,lx. , xciv.Royal Commission on Vaccination, Nos. II , 21 ,35, 39, 113, 139, 141 , 162 ,167 , 169 , 175 , 177 , 183 ,199, 202, 204, 206, 207 ,208 , 241 , 258 , 326 , 416 .Ibid. , pp. 213-215. Jan. , 1891 .Several British Medical Journal, Nov.29, 1890, vol . ii. , p. 1233 .Appendix ix. to Final Report,R.C.V.523 ormoreAppendix ix. to Final Report,R.C.V.It might have been anticipated that some furtherlight would have been thrown on cases of this descriptionby Dr. Acland in his article in Allbutt's " Systemof Medicine, " but he contents himself by quoting theopinion of the Royal Commission that the relationshipof cow-pox to syphilis " is a point of speculative,almost it might be said of transcendental pathology,"and, although he admits that Nos. 109, 113 , 207, and416, in Appendix ix. to the Final Report of the RoyalCommission, are similar to the Leeds case and othersdescribed by Mr. Hutchinson, he apparently has nothingCALF LYMPH AND VACCINO -SYPHILIS. 317further to add, for he remarks that " it would not bepossible here to enter into these cases in detail. " 'If it be a fact, as maintained by Dr. Creighton , thatthe phenomena of vaccino -syphilis so-called, are due tothe inherent, though mostly dormant natural historycharacters of cow-pox itself, we should expect the sameappearances to take place occasionally in cases of calflymph ; and in this connection the experience recordedby Mr. Hutchinson in the " Archives " for January, 189T(pp. 213-215 ), is of interest. He particularises a case ofvaccination with calf lymph presenting certain symptomssimulating syphilis.The child was born of healthy parents in July, 1890 ;was perfectly healthy at birth ; was vaccinated at threemonths of age with Renner's calf lymph, at the sametime as several others who did well ; on the eighth day,only one place seemed to have taken, but later on allthree looked satisfactory ; at the end of three weeks, thearm was inflamed, and there were large black scabs withpus at their edges ; a week later a large slough comprisedall the vaccination sores and passed deeply almost tothe bone, and there was also a pustule on the nose, andthree nodes on the skull .Mr. Hutchinson compares this case with another hehad described in an earlier number of the " Archives "(October, 1889, p. 110). These two cases resembled oneanother, in that in both the infant was perfectly healthyup to the time of vaccination ; the lymph used was nottaken from the human subject, the skin around thevaccination sores passed into gangrene, with at the time1 Allbutt's " System of Medicine," vol . ii. , p. 604. London. 1897.318 INJURIOUS results OF VACCINATION.a large glandular swelling in the armpit. There werealso periosteal swellings of considerable size on the skullbones, suspicious sores on the skin ; and both patientsappeared to be much benefited by mercurial treatment.Mr. Hutchinson says-" It is obvious that these twocases give mutual support to the belief that no accidentalcontamination of the calf lymph by syphilitic secretionsoccurred. This was a suggestion which, although therewas not the slightest evidence in its support, it wasdifficult to wholly exclude in an isolated case. It is,however, improbable in the highest degree that such anaccident should occur in two cases, and in each shouldbe followed by precisely similar results ." There remains then the question : Were these infantsthe subjects of a latent inherited taint which vaccinationroused into activity ? In neither case was there theslightest evidence that either parent had suffered fromsyphilis, and in neither had the infant prior to vaccinationshown any symptoms. In one case the child wasa first- born , but in the other there was a healthy elderchild." The final supposition is that it is possible for vaccinationindependently of any syphilis, whether implantedor hereditary, to evoke symptoms which have hithertobeen regarded as peculiar to the latter malady, andwhich are apparently greatly benefited by specific treatment.On this point we must hold our minds open tothe reception of further evidence."A case perfectly parallel with the above-mentionedand the Leeds case was that described by Dr. FrederickTaylor and Mr. Edmund Fyson before the Royal Commission( Sixth Report, pp. 196-198). Every possibleDISASTERS IN THE AMERICAN CIVIL WAR. 319precaution appears to have been taken. The infant wasin good health. Dr. Renner's calf lymph had been used,and the needle with which the child was vaccinated hadnever been employed before. Gangrene of the pocksensued, and also gangrenous spots in other parts, andthe case terminated fatally.When it is said that vaccino-syphilis is rare, it mustbe remembered that these and other cases similar haveonly recently been published, and until further informationis forthcoming, it would be hazardous to assertthat a general introduction of calf lymph would rid usof the danger of vaccino-syphilis ; indeed, it remains tobe proved that by the repeated transmission throughthe bovine species, cow- pox will not again acquire muchof its old character. Before the Royal Commission, Dr.Cory gave his experience of 32,002 vaccinations performedat the calf lymph station ; 323 cases returnedfor complaint, 260 of which had sore arms , and Dr.Cory gave it as his impression that you got more sorearms after using calf lymph than from the humanisedvariety. This experience has been borne out by othercompetent observers .1Before concluding the evidence under the heading of" Syphilis, " I wish to allude to the disastrous consequencesof vaccination in the American Civil War( 1861-65 ), in which some hundreds of men were affectedwith a disease presenting all the characters of syphilis .The facts are related by Dr. Joseph Jones, andthe conditions described were truly frightful. The1 In this class of cases there was unwillingness of the sore to heal, andsome induration. Q. 4,377, 4,380.320 INJURIOUS RESULTS OF VACCINATION .symptoms included phagedenic ulcers, with induratedand everted edges, secondary skin affections, ulceratedthroats, loss of hair, and other phenomena distinctiveof syphilis. In some cases the gangrenous ulcerscaused extensive destruction of tissue, exposing arteries,nerves, and bones, in many cases necessitatingamputations.Dr. J. T. Gilmore, in a letter to Professor F. Eve,referring to three hundred cases in the Georgiabrigades , remarked-" The cases presented the appearancesthat are familiar to those of us who were connectedwith the Confederate army-large rupia- lookingsores, sometimes only one ; generally several on thearm in which the virus was inserted. In a number ofcases these sores extended, or rather appeared on theforearm, and in two cases that I saw, they appeared onthe lower extremities. The men suffered severely fromnocturnal rheumatism. Several cases had, to all appearances,syphilitic roseola. I saw enough of thetrouble to convince me thoroughly that the virus owedits impurity to a syphilitic contamination. " יDr. James Bolton testified that " on careful inspectionthe ulcers presented the various appearances of genuinechancre. In some instances there was the elevated,cartilaginous, well-cut edge surrounding the indolent,greenish ulcer ; in others there was a burrowing ulcer,with ragged edge ; in others there was the terribledestructive sloughing process devastating the integumentsof the arm. Many of the cases were so situated1 " Medical and Surgical Memoirs," vol. iii . , part 1 , p. 466. JosephJones, M.D. New Orleans.DISASTERS IN THE AMERICAN CIVIL WAR. 321that their history could be preserved, and in thesesecondary symptoms appeared, followed in due time bytertiary symptoms. The chancre was followed successivelyby axillary bubo, sore throat, and various formsof eruption ( syphilis dermata), while the system fell intoa state of cachexia. " ¹Dr. E. A. Flewellen testified that " while the armyof General Bragg was at Tullahoma, I was medicaldirector, and I know that very great complaint wasmade to me as to the character of the vaccinationpractised in the army. A large number of men wererepresented as unfit for duty. I think that one divisionrepresented nearly a thousand men as unfit forduty on account of spurious vaccination. I saw anumber of cases in the early progress of the vaccination,but they presented nothing abnormal that I coulddetect. But, as it advanced, the cases seemed to havethe appearance very nearly of syphilitic rupia. It diffuseditself more or less over the whole surface. A largenumber of surgeons regarded it as a complication ofvaccinia and syphilis. Finally, they settled into theopinion that it was not syphilitic. There never was, Imay say, any settled opinion among the surgeons of theConfederate army as to what was the true character ofthis impure virus . " 2Dr. George H. Hubbard relates that on November 30,1863 , he arrived at Fort Smith, Arkansas, having beenappointed Medical Director of the Army of the Fron1 " Medical and Surgical Memoirs," vol. iii. , part 1 , p. 467. JosephJones, M.D. New Orleans.* Ibid. , p. 480.322 INJURIOUS RESULTS OF VACCINATION.tier. His attention was immediately directed to severalhundred men disabled in consequence of " spuriousvaccination. " A Medical Board was appointed to investigatethese cases, and they reported : "At thetime we examined the patients, some had well- markedHunterian chancre ; some had large excavated ulcers,with edges everted above the raw and surrounding induration;the centres, when not recently cauterised, wereofa brownish hue-some,whose primary ulcers were abouthealed, had secondary symptoms, such as swelling andulcerations of the glands in different parts of the body;while others had pain and stiffening of the joints. Thedisease was brought to the First Arkansas Infantry bydeserters from the Confederate army, and in ouropinion is syphilis. " ¹Dr. William F. Fuqua, formerly surgeon of the 7thFlorida Regiment, reported fifty- two cases in Confederatesoldiers who presented abscesses in the axillary glands,pains in the limbs and joints, ulceration of the throat,buboes, coppery-coloured eruptions, loss of hair, andthese symptoms were only relieved by anti-syphilitictreatment. The cases were attributed to inoculationwith virus from the arm of a sailor who was labouringunder syphilis .Although the annals of vaccination disasters do notfurnish any other records of vaccino-syphilis on sovast a scale as that which occurred in the AmericanCivil War, other disasters have been recorded of1" Medical and Surgical Memoirs," vol. iii. , part 1 , p. 483. JosephJones, M.D. New Orleans .2 Ibid. , p. 471 ." SPURIOUS VACCINATION " AT GRANITEVILLE. 323sufficient importance to demand special reference .Among these may be mentioned the cases of " spuriousvaccination " at Graniteville, related by Dr. W. F.Percival , and included in Dr. Jones' work. Dr. Percivalsays-" About the last of April, 1866, I was requestedto take charge of some cases of spurious vaccinationat the manufacturing village of Graniteville. Onehundred and fifty cases were presented for examination,men, women, and children of all ages, from fiftyyears to twelve months. The larger proportion wereoperatives in the factory, the others engaged in outdoorwork . There was every variety of constitution, fromthe pale, attenuated girl, to the hardy and robustlabourer. Of the hundred and fifty cases, ninety - threehad been previously vaccinated. The appearance ofthe sore was identical in every case, viz. , an excavatedulcer, of circular form, with raised and hardenededges and base. They varied in size, from one halfto two inches in diameter, covered with grey or darksloughy matter, and secreting unhealthy pus. Therewas no appearance of granulation . In some casesulcers of a similar character appeared on the armsaffected ; in others on the opposite arm, and in a fewon the lower limbs. In some, abscesses formed onthe inside of the arm, and in nearly all the axillaryglands were inflamed, and many suppurated. A thickand unhealthy crust would form, to be soon separatedby the pus which accumulated beneath. In one case,there was a copper-coloured eruption on the body andlimbs ; in two or three the hair dropped off. Noneof these cases were in the primary stage. The diseasehad existed from three to eight weeks. Most of them324 Injurious results OF VACCINATION.pursued their ordinary avocations, as far as possible,and complained of no constitutional symptoms, or anyloss of appetite. The history of these cases, as givento me by the individuals first vaccinated, was thatthey had obtained the virus from a man whom theyafterwards discovered to have had primary syphilis.One was vaccinated from the other, and so it spread.None of the ulcers had evinced any tendency toheal." 1 Dr. Percival adds that the usual treatmentfor venereal ulcers effected a cure in from three to sixweeks.I may also allude to the disasters resulting fromvaccination at Algiers in 1880.On December 30 fifty-eight recruits of the 4th Regimentof Zouaves were vaccinated from a child whichlooked perfectly healthy. They were all infected withsyphilis, and about half are reported to have died, theremainder being dismissed the service. No blamewas attached to the operating surgeon. Anotherseries which created a painful impression on the publicat the time was that of fifteen young school -girls whowere syphilised by vaccination at Lebus (Prussia) in1876.Leprosy.2There is considerable evidence that leprosy has beeninvaccinated, and the question has been raised as towhether some part at least of the recent spread of the1 " Medical and Surgical Memoirs," vol. iii. , part 1 , p. 478. JosephJones , M.D. New Orleans.2 Third Report, Royal Commission on Vaccination . Q. 9,540, 9,736.DR. HAWTREY BENSON'S CASE .325disease in certain countries is not due to the practice ofarm -to-arm vaccination. This has been so fully discussedin a volume entitled " The Recrudescence ofLeprosy " ¹ that it might be thought unnecessary tore-open the subject, especially as the facts which it isproposed to lay before the reader must be largely arepetition of what has been so exhaustively treated inmy father's work. The matter, however, is admittedlyof such serious and far-reaching importance that noaccount of the century's experience of vaccinationwould be complete which did not deal with the mainpoints of this question .It is not proposed to discuss the etiology of leprosy,except in so far as to show that it is a communicabledisease, and may be communicated by inoculation orby vaccination .There are instances on record of Europeans contractingthe disease in leprous countries, as, for instance,the case of Father Damien in Molokai, Father Boglioliin New Orleans, a French Sister of Mercy in FrenchGuiana, and another in Tahiti ; but perhaps the mostimportant case is that related by Dr. Hawtrey Benson.2An Irish soldier returned home from India, where hehad resided for twenty-two years ; a few months afterwardssymptoms of leprosy developed. The patientwas under Dr. Benson's care at the City of DublinHospital , but ultimately went home, where he died ofthe disease. During this last period of his life his1 " The Recrudescence of Leprosy, and its Causation." William Tebb.London. 1893 .* Dublin Journal of Medical Science , vol. Ixiii. , pp. 562, 563. (June,1877. )326 INJURIOUS results OF VACCINATION .brother slept in the same bed, and wore the leper'sclothes. The brother had never been out of Ireland,except once, forty-six years previously, when he spentsome time in England. He developed leprosy, andDr. Benson exhibited the case before the MedicalSociety of the College of Physicians, Ireland, whenthe diagnosis was confirmed by those acquainted withthe malady. In making his concluding observationsbefore the Society, Dr. Benson pointed out thatone fragment of positive evidence on the subject wasworth a vast amount of negative evidence.This case must be regarded as affording absoluteproof of the communicability of leprosy from person toperson.¹An experiment made on the condemned criminal,Keanu, by Dr. Edward Arning, is interesting from the1 For further testimonies seeBakewell . Q. 3,656 , Report from the Select Committee on the VaccinationAct ( 1867) . 1871 .Tilbury Fox. " Skin Diseases," third edition, p. 322. London. 1873.Vandyke Carter. " On Leprosy and Elephantiasis," p. 187, foot- note.London. 1874 .Macnamara. " Leprosy a Communicable Disease." London. 1889 .Moore. Journal of the Leprosy Investigation Committee, No. 1 , p. 28 .August, 1890.Francis. Ibid. , p. 56.Cayley. Ibid. , p. 36 .Murray. Ibid. , p. 46.Hanson. Ibid. , No. 2 , p. 64. February, 1891 .Report of the Cape of Good Hope Leprosy Commissioners , 1895 , vol .iv. , p. 101 .Report of the International Leprosy Conference, vol. ii. , pp. 191 , 192.Berlin . 1897 .2 Journal of the Leprosy Investigation Committee, No. 2, pp. 132, 133 .February, 1891 .THE INOCULATION OF LEPROSY . 327point of view of the possibility of the invaccination ofleprosy. The Hawaiian , who, at the time of the operation,was carefully examined by several physicians andpronounced to be in perfect health and remarkablystrong, was inoculated with a portion of a leprousnodule on the left forearm. A month later the mansuffered from rheumatic pains in the joints of the leftarm, and a painful swelling of the ulnar and mediannerves . In the course of six months a small leprousnodule was formed on the keloid spot where the inoculationtook place, and leprosy bacilli were detected atthe seat of the keloid scar for a period of sixteenmonths after the operation. Distinct symptoms ofleprosy were observed three years after the inoculation,and in another year the disease was at its full height.It may be mentioned that the patient was isolated fromthe day of the operation for three years afterwards. Ithas subsequently transpired that a son, a nephew, and acousin of Keanu's, have shown symptoms of the disease,but Dr. Arning, urges that at the time of the operation,Keanu himself was perfectly free from leprosy, and thatdistinct signs appeared three years afterwards , and atpresent ( 1891 ) furnishes a typical case of generalleprosy.Mr. C. N. Macnamara, ¹ in referring to a report on thiscase by Dr. N. B. Emerson, President of the Board ofHealth, and Mr. J. H. Kimball, Government physician ,Honolulu, says-" This report establishes unequivocallythe fact that the inoculated man has become leprous ;1 " Leprosy a Communicable Disease," second edition, p. 45. C. N.Macnamara. 1889.328 INJURIOUS Results OF VACCINATION .and as he had been inoculated three years previously,there is every reason to believe that the disease is theresult of the inoculation."Keanu has since succumbed to the leprous disease.The inoculability of leprosy once established, itscommunicability by arm-to-arm vaccination must beaccepted, and in order to throw some light on thesubject, Dr. Edward Arning vaccinated a number oflepers. He says-" These experiments lead to theresult I anticipated. In cases of extensive cutaneousleprosy, in which skin apparently healthy containsbacilli , these were likewise to be detected in thelymph ; but there were no bacilli to be found in thelymph taken from cases of pure Lepra nervorum, inwhich no trace of the bacillus is to be found in theskin. " ¹Other experiments have been recorded by Drs.Beaven Rake and G. A. Buckmaster. Most of thesewere negative, but we read that " Suspicious lookingrods taking fuchsin were seen in one case in vesiclesraised over tuberculated ears, and in another case invesicles over anæsthetic patches." Even if these resultshad all been entirely negative, it would hardly detractfrom the value of Dr. Arning's careful investigations .Further evidence of the communicability of leprosy byvaccination is furnished by cases which have beenrecorded from time to time.1Journal of the Leprosy Investigation Committee, No. 2, p. 131 .February, 1891 .2 Ibid. , No. 4, p. 34. December , 1891 .SIR WILLIAM GAIRDNER'S CASES. 329The instances which have probably attracted the mostattention are those related by Sir William Gairdner inthe British Medical Journal of June 11 , 1887 (vol. i. ,pp. 1269, 1270), in an article entitled " A RemarkableExperience concerning Leprosy; involving certain Factsand Statements bearing on the Question-Is Leprosycommunicable through Vaccination ? " The case asstated by Sir William Gairdner is as follows :-" The time seems to have arrived when, without injury or offenceto anyone concerned, it is possible to bring under the notice of mymedical brethren some facts, and some inferences arising more orless directly out of the facts, in a case which occurred to me someyears ago, but which I have found it necessary hitherto to dealwith as involving matters of professional confidence not suitablefor publication. Even now I shall deem it expedient to frame thismere narrative in such terms as shall not point to any definitelocality, or to any recognisable person, among those chiefly concerned; although, by a formal certificate granted only the otherday, I feel, as it were, absolved from the last tie that bound me, evenunder the most fastidious sense of professional duty, to reticence." Six or seven years ago the parents of a young boy, fairlyhealthy in appearance, but with a peculiar eruption on the skinbrought him to me, and along with him a letter from a medicalgentleman whom I had entirely, or almost entirely, forgotten, butwho stated himself to have been a pupil of mine in Edinburghconsiderably over twenty years before. It is unnecessary toenlarge on the particulars of this case further than to state thatafter more than one most careful examination, in which I hadthe assistance of my colleague, Professor M'Call Anderson, wecame to the conclusion which we announced to the parents,that the boy was suffering from incipient, but still quite wellmarked,leprosy in its exanthematous form ; a diagnosis afterwardsamply confirmed. What struck me at the time as most peculiarwas, that this case, coming from a well-known endemic seat ofleprosy (an island within the tropics) and with a letter involvingmedical details by a medical practitioner of many years' local22330 INJURIOUS results OF VACCINATION.experience ; sent to me, moreover, for medical opinion andguidance, should not have been more frankly dealt with by adiagnosis announced even to the parents, before they left theisland. The father of the child was a sea-captain constantlyengaged in long voyages for the most part between this countryand the island alluded to. Both father and mother were Scotch,and there were several other children, all reported as quitehealthy, as also were both the parents. Under these circumstancesI wrote to the medical man-who in the sequel may becalled, for brevity, Dr. X.-simply stating the diagnosis arrivedat, and indicating the line of treatment proposed. The parentswere informed that it would be best for the child to live in thiscountry, and his mother agreed to remain with him accordingly.And, as they appeared anxious to have every available suggestionand advice, I mentioned the name of Dr. Robert Liveing ashaving given much attention to the subject, and offered to writeto him if they would take the boy to London, as they appeareddesirous of doing. Although I wrote to Dr. Liveing, circumstancesunknown to me led to a change in their plans, and, instead ofgoing to London, they went to Manchester, where I believesome physician was consulted, but I do not remember who hewas. Ultimately, the mother determined for a while to settlein Greenock, and I placed her accordingly in communicationwith Dr. Wilson of that town, who for some time thereafterremained in medical charge of the case ." Meanwhile, the course of post brought me in a few monthsa reply from Dr. X., not only entirely assenting to our diagnosisas communicated to him, but stating that he had been perfectlywell aware from the first of the case being one of leprosy, buthad deliberately chosen not to affirm the fact or even to alludeto it in any way, either in his communications with the parentsor in his letter to me. No reason was assigned for this (as itappeared to me) very remarkable reticence ; but, as I did notwish to have the credit of having discovered for the first timewhat a gentleman so much more familiar with the disease mighthave been supposed to have overlooked, I took means to informthe parents of Dr. X.'s reply, and of his having been all alongof the same opinion with regard to the disease as we were.SIR WILLIAM GAIRDNER'S CASES. 331"After this the matter passed out of my mind, and for severalyears I neither saw nor heard of this child except accidentally,and in a way entirely to confirm first impressions. About threeyears ago, however, while engaged in lecturing on specific diseases,and among others, briefly, on leprosy, I made an effort to find outsomething more about this patient. The mother had removedfrom Greenock, and had brought over the whole family to Helensburgh,where, as I learned, they were visited by Drs. Reid andSewell, and from the latter I now learned that the poor boy hadgone steadily to the worse, and was extremely feeble, coveredwith sores, and in a most deplorable condition physically, but stillreceiving every attention and care that constant medical treatment,with the most faithful and loving maternal nursing, couldafford to lighten his sufferings. I accordingly proposed, withinthe next few days, a visit to my old patient as a matter of satisfactionto myself. Unhappily there was no other apparent object,either as regards diagnosis or treatment, for a visit which was,nevertheless , very gratefully accepted." The case was now in the most advanced stage of leprosy,proceeding to mutilation of the extremities, and accompanied notonly by external sores, but presumably by internal lesions, whichhad reduced the patient to the last stage of emaciation. It wason this visit that the curious particulars now to be related werefirst brought to my knowledge by Dr. Sewell, and afterwards confirmedby the statement of the mother, showing very clearly,though, of course, upon second-hand information to a certainextent, that Dr. X. had a very special reason for his extraordinaryreticence in the first instance. Her husband, who in his frequentvoyages had opportunities of coming into communication withDr. X., had remarked to him how very strange it was that, evenin writing to a medical man about the case, he had given no hintof his opinion about it. The doctor's reply to this was, in theend, to the effect that he had kept silence because he did not wishto compromise a boy of his own, whom he ( Dr. X. ) believed to bea leper, and from whom he believed at the time that the boy hehad sent to this country had become infected with the disease.He further explained that he had vaccinated his own boy withvirus derived from a native child in a leprous family, and, as I332 INJURIOUS RESULTS OF VACCINATION.understood(though perhaps not definitely so stated), that leprosyhaddeclared itself in the native child after the vaccination ; and,further, that (using his own child as a vaccinifer) he had vaccinatedour patient directly from him. Before sending the lastnamedpatient away with his parents, he had satisfied his ownmind not only that his own boy was leprous, but that he had inthis way become the source of the disease to another; but thedisease in his own child being in a very mild form, he was anxiousnot to disclose its existence. Meanwhile Dr. X. had died ; hisestate had passed into the hands of trustees ; and I was informedthat this reputed leper-boy had been, under the instructions of hisfather and his guardian, placed and retained at a public schoolwell known to me in this country, and that the boy was pursuingthe usual course of a public school education, in entire unconsciousnessof the disease with which he was supposed to be affected." This information, so communicated, placed me in rather adifficult dilemma, namely was I justified in taking steps toascertain the truth of the story as regards Dr. X.'s boy, either bypersonal investigation or, at least, by inquiries conducted so as toresult in a well-grounded and scientifically exact opinion as to thefacts ? And, further, supposing that such opinion should turn outto be that Dr. X.'s boy was a leper, was it a matter of duty onaccount of others to formally disclose the fact, be the consequencesto the boy what they might ? It was hardly probable that a boygenerally known to be a leper would be retained permanently inany public school in this country, even had it been unquestionablya matter of medical doctrine that such a proceeding was quitesafe. On the other hand, the boy was receiving the benefits of anEnglish education at the express wish and on the responsibility ofhis father and guardian, and without (so far as appeared) anymisgivings on the part of anyone. He was an orphan, and inwhat was to him a foreign land ; his remaining under instructionmight be, and probably was, a matter of the greatest possibleimportance to him. To bring him, therefore, even by an indiscreetinquiry, under the ban which in many or most countries stillattaches to leprosy was certainly no part of the business of an outsider,and could only be justified at all by an overwhelming senseof duty to others .SIR WILLIAM GAIRDNER'S CASES. 333" Under these circumstances I thought it well to consult,privately, one or two of those friends in London whom I believedto know most about leprosy, and among others Dr. Liveing, whomI was able to remind, at this stage, of my previous letter. Thesefriends concurred in assuring me that, in the rather improbableevent of their being personally consulted as to the retention of aleper in a public school ( it being presumed, of course, that he wasphysically fit otherwise), they would have no hesitation at all inaffirming that the other boys would not be endangered by suchproceeding. As I happened to be very well acquainted with oneof the medical officers (though not the ordinary medical officer) ofthe school in question, I communicated these opinions to him, andstated to him at the same time the extraordinary circumstanceswhich had begotten, for me, such a lively interest in the son ofDr. X. In the course of a few days I was informed that an inquiryhad been held by the medical staff ; that the boy had been sent forand privately examined (though not ostensibly ill in any sense) ;and that it was, beyond all doubt, considered to be a case ofleprosy. The medical authorities decided, however, that underthe circumstances it was not their duty to sound the alarm, or inany way to disturb the boy's education ." From this time onwards (except the death of the first patientsoon afterwards) I heard nothing more of these matters till a fewweeks ago, when I was asked to see Dr. X.'s son professionallyon behalf of the school authorities ; and, if so advised, to requestDr. Anderson also to give an opinion as to the present state ofhealth of this young man, who happened at the time to be visitingsome friends in Glasgow. It was represented to me that he hadmaintained, on the whole, fairly good health since I last heardof him through my medical friend, and had not been incapacitatedfrom school work except on account of a contagious eczemawhich had been prevailing, and with which he had been affectedin common with other boys. Apparently, however, the opinionhad arisen that his general health was not quite so good, andthat in view of a cutaneous affection of this kind, apparentlycommunicable, existing, it was no longer expedient that he shouldremain at the school. Indeed, I could not but come to theconclusion that his removal, on public grounds, had been practi334INJURIOUS results OF VACCINATION .cally settled ; and, with every desire to soften the blow as muchas possible to the poor boy, it was felt to be necessary that hisguardian, at least, should receive unequivocal and unbiasedtestimony as to the actual state of the facts and circumstancesunder which the decision was arrived at . Under these circumstancesI saw and examined this boy, and made a report, alongwith Dr. Anderson, to the effect that the disease was evidentlyleprosy, though of a remarkably mild type, as shown by discolourationsand cicatrices, and also by large anesthetic areason the back of one limb. All breaches of surface, however, andall discharge had ceased at the time of our report, and Dr.Anderson felt still in a position to affirm that no danger to otherscould occur from the boy's remaining at school. On this lastpoint I did not feel able to give an unqualified assent to mycolleague's opinion ; but as regards the matters of fact andobservation there was no doubt whatever, and our report accordinglyon these was substantially as above. "In a subsequent communication, Sir William Gairdnersays-" Dr. X. confessedly vaccinated his own child froma leprous family, though probably not from an actual orapparent leper, and then vaccinated the ' sea -captain'sboy ' from his own. " ¹Mr. C. N. Macnamara, in alluding to these and othercases of a similar kind, remarks that they " seem torender it probable that leprosy may be conveyed froman affected to a healthy person in vaccine lymph ; andin localities where leprosy is endemic, we should becareful as to the source from which vaccine lymph isobtained . " ?One of the earlier references to the subject was bySir Ranald Martin, who says, " The dangers to Euro-British MedicalJournal, vol. ii . , pp. 799, 800. ( October 8, 1887. )* Art . on Leprosy in Davidson's " Hygiene and Diseases of WarmClimates, " p. 445. London. 1893 .SIR RANALD MARTIN'S CASE . 335peans arise chiefly from vaccination, and from wetnursing.I felt that very early in my career in India,and I took the precautions which are here recorded.I saw an English lady last year in a horrible condition(she said), from having been vaccinated from a leprousnative child. " יDr. Hall Bakewell, who has occupied the position ofVaccinator-General and Medical Superintendent of theLeper Hospital at Trinidad, also alluded to cases beforethe Select Committee of the House of Commons in1871 ( Q. 3,564). " I have seen several cases in whichit (vaccination) seemed to be the only explanation. Ihave a case now under treatment of the son of a gentlemanfrom India who has contracted leprosy, both theparents being of English origin. I saw the case of achild last year who, though a creole of the Island ofTrinidad, is born of English parents, and is a leper,and there is no other cause to which it is attributable."Mr. John D. Hillis gives the following cases, in whichhe says there could be no doubt the disease was producedby vaccination." Joseph Francis C-, a fair Portuguese, born inDemerara, now aged twenty years. His parents arealive and healthy. He has been suffering for the lastten years from tuberculated lepra. He has a sister,aged eighteen years, at present (1879) an inmate ofthe Asylum, suffering from the same form of leprosy.They were both admitted on July 30, 1877, from MurrayStreet, Georgetown. They have three sisters and one1 Report on Leprosy by the Royal College of Physicians , Appendix,p. 227. London. 1867 .336 INJURIOUS RESULTS OF VACCINATION.a reddishbrother,who are alive and well. Our patient, J. F. C-,and his sister were vaccinated with lymph obtainedfrom a member of a Portuguese family' in whomleprosy was afterwards found to exist. They werethe only members of the C- family vaccinatedwith this lymph. Within eighteen months of theperformance of the operation by Dr.brown spot appeared on the inner side of the rightthigh, preceded, it is stated, by some constitutionaldisturbance ; this spot was raised and tender, accompaniedby profuse sweating all over the body, andremained for some time. Subsequently other spotsmade their appearance on the right buttock (whichdisappeared shortly after), between the shoulders, andon each cheek. They were all ushered in by moreor less well-marked febrile symptoms. A red patchnext appeared on the forehead, and epistaxis set in,periodically occurring to this day. Tubercles thenmade their appearance on the face, the other patchescontinuing to increase in thickness and roughness, andforming tubercular infiltration. The latter was removedby gurjun oil, under which treatment many ofthe symptoms were ameliorated."" State and Condition on November 30, 1879.-He hasa light -brown irregular patch on the front of his chest ;this has been larger, thicker, and mahogany-coloured,and has evidently undergone partial absorption. Thereis a patch of tubercular filtration on the back of thearms, and at the bend of the elbows. The fingers areMr. Hillis says, " It is within the knowledge of Dr. Manget, Surgeon-General, and the author, that this family are at present afflicted withtuberculated lepra. "MR. HILLIS' CASES. 337swollen, shining, and dark-looking, a solitary tubercleforming on the back of the hand. The swollen conditionof the fingers and hands is very characteristic.There are two tubercles on each cheek, the size of largemarbles ; the lobes of the ears are thickened , and atubercle is forming on the upper tip. There is noappearance of hair growing on the face. There arereddish- brown discolourations on the front and back ofthe legs. There are a few small scattered tubercles onthe dorsum of the feet, and the lower part of the legsare swollen and hard to the touch . There are tubercleson the scrotum, an ulcer on the leg where a tuberclehas ulcerated, and the larger tubercles are slightlyanæsthetic. This young man is one of the carpentersof the institution ; he is in hopes the treatment nowbeing adopted may yet arrest the disease which is,however, making slow but sure progress. "Mr. Hillis quotes the following case from a work byDr. Piffard, of New York :-" William T-, aged twenty- five years, was admittedinto Bell Hospital in May, 1864. He was of Englishparentage, but was born and passed his early life inBritish Guiana. After a vaccination performed whenyoung, his arm became greatly swollen and inflamed,and large sloughs separated. Investigation revealedthe fact that the vaccine virus had been taken from anegro whose mother was a leper. At the age of sevenyears some brownish spots appeared upon his back andarms ; and at the age of eleven a blister formed on the1 " Leprosy in British Guiana," p. 30, 31. London. 1881 .* Ibid. , p. 208 .338 INJURIOUS RESULTS OF VACCINATION .palm of the right hand, followed by permanent contractionof the flexor tendons. A few months later hefelt a tingling sensation around the nail of the rightindex finger, followed by a line of suppuration and lossof the nail. The finger soon healed, but the samemorbid process separated itself in the other fingers ofthe same hand. After a few months, according to hisstatement, the skin of the distal phalanges split, andthe flesh shrank away from the bones, leaving themexposed. The bones separated at the joints and thestumps healed. These various processes occupiedeighteen months or two years . The disease thenaffected the distal phalanges of the left hand in thesame manner. After this it attacked the right foot,and a slough formed over the lower part of theinstep. The great toe then became swollen, the skinsplit, and its distal bone separated, then, withoutmuch regularity, the remaining phalangeal bones offingers and toes necrosed and came away. "Sir Erasmus Wilson relates a case in the 1867 Reportof the Royal College of Physicians ( Appendix, p. 235 ).Elephantiasis tuberculosa ; duration of latent period, twoyears ; total duration, five years ; no pains ; febrileattack simulating rubeola ; vaccinatedfrom a nativechild." A young gentleman, aged sixteen, with fair hairand complexion, and somewhat more youthful in appearancethan might be expected of his age, has beenafflicted with the tubercular form of leprosy about fiveyears. He was born in Ceylon, is the son of Europeanparents, and one of six children, all of whom areOPINION OF THE COLLEGE OF PHYSICIANS. 339healthy. His father and mother have always enjoyedgood health, the father having resided in Ceylon fortwenty years, the mother since her marriage. He wasnursed by his mother, but vaccinated with lymph takenfrom a native child." ( For detailed description ofsymptoms, see Physicians' Report. )The College of Physicians, in their Report (p. lxxiv. ,foot -note) , refer to the evidence of Sir Erasmus Wilsonand Sir Ranald Martin thus : " The question alluded toin the communications from Mr. Erasmus Wilson andSir R. Martin (vide Appendix) as to the transmissionof leprous disease by vaccination and wet-nursing, isone of special interest to Europeans resident in Indiaand other tropical countries, and calls for a searchingexamination."The following case of Elephantiasis anæsthetica isalso recorded by Sir Erasmus Wilson.¹" A lady, aged twenty- six, the wife of an officer of theIndian army, became affected with elephantiasis in 1861 .She was born in Calcutta of European parents, andbrought to England when two years old ; she returnedto India in 1853 ; was married in 1855 ; has been eightyears married, and has now ( 1863 ) revisited Englandfor medical treatment, the length of her residence inIndia being ten years. In 1861 , being then in Oude,she was vaccinated from a native child, and shortlyafter the vaccination ' a slight spot came on her cheek,and increased in size to the diameter of a shilling.' Itwas hard to the touch, a little raised above the level of1 " Diseases of the Skin," sixth edition, pp. 620-622. Erasmus Wilson,F.R.S. London. 1867 .340 INJURIOUS Results OF VACCINATION .the surrounding skin, and of a dull red colour, withoutpain or tenderness. The swelling was painted withiodine, and afterwards blistered several times, and theblister kept open ; but although somewhat reduced insize, the prominence was not removed. About sixmonths later, dull red flat spots appeared, dispersedover the greater part of her body. Her hands and feetbecame swollen, and she had pains of some severity inher joints and feet. "The following cases were published in an article byDr. Daubler in " Monatshefte für praktische Dermatologie," February 1 , 1889, vol. viii ., pp. 123-129.Case 1. Mrs. H-, from W-, thirty-six years ofage, married , and the mother of a healthy child oftwelve. The closest inquiries established beyond doubtthat her family was quite free from leprosy. Severalyears previously, in consequence of an epidemic ofsmall-pox, she was re-vaccinated. During the twomonths immediately following re-vaccination she experiencedattacks of shivering three to five timesweekly, was thirsty, but passed less urine than usual ;at the same time the vaccine wounds swelled andbecame brown, and the patient experienced greatlassitude. The patient had been vaccinated in threeplaces on each arm over the insertion of the deltoid,and when she saw the medical man two and a halfmonths after vaccination the vaccine wounds wereswollen. The swelling had been noticed on the thirdday after vaccination, and reached its greatest heighteight days afterwards. At this time the parts becameyellowish, and fourteen days after vaccination aroundeach of the vaccine cuts there was a raised yellowishDR.DAUBLER'S CASES. 341brown discolouration of the skin of the size of a twoshillingpiece. These patches gradually became flatterafter about five weeks from the date of vaccination, butincreased in area, and when seen by her doctor tenweeks after vaccination the skin of the arms and ofthe upper third of the forearms was brown in colourand wrinkled. The brown spots extended still further ,and after three more weeks, during which time she wasfeverish and ill, the patches became smaller and smaller,but the skin never regained its normal colour. In thefourteenth week after vaccination she had a severerigor, which was twice repeated during the followingweek ; subsequently the attacks of fever were lessfrequent and violent. At and shortly after the timeof the most severe rigors brownish spots appearedon the forehead and cheeks . Eighteen weeks aftervaccination tubercles developed on the brow andshortly afterwards on the cheeks. Two years laterthe woman was sent to the leper asylum at RobbenIsland, where she was seen and photographed byDr. Daubler, tubercular leprosy having fully developed.Dr. Daubler here gives a minute description of thesymptoms, and with regard to vaccination he says thatthe old vaccination scars were visible, but there werenone from the re-vaccination which took place threeand a half years previously, as there were then nopustules formed, but only swelling and discolourationof the skin occurred .Case 2. R. du Toit, a half-caste girl, aged fifteen,also from W-, and in whose family no cases of leprosyever occurred. The patient stated that she had always342 INJURIOUS RESULTS OF VACCINATION .been healthy till vaccination, which was performed bythe same doctor, and at the same time as Mrs. Н—.At first the same local appearances were noticed on thearms as in the case of Mrs. H-, but after two months,prominent dark patches appeared on the forehead andcheeks, and after three months more leprosy was fullydeveloped on the forehead. When seen and photographedby Dr. Daubler, the disease had lasted threeand a half years. Inquiries made in W- (the domicileof the two patients), and also from the doctor who performedthe vaccinations, showed that the person fromwhom the lymph was taken to vaccinate these twopatients had died a short time previously from tubercularleprosy, other members of the family being leprous ,facts of which the doctor was , however, ignorant.Concerning the question as to whether vaccinationis responsible to any extent for the spread of leprosyin certain countries, the following from Dr. EdwardArning is not without interest : -" Another point which requires our notice regardingthe Hawaiian leprosy epidemic, and which was speciallyraised by the late Dr. Hillebrand ' Has leprosy beenspread in that island by means of universal vaccination ? '" There can be no doubt as regards the synchronousnessof the diffusion of leprosy and the introduction ofvaccination into the Hawaiian Isles ; but it still remainsan open question whether it is possible to form a positivecausative connection between the two. I find that thefirst authentic record of leprosy cases dates from theyear 1830, though the terrible diffusion of the diseaseover the whole group of islands occurred twenty- fiveyears later, at a time when a severe small -pox epidemicDOES VACCINATION SPREAD LEPROSY ? 343was raging. This occasioned universal vaccination,which, however, was performed in a careless way, andprincipally by laymen. And it is this fact that Hillebrandand others consider the foundation for theirargument regarding the diffusion of the disease bymeans of vaccination . We do not desire to overlookthis fact of simultaneousness, but we are able to giveit a different explanation. When we consider thatcases of well-defined leprosy existed in 1830, we mustnecessarily date the importation of the disease somefew years earlier. During the subsequent few yearswe perceive that the disease gradually expanded aroundthe centre of origin. The explanation of the apparentsudden diffusion of the disease at the beginning of 1850,must lie in the fact that leprosy is essentially a familydisease, though possibly neither congenital nor hereditary.A sufficiently long time had elapsed from thetime of the importation of the disease down to theperiod in question, to enable a new generation to springup; and this new generation formed new families, andfrom each of these individual centres leprosy was againdiffused . Moreover, we must bear in mind the immenseinfluence which from 1830-1850 the introduction ofcivilisation , and the influx of a great Mongolian andCaucasian population must necessarily have had uponthe natives. There is another observation bearing uponthe connection between leprosy and vaccination, whichI consider of still greater importance. This dates froma later period in which no concomitant factors, as in theabove, come into play." I am able to state-having excellent authority forso doing, though unfortunately no statistics-that a344 INJURIOUS RESULTS OF VACCINATION .very remarkable local accumulation of fresh leprosycases took place in 1871-72, in a place called Lahaina,on the Island of Mani. This happened about one yearafter a universal arm-to-arm vaccination, which had beenmost carefully performed. About fifty to sixty casesoccurred suddenly in this locality, which up to that timehad been comparatively free from the disease." 1Dr. Arning emphatically condemns arm-to-arm vaccinationin leprous countries. He says-" When in Hawaii I attended a German boy, agedtwelve, who suffered from leprosy, from whom when hewas seven years old several white families had beenvaccinated. I am not able to assert that leprosy wasspecially diffused on account of this, but still I considersuch a fact to indicate that an arm-to-arm vaccinationshould be prohibited in countries in which leprosyabounds." 2In a recent essay by Dr. James Cantlie, we havefurther corroboration that in the Sandwich Islands andelsewhere, the spread of leprosy has to a certain extentbeen caused by vaccination. A series of questions weresent out to a number of authorities in China, Indo-China, Malaya, the Archipelago, and Oceania, andamong them it was asked , " Has leprosy increased withthe use of vaccination ? "Among the replies are the following importanttestimonies :-Dr. Macdonald, of Fatshan, near Canton, says, " Ithink leprosy is on the increase with the increasing1Journal of the Leprosy Investigation Committee, No. 2, pp. 130, 131 .February, 1891 .2Ibid. , pp. 131 , 132.DOES VACCINATION SPREAD LEPROSY ? 345population of the country, and that vaccination is aslight factor in the increase. Lack of efficient segregation,however, accounts for most of it." ¹With regard to Swatow, Dr. Anna Scott reports(p. 308)-" I answer a most emphatic ' yes ' to thisquestion. The increase of leprosy among children isfrequently remarked upon by our (mission) people, andI have been forced to the conclusion that vaccinationfrom arm to arm, practised by a class of Chinese(quack) doctors, has caused this very marked increase."Dr. Albricht, of Sourabaya, Java, writes (p. 358)-" I cannot bring decisive proof that there is a connectionbetween vaccination and leprosy, but the tendency ofbelief is in that direction. "With regard to Hawaii, Dr. C. B. Wood writes (pp. 375,376)-" A number of years ago, when arm-to-arm vaccinationwas practised, it undoubtedly helped to spreadleprosy. All vaccine now used is imported, hermeticallysealed. " And Mr. Richard Oliver reports to the sameeffect (p. 376)-" In years gone by vaccination undoubtedlycaused increase of leprosy, owing to thelymph being obtained indiscriminately and carelessly."With these important testimonies from responsibleofficials, it is difficult to resist the conclusion that vaccinationhas acted as a factor in the spread of leprosy.Erysipelas.Erysipelas and allied septic conditions are perhapsthe most frequent of the more serious complications of1 " Prize Essay on Leprosy," p. 305. Thompson and Cantlie. NewSydenham Society. London. 1897.23346 INJURIOUS RESULTS OF VACCINATION .vaccination. The recorded deaths from " erysipelas aftervaccination " in England and Wales for the years 1859-80are as follows. Since 1880 the deaths from " erysipelasafter vaccination" have been merged into the generalheading of " Cow-pox and other Effects of Vaccination. "Deathsfromerysipelas aftervaccination.Year.Deathsfromerysipelas aftervaccination .Year.18591860... ... 5 1870 20... ... 3 1871 ... 241861 2 ... 1872 16...1862... ... 3 1873 ... ... 191863 ... ... II 1874 ... ... 291864 ... 13 1875 ... 371865 10 ...... 1876 21......1866... 10 ... 1877 ... ... 291867 ... ... 4 1878 ... ... 351868 ... ... 9 1879 ... ... 321869 ... 191880 39Itmust not be assumed that these deaths are all thathave occurred from "erysipelas after vaccination "during the period named. This matter will be furtherdiscussed in a subsequent part of the present chapter.The early descriptions of cow-pox seem to show thata certain amount of inflammation is a part of the diseaseitself. Jenner, in his account of the vaccination of hisfirst case, Phipps, describes an efflorescence spreadinground the incisions, which had more of an erysipelatouslook than was commonly seen when small-pox was inoculated.Again, he says :-" In calling the inflammation,that is excited by the cow-pox virus, erysipelatous,perhaps I may not be critically exact, but it certainlyapproaches near to it. " ¹1 " Further Observations on the Variola Vaccina, or Cow -pox ," p. 61 .Edward Jenner , M.D. , F.R.S. London. 1799.COW- POX AND ERYSIPELAS. 347Jenner records an instance in which an extensiveinflammation of the erysipelatous kind appeared withoutany apparent cause upon the upper part of the thigh ofa sucking colt." The disease was communicated to aherd of cows, and thence to milkers ; and produced inthem true cow-pox. Jenner's writings, however, do notappear to inspire that confidence which we might haveanticipated, and thus it may be thought advisable tosupplement his evidence. One of the leading Germanauthorities, Bohn, concluded that " the lymph of a trueJennerian vesicle, pure and clear, is therefore endowedwith a power of engendering erysipelas." 2 I may alsomention that Unna, in his work on the pathology ofthe skin, in describing a normal vaccination with animallymph, talks of the contents of the pock on the ninth ortenth day as " seated on a deeply- reddened, erysipelaslike,swollen base."The following are a few of the cases of vaccinal erysipelaswhich have been described from time to time : —In the American Journal of the Medical Sciences forOctober, 1850, Mr. W. Morland, the Secretary of theBoston Society for Medical Improvement, gives extractsfrom the records of the society, relating to erysipelasfollowing vaccination, and reported on by medical men.Eleven cases were given, three being fatal ; of the eight1" An Inquiry into the Causes and Effects of the Variola Vaccina,"p. 72. Edward Jenner , M.D. , F.R.S. London. 1798 ." Handbuch der Vaccination," p. 174. Leipzig. 1875-" The Histopathology of the Diseases of the Skin," p. 449. By Dr.P. G. Unna. Translation from the German by Norman Walker, M.D. ,F.R.C.P. , Ed. Edinburgh and New York. 1896.* American Journal of the Medical Sciences, N.S. , vol . xx. , pp. 318-321 .348 INJURIOUS RESULTS OF VACCINATION .non-fatal ones, four were very severe, of which threewere attended with extensive sloughing.In the Dublin Medical Press¹ of April 25, 1860, Dr. J.Smith Chartres related that in the previous October hehad under his care four cases of severe phlegmonousinflammation of the upper extremity occurring aftervaccination ; in one instance the destruction of thetissues was so extensive as to necessitate amputation.Mr. J. W. Wells, in the Lancet of May 30, 1863 (vol. i. ,pp. 618, 619), relates the case of a lady, aged 55 years ,who underwent re-vaccination ; symptoms of phlegmonouserysipelas developed on the following day, andshe died four days after the operation .In 1876 there was an official Inquiry at Gainsboroughby Mr. Netten Radcliffe, of the Local Government Board,into cases of erysipelas following vaccination, of whichsix died ; a searching investigation failed to dissociatethe operation from the fatal erysipelas .In 1882 another Local Government Board Inquirywas held by Mr. Henley and Dr. Airy at Norwich intocertain deaths alleged to have been caused by vaccination.It was shown that eight children suffered fromerysipelas " due to some abnormal peculiarity or contaminationof the lymph' ; " 2 of these, four died .3On the 25th May, 1883, sixty-eight recruits werevaccinated at Dortrecht, Holland. Of these seven were1 Dublin Medical Press, 2 S. , vol . i . , pp. 323 , 324.Copy of " Report to the President of the Local Government Boardby the Inspectors Appointed to Inquire into certain Deaths and Injuriesalleged to have been caused by Vaccination at Norwich," p. 9. ( Orderedby the House of Commons to be printed, 24th October, 1882. )Q. 9,465-9,468 . Third Report, Royal Commission on Vaccination.DR. VACHELL'S CASES. 349attacked with erysipelas, and three died. In consequenceof these cases, the Minister of War, Mr. Weitzel ,issued a circular notifying recruits that hereafter revaccinationwas not obligatory in the Netherlands army.Before the South Wales and Monmouthshire Branchof the British Medical Association, on November 15,1883 , Dr. C. T. Vachell, of Cardiff, related a series of caseswhere erysipelas followed vaccination. On November 1 ,a child, aged three months, and an adult were vaccinatedwith lymph obtained from London. On theeighth day the arm of the adult was much swollen andred. On the same day the child presented every appearanceof having been successfully vaccinated, and fivetubes were charged from it. On November 10 fivechildren were vaccinated from these tubes. On the 11thand 12th all these cases were attacked with erysipelas ofthe arm vaccinated, and , on inquiry, it was found thatthe child from whom the vaccine lymph had been takenwas attacked with erysipelas on November 9.The Lancet of November 24, 1883 (vol. ii., pp. 919, 920),relates on the authority of the Suffolk and Essex FreePress that two children named Elliston and Griggs werevaccinated on October 16. They remained well until theirvisit to the vaccination station on October 23, when oneof them supplied lymph for the vaccination of two otherchildren, and was noticed by the mother to have aswollen face at the time of leaving the station. Subsequentlythe vaccinifer and one of the vaccinees diedfrom erysipelas, as well as the other child vaccinated onthe 16th October.1 British Medical Journal, vol . ii . , p. 1213. ( December 15 , 1883. )350 INJURIOUS RESULTS OF VACCINATION.Dr. P. S. Fentem, in the Lancet of December 8, 1883(vol. ii., p. 1010), reports the following:-On October 2he vaccinated seven children from the same tube oflymph. Three of them developed symptoms of erysipelasabout the 'vaccination marks on the twelfth,thirteenth, and fourteenth days afterwards, and oneterminated fatally. He noted that the sanitary surroundingsin two of the cases were unsatisfactory, butattributed the erysipelas to a certain kind of soap usedto wash the clothes of the three children.Examples of acute septic poisoning occurred in thecourse of some vaccinations at Asprières (Aveyron) inthe month of March, 1885. An official report wasissued, from which it appeared that forty-two infantswere attacked, six of whom died. The symptoms ofthose who died comprised repeated vomiting, diarrhea ,great agitation, and, in two cases, convulsions. 'Among the older records of the Local GovernmentBoard are the following :-(1 ) A series of nineteen cases of erysipelas from vaccinationat Warrington, with five deaths, in 1871 .(2) A case of serious erysipelas from vaccinationwith National Vaccine Establishment lymph at StokeNewington in 1871 , in which inquiry elicited thatviolent inflammation had occurred in others vaccinatedwith lymph from the saine vaccinifer ; the vacciniferhaving an inflamed arm on the thirteenth day and asmall abscess in the axilla.1 Third Report, Royal Commission on Vaccination, Appendix, pp. 210-213." Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 192 .VACCINAL ERYSIPELAS. 351(3) Six cases of serious inflammation and threedeaths in a series vaccinated with ninth-day lymphfrom one vaccinifer at Appleby, in 1873.(4) Several cases of erysipelas and inflammation, withfive deaths, in a series of vaccinations at Chelsea, in 1875 .(5) Twelve cases of excessive inflammation, six oferysipelas, with three deaths, two cases of axillaryabscess, and one large ulcer, in a series of vaccinationsat Plomesgate, in 1878.(6) Ten cases of erysipelas or abscesses, with fourdeaths, and several cases of eczema in a series of vaccinationsat Clerkenwell, in 1879, in which " it is clearthat the erysipelatous contagion was imparted at thetime of vaccination . "(7) Three cases of extensive erysipelas from vaccinationat Blandford, in 1883 .(8) Three fatal cases of erysipelas from vaccinationat Sudbury, in 1883 .Between the Ist of November, 1888, and the 30th ofNovember, 1891 , one hundred and thirty-two cases ofinflammatory or septic disease (mostly erysipelas)following vaccination and terminating fatally, were thesubject of inquiry by the Local Government Board.Numerous cases have also been investigated by theRoyal Commission on Vaccination, and are cited inAppendix ix. to their Final Report.Cases of erysipelas following vaccination are notinfrequently objected to on the ground that the diseasemust have been acquired subsequently to the act ofvaccination, and therefore, it is said, preventable.Doubtless many cases may be attributed to the carelesstreatment of arms, insanitary surroundings of the352 INJURIOUS RESULTS OF VACCINATION.patient, and other conditions not directly related to theoperation ; but the State which compels vaccination willhardly escape responsibility for these accidents ; and,from the conditions under which a number of our poorstill live, it may be doubted whether there would notalways arise cases of the description under consideration.Attempts have been made to distinguish these casesfrom those in which the lymph itself is at fault. It hasbeen suggested that the incubation period will afford ameans of settling the difficulty. In certain experimentsmade by Fehleisen' it was found that the incubationperiod varied from fifteen to sixty-one hours ; but itmust be remembered, as Dr. Acland has pointed out,that clinical observation gives " much wider limits ." 2The length of the incubation period of erysipelas mayvary " in a remarkable degree," 3 as has been shown bycertain series of cases reported on by medical men onbehalf of the Vaccination Commission, where severalof the children vaccinated at or about the same timehave been affected, and thus pointing to a contaminationof the lymph.Thus, in a series of cases in some villages nearNorwich (No. 23), Dr. Barlow found from his briefprovisional investigation that " some septic materialhad been introduced at the time of the insertion ofthe vaccine lymph. " 4 The inflammation commencedat intervals from the first to the tenth day." Bacteria in Relation to Disease," p. 283. Edited by W. WatsonCheyne, M.B. , F.R.C.S. New Sydenham Society. 1886."Appendix ix. , Final Report, Royal Commission on Vaccination, p. 246,foot-note.Ibid., p. 294. * Ibid. , p. 232.VACCINAL ERYSIPELAS . 353In a series investigated by Dr. Acland ( No. 115 ) therewas a still greater range ; that is to say, the erysipelasappeared at intervals of six hours, sixteen hours, fivedays, and nineteen days in four cases where it wasalmost " a certainty that the infection of the erysipelaswas derived from the vaccinifer."Dr. Acland also records another series (No. 181 ) ofsix children attacked in whom " it can hardly be doubtedthat the abnormal results were due to the quality of thelymph. " The period varied from two or three days tomore than two weeks. ( For further testimonies regardingthe variability of the incubation period of erysipelassee Tillmanns in Deutsche Chirurgie, vol. v. , pp. 96,120, 121. Stuttgart. 1880.)It is also argued that if only one or two childrensuffer out of a certain number vaccinated, that thiswould exclude the lymph ; but it may be pointed outthat in cases of syphilis it is unusual for all thosevaccinated with the same lymph to be attacked. ThusTrousseau records an instance where only one out offive children vaccinated from the same vaccinifer contractedsyphilis ; and in the Paris case recorded byGuérin one out of forty infants vaccinated was attacked.Mr. Jonathan Hutchinson 5 remarks that in his firstseries of cases two out of twelve successfully vaccinated1Appendix ix. , Final Report , Royal Commission on Vaccination, p. 294.2 Ibid. , p. 369.3 " Bulletin de l'Académie Impériale de Médecine," I S. , vol . xxx. , pp.144, 145. 1864-65 .* Ibid. , I S. , vol . xxxiv. , p. 512. 1869.5 " Illustrations of Clinical Surgery," vol. i. , pp. 129, 130. London.1878 .354 INJURIOUS RESULTS OF VACCINATION .wholly escaped, in his second series of about twenty-sixcases more than one-half escaped, and in the thirdseries only one out of twelve is known to have beenattacked, while in the fourth series only one sufferedand probably six or eight escaped.These facts point to the conclusion that the lymphcannot be exonerated by any such criteria as have beensuggested.Tubercle.In the case of consumption, tubercle, and scrofula,there is not the same amount of unimpeachable evidenceof their connection with vaccination as in the diseasesbefore considered. Dr. Acland says-" Althoughvaccination may be in no way the cause of the disease,it may and must always be difficult in such cases rightlyto apportion the precise effect of inheritance, circumstances,and vaccination; especially if, owing to feeblehealth , degenerate tissues, and bad surroundings, vaccinationhas been followed by ulceration, glandularabscesses , or some other complication likely to excitefebrile disturbance." The Vaccination Commissionersallow (section 417) that " It may, indeed, easily be thefact that vaccination, in common with chicken-pox,measles, small-pox, and other specific fevers, doesoccasionally serve as an inciting cause of a scrofulousoutbreak. " In this connection some suggestive figuresare given by two French writers, Rilliet and Barthez ,who found that in 208 vaccinated children 138 diedtubercular and 70 non- tubercular, whereas in 95children who died unvaccinated 30 were tubercular1 Allbutt's " System of Medicine, " vol. ii. , p. 623. London. 1897.VACCINATION AND TUBERCLE. 355and 65 not so.1 Dr. James Copland, who quotes thesefigures, remarks that " it cannot be doubted that vaccinationfavours the prevalence of the several formsof scrofula." 2 Again , he says-" Notwithstanding thelaudation bestowed upon vaccination, I believe that, asthe lapse of time allows the fact to be more fullydemonstrated, it will be found to be a not unfruitfulsource of scrofula and tubercles . " 2Dr. Felix von Niemeyer writes :-" The injurious influencewhich diseases have on the constitution, andthereby on the tendency to consumption, manifestsitself most frequently and in the most lasting manner inearliest infancy. It is fortunate if children escape disease,particularly in the first years of their life, during whichby far the most rapid development of the body takesplace, and when by favourable or unfavourable externalcircumstances the foundation is laid, in a great measure ,for a strong and robust, or a weak and delicate health.Even vaccination may, by the febrile disturbance precedingthe eruption, as well as by that accompanyingthe suppuration, both of which are never absent, andaccording to my numerous thermometrical observationssometimes reach a very high degree, considerablyweaken, more especially those children who are notvery strong, and may leave behind it the germs of adisposition to consumption. " 31 " Traité Clinique et Pratique des Maladies des Enfants," vol . iii. ,p. 116, foot-note. Paris. 1843 ." Copland's " Dictionary of Medicine," vol. iii . , pp. 740, 741. London.1858.3 " Clinical Lectures on Pulmonary Consumption, " p. 22.from the second German edition by C. Baeumler, M.D.Sydenham Society. London. 1870.TranslationThe New356 INJURIOUS RESULTS OF VACCINATION .This eminent authority adds, " I must protest againstunconditional compulsory vaccination, particularly duringthe first two years of life. "Other writers have endorsed Dr. Niemeyer's opinion.Thus, Dr. Rühle, in an article on " Pulmonary Consumptionand Acute Miliary Tuberculosis," remarks that" Scrofula also often appears for the first time afterrecovery from certain diseases, such as the acuteexanthemata, and especially measles. Vaccination hasalso been regarded as a cause, and probably correctly.It does not, however, seem to produce scrofula directlyby the inoculation of a ' scrofulous poison,' but byinducing the manifestation of the hitherto latent scrofuloussymptoms, through an abnormal course of thevaccine pustule and the active fever accompanying it,in the same way as other febrile diseases of childrenact."Dr. Birch- Hirschfeld, in the same work, observes :-" Frequent experience shows that vaccination also maynot infrequently be followed by a breaking out ofscrofulous symptoms " 2-although he remarks that itis to be supposed that in the majority of these casesvaccination only excites the dormant disease.Apparently the German Government were fullyalive to the danger, for their statute prohibited thetaking of lymph from a scrofulous child ; but, as Dr.Birch - Hirschfeld says, " This caution, however, becomesillusory, in the majority of cases, so far as first vaccina-1 Ziessen's " Cyclopedia of the Practice of Medicine ," Englishedition, vol . v. , p. 485. 1875 ." Ibid. , vol. xvi . , p. 773 .ANIMAL LYMPH AND TUBERCULOSIS. 357tions are concerned, because scrofulosis generally doesnot show itself during the first years of life, and prooffor the possible existence of a scrofulous constitutioncan be found only by an examination of the physicalcondition of the parents, brothers, and sisters of thechild." 1It is generally held that tubercle is due to a specificorganism, and hence the possibility of its communicabilityby vaccination must be admitted. The experimentswhich have a practical bearing on this subject arethose of M. Toussaint. He vaccinated a tuberculouscow on the vulva with lymph from a well - formedvaccine vesicle raised on a healthy child of strongparentage. With lymph from the pocks on the cow hevaccinated four rabbits and a pig. Two rabbits killedtwo months afterwards were found to be suffering fromtuberculosis at the point of inoculation, in the glands,and also in the lungs. The pig developed signs oftuberculosis both local and general .The Medical Times and Gazette, in referring toToussaint's experiments, says, " The significance of theseexperiments can scarcely be overrated ; for, though ajudicious vaccinator would not use lymph taken froma child who exhibited already evidence of the disease,the chances of cows in whom spontaneous vaccinia mayappear, and whose lymph would at the present time be1 Ziemssen's " Cyclopædia of the Practice of Medicine ," Englishedition, vol. xvi . , p. 774.2" Comptes Rendus Hebdomadaires des Séances de l'Académie desSciences," vol . xciii. , pp. 322-324. 1881 .358 INJURIOUS RESULTS OF VACCINATION.eagerly sought after, being, like so many of their species,tuberculous, are great ; and it would seem, in consequence,that the dangers of animal vaccination maybe greater than those of human, which are supposed tobe avoided by having recourse to the cow." 1"Although Sir Richard Thorne, in his recent report tothe Local Government Board, refers to this danger asvery remote," it is evidently one which is apprehendedby the Medical Department of the Local GovernmentBoard ; for, with a view of reassuring the public, hestates that the tubercle bacillus, when experimentallyadded to a mixture of lymph and an aqueous solutionof glycerine, rapidly loses its vitality. Considering thatthe researches of Dr. Arthur Ransome and others haveindicated that small quantities of glycerine favour thegrowth of tubercle in culture media, it may be anticipatedthat Sir Richard Thorne's statement will be receivedwith a certain amount of scepticism .Lupus has occasionally been found growing in the siteof vaccination. Mr. Hutchinson has figured a case ina child eight years of age. The disease occurred inand around a vaccination scar, and commenced a fewmonths after the operation. Cases of a like natureMedical Times and Gazette, vol . ii . , p. 291. ( September 3 , 1881. )2 " Proceedings of the Royal Society for 1897 ," vol. lxii . , pp. 187-200.See also Nocard and Roux in " Annales de l'Institut Pasteur for 1887 ,"vol . i. , pp. 19-29 ; Crookshank in " Transactions of the Pathological Societyof London for 1890-91 ," vol. xlii. , pp. 333-336 ; and Beevor, ibid. , pp.344,345.3 " Illustrations of Clinical Surgery," vol . i . , p. 141 , plate xxv. , fig. 1 .London. 1878 .TETANUS AFTER VACCINATION . 359have been described by Besnier¹ and Lennander. Dr.Colcott Fox mentions three instances of lupus invaccination scars. In one case the lupus was leftbehind when the vaccination lesions healed. A patientwas also examined by Dr. Acland on behalf of theRoyal Commission on Vaccination (see No. 26, Appendixix.; also Mr. David Daker's evidence pp. 141 , 142 ,Sixth Report).Tetanus.It will have been observed that most of the disastersalleged to be induced by vaccination come under theheading of inoculable diseases ; tetanus, or lock -jaw, isno exception to this rule. The following cases have beenreported from time to time, and it must not be assumedthat they represent the total number of cases of tetanusattributable to vaccination .Reported by(1 ) Dr. Joseph B. Cottman. New Orleans Medical andSurgical Journal, 1854-55, vol. xi. , p. 783. Negressaffected with tetanus following vaccination ; period oftime not stated. Recovery in two weeks by use of largedoses of opium.(2) Dr. George Ross. The Southern Clinic, 1878-79,vol. i. , p. 468. Boy, three and a half years old whenvaccinated. Tetanus supervened three weeks afterwardswith death on the third day. No other lesion beyondvaccination.1 " Annales de Dermatologie et de Syphiligraphie, " vol. x. , pp. 576 , 577 .Paris. 1889.2 " Upsala Läkareförenings Förhandlingar," vol . xxv. , pp. 65-70.Upsala. 1889-90.The Practitioner, vol . lvi . , p. 500. ( May, 1896. )360 INJURIOUS RESULTS OF VACCINATION .(3) Dr. Theodore Dimon. St. Louis Courier ofMedicine,1882, vol. vii. , pp. 310-312. Boy, nine years old ; vaccinatedJanuary 6, 1882, with bovine lymph. Tetanussupervened on January 27 ; no cause discovered exceptvaccination, which was followed by an irregular shapedulcer. Boy died on the tenth day.(4) Dr. H. J. Berkeley. Maryland Medical Journal,1882-83 , vol. ix., pp. 241-245 . Healthy man, forty yearsold; vaccinated in the middle of January, 1882. Tetanussupervened on February 7 ; death on February 13. Nolesion discovered except at the point of vaccination,which was occupied by a deep ulcer, with an inflamedand indurated border.(5 ) Dr. W. T. C. Bates. “ Transactions of the SouthCarolina Medical Association," 1882, vol. xxxii. , p. 105 .Mulatto boy, aged five years ; vaccinated February 9,1882, with humanised lymph. Tetanic symptoms supervenedon March 8. No other cause but vaccinationdiscovered. Boy lived fifteen days .(6) Dr. R. Garcia Rijo. " Cronica Médico - Quirurgicade la Habana, " 1886, vol. xii. , p. 388. White child, twoyears old ; vaccinated in April, 1886. Characteristictetanus appeared in latter part of May. No lesionbeyond vaccination discovered. Death followed on thefourth day.(7) Dr. Zahiroodeen Ahmed. Indian Medical Gazette,March , 1889, vol . xxiv. , p. 90. Adult, aged twenty- one.The symptoms appeared fourteen days after primaryvaccination .( 8) Local Government Board, Case x. , Appendix ix. ,Final Report, Royal Commission on Vaccination.Female, aged two months ; vaccinated on SeptemberTETANUS AFTER VACCINATION . 36110, 1889. Symptoms of tetanus first appeared onOctober 2 , and patient died on the 5th of October.Female(9) Dr. S. W. S. Toms. Medical News (Philadelphia),February 24, 1894, vol. lxiv., pp. 209-212.white child, five years five months old. VaccinatedNovember 6, 1893, with bovine lymph on ivory point.Characteristic trismus on November 30, with death onDecember 5 .For two recent cases of tetanus following vaccinationsee Medical Record, New York, January 22, 1898, vol.liii. , p. 129, and Indian Lancet, Calcutta, January 1 , 1898 ,vol . xi . , p. 42 .Dr. Acland mentions that the case included in theVaccination Commission Reports (No. x.) is the onlyone he is acquainted with in more than five millionvaccinations in this country. This would tend to showthat in England tetanus after vaccination is very rare,as we should expect it to be. It would be more interestingif we had the figures for Calcutta and other parts ofIndia. In an address to the Medical Society of Calcutta,on January 5, 1892, Sir Spencer Wells 2 stated that theinfant mortality from tetanus in that city during theyears 1881-90 almost equalled that for all other infantilediseases added together. Of course, I do not wish toimply that this large mortality is in any way attributableto vaccination ; but before deciding the question of thefrequency or otherwise of tetanus after vaccination weshould have before us the statistics from countrieswhere tetanus is prevalent.¹ Allbutt's " System of Medicine," vol. ii. , p. 598. London. 1897 .* Report on Sanitary Measures in India in 1891-92, p. 108.24362 INJURIOUS RESULTS OF VACCINATION .The Amount of Vaccinal Injury.It is impossible to form any accurate estimate of thetotal amount of serious and fatal injury produced byvaccination ; the following table only gives the deathsrecorded by the Registrar-General :-England and Wales. Deaths from cow-pox and other effectsof vaccination, from 1881 to 1896.1881 ... ... 58 1889 ... 581882 ... 65 1890 ... ... 431883 ... 55 1891 ...... 431884 ... 53 1892 ... ... 581885 ... ... 52 1893 ...... 591886 ... ... 45 1894 ... ... 501887 ... 45 1895 ... 561888 ... 45 1896 ... 42This shows that in England and Wales, according tomedical death-certificates, one child on an average diesevery week from the effects of vaccination. This fatalrecord , however, does not by any means represent thedamage done by the operation, as for every death theremust be a very large number of children who are injured,but survive for years with enfeebled constitutions.It has been noticed in the earlier part of the presentchapter that in all probability cases of vaccino-syphilisremain unrecognised, and there also seems reason tobelieve that, even if recognised, a certain number areunreported. In support of this, I may quote from ProfessorAlfred Fournier's work on vaccino-syphilis. Hesays-" There are certainly many more cases of vaccinalsyphilis on the cards or in the memories of practitionersthan in the columns of our journals. For myself, had IDR. PRINCE MORROW'S OPINION . 363up to this day published a single one of the numerouscases of this kind which I have observed, whether in myprivate practice or in hospital ? But how many of mycolleagues might say as much ? There is more. Thesame reticence must have sometimes concealed importantcases. For myself alone, I had knowledge oftwo actual epidemics of vaccinal syphilis, which havebeen kept secret, and upon which I have been able toobtain only incomplete information, the affair havingbeen hushed up."1The Royal Commission also remark (section 426)that " it is not to be forgotten that a natural reluctanceto register deaths as due to syphilis may have preventedsome cases where recently vaccinated persons have diedfrom that disease from being made public."Dr. P. A. Morrow, in referring to eruptions incidentto vaccination, observes " It must be confessed that theprofession has manifested a most decided unwillingnessto recognise their direct dependence upon vaccination. " 2Again, in the Local Government Board Inquiries onerysipelas, held by Mr. Netten Radcliffe at Gainsborough,and by Mr. Henley and Dr. Airy at Norwich, beforereferred to, there were in all ten deaths, and in only oneof these was vaccination mentioned on the certificate ofdeath . Also, in an Inquiry, on behalf of the RoyalCommission, on a series of injuries from vaccination atsome villages in Norfolk, in 1890, Dr. Barlow found ,from the brief provisional investigation he was able to1 " Leçons sur la Syphilis Vaccinale, " p. 53, foot-note. Alfred Fournier.Paris. 1889.2Journal of Cutaneous and Venereal Diseases, vol. i. , p. 176. (NewYork. March, 1883. )364 INJURIOUS RESULTS OF VACCINATION.make, that some septic material had been introduced atthe time ofthe insertion ofthe vaccine lymph, and thatthis was mainly responsible for the untoward resultsobtained. There were three deaths, and in none ofthese was the word " vaccination " mentioned on thedeath-certificate.Inthis connection Professor Schaefer, of the Women'sMedical College, Kansas City, remarks-" The pathologyof vaccination is a subject upon which very littlehas been written by writers on vaccination. There isno doubt that every experienced physician has seen oneor more cases of severe localised sepsis following theoperation of vaccination. It will be found, on surveyingthe field, that such accidents are by no means rare,contrary to the statements of the books, as we havebeen made to believe. " IDr. Bridges, formerly Inspector of the Local GovernmentBoard, gives the following explanation-" Medicalstatistics cannot be quite trustworthy on this point fromthe nature of the case. A doctor vaccinating a childwill obviously be unwilling to say that vaccination didharm, unless he is a man above the ordinary standardof courage and conscientiousness statisticsfounded on such uncertain facts-facts dependent notmerely on the skill but on the moral courage of thedoctor, can have no possible value. " 2 It is interestingto notice that history apparently has repeated itself; forSir Richard Blackmore, writing in 1723 about the pre-Journal of Cutaneous and Genito- Urinary Diseases, vol. xiv. , p. 399.(New York. October, 1896. )* Positivist Review, vol. iv. , p. 225. (November, 1896. )PREVARICATIONS OF THE INOCULATORS. 365varications of the inoculators, says-" It is in vain togive this matter another more favourable turn for theoperators, by saying, the patient was of a weakly constitution,and full of ill humours, or that he was of afroward and perverse temper, and died by a fit of peevishness,or that he was carried off by terrible convulsions,and not by the small -pox ; for inen of the least sagacitymust see through these ridiculous evasions invented tocover true history and defeat our inquiry into matter offact, and to buttress up the reputation of the inoculators. " 1On the following page he observes " To say that thesmall-pox, which the convulsions attended, was not thecause of the patient's death, but the convulsions, is thesame thing as to affirm that the axe that cuts off atraitor's head , is by no means the cause of his death, butthe effusion of blood and trembling motions of the body,that followed the separation."The Royal Commission (section 379), while admitting,as they were bound to do, that some risk attaches tovaccination, have attempted to minimise the dangers ofthe operation by comparing the risk to that of railwaytravelling ; in this they were promptly taken up byDr. Collins and Mr. Picton in their Statement ofDissent (section 184), who show from the Board ofTrade returns that the proportion returned as killed(from causes beyond their own control) to the numbercarried by railway was I in about 35,000,000, while therisk of dying from vaccination to the number vaccinated,according to the death-certificates of medical men, wasI in 14,159. Of course, these latter figures give no idea" Treatise upon the Small - pox," p. 93. Sir Richard Blackmore, MD. ,F.R.C.P. London. 1723.366 INJURIOUS RESULTS OF VACCINATION.of the total risk of vaccination, but they serve to showthe bias of the majority of the Vaccination Commissionersin their treatment of this subject.Animal Lymph.This new departure, recommended by the Royal VaccinationCommission, amounts to a virtual condemnationof the arm-to-arm system which has been enforced uponthe people for half a century. It is therefore importantto inquire whether a general introduction of calf lymph,as proposed, would be attended with any diminution inthe danger which appears to be inseparable from thepractice of vaccination. In the case of syphilis, facts andconsiderations have been presented to the reader forbelieving that this disease, or symptoms indistinguishabletherefrom, would not necessarily be excluded by the employmentof calf lymph ; as the Lancet observed incriticising an article by Dr. Henry A. Martin-" Thenotion that animal lymph would be free from chances ofsyphilitic contamination is so fallacious that we are surprisedto see Dr. Martin reproduce it, and so contributeto the perpetuation of the fanciful ideas which too commonlyobtain on the origin of vaccino-syphilis. " 'The remaining diseases which concern us in thiscountry are tubercle, to which I have already alludedin this connection, erysipelas, and other inflammatorycomplications, and skin diseases ; and, with regard tothese last, there is every reason to believe that theintroduction of animal lymph would be a disadvantageas compared with the present system .The Lancet, vol . i. , p. 909. (June 22, 1878. )MR . ROBERT CEELY ON ANIMAL LYMPH . 367In the American Medical Times for March 8, 1862 ,Dr. Henry M. Lyman observes-" It is certain that thedisturbances, produced by the use of a virus which hasbeen newly derived from the cow, are generally muchmore marked than the effects which follow the use ofa more perfectly humanised lymph. " 1With reference to the irritating effect of animal viruson the skin, we learn, on the high authority of Mr. RobertCeely, that " those who believe their children will escapecutaneous eruptions when vaccinated direct from thecow, will be greatly mistaken . Many children haveskins-all children more or less-prone to throw outeruptions, papular, vesicular, pustular, or exanthematic,upon the excitement of the least increased vascularaction. Hence ordinary vaccination will cause whatmost other febrile and cutaneous irritations produce.Hence more irritating lymph, as it is when direct fromthe cow, will be more effective in the production of theabove results. But there is a special vesicular vaccineeruption attending the acme and decline of the vaccinedisease. The Germans have called it ' Nachpocken. ' Ihave often, nay almost always, seen it as a secondaryeruption on the teats and udders of the cows immediatelybefore and after the decline of the disease in them.The same I have repeatedly seen in children, especiallyin the early removes from the cow; and still continueat times to witness it, to the great temporary disfigurementand annoyance of the patient, and the chagrinand vexation of the parent. It is essentially a genuinevaccine secondary eruption . I have witnessed it in1American Medical Times, vol . iv. , p. 135.368 INJURIOUS RESULTS OF VACCINATION .vaccinating the dog. I have coloured illustrations ofthis secondary eruption in man and animals, and haveseen some severe and a few dangerous cases in childrenwhere the skin and visible mucous membranes werecopiously occupied with it." 123It may also be noticed that Professor Depaul, of theParis Faculty of Medicine, expressed the opinion thatcalf lymph is more frequently followed by secondaryvaccinal eruptions. Ever since Ceely's day numerousauthorities have pointed out the greater potency of calflymph: thus Dr. Henry Blanc, a prominent advocate ofthis vaccine, in a treatise on " Compulsory Vaccination,"remarks on its " greater activity; " and the editor ofthe Practitioner, in reviewing the pamphlet, pertinentlyobserved that " the very argument which Dr. Blanc urgesin favour of the superior value of heifer vaccination is adistinct and serious objection to it. " 4By far the most damaging reports on animal lymph,however, come from those who have had the greatestexperience of its effects, viz. , the vaccinating surgeonsin the United States; for this method of inoculationwas adopted in the States much earlier and with muchgreater fervour than it ever has been in this country,and for the reason that humanised virus was found tobe attended with such serious consequences.In the Sixth Annual Report of the Board of HealthBritish Medical Journal, vol. i. , p. 19. (January 7, 1865. )* Ibid. , vol. ii . , p. 22. (July 3, 1880. )3 " Compulsory Vaccination : An Inquiry into the Present UnsatisfactoryCondition of Vaccine Lymph," pp. 16, 24. Henry Blanc, M.D. , F.R.G.S.London. 1869.* The Practitioner, vol. iii . , p. 236. ( October, 1869. )ANIMAL LYMPH IN THE UNITED STATES. 369of the State of New Jersey, Dr. Thomas F. Wood, inanswer to certain queries relative to vaccination, says :-" Vaccination with bovine lymph has brought to light aseries of phenomenal symptoms, except to those medicalmen who have kept fresh in their minds the descriptionsof Jenner and the early writers. Jenner described thedisease caused by early removes from the cow, and heconsequently gave a picture of only the intensest formsof it, in his ' Inquiry ' and ' Further Observations .' Aglance at the coloured engravings in Jenner's greatwork, in Woodville's, Pearson's, Bryce's, Willan's, andall others, shows that the vesicle was larger and theareola more intensely red than in the cases familiarto us up to the time of the introduction of the Beaugencylymph. The reader of the early vaccinographers canhardly believe there was not some exaggeration in theirdescriptions of the serious constitutional symptoms, andthe bad ulcers which sometimes succeeded vaccination ;ulcers so bad, indeed, that they had to be treated withsolution of white vitriol . " 1Continuing, he observes that " the degree of sicknessis generally greater following bovine vaccination. " 2Dr. Ezra M. Hunt, Secretary of the New Jersey StateBoard of Health, observes that " the degree of sicknessis, as a rule, greater in a genuine bovine than in ahumanised vaccination, and quite corresponds to Jenner'sstatement, made as to his own cases. " 3 With regard toeruptions-" Like the original cow lymph, as used byJenner, it is more active in its effects, and therefore is1 Sixth Annual Report of the Board of Health of the State of NewJersey, pp. 37, 38 .Ibid. , p. 39.( 1882. )Ibid. , p. 51 .370 INJURIOUS RESULTS OF VACCINATION .more likely to excite local irritation, and to be the occasionfor the appearance of some eruptive disorders, towhich the person may be inclined. " 1Dr. E. L. Griffin, President of the Wisconsin Board ofHealth, says-" The constitutional symptoms followingthe use of pure bovine lymph , and those induced bylymph humanised by a few removes from the heifer, aregenerally of a like character and degree. In the case ofboth, these symptoms are sometimes quite severe. Thecause is quite often found in the condition of the patienthimself. It must be admitted that during the past yearan unusual amount of severe constitutional symptomsand local complications have followed the use of bovinelymph. " ? About skin diseases he observes " Thefrequency of vaccinal erythema following the use ofbovine lymph is a noticeable phenomenon. This constitutionalmanifestation of the vaccinal disease isseldom observed in the use of humanised lymph ofdistant removes from the heifer. " 3 Dr. Griffin thoughtthe eruption to be of small account, and that it onlyindicated a thorough saturation of the system with thevaccinal disease.In the Report of the Oxford Local Board to the NewJersey Board of Health, Dr. L. B. Hoagland, in referringto an epidemic of small - pox, says-" About fifteenhundred persons were vaccinated during its prevalence,one - third of them with humanised virus, and theremainder with non-humanised bovine virus, the constitutionaleffect being much the more marked when theSixth Annual Report of the Board of Health of the State of NewJersey, p. 54. ( 1882. )Ibid. , p. 65 . 3 Ibid.ANIMAL LYMPH IN THE UNITED STATES. 371latter was used. One child, of five years, lost its life bytaking cold in her arm ; gangrene set in, and she diedfrom septicæmia. Some of the sores were three or fourmonths in healing. " ।Dr. William M. Hartpence, in the report of theWashington Local Board , remarks that " Bovine viruswas generally used, and our observations lead us toconclude that the constitutional effects were greater in alarger number of cases than we had observed in yearspast when using humanised virus ; and, also, our experiencemakes us believe that the resulting sores werelonger in healing (speaking in general) than with thehumanised virus." "Dr. E. J. Marsh, President of the Patterson Board ofHealth, said that although he had tried both varieties oflymph, " In my use of bovine lymph it was observedthat the vaccine vesicle resulting was much larger, theareola and inflammatory induration were more extensive,the crust large, flat and thin, generally ruptured, andcame away before the sore was cicatrised. In twoinstances the inflammatory action was so high that thevesicle sloughed out en masse, leaving a deep ulcer ." *The second Annual Report of the State Board ofHealth of Indiana, for the year ending October 31 , 1883 ,furnishes a list of reports on small-pox and vaccinationfrom the Health Officers throughout the State. Thefollowing relate to the effects of animal virus.Dr. Henry Gers, of Washington, reported that, three1 Sixth Annual Report of the Board of Health of the State of NewJersey, p. 180, 181 .* Ibid. , p. 182 .( 1882. )* Ibid. , p. 70.372 INJURIOUS results OF VACCINATION.years previously, unpleasant effects were noticed fromsupposed bovine virus. (P. 185.)Dr. D. W. Butler, of Connersville, said that bovinevirus was used entirely, and some cases of vaccinationwere unusually ill, with an eruption over the entirebody. (P. 186.)Dr. J. M. Gray, of Noblesville, remarked that in 1872erythema, as a result of vaccination, was quite common.In his experience bad results were more frequently seenafter bovine virus. ( P. 186.)Dr. N. S. Shipman, of Seymour, observed thatnothing but bovine virus was used, and " In a fewinstances we had ulcerous-looking sores, lasting sometimesfor six months." P. 187.)Dr. J. T. Jones, of Franklin, reported on a greatnumber of bad arms as the result of vaccination withbovine virus. ( P. 188.)Dr. Horace E. Jones, of Anderson, stated that " phlegmonousabscesses and sloughing ulcers frequentlyoccurred " as the result of bovine virus . ( P. 190.)Dr. S. H. Pearse, of Mount Vernon, reported thatbovine virus only was used, and that he saw no differencebetween the bovine and human. He observed thata year previously " extensive inflammation " followedthe use of bovine in two cases, and he remarks that inconsequence of a case of small-pox fourteen peoplein one house were vaccinated , all of whom had sorearms. (P. 190.)Dr. George B. Walker, of Evansville, ascertained thatthe bovine lymph was " more violent and caused troublesomeulceration, and sometimes eruption over the body ."(P. 191. )ERUPTIONS FROM ANIMAL LYMPΗ. 373Dr. C. E. Lining, of Evansville, reported some verybad arms, more following the use of bovine virus.And, lastly, Dr. J. R. Crapo, of Terre Haute, notedsevere dermatatis, and an eruption over the whole body,resembling lichen or eczema, as the result of the use ofanimal lymph.In the Journal of Cutaneous and Venereal Diseases Dr.Morrow bears out the almost universal opinion ofmedical men in the United States when he says-" Theexperience of the profession in this country with bovinelymph shows that it is slower in its development, moreintensely irritant in its local and constitutional effects ,and more prolonged in its active continuance. " ¹Dr. Alexander Napier, Assistant to the Professorof Materia Medica, Glasgow University, and Physicianto the Skin Department, Anderson's College Dispensary,calls attention to a certain remarkable group ofskin eruptions, which he finds reported in the Americanjournals, and with scarcely an exception they related tocases where animal lymph was used. He first refers toinstances reported by Dr. Rice in the Chicago MedicalJournal and Examiner for February, 1882 , in which thatgentleman states that " about one in ten of all vaccinatedhave bad arms, with a high grade of fever, anderuption resembling somewhat that of rötheln or Germanmeasles ."Further cases are given in the Boston Medical andSurgical Journal for 1882. In the number for MarchJournal of Cutaneous and Venereal Diseases, vol. i. , p. 167. (March,1883. )* Glasgow Medical Journal, new series, vol. xix. , pp. 424-432. (June,1883. )374 INJURIOUS RESULTS OF VACCINATION.23 , 1882, Dr. Alfred H. Holt¹ records eruptions in fivesuccessful primary vaccinations with bovine lymph .The rash resembling German measles appeared aboutnine days after vaccination, was attended with considerablefever, and, when it faded, a brownish stainwas left on the skin. Dr. Holt thought it was areasonable presumption that the eruption was due tovaccination , and remarks (p. 272)-" If such is the case,and this result is going to occasionally follow vaccinationwith animal virus, it is highly important that the factbe known."In the Journal for April 13, 1882 (p. 356), Mr. VincentBowditch recorded three similar cases ; the eruptionappeared on the ninth day, and was succeeded by brownstaining of the skin as in Dr. Holt's cases. In one of thepatients there was considerable constitutional disturbance,fever, headache, and malaise, and he remarks thatother physicians in the town had similar cases.Dr. A. I. Lawbaugh, in the issue for April 20, 1882(p. 384), says that in eight hundred of his own successfulprimary vaccinations with bovine lymph, sixty- eightwere attacked with a similar eruption, which was duskyred, covering nearly the whole surface of the body. Theeruption somewhat resembled measles ; and there wasintense itching, and a brown stain was left which disappearedin a few days. n thirteen successful primaryvaccinations with humanised lymph, one remove fromheifer , three had eruptions; but there were no eruptionsin two hundred successful re-vaccinations. He remarksthat his brother practitioners have noticed similar experiences.Boston Medical and Surgical Journal, vol. cvi. , pp. 271 , 272.(March 23, 1882. )DR. NAPIER'S CASES. 375Dr. Morton Prince, in the number for April 27 (p . 394) ,observed that, as city vaccinator, since the beginning ofthe year he had performed seven thousand vaccinations,and that skin eruptions accompanying successful vaccinationwere so frequently observed that he ceased toregard them as either unusual or accidental. He describespapular and erythematous eruptions, the formerbeing so common as to " cease to attract notice. " Dr.Prince furnishes notes of two cases of urticaria withsevere constitutional symptoms accompanying vaccination,and one of very marked and widespread erythema.He adds (p. 395)-" Judging from the number of timesI have been questioned by anxious parents on themeaning of these eruptions, I believe with Dr. Holtthat the fact of their liability to follow vaccinationshould be widely known."Dr. Napier's own cases are as follows :-¹I. A healthy child vaccinated with calf lymph.Normal course till tenth day, when a plentiful crop ofpapules appeared on the lower limbs, lower part oftrunk, and arms. The eruption disappeared in threedays.2. A child vaccinated with lymph taken from apatient who had been vaccinated with calf lymph eightdays previously. Normal course till the eleventh day,when large rings of erythema exudativum appeared onarms and thighs ; on the following day the eruptionspread, and changed from a purplish to a yellowish red ;it faded on the third, and completely disappeared on the1 See Glasgow Medical Journal, new series , vol. xix. , pp. 426-428 .(June, 1883. )376 INJURIOUS RESULTS OF VACCINATION .fourth day. The right hand and arm and left foot andankle were much swollen and deformed. No pain norirritation ; fever slight. Two other children vaccinatedwith the same lymph presented nothing abnormal .3. A sister of the preceding. In this case calf lymphused. Normal course till the tenth day, when a vividred, papular, measly eruption appeared over the wholebody, face, and head. Faded greatly in twenty- fourhours, and completely in two days .4. Calf lymph vaccination. Normal course till theninth day, when eruption precisely resembling the lastcase appeared. It faded by the evening of the next day.5. A doubtful case, which Dr. Napier hesitated toplace in the same category, as the interval before eruptionappeared was very long. Child was vaccinated withhuman lymph. On the twenty-eighth day eruptionexactly resembling that of measles appeared on thescalp and face, and to a lesser extent on the neck, chest,and upper arms ; it disappeared in five days. Therewas no catarrh, and no other member of the familywas affected .In summing up these experiences, Dr. Napier remarked(p. 430)-" In nearly every instance I havementioned in which spontaneous generalised eruptionsfollowed vaccination, the lymph used was animal lymph,not humanised lymph . What does this indicate ? That,as Dr. Cameron, M.P. , once argued before this Society,the nearer the virus to its original source in the daysof Jenner, the stronger it is, and the more efficientthe protection it affords ? Without venturing to giveany opinion as to the greater efficacy of calf lymphvaccination as a prophylactic against small-pox-aOPINION OF DRS. ACLAND AND BARLOW. 377matter which can only be settled on the basis of awide statistical inquiry-it seems very clear that inanimal lymph we have a more powerful material, onewhich more deeply and obviously affects the systemthan our ordinary humanised lymph, if the degree ofconstitutional disturbance is to be taken as an indexof the effectual working of the virus. " 1More recently we find in an article on " Small -poxin San Francisco, " by Dr. S. S. Herrick, the followingremarks :-" Besides the uncertainty of the bovine virus,there are other features of common occurrence, whichare not pleasant and which are not found in the humanproduct. The sores are apt to be quite serious incharacter ; a considerable eruption on the body is liableto take place ; and the points of vaccination frequentlydevelop a raspberry-like excrescence (sometimes a trueecchymosis) which may remain for weeks, and is oftenmistaken by the inexperienced for the normal result ofvaccination." 2Apparently the experience of the profession in thiscountry, as far as it goes, is much the same as has beenreported from America. Thus Drs. Acland and Barlow,who investigated cases of vaccinal injury for the RoyalCommission, " are of opinion that a certain proportionof children will always suffer after vaccination fromvarious forms of cutaneous eruption. These seem to bemore frequent after vaccination with calf lymph, and1 Glasgow Medical Journal, new series , vol . xix. , p. 430.2 Tenth Biennial Report of the State Board of Health of California,p. 139. ( 1888. )3Royal Commission on Vaccination, Dissentient Commissioners' Statement, section 186 .25378 INJURIOUS results OF VACCINATION.are for the most part free from danger, though oftengiving rise to considerable distress. " They also thinkthat " calf lymph as now usually employed tends toproduce more severe inflammatory reaction than thatwhich has been humanised ."Lastly, the Commissioners, although insisting thatparents should have the option of calf lymph for theirchildren (section 437), apparently do not recommendit with any degree of confidence ; for, a little above, onthe same page, they inform us that some of the bestqualified witnesses have expressed a deliberate preferencefor arm-to-arm vaccination, believing that theadvantages of calf lymph are more imaginary than real.A diminution, therefore, in the mortality and in theamount of suffering can hardly be expected from thisnew departure in the Jennerian cultus.Glycerinated Lymph.It has been frequently suggested that some of themost serious of the unfortunate results arising fromthe use of animal vaccine might be prevented, or at allevents mitigated, by improvements in existing modesof its collection and preservation ; but, up to the presenttime, in no country, though much ingenuity has beenexercised, has a really safe variety been discovered.A method, which has recently found favour in officialquarters, and seems likely to be adopted as far as publicvaccination is concerned, consists in the addition ofglycerine to the lymph ; it is hardly necessary to observethat this would be an entirely new departure from thepresent system of public vaccination, which is designed,as far as possible, to secure vaccination with fresh lymphGLYCERINATED CALF VACCINE LYMPH. 379from arm to arm. The alleged advantages of theadmixture with glycerine are, that all micro-organisms,with the exception of the vaccine germ, are therebyrendered inert and innocuous. Now, if it be true thatglycerine has this very extraordinary action, we mayinfer that lymph which has not been glycerinated containselements of danger. The promoters of glycerinatedlymph , viz. , the Local Government Board, are to becongratulated on this somewhat tardy admission of adanger which they have for years strenuously denied.¹This method of preservation appears to have beensuggested in or about the year 1849,2 and it has beenused extensively at one time or another, not only onthe continent of Europe, India, and Japan, but also inEngland .Dr. Renner, the well-known purveyor of calf lymph,writes to the British Medical Journal of October 30,1897 (vol . ii . , p. 1298)—“ I have myself prepared andsupplied none but glycerinated calf vaccine ever sincethe year 1883 at my establishment, except on ' points,'which, however, I have discontinued long ago, and Ihave frequently demonstrated my procedure in alldetails privately and in public ; " and hence we haveabundant means of testing whether glycerinated lymphis so very innocuous after all .In this connection the experience of the late SirGeorge Buchanan, Principal Medical Officer to theLocal Government Board, is of interest. It will be1 See " Facts concerning Vaccination for Heads of Families." ( Revisedby the Local Government Board, and issued with their sanction . )See Medical Times, vol. xxi . , pp. 227, 248. ( March 23 and 30, 1850. )380 INJURIOUS RESULTS OF VACCINATION.remembered that I have adverted to certain vaccinationsin the Isle of Rügen in 1885 , where of seventyninechildren vaccinated, all but three were attackedwith impetigo contagiosa, and by infection the diseasewas spread to three hundred and twenty out of a populationof five thousand inhabitants. The Rügen lymphwas mixed with glycerine (glycerinum purissimum), andit has been suggested by the late Sir George Buchanan¹that this was the cause of the untoward occurrences.He handed round to the members of the EpidemiologicalSociety a plan showing the component parts ofthe " stuff " used by Dr. Ebert in his Rügen vaccinations(p. 115) . Sir George had " heard of dilutions of lymphwith glycerine, always from people complaining of thelymph " (p. 117). And he concluded his remarks byobserving-" It will, I trust, be long before such preposterousadulterations of vaccine give the opportunity ofinvestigating their results in English practice " (p. 118) .It may be mentioned that the Chairman of the RoyalCommission, Lord Herschell, when this subject wasunder discussion, clearly indicated by his questions tomy father, when under examination, his opinion withregard to the danger of adulterating lymph withglycerine. This will be seen by the following :-Q. 9,804. ( Chairman. ) If there is a practice ofmixing the vaccine lymph with foreign" Transactions of the Epidemiological Society," 1885-86, new series ,vol. v. , pp. 114-118.* The Royal Commission say ( section 448)-" It was at one time suggestedthat the introduction of glycerine was likely to be mischievous.The question is one a further investigation of which is obviously desirable."LORD HERSCHELL ON GLYCERINATED LYMPH. 381matters, those foreign matters, if one ofthem is glycerine, may well be subject topollution ?-The intention is to improvethe quality of the lymph-to render itmore innocuous.Q. 9,805 . But you may have the best of intentionsin that direction, and you may carrythem out ; but unless the individual whogets the lymph from the Institution usesthat lymph just as he gets it, mixingnothing with it, the best of arrangementsin the Central Institution will not preventthings going wrong ?-That is so.Q. 9,810. ... but, it is surely a point of importancewhether it was a result arising from theuse of vaccine matter procured from awell- constituted establishment, or whetherit arose from the mixture of the vaccinematter with something else by the practitionerwho used it. You would admitthat, I suppose ?-I see that clearly.Dr. Lürman, of Bremen, gives an account of anepidemic of catarrhal jaundice in 1883-84 in a largeshipbuilding and machine-making establishment in thattown, which is of interest from the fact that the patientshad been re-vaccinated with glycerinated lymph. Onehundred and ninety- one persons were attacked. Thedisease began with symptoms of gastric and intestinalcatarrh , which persisted a week or more, until jaundice1 Berliner Klinische Wochenschrift, vol. xxii . , pp. 20-23 . ( January 121885. )382 INJURIOUS RESULTS OF VACCINATION .appeared. The symptoms comprised epigastric oppression,anorexia, vomiting, faintness, and there was usuallyconstipation . Yellow vision occurred in a few instances.In one case the patient suffered from general dropsywith cerebral symptoms, but none of the cases werefatal . Eighty-seven persons in the establishment, whowere re- vaccinated by other surgeons and other lymph,remained unaffected. Dr. Edwardes , who relates thesecases in the London Medical Record of April 15, 1885(vol. xiii. , p. 142), remarks that the epidemic wascausally connected with the re-vaccination, in someway or other. "66A feature of glycerinated lymph appears to be that,when it takes, great intensity of action is observed,both local and general. Thus Dr. James Cantlie¹ refersto " much constitutional disturbance " produced byJapanese lymph. I may also allude to an article byDr. Robert J. Carter. " He details the results of 319re-vaccinations with glycerinated calf lymph . Heobserves that in 106 of the patients the axillary glandswere " large, hard, and tender, and in some instances exquisitelypainful ; " in 3 of the cases the glands abovethe collar-bone were also affected. In 9 cases lymphangitiswas present, the lymphatic vessels being felt as hard,swollen, tender cords along the course of the axillaryvessels. In 98 of the patients there was ædema andinduration of the arm, and these manifestations were ofa " curiously persistent character. " Dr. Carter remarkedthat they were apparently dependent on the intensity ofthe local inflammation at the site of the vaccination .British Medical Journal, vol . ii. , p. 762. ( October 5, 1889. )The Lancet, vol. i. , pp. 1611 , 1612. (June 12, 1897. )GLYCERINATED LYMPH IN INDIA. 383Abundant evidence of the danger of glycerinatedlymph is adduced in Appendix ix. to the Final Reportof the Royal Commission. The cases are, of course,mostly erysipelas or of a septic nature ; and, withoutincluding those of a less severe character, they number84, and of these no less than 24 were fatal.¹In India glycerinated lymph has been a failure in everyway. In the first place, the success per centum has beenvery low, as will be seen from the following figures forMadras Presidency in 1894-95 :-Animal lymph .Number Successvaccinated. per cent.Direct from calf 378,955 97.4Preserved in glass tubes or plates 142,899 94 1Preserved with glycerine 642,296 89.2In 1895-96 the results are much the same :-3Animal lymph .Direct from calf ...Preserved in tubesPreserved with glycerinePreserved with lanolineNumber Successvaccinated. per cent.300,518 97.898,703 95.1... 641,181 89.523,193 94.5This low percentage of successful results is naturallyregarded as a very serious objection. In the Memorandumby the Army Sanitary Commission on theReport of the Sanitary Commissioner of Madras for 1894,it is stated :-" In the Madras Presidency, preservedlymph is largely used . No fewer than 642,296 personswere vaccinated with lymph preserved with glycerine.It is, we think, no matter of surprise that of these only1 See Nos. liii. , lxxxii. , xcix. , cviii. , cxii . , cxxvii . , cxxviii. , cxxxiv. ,cxliv. , cxlviii . , cl . , clxxxi. , clxxxix. , 21 , 81 , 122, 168 , 207, 208, 218 , 221 ,236, 237, 244, 249, 251 , 258, 312 .*Report on Sanitary Measures in India in 1894-95 , p. 113.3 Ibid. 1895-96 , p. 102 .384 INJURIOUS RESULTS OF VACCINATION .89.2 per cent. proved successful cases of vaccinationThis messing with vaccine lymph mixed with glycerineis evidently not only an expensive procedure, but disappointingin its results. Altogether, vaccination in theMadras Presidency seems to us to be capable of improvement."It appears that the results have been so unsatisfactorygenerally, that the preparation of glycerinated lymph,after a fair trial, has been entirely discontinued in theCalcutta and Darjeeling Depôts, the principal reasonassigned by the Sanitary Commissioner for Bengal beingthat " Glycerine is a nutritive medium for the growthof putrefactive and other germs, and, being fluid, thegerms soon pervade it throughout ; and, as a fact,this preparation (glycerinated lymph) in India soon becomesputrid and septically dangerous." 2 And whenwe consider that glycerine in small doses stimulates thegrowth of the tubercle bacillus, and even when undilutedwill not destroy the streptococcus of erysipelas, it seemsdoubtful whether the addition of the aqueous solutionof glycerine to the lymph as recommended by theGovernment will have any effect in lessening thedanger and amount of suffering attending the practiceof vaccination; and when the alleged prophylaxy ofvaccination is allowed to be so ephemeral by some ofits ablest defenders, the State may surely, as in the caseof other medical prescriptions, leave the matter to theparent, who, after all, is the most concerned, to saywhether his child shall be vaccinated or not.1 Report on Sanitary Measures in India in 1894-95, p. 217 .2 Indian Lancet, vol. ix. , p. 221. ( March 1 , 1897. )* Local Government Board, Report of the Medical Officer for 1896-97 ,p. 271 .CHAPTER X.SUMMARY AND CONCLUSIONS.BEFORE summing up my conclusions, a few words concerningthe enforcement of vaccination may not be outofplace, and my task has been simplified by the Reportof the Royal Commission. Four of the Commissionershave recommended that compulsion should be altogetherabolished, and the remaining nine, that honestobjectors should not be subject to fine or imprisonmentfor refusal to allow the vaccination of those for whomthey are responsible. Those who have studied theevidence given before this important tribunal, andespecially the Blue Book ' of 453 folio pages containingthe records of vaccinal disasters, will concur in accordingto the Commissioners their appreciation of these wiseand humane recommendations.The following are the points emphasised in mychapter on this serious aspect of the question:-1. That the principle and practice of vaccinationinvolves the introduction of a specific disease at leasttwice, and, according to numerous authorities, many1 " Papers relating to cases in which death or non-fatal injury wasalleged or suggested to have been caused by, or otherwise connected with ,vaccination. " Appendix ix. to the Final Report of the Royal Commissionon Vaccination .386 SUMMARY AND CONCLUSIONStimes into the human organism; that this specificdisease causes an undeniable impairment of healthand vitality, it being adistinctly morbid process.2. That the operation ofvaccination may occasion adefinite risk to life, one death on an average beingofficially registered from this cause every week inEngland and Wales.3. That there is good reason to believe that thisrecord greatly underestimates the fatalities and injuriesdirectly resulting from the operation.4. That no lymph, whether human or animal, oradulterated with other substances, can be guaranteed asfree from danger.5. That there is unimpeachable evidence proving thata variety of inoculable and some incurable diseases areinduced by vaccination.6. That there is no guarantee that syphilis, orsymptoms undistinguishable from this malady, may notbe induced by the inoculation of either human or animalvirus. One of the greatest of our physicians, the lateSir Thomas Watson, in referring to the risk of vaccinosyphilis, says :-" I can readily sympathise with, andeven applaud, a father who, with the presumed dreador misgiving in his mind, is willing to submit to multipliedjudicial penalties rather than expose his child tothe risk of an infection so ghastly." 1This outspoken deliverance was written twenty yearsago, when very few medical men had ventured to questionthe justice of compulsion, and is the more valuable,1 The Nineteenth Century, vol. iii. , p. 1006. (June, 1878. )COMPULSORY VACCINATION . 387inasmuch as Sir Thomas Watson was a firm believer inthe efficacy of vaccination .Once admitted that the risk is real, and one whichno amount of care can guard against (even if vaccinationwere a preventive of small-pox), all ground forcompulsion vanishes ; for it then becomes a question ofparental or individual responsibility, as in the case ofany other operation or treatment involving risk to lifeand health. No surgeon would dream of administeringchloroform or of performing the most trivial operationwithout first obtaining the patient's consent; and, therefore,no authority, whether medical or State, has theright to attempt to override a parent's or patient'sscruples. The matter should thus be left to the optionand good sense of the individual, as in the case of othermedical prescriptions. Compulsory vaccination is noweven by medical men beginning to be recognised as agrievous and mischievous mistake, and I have not theslightest doubt that the profession would willingly relinquishit to-morrow, if their credit and prestige were notso deeply involved. It seems, therefore, that theagitation for the repeal of the Vaccination Acts mustof necessity come, as it always has done, from thepeople themselves. Parliament, confessing its ownincompetence, and relying on medical promises whichhave been falsified all along the line of a century'sexperience, has decreed that vaccination shouldbe obligatory. Parliament must, therefore, be persuadedto undo the evil it has unwittingly committed.Unfortunately, the dead cannot be recalled to life, norcan the parents of those who have been injured bythe operation be compensated; nor will the scandalous388 SUMMARY AND CONCLUSIONS .and unrelenting persecution of upright and otherwiselaw-abiding citizens, whose only offence has been adetermination to preserve their children's bodies fromthe risk of inoculated disease, be easily condoned.The cruel hardship of qualified persons deprived ofemployment in the public service by reason of theirrefusal to submit to vaccination and re-vaccination callsfor prompt redress. This injustice is acutely felt in thecase of pupil teachers in the public elementary schools ;and the penalty for non-compliance is immeasurablygreater than the payment of a fine and costs. As the Commissioners,after seven years' inquiry, have recommendedthat all parents who conscientiously object to vaccinationshall no longer be subject to penalty, it is manifest thatthe refusal of employment in the public service to theseconscientious nonconformists cannot be logically orfairly defended.Pending the repeal of the Vaccination Acts, ourlegislators are in the responsible position of being aparty to the enforcement of a surgical operation, provedby the Royal Commission to be attended with danger,on every child born in this kingdom ; a compulsion,it may be added, about the expediency of which thepeople of this country have never had an opportunityof passing an opinion. In the meantime death-certificatesof children killed by vaccination are accumulatingat Somerset House, and most of these are doubtlessa direct consequence of this law.The more hotly-disputed question of the value ofvaccination itself has been considered in the foregoingpages at some length, and it only remains to brieflysummarise the various points.THE VARIOLOUS TEST. 389In the early days of vaccination, before it could beput to the test of experience, it appears to have beenfelt that the inoculation test would furnish absoluteproof of the protection afforded by the practice againstsmall-pox. In the first chapter of this volume it hasbeen shown that the lymph which convinced the professionof the efficacy of vaccination was Woodville's“hospital matter, " which was unquestionably contaminatedwith small-pox-hence the immunity whichit is claimed resulted from its use may have been animmunity produced by small-pox, which thereforeproved nothing in favour of vaccination. The fewvariolous tests which were performed by Jenner himselfhave been shown to be inconclusive ; and it issignificant that Jenner very early discarded the test infavour of that of re-vaccination .From the earliest days of vaccination numbers ofcases have been recorded of every description of smallpoxfollowing vaccination, from the mildest to the mostsevere and fatal, and within the shortest periods of theoperation. In the absence of any reliable method ofestimating the proportion of the population vaccinated,it is impossible to compare the relative attack- incidenceof small-pox in the two classes; but it is important tonote that the proportion of vaccinated cases in wellvaccinateddistricts has ranged as high as 95, 98, oreven 100 per cent. A method of comparison free fromobjection is the attack-incidence of small-pox indifferent towns. Gloucester in 1895-96 had an attackrateof 48 per 1,000, or about the same as that for thewell - vaccinated town of Willenhall in 1894, and the390 SUMMARY AND CONCLUSIONS.unvaccinated towns of Keighley and Leicester in therecent epidemics had only rates of 2.2 and 19 per 1,000respectively.With regard to the death-incidence, we may comparethe death- rates of small-pox at different periods in thehistory of vaccination, or in different towns ; or wemay split up the cases of small-pox into two classes,vaccinated and unvaccinated, and compare the casemortalityin each class. In the chapter on mitigation, Ihave dwelt at some length on the objections to thelatter method of procedure; and in my judgment theyare so vital that the evidence under this heading, inattempting to arrive at a decision as to the value ofvaccination, must be set on one side.There remains to consider the death-rates from smallpoxat different times and places, and, as the protectionis admittedly only of a temporary nature, to take intoaccount the proportion of the mortality borne bychildren. I have shown that the small-pox mortalitybegan to decline about 1781 , long before the introductionof vaccination ; and it was accompanied by adecline in fever and in deaths from all causes, and wasdue to the development of sanitary improvements. Thedecline continued after the introduction of vaccination,and it is almost certain that part of this reduction wasdue to the cessation of small-pox inoculation.¹Since the commencement of registration, the factslaid before the reader show that small-pox has paid no• The inoculation of out -patients at the London Small-pox Hospital wasdiscontinued in 1808. Baron's " Life of Jenner, " vol. ii. , p. 238.THE DECLINE IN SMALL- POX . 391heed to vaccination at all, one of the worst epidemics ofthe century taking place after seventeen years of compulsion; and quite recently, especially in London, as appearsby the figures cited , we have a remarkable declineof small -pox coincident with diminishing vaccination.Neither does vaccination seem to have had any effecton the severity of the disease ; the case-mortality beingas high in 1871-72, with a large percentage of thecases of small-pox vaccinated, as it was in the lastcentury, before Jenner's discovery. Hence, up to thetime of this epidemic the diminution of pock-markedfaces, as far as any diminution had been observed,cannot have been due to any diminished severity of thedisease, but must be attributed rather to a decline inthe prevalence of small-pox itself. Since 1871-72 , however,there has been a great decline in the severity ofthe disease, which has, doubtless, resulted from improvedhygiene and altered methods of treatment. It may alsobe noted that since the last century typhus, which isspread in much the same manner, has shown a greaterreduction than small-pox, and is now an almost extinctdisease.The death - incidence of small-pox in different townsis another method of comparison not open to objection .Gloucester heads the list of recent epidemics, with adeath- rate of over ten thousand per million ; but it hasbeen shown that in a list of twenty-four well-vaccinatedtowns the death- rates have varied from six thousand tonearly ten thousand per million, and hence the figurefor Gloucester is deprived of much of its significance.That unvaccinated towns can be kept comparatively392 SUMMARY AND CONCLUSIONS.free from small-pox is conclusively proved by the experienceof Keighley and Leicester, which had only ratesof two hundred and eighteen and one hundred and fourteenper million respectively, in the recent epidemics ;and that the most complete vaccination of a districtpossible will not prevent a serious epidemic, is shown inthe case of Mold, which, in spite of the vaccination ofevery child born and remaining in the district foreighteen years previous to the epidemic, had a small-poxdeath - rate of 3,614 per million, in 1871-72 .The last argument urged in the defence of vaccinationis the change in age-incidence. That this is not broughtabout entirely, or even principally, by vaccination, isclear, from the fact that a similar change has occurredin the unvaccinated, and therefore independently ofvaccination.Another important matter to which attention hasbeen directed is that, since the commencement of registration,the greatest decline in the infantile share ofsmall -pox deaths took place about 1871-72, and was notassociated with a very large increase in the amountof public infantile vaccination ; whereas the greatestincrease in public infantile vaccination was in the yearsfollowing the compulsory Act of 1853, and this wasaccompanied by quite a trifling reduction in the infantileproportion of the small -pox mortality.The Commissioners appear to attach considerableimportance to a comparison they make of the children'sshare of small-pox deaths in certain vaccinated andunvaccinated towns. Thus they show for recent epidemicsthat at Leicester and Gloucester the proportionMR. ALEXANDER PAUL ON AGE- INCIDENCE. 393of children's deaths from small-pox under ten years ofage was much larger than in the well-vaccinated townsof Sheffield and Warrington. In my second chapterI ventured to criticise these figures on the ground thatthe experience was not sufficiently extensive, and Ishowed that England and Wales in 1871-72, with only5 per cent. vaccination default, had almost as largea proportion of small - pox deaths under ten yearsof age as there were at Dewsbury in 1891-92 witha default of 37 per cent. , and I also pointedout that Mold and Willenhall, both extremely wellvaccinatedtowns at the time of their respectiveepidemics, had a large percentage of their small-poxdeaths under five years of age, and I instanced theepidemic in the unvaccinated town of Keighley, withseven small -pox deaths all over five years of age.Since writing my second chapter I have had theadvantage of consulting an important contribution tothe age - incidence controversy by Mr. Alexander Paul.¹He points out from the Commissioners' own figures thatthe children's percentages of small-pox deaths in thetowns specified only show similar variations to theirpercentages of small-pox illness ; whereas, according tothe theories of the Commissioners, the variations shouldbe far greater, for they think that the power of vaccinationto modify the character of small-pox is greatestduring the years immediately succeeding the operation.1" A Royal Commission's Arithmetic : A Criticism of VaccinationStatistics, and a Plea for Fresh Figures and Fair Inferences." AlexanderPaul . London. 1897 .26394 SUMMARY AND CONCLUSIONS.The following are the figures¹ for the attacks and deathsplaced side by side :-Children, aged 0-10.Percentage borne Percentage bornebythem oftotal small -poxdeaths.Epidemics.bythemoftotal small -poxillness.Warrington, 1892-93 ... 9.83 22.58Sheffield, 1887-88 12:42 25.60London, 1892-93 15.21 36.82Dewsbury, 1891-92 ... 21.64 51.82Gloucester, 1895-96 ... 35.67 64.52Leicester, 1892-93 ... 30°53 71.43 (or 66.60)、Of course the question will be raised, that, granted thedeaths only follow in the same proportion as the attacks,that is to say, that no extra penalty must be paid in theshape of death for neglecting vaccination, this will notaccount for the varying proportions of the children'sshare of small-pox illness in the different towns, whichranged from 9.83 per cent. at Warrington to 35.67 percent. at Gloucester.Mr. Paul explains this and I think the explanationis a reasonable one-by the varying incidence of smallpoxattack on adults and children in the several towns.Thus, at Warrington, small-pox was mainly spread inthe forges near the hospital ; at Gloucester an importantfactor was the introduction of the disease into the publicelementary schools ; and at Leicester the proximity ofthe scarlet fever wards to the hospital where small -poxThe figures for the deaths are those given by the Commissioners, thosefor small -pox illness being calculated from the Final Report of the RoyalCommission by Mr. Paul.AGE - INCIidence oF VACCINATED SMALL- POX . 395cases were treated undoubtedly raised the children'sshare of small -pox illness.The vaccination hypothesis I believe to be untenable,both for reasons given by Mr. Paul and also becauseit does not fit in with the experience of the earlyobservers on the relation of small-pox to vaccination.If there is anything at all in the theory that ina vaccinated population the children's share of smallpoxillness will be low, and vice versâ, it will be admittedthat in an extreme case-i.e. , where all the patientssuffering from small-pox have been vaccinated-thechildren's share of illness should be very low, indeedlower than the 9.83 per cent. at Warrington ; this isentirely at variance with the experience of vaccinatedsmall-pox in the early days, before the age- incidenceof small-pox had commenced to change. Indeed, thelarge proportion of young or recently-vaccinated casesled Mr. Edward Greenhow and others to suspectthat cow - pox was wholly, or in part, losing itsvirtue ; for he found that the numbers attacked werein the inverse ratio to the number of years which hadelapsed since they were vaccinated. One of Dr.Thomson's correspondents, Mr. William Gibson, givesfigures for the epidemic at New Lanark (see p. 152),where of 251 vaccinated cases of small-pox, 191 or 76·1per cent. took the disease at intervals, up to ten yearsafter vaccination. This high percentage is what weshould naturally expect at a period before the ageincidenceof small-pox had commenced to change. Theonly escape I can see for the supporters of vaccination,is to say that all the early operations were ineffectual,396 SUMMARY AND CONCLUSIONS.which is a dangerous argument for those who urge thatthe decline of small-pox was due to this prophylactic.This matter of the varying age-incidence of smallpoxin the different towns has been dwelt on so fullybecause much has been made of it by the Commissioners,but there are other points connected with thesubject which have been carefully worked out by Mr.Milnes, and tend to show that the only other diseasesat all comparable with small-pox have shown a similarchange in their age- incidence, and that it is sanitationto a large extent which must be held accountable,although, for reasons given in my third chapter, anothercause has doubtless been at work that is to say, ashifting of the small-pox mortality on to other diseases,such as measles and whooping-cough, which would thusexplain the insignificant reduction which has taken placein the mortality from these complaints .It may be asked at this juncture, how it is, with thesame set of facts before me, I have arrived at a differentconclusion to the Commissioners. My readers mayperhaps be able to judge for themselves if I putbefore them the facts which influenced this body totheir somewhat halting opinions. The essence of thecase which convinced the Commissioners of the efficacyof vaccination was given by their Chairman, Lord Herschell, at a meeting held on March 31, 1897, for thepurpose of raising a fund for a national memorial toEdward Jenner. '1 For full report of speech see British Medical Journal, vol. i. , pp.1247 , 1248. ( May 15 , 1897. )LORD HERSCHELL ON VACCINATION . 397After a few preliminary remarks on the terrors ofsmall-pox in the last century, and its decline after theintroduction of vaccination, Lord Herschell introducesthe statistical case for vaccination, and he deals withthree points-the first being the varying age-incidenceof small-pox in the six towns, the second the fatality ofthe vaccinated and of the unvaccinated in these towns,and the third point being an examination into thebehaviour of small-pox before and since vaccinationwas made compulsory. The first two matters havebeen dealt with so fully in this volume that I think itis hardly necessary to say anything further. Withregard to the third point, I will state the case in LordHerschell's own words. " I am going to invite yourattention," he says, " to the figures with reference to theeffects of the introduction of compulsory vaccination intothis country. It is undoubtedly recognised now that theprotection of vaccination is not permanent. It operatesmost effectually during the earlier years rather than thelater after the operation has been performed, and it isprobably during the first nine or ten years after vaccinationthat its operation is most efficient. Bearing that inmind, let me invite your attention to this, that in theyears from 1848 to 1854-that is, before the introductionof compulsory vaccination -the deaths of children underfive years of age were 1,514 to every million personsliving, and that from 1885 to 1894 they were 50 to everymillion persons living. Now take the other end of thescale-45 years and upwards. Of course, those of thatage would be no more affected by compulsory vaccinationbetween 1885 and 1894-the law having been passedin 1853-than children would be in the year prior to its398 SUMMARY AND CONCLUSIONS.introduction. In that class the deaths only fell from 24permillion to 19. "These figures have been taken from page 48 of theFinal Report of the Royal Commission, and the followingtable also gives the figures for the intervening yearperiods :-Deaths from small -poxpermillion living.Years. Under5. 45 and upwards.1848-54 1,514 2401855-64 788-8 36.21865-74 ... ... 782.5 87.51875-84 127.8 33.91885-94 .. 50°2 190I do not gather that Lord Herschell wishes to foundany argument from the latter part of his statement withreference to the reduction in the adult mortality from24 to 19 per million ; but it may be noted that prior tothe decline there was a large increase in the adult mortality,which has led Dr. Bridges to doubt if vaccinationever would have been made compulsory if these resultshad been anticipated. The point, no doubt, to whichLord Herschell wishes to draw attention is the declinein the children's mortality from 1,514 to 502 permillion. It will be observed that Lord Herschell omitsto state that there has also been a large decline in feverduring the period under review, nor does he hint thatthere may be a cause other than vaccination whichwould act more powerfully in children than in adultsviz., sanitation-to account for the reduction in themortality from small-pox.Let us now examine the facts Lord Herschell haspresented. In the first place, exception must be takenLORD HERSCHELL ON VACCINATION .399to the statement that the years from 1848 to 1854 arebefore the introduction of compulsory vaccination, forduring the year 1854 the public vaccinations in thiscountry reached a higher figure than they have evertouched in any year before or since, owing to the Actof 1853 ; secondly, it is unfair to put forward the period1885-1894 as if it were a period during which the vaccinationof children had been completely carried out, for,as I have shown, there has been a large reduction inthe infantile vaccinations as compared with the period1875-84, and Lord Herschell's own figures show thatcoincident with this reduction there has been a declineof 61 per cent. in the children's small-pox mortality.This decline he has placed to the credit of the prophylactiche is defending, and then he says he is" surprised " at the force of the evidence adduced infavour of vaccination .Although there does not appear to be trustworthyevidence to show that vaccination possesses any influenceover the prevalence or mortality of small-pox, it isunfortunate that a too implicit belief in its efficacy hasgiven rise to the pernicious doctrine that sanitarymeasures are of no avail in preventing this disease.We can quite understand that the owners of filthyrookeries and other insanitary premises are only tooready in their own interests to welcome such a theory,but for a great profession to have become wedded tothe doctrine has, I believe, greatly impeded the progressof sanitary reform; for while outbreaks of other diseases ,such as typhus, typhoid, cholera, and scarlet fever, haveproved valuable object lessons for municipal sanitaryamelioration, each epidemic of small-pox appears to400 SUMMARY AND CONCLUSIONS .have taught the profession little or nothing but thenecessity of repeated vaccinations.It is true that there have been occasional gleams oflight from the more independent thinkers in the medicaland lay press, but these have been unequal to directpublic authorities towards the only remedial and scientificpreventive-personal and municipal sanitation.Those who have followed the facts presented in thisvolume concerning the insanitary condition of Londonin previous centuries can have come to no other conclusionthan that this was the chief cause of the largesmall -pox and typhus death -rates. What else could beexpected with the narrow streets, courts, and alleys ;the imperfectly-constructed houses with little or nocurtilage ; the almost total absence of external ventilation; the exclusion of light and air by the operation ofthe window- tax ; the dense overcrowding ; the almostconstant inhaling of putrid excrement ; the loathsomeeffluvia from the intramural burial-grounds ; the limitedwater supply-these, added to the filthy personal anddomestic hygiene, cannot have failed to have influencedthe spread and mortality from these diseases. Neitheris it to be wondered at that the insanitary state of theprisons, as described by Howard, favoured the spread ofsmall-pox and typhus to the " destruction of multitudes."Much the same state of things prevails in partsof Egypt, China, and India of to-day, and it is thesedistricts where insanitary conditions are rife whichdemonstrate the utter futility of vaccination to copewith epidemic small -pox.In the Report on Sanitary Measures in India in1879-1880, p. 142, it is stated :-" The vaccinationSMALL- POX AND SANITATION. 401returns throughout India show the same fact, that thenumber of vaccinations does not necessarily bear aratio to the small-pox deaths. Small-pox in Indiais related to season, and also to epidemic prevalence ;it is not a disease, therefore, that can be controlled byvaccination, in the sense that vaccination is a specificagainst it. As an endemic and epidemic disease, itmust be dealt with by sanitary measures, and if theseare neglected small-pox is certain to increase duringepidemic times."Again, in the Memorandum of the Army SanitaryCommission on the Report of the Sanitary Commissionerfor the Punjab, for 1879, we read that " Vaccination inthe Punjab, as elsewhere in India, has no power apparentlyover the course of an epidemic. It may modifyit and diminish the number of fatal cases, but the wholeIndian experience points in one direction, and this isthat the severity of a small-pox epidemic is moreclosely connected with sanitary defects, which intensifythe activity of other epidemic diseases, than is usuallyimagined, and that to the general sanitary improvementof towns and villages must we look for the mitigation ofsmall -pox as of cholera and fever. " 1Thus it is on sanitation that we must henceforwardrely for the prevention and extermination of epidemicdiseases. The most necessary measures for the preventionof small -pox must therefore include-( 1 ) Demolition of dwellings unfit for human habitation.(2) Construction of houses to secure adequate externalReport on Sanitary Measures in India in 1879-80, p. 186.402 SUMMARY AND CONCLUSIONS.and internal ventilation, and the prompt removal of allfilth accumulations from the premises.(3) Adequate water supply and efficient seweragesystems.(4) Provision of open spaces in towns.Another wise method of prevention has been revivedin recent years, and this is the separation of the sickfrom the healthy. This system is mentioned in thewritings of Rast, Haygarth, and Faust, in the lastcentury, and was tried experimentally at Chester ; butthe advent of vaccination, with the confident promisesmade on its behalf, put a stop to further developmentof isolation at that time. Attention was again drawn tothe subject in 1868, by Sir James Simpson, in a paperentitled " Proposal to Stamp out Small-pox and otherContagious Diseases ; " and it was shortly afterwardsput to a practical test. Where it has been tried, coupledwith sanitation, as at Leicester and in the county ofLondon, it has been pre-eminently successful in reducingthe small -pox mortality. At the present time, compulsoryvaccination, by paralysing efforts in other directions,blocks the way towards sanitary reform. When the lawsare abrogated vaccination must, like all other medicalprescriptions and surgical operations, rest upon its ownmerits, or, in other words, on its inherent persuasiveness,unaided by the arm of the law. The practice will then,in my opinion, in the not very distant future be surelyabandoned.This will prepare the way for a new era of improvedhealth and human happiness, the result of scientificsanitary amelioration in all departments of our social,domestic, and municipal life.TRADITION OF THE DAIRYMAIDS. 403In due course of time the tradition of the dairymaidsof Gloucestershire will take its proper place among thelegends and folk-lore of the past ; and, if allowed toprophesy, I cannot help thinking that another generationwill look back with amazement and incredulity that fora hundred years the people of these islands should haveworshipped at the shrine of a strange, unreasonable, andmischievous superstition .
130012001100100090080070060050040030020010023561838718408918502SuccessSmall-f1850
APPENDIX.ENGLAND AND WALES .Successful Public Vaccinations under one year of age from1845-97.Years endingSeptember 29.Number ofunions andBirths.Successful public Percentage ofvaccinations under vaccinations.parishesone year of age . to births.returned.1845 580 486,632 147,958 30°41846 539 483,480 132,548 27.41847 621 523,682 141,487 2701848 627 532,046 169,611 31.91849 635 558,102 160,448 28.71850 637 559,721 168,703 3011851 639 592,347 181,351 30.61852 639 601,839 194,089 32.21853 638 601,223 195,700 32.61854 649 623,699 395,658 63.41855 653 623,181 343,029 5501856 653 640,840 341,231 53.21857 654 649,963 329,275 50.71858 656 654,914 333,579 50.91859 657 669,834 328,988 49.11860 657 689,060 349,142 50.71861 660 685,646 325,098 4741862 662 702,181 336,885 4801863 664 720,660 385,515 53.51864 665 739,236 363,885 49.21865 665 742,680 355,892 47.9665 743,859 338,664 1866 45.5406APPENDIX.Number ofYears endingSeptember 29.unions andBirths.parishesSuccessful public Percentage ofvaccinations under vaccinationsone year of age. tobirths.returned.1867 663 766,635 353,308 4611868 658 771,905 385,635 5001869 653 779,039 406,246 5211870 647 785,775 392,869 5001871 . 647 792,663 455,416 57.51872 647 810,291 462,321 57.11873 647 832,255 469,538 56.41874 647 845,286 470,256 55.61875 648 853,049 475,539 55.71876 650 881,518 486,031 5511877 649 881,897 498,577 56.51878 649 892,823 494,028 55.31879 649 884,995 500,646 56.61880 649 889,893 494,942 55.61881 647 874,474 501,125 57.31882 647 888,026 495,374 55.81883 647 892,524 495,056 55.51884 647 896,179 483,742 5401885 647 899,776 489,815 54.41886 647 906,819 480,306 5301887 647 885,860 457,301 51.61888 647 880,329 450,069 5111889 647 885,005 427,422 48.31890 648 883,647 412,388 46.71891 648 898,573 388,285 43.21892 648 901,459 375,634 4171893 648 912,325 369,627 40.51894 648 884,174 355,788 40° 21895 648 929,091 326,053 3511896 648 898,114 313,581 34.91897 649 930,707 295,727 31:8APPENDIX . 407ENGLAND AND WALES .For Small-pox, the death-rate per million living, from1838-42, and 1847-97.Small -poxdeath-rateper million living.Small-poxdeath-rateper million living.Years. Years.1838 ... ...1839 ... ...1,0645891868931869 701840661... ... 1870 1161841 400 1871 ...1842 168 1872 ......1,0158241843 ? .. 1873 ... ΙΟΙ1844 ? 1874 ... 911845? 1875 401846 ? 1876 ... 1031847 ...... 246 1877 1781848 ... 397 1878 ... 791849 ... 264 1879...... 251850262 1880... ...... 291851 ... 389 1881 ... 1241852 401 1882 ... 541853 ... 171 1883 ... 391854 151 1884 871855 ... 134 1885 ... 1071856 ... 1191886 131857 ... ... 204 1887 21...1858 3321888 ... 411859 195 1889 41860 138 1890 ... 41861 66 1891 51862 80 1892 ... 191863 ... 289 1893 ... 531864 367 1894 ... 311865 303 1895 ... ... 101866 ... 141 1896 ... 22 ...1867 116 1897 11 Except for the year 1897, small- pox includes chicken- pox .,-.'1FOSP7AFMO2T1AX-AL3L0LITYLocalityoftheepidemic.Period.Authority .Cases.Deaths .Poefrcentagef.atalitiesHalifaxRochdaleLeedst,pBHaorarawlidaisfrfhodarsxd-a,ppHaanarroltitishfhearxBradfordW-akefieldA--uLnsydhneteronMacclesfieldStockportWinter of 1721 to,A1(p7r2i2lT..PNhreitaltnlseton...,xv5pxo1xlii276 43 15.9Winter of 1721 toApril ,1722 Ibid. 177 3821'41otW7foi2n1terApril ,1722 Ibid. 792189 23.81722Ibid .,p.221 297 59 19.91722Ibid .,p.221 268 2810.41722 Ibid .,p.221129 36 27.91722 Ibid .,p.221 41857 13.61722 Ibid .,p.221279 562001722 Ibid .,p.221 302 37 12'21722 Ibid .,p.221 287 73 25.4Hatherfield1722 Ibid .,p.221 18020 11'1Chichester 1722 (to Oct. 15 ) Whitaker.Ibid.,p.223994168 16.9Haverfordwest1722Perrot Williams .Ibid .227 52 22.9.,BSaRaonirrdpsbptyoanndden,fppHoaoaafrurlirtisfhax1722mtftihroleowemns{" .JNuertitnl'eston,f"1A"o7cr2c3ount 230 38 16.5p.7Bolton 1)(?723{Jurin's f"A"ocrcount1723 ,p.8}406 89 21.6-Ware 1)(?723 .Ibid 61272 117Salisbury1723 (?) Ibid.1,244 165 13.2Rumsey,Hants1723 (?) Ibid. 913 143 15.6Havant1723 (?) Ibid.264 61 23.1BedfordShaftesbury,CnDoeeladcrhheasmterPlymouth-,nBAeayannrbhuory--SoAtnvroatnford,,12D75e2c5ember,t1N2o7o92v6.,12D75e2c5ember)(?1723Jurin's "Accountودfor7861.,p8723 147 18.41)(?724 I.,.f11pob27ri2d4 660100 15.11)(?724 .Ibid339106 3131)(?724 .Ibid 188 32 17.21S,,277e2p3tember R.,rMWeeracv.st.sore1,tD2o7e92c4. .,.fI15pob75ri2d5 133 25 18.81S,,27e72p3temberDr. Letherland .Ibid . 56289to Dec. 29 ,1724 15.8,,12S77e2p3tember..IDDbrii.cdkson,tD12oe79c2.4,12S77e2p3tember,t1D2o7e92c4.341 64 18.8S..ISHiblariondasne 105 20 190,,1S27e92p5tember,CoDLafryn.ntcehrb,JiuA"nurcri-yn's.,.f1c1"po7o7ru2n6t}503 6112'IIbid . 36233 9.1D,..iJIBnruber.iaidrnd73 15 20.5M-lBeoolotrosnCobhamDoverDeal,nWKeoearmrcpessteeyrUxbridgeHastingst,N12oo79v2.61727,1275261729-30,iDSTnrch.hoeruoclhdzf""Aeocrrc'sount11a77n22d78..,PDTFhrrri.aelnwsenv..,x1pox0lx8vii140 51 36.4705 97 13.713,192 2,26417.25..,.,.i,1"5Biov"HCE1pAi1fnroi1rp8p9ilse8i9.ttid4aogeirhmnytiocns27410 APPENDIX.EGYPT .Theaverage annual strength of the British army in Egypt, withthe number of admissions and deaths from small-pox for thefourteenyears 1882-95 :-Small-pox.1882 ... ... ...Strength.6,198Admissions . Deaths.301883 ... ... 7,897 8 31884 ... ... ... 6,468 25 I1885 ... ... ... 9,593 52 41886 11,062 51 31887 ... ... ... 5,272 26 41888 ... ... ... 3,346 14 41889 ... ... ... 3,431 4261890 ... ... ... 3,209 Ο Ο1891 ... ... ... 3,172 I1892 ... ... ... 3,102 2 Ο1893 ... ... 5,073 4 Ο1894 ... .. ... 5,226 0 Ο1895 ... ... ... 4,504 50INDIA .Theaverage annual strength ofthe number of admissions and deaths from small-pox for thefourteenyears, 1882-95.the British army in India, withSmall-pox.Strength. Admissions . Deaths.188257,344 44 41883 ... ... ... 56,190 105 91884 ... ... ... 55,252 7781885 ... 57,165 12 Ο1886... ... ... 61,757 22 I1887 ...... ... 63,942 40 21888 ... ... 68,795 106 101889 ... ... ... 68,545 152 171890 ... ... ... 67,456 36 41891 ... ... ... 66,178 14 I1892 ... ... ... 68,045 18 31893 ... 69,865 33 41894 ... ... ... 70,983 13 31895 ... 68,331 19 2APPENDIX . 411LEICESTER.Thepopulation of Leicester with attacks and deathsfrom smallpoxforthefourteen years 1882-95 :-Small-pox.Population. Attacks. Deaths .1882 126,275 29 (25) 51883 ... ... 129,483 12 (9) 31884 ... ... 132,773 6(3)1885 ...... 136,147 8 Ο1886 139,606 I Ο1887 ... 143,153 10 (9) 01888 146,790 22 (21) 01889 ... .. 150,520 Ο Ο1890 ... 154,344 Ο 01891 ... ... ... 177,353 Ο 01892 ... ... ... 180,066 38 61893 ... 184,547 308 151894 189,136 8 Ο1895 193,839 41Up to the year 1889 the figures have been taken from Diagram Dfacing p. 435, Fourth Report, Royal Commission on Vaccination.several instances the number of attacks is in excess of those given by theMedical Officer of Health in his report on the Leicester small -poxInepidemic, 1892-93. Dr. Priestley's figures, where they differ, are givenin brackets.VACCINATION ACT, 1898 .(61 AND 62 VICTORIA, CAP. 49.)BE it enacted by the Queen's most Excellent Majesty,by and with the advice and consent of the LordsSpiritual and Temporal, and Commons, in this presentParliament assembled, and by the authority of thesame, as follows :-1.-( 1 . ) The period within which the parent or other personhaving the custody of a child shall cause the child to be vaccinatedshall be six months from the birth of the child, instead ofthe period of three months mentioned in section sixteen of theVaccination Act of 1867, and so much of that section as requiresthe child to be taken to a public vaccinator to be vaccinated shallbe repealed.(2.) The public vaccinator of the district shall, if the parent orother person having the custody of a child so requires, visit thehome of the child for the purpose of vaccinating the child.(3.) If a child is not vaccinated within four months after itsbirth, the public vaccinator of the district, after at least twentyfourhours' notice to the parent, shall visit the home of the child,and shall offer to vaccinate the child with glycerinated calf lymph,or such other lymph as may be issued by the Local GovernmentBoard.(4. ) The public vaccinator shall not vaccinate a child, if, in hisopinion, the condition of the house in which it resides is such,APPENDIX . 413or there is or has been such a recent prevalence of infectiousdisease in the district, that it cannot be safely vaccinated, and inthat case shall give a certificate under section eighteen of theVaccination Act of 1867 of postponement of vaccination, andshall forthwith give notice of any such certificate to the medicalofficer of health for the district .(5. ) Notwithstanding any regulation of any lying -in hospital orinfirmary, or other similar institution, the parent of any child bornin any institution shall not be compelled under such regulation orotherwise to cause or permit the child to be vaccinated at anytime earlier than the expiration of six months from its birth.2.-( 1 . ) No parent or other person shall be liable to anypenalty under section twenty-nine or section thirty-one of theVaccination Act of 1867, if within four months from the birth ofthe child he satisfies two justices, or a stipendiary or metropolitanpolice magistrate, in petty sessions, that he conscientiouslybelieves that vaccination would be prejudicial to the health of thechild, and within seven days thereafter delivers to the vaccinationofficer for the district a certificate by such justices or magistrate ofsuch conscientious objection .(2.) This section shall come into operation on the passing ofthis Act, but in its application to a child born before the passingofthis Act there shall be substituted for the period of four monthsfrom the birth of the child the period of four months from thepassing of this Act.3. An order under section thirty-one of the Vaccination Act of1867 , directing that a child be vaccinated, shall not be made onany person who has previously been convicted of non-compliancewith a similar order relating to the same child.4.-No proceedings under section thirty-one of the VaccinationAct of 1867 shall be taken against any parent or person who hasbeen convicted under section twenty-nine of the said Act onaccount of the same child, until it has reached the age of fouryears.5.-Persons committed to prison on account of non-compliancewith any order or non - payment of fines or costs under theVaccination Acts shall be treated in the same way as first -classmisdemeanants.414 APPENDIX.6.-The Local Government Board maymake rules and regulationswith respect to the duties and remuneration of publicvaccinators, whether under contracts made before or after thepassingofthis Act.7.-The Local Government Board may by order, if in theiropinion it is expedient by reason of serious risk of outbreak ofsmall-pox or of other exceptional circumstances, require theguardians of any poor law union to provide vaccination stationsfor the vaccination of children with glycerinated calf lymph orsuch other lymph as may be issued by the Local GovernmentBoard, and modify as respects the area to which the order applies,and during the period for which it is in force, the provisions ofthisAct requiring the public vaccinator to visit the home of thechildotherwise than on request of the parent.8. The clerk of any sanitary authority which shall maintainahospital for the treatment of small-pox patients shall keep a listofthe names, addresses, ages, and condition as to vaccination ofall small-pox patients treated in the hospital, such entries to bemade on admission, and shall at all reasonable times allowsearches to be made therein, and upon demand give a copy underhis hand or under that of his deputy of every entry in the same onpayment of a fee of sixpence for each search, and threepence foreach copy.9. The enactments mentioned in the schedule to this Act arehereby repealed, during the continuance of this Act, to the extentspecified in the third column of that schedule.10.-( 1 . ) This Act shall not extend to Scotland or Ireland.(2.) This Act shall, except as by this Act specially provided,come into operation on the first day of January one thousand eighthundred and ninety-nine, and shall remain in force until the firstday of January one thousand nine hundred and four.(3.) This Act may be cited as the Vaccination Act, 1898, andthe Vaccination Act of 1867, the Vaccination Act, 1871 , the VaccinationAct, 1874, and this Act shall be construed together as oneAct, and may be cited collectively as the Vaccination Acts, 1867to 1898.APPENDIX . 415SCHEDULE .Session and Chapter.REPEALS.Short Title.30 and 31 Vict. The Vaccinationc. 84. Act of 1867.34 and 35 Vict. The Vaccinationc.98. Act, 1871 .Extent of Repeal .Section six .Section seven from " and shall"provide all stations" to theend of the section.So much of section eight as fixesthe amount of payment thereunder.Section twelve.Insection fifteen, from" according"to the provisions" to " per-" forming the operation."Section sixteen, the words " with-"in three months after the"birth of such child," and from"within three months after" receiving" to " period as" aforesaid ," and from " and" the public vaccinator" to theend of the section .Section seventeen, to " vaccina-" tions and," and in the samesection the words " if the" vaccinator so direct," andthe words " and inspected as" on the previous occasion."Section nineteen.In section twenty, the words"brought to him for vaccina-In section twenty-nine the words"to take such child or," thewords " to be taken," and thewords " according to the pro-" visions of this Act."In section thirty- seven the word"of."Section ten.In section eleven the words" take or " and the words " to"be taken."
INDEX .ABERGAVENNY. PAGESmall - pox in 1871-72Acland, Dr. T. D.64Age- incidence.Ofsmall-pox (see Small-pox).Symptoms accompanying vaccinationConvulsions supervening on vaccinationVaccinaleruptionsVaccine généraliséeAge-distribution of eczema caseselationship of cow-pox to syphilisIncubation period of erysipelasVaccination and scrofulaCase oflupusfollowing vaccinationTetanus following vaccinationCalf lymphAdenitis complicating vaccinationAdmiralty.Vaccination failures on H.M.S. " Phaeton "Of fever (typhus, typhoid, and simple and ill - defined fevers ) 46 , 47 , 396273, 274273, 274289, 290285291316, 317352 , 353354359361377,378111 , 274, 351 , 354, 382149Of typhus fever 48, 49, 396Oftyphoid fever 49, 396Ofinfluenza 49,50And sanitation 75, 76 , 396 , 398, 399Ahmed, Dr. Z.Case of tetanus following vaccination 360Air-spaces in towns.Salutary effect ofAiry, Dr.Norwich cases of vaccinal erysipelas ( 1882 )Albricht, Dr.On the spreading of leprosy by vaccinationAlgiers.Vaccino-syphilis ( 1880)61-65, 251348, 363345324418INDEX.American Civil War.Vaccino - syphilisAnimal Lymph .And vaccino-syphilisAnd tubercleSkin diseases and inflammatory complications fromMr. Robert Ceely onDr. Cory's experienceDr. Prince Morrow onDrs . Acland and BarlowVaccination CommissionersAppleby.Serious and fatal vaccinal injuries ( 1873 )Army.Small - pox after re - vaccinationArning , Dr. Edward.Experiment on condemned criminal, KeanuResults of vaccination of lepersOn the spreading of leprosy by vaccinationAsprières.Cases of septic poisoning after vaccination at ( 1885 )Atthill, Dr." Good " and " bad " marksAuckland.Small -pox in 1871-72Auzias -Turenne, Dr.Relationship of cow- pox to syphilisAynho.Small - pox in 1723-24BADCOCK , Mr. John.Personal experience of small- pox after re- vaccinationPAGE319-322316-319, 366, 386357,358366-378367, 368319373377, 378366 , 378351224-231 , 410326, 327328342-34435020364, 94, 95309, 31043. 44, 181 , 409214, 215Bakewell, Dr. Hall.Communicability of leprosy 326Leprosy and vaccination 335Ballard , Dr Edward.Vaccination not a " trivial " operation 270Vaccino - syphilis 295Perfect vaccine vesicle may furnish syphilitic virus 307Report on Leeds caseBarker, Mr. J.Fever epidemic ( 1741 )Barlow , Dr.Report on Leeds caseVaccinal injuries in some Norfolk villages ( 1890)312-31438314Calf lymph352, 363, 364377, 378INDEX . 419Baron , Dr. John.Eruptions from Woodville's lymphOn Jenner's evasionsJenner's persistency::Jenner and his medical confrèresReports of vaccination failures begin to multiply ( 1804)PAGE2125, 2627, 28106113, 114Opposition to vaccination ( 1808 ) 124, 125Clamour about prevalence of small- pox after vaccination 143Hesitation of respectable persons concerning vaccination ( 1818) 143Barry , Dr. F. W.Small-pox at Sheffield, 1887-88 (see Small- pox) .Immunity to small-pox in the unvaccinated 170, 171Small-pox after recent vaccination at Sheffield ( 1887-88) 171-173Sheffield " census "Barthez , Dr.Small-pox after re-vaccination at Sheffield ( 1887-88)Barthélemy, Dr.On blood being omnipresent in vaccine lymphVaccination and tubercle221 , 222176 , 177307354, 355Bates , Dr. W. T. C.Case of tetanus following vaccination 360Bavaria.Small-pox after vaccination ( 1871 ) 175, 176Baylies , Dr. William .Immunity to small - pox in the unvaccinated 166, 167Beale , Dr. Lionel.Immunity to small-pox in the unvaccinated 169Beaney, Dr. James G.Injurious results of vaccination 281Vaccino-syphilis 281, 294Beddoes , Dr. Thomas.Criticises Jenner's theories 16Bedwellty.Small -pox in 1871-72 64, 94, 95Bell , Dr. Benjamin .Injurious results of vaccination 280Bellows, Mr. John.Experiences in the Franco - Prussian War 83Benson , Dr. Hawtrey.Case proving communicability of leprosy 325, 326Berkeley, Dr. H. J.Case of tetanus following vaccination 360420 INDEX .Berlin.PAGEInsanitary condition prior to 1872 259Small -pox in 1870-72 175, 198, 231Sanitary works at, with decline in mortality 259Berlin Leprosy Conference ( 1897) .Communicability of leprosy 326Berry, Mr. George.Diagnosis between a vaccine sore and syphilis 310Besnier, Dr.Case of lupus following vaccination 359Bideford.Small-pox in 1871-72 95Biggs, Mr. J. Т.Small-pox at Leicester 88, 411Bigsby, Dr. J. J.Scar theory at Newark ( 1839) - 203Birch -Hirschfeld, Dr.On vaccination and scrofula 356, 357Birdwood, Dr. R. A.Vaccination absolute protection up to no age whatever 164, 165On the obscuring of vaccination scars by eruptionFallacy of classifying small -pox cases by vaccination marksAdvocates " the production of one vaccine vesicle only "Causes of blindness associated with small-pox -194194, 195212266Birkenhead.Small -pox in 1877 - 246Birmingham.Park-space and death - rates from zymotic diseases ( 1870-79 ) 62Small -pox in 1891-94 92, 175 , 178 , 185Blackmore, Sir R.Blindness.Mild small -pox in the eighteenth centuryPrevarications of the inoculatorsBlair, Mr.Case of small-pox after vaccinationBlank, Dr. Henry.Animal vaccinationBlandford.Fire and small-pox ( 1731 )Vaccinal erysipelas ( 1883 )From small -pox, causes ofBlood.Omnipresent in vaccine lymphBoddington, Mr. (surgeon) .Letter of remonstrance to Jenner188364, 36511636826535126630725INDEX. 421Bristol.Bohn, Dr. H.Cow-pox and erysipelasBolton, Dr. James.Vaccino-syphilis in the American Civil WarBorington, Lord.Brings in bill to check small- pox inoculation ( 1813 )Boulger, Surgeon I.Re-vaccinated small-pox in the army at Cairo ( 1885 )Bowditch , Mr. Vincent .Results of animal lymphBradford.Bremen.Park- space and death - rates from zymotic diseases ( 1870-79)Epidemic of jaundice from glycerinated lymph ( 1883-84) -Bridges , Dr. J. H.Advocates alteration of vaccination lawsThe unvaccinated not a danger to their neighboursValue of returns of vaccinal injuriesBrighton.Park - space and death- rates from zymotic diseases ( 1870-79)Park - space and death - rates from zymotic diseases ( 1870-79)PAGE347320, 321132226-23137462381 , 382451783646262British Annals of Medicine.Deprecates silencing of inquiry into vaccination question - 152British MedicalJournal.Insanitary surroundings of the unvaccinatedInfluence of sanitary measures on snıall- pox197258Vaccino- syphilis 293, 294Bromley.Small -pox after vaccination ( 1881 ) 175Brooke, Dr. F. B.Report on Gloucester Hospitals ( 1896)Brown , Mr. Thomas (a critic of vaccination).- 99-102Cases of small-pox after vaccinationAcknowledges his former partiality -Opinion that vaccination must be surrenderedHis treatment by Jenner127127127128Browning, Dr. B.Experience with " good " marks 203Buchan , Dr. William .Effects of insanitary surroundings 75Intramural burial-grounds (eighteenth century).Treatment of small- pox (eighteenth century )77263, 264Buchanan, Sir George.Refers to glycerine as " preposterous " adulteration of vaccine 380422 INDEX .Buckmaster , Dr. J. A.Results of vaccination of lepersPAGE328Burial -grounds ( intramural) .Influence on mortality 76, 77, 400Burnett , Dr. W.Small -pox after vaccination on H.M.S. “ Phaeton " 149Butler, Dr. D. W.Animal lymph 372CAIRO.Re- vaccinated small-pox in the army ( 1885 ) 226-231Caistor.Small -pox in 1871-72 94,95Calcutta.Glycerinated lymph tried at, and given up 384Calf lymph ( see Animal Lymph) .Cambridge.Small -pox after vaccination ( 1808) 124Canning, Mr. George.Opinion on compulsory vaccination 162Cantlie, Dr. James.Immunity of plague attendants 233Recent Essay on leprosy referred to 344Constitutional disturbance from Japanese (glycerinated) lymph - 382Cape of Good Hope Leprosy Conınmissioners.Communicability of leprosy 326Carlisle .Small-pox in 1779-87Carpenter , Dr. W. B.43Vaccination at Montreal prior to small-pox epidemic ( 1885 )Statistics of small-pox in the Franco- Prussian WarInfluence of sanitary measures on small -pox mortalityCarr, Mr. Henry.How small - pox is propagated -102, 103237-239258255Carter, Mr. Brudenell.On vaccino- syphilis 295Carter, Dr. Robert J.Vaccinal injuries from glycerinated calf lymph 382Carter, Dr. Vandyke.Communicability of leprosy 326Cayley, Dr.Communicability of leprosy 326Ceely, Mr. Robert.On vaccination cicatrices wearing out 193Animal vaccination and skin eruptions 286, 367 , 368INDEX . 423Chadwick , Sir Edwin .Influence of sanitary measures on small - pox and typhusChartres , Dr. J. Smith .PAGE257, 258Cases ofphlegmonous inflammation of the arm after vaccination 348Chelsea.Fatal vaccinal injuries ( 1875 )Chester.Small -pox in 1774 -System of small -pox prevention (eighteenth century)Chester- le- Street ,Small -pox in 1871-72Chicken-pox.Deaths , Registrar-General on" Confluent " cases" Malignant ""casesChrist's Hospital.Immunity from zymotic diseasesChurchill , Dr. Fleetwood.On the requisite number of vaccination marks -Clapham.Cases of vaccinal injury ( 1800)Clerkenwell.Vaccinal injuries ( 1879)Colin, Dr.Immunity of the unre- vaccinated35143, 97, 182, 18340264, 95, 9645159, 160160251Estimates small -pox mortality of garrison at Paris ( 1871-72 )Collie, Dr.Cases of small - pox after re-vaccinationCollins Dr. W. J. (see Royal Vaccination Commissioners).212274, 275351232238220, 221Cologne.Small - pox after vaccination ( 1871-73) 175Compulsory vaccination 162-164 , 178 , 356 , 384, 386-388 , 402Convulsions supervening on vaccination - 274Cooke, Mr. Charles .Case of small-pox after natural cow- pox 110Copland, Dr. James.Thinks vaccination could never altogether banish small-pox" Transcendental laudation " of vaccination" Reverberated encomiums from well- paid vaccination boards "Vaccination and scrofulaCory, Dr. Robert.Experience of calf lymphCottman, Dr. J. B.Case of tetanus after vaccination165165165355319359424INDEX .Coupland, Dr. PAGEGloucester small-pox epidemic-causes of extension : 97-99Immunity to small-pox in the unvaccinated 171Scar statistics, Dewsbury ( 1891-92) - 213Small- pox at Dewsbury ( 1891-92) confined to working classes 247Cow-pox.JennerJenner first interested in 9Symptoms 16, 109-111 , 270-274, 276, 311Deaths, England and Wales ( 1881-96 ) 362"Spurious" 26-29, 108 , 109, 111 , 114And erysipelas 346, 347Identity with small - pox repudiated -Relationship to syphilisCrapo, Dr. J. R.Animal vaccinationCreighton, Dr. Charles.Small-pox in the seventeenth centuryExtent of ( small -pox ) inoculation practised from 1721-28 -Window- tax30, 309309-319373425966, 6767, 68180, 408, 409309, 317Insanitary condition of London in 17th and 18th centuriesSmall -pox fatality in 18th centuryRelationship of cow-pox to syphilisCrookshank , Prof. Edgar.Woodville's casesCross, Mr. John.Norwich small -pox epidemic ( 1819) confined to lower classesTreatment of small-pox ( 1819)Cutler , Dr. William C.Skin diseases attending vaccinationDAIRYMAIDS.The tradition of theDalton , Dr. J. Н. С.Scar statistics22245264, 265288, 289- 9,403213Cases of small -pox after re - vaccination 223Darby, Dr.Cases of small- pox after re- vaccination 216Darjeeling .Glycerinated lymph tried at, and given up 384Darlington.Small -pox in 1871-72 64Daubler, Dr.Cases of leprosy after vaccination 340-342Davidson, Mr. P. M.Scar statistics 207-210INDEX . 425Davies, Dr. PAGESmall-pox fatality in vaccinated and unvaccinated 184Decanteleu .Varieties of vaccination cicatrices 201Dennett , Mr. C.Immunity to small - pox in the unvaccinated168Depaul, Prof.Animal vaccination 368Dewsbury.Small -pox in 1891-92Small-pox epidemic ( 1891-92) confined to working classesDimon , Dr. Theodore.Case of tetanus following vaccinationDimsdale , Dr. Thomas ( inoculator)Dortrecht.Vaccinal erysipelas among recruits ( 1883 )Dover.Small -pox in 1871-72Drew , Mr. Walter .Case of small -pox after vaccination -- 52, 213 , 151 , 247, 393247360- 11 , 12348, 34994, 95118Drysdale , Dr. Charles .Vaccino- syphilisDudley.Small-pox in 1871-72Dunning, Mr. Richard.29564, 94, 95Sceptical about merits of vaccinationReassured by Jenner114114, 115Cases of small - pox after vaccination 117Durham.Small-pox in 1871-72 64, 94, 95EASINGTON.Small -pox in 1871-72 64, 94, 95Eczema after vaccination 290, 291 , 351Edinburgh Medical and SurgicalJournal.Pays amende honorable to Mr. Thomas Brown128Edinburgh Review.Criticism on vaccination - 148Edwardes, Dr.On jaundice epidemic at Bremen ( 1883-84)382Egypt.Re- vaccinated small-pox in the army 225-231 , 410Ellenborough, Lord.On vaccination 13428426 INDEX .Epidemiological Society.Enteric Fever ( see Typhoid Fever) .Promote the first Compulsory Vaccination Bill ( 1853 )Opinion that the unvaccinated are a danger to societyOn vaccination scars wearing outAssertion respecting safety of vaccinationErasmus .On practice of strewing floors with rushesErysipelas.VaccinalAnd cow-poxIncubation period variableEvelyn, John.Small -pox in his familyFARN, MR. (of National Vaccine Establishment) .Cannot guarantee purity of vaccine lymphFarr, Dr. William .Small-pox and fever death - rates ( 1629-1835)Zymotic diseases replace each otherInfluence of sanitary measuresPAGE163, 164164193267, 26870281 , 345-354346, 347352, 35342268, 26957,5885257281Farrar , Dr. Reginald.Fatality from calf lymphFehleisen , Dr.Incubation period of erysipelas 352Fentem , Dr. P. S.Cases of erysipelas after vaccination 350Fever (typhus , typhoid, and simple and ill-defined fevers) .Death- rates (1629-1835) - 57Death- rates ( 1838-95) 40Registrar -General on cause of decline 41, 42Age- incidence 46, 47Flewellen , Dr. E. A." Spurious " vaccination in the American Civil War 321Fluder, Mr. Charles.Vaccinal injuries ( 1833 ) - 278, 279Forbes, Mr. William .Case of small -pox after vaccination - 115Fosbrooke, Rev. T. D.“Spurious " cow-pox 110, IIIFournier, Professor.Vaccino-syphilis " a real and serious danger " 294Vaccino- syphilis cases more numerous than recorded 362, 363INDEX . 427Fox . Dr. Colcott .Urticaria complicating vaccinationAge-distribution of eczema casesThree cases of lupus following vaccinationFox, Dr. Tilbury.Impetigo contagiosa following vaccinationCommunicability of leprosyPAGE290291359291326Francis , Dr.Communicability of leprosy 326Franco- Prussian War.And small - pox mortality 80-83, 237-240Frank, Dr. Louis .Adenitis complicating vaccination 274Vaccination and skin diseases 288Urticaria complicating vaccination 290Freycinet, M. de.Statistics of small-pox in the Franco- Prussian War 239Fuqua, Dr. William F.Vaccino-syphilis in the American Civil War 322GAINSBOROUGH .Erysipelas after vaccination (1876)Gairdner, Sir William .Cases of leprosy following vaccinationGaitskell , Mr. William.Malignant small -pox after vaccinationGarceau, Dr.Causes of Montreal small-pox epidemic ( 1885 )Gardner, Mr. Edward.28 On vaccination falling into disrepute at Frampton ( 1817 ) -Gateshead.Small -pox in 1871-72Gatti ( French inoculator)Gayton , Dr. William.348, 363329-33414410314264. 95, 96IIPrimary vaccination " a very fleeting protection indeed "Mild small- pox in the unvaccinated164190Fatality of malignant small pox in vaccinated and unvaccinated 190His method of classifying cases of small -pox 194 , 202Causes of high small-pox fatality in the unvaccinated197Cases of small-pox after re-vaccination 216-218German army.Small-pox in 234-236428INDEX.German Laws. PAGEProhibit taking lymph from a scrofulcus child - 356Gers, Dr. Henry.Animal lymph 371 , 372Gibson, Mr. William .Age-incidence of vaccinated small -pox 152, 395Gilmore, Dr. J. T.Vaccino- syphilis in the American Civil War 320Glasgow.Mortality from small- pox, measles, whooping- cough ( 1783-1812) 84Gloucester.Small -pox in 1895-96 51-53, 96-102 , 185 , 263 , 389 , 391-395Gloucester Hospital ( 1896 ).Sanitary administration “ shockingly neglected "Treatment of patients compared with that of last centuryGlover, Dr. J. G.Leicester system of small-pox preventionGlycerine.Action of, on the growth of the tubercle bacillusAlleged advantages of its addition to vaccine lynophGlycerinated lymph.Suggested in 1849Used extensively in Europe, India, and Japan10026390, 91358379376379Promoted by the Local Government BoardCondemned by Sir George BuchananLord Herschell's opinion ofThe Royal Commission onEpidemic of jaundice " causally connected " with379379, 380380, 381380381, 382Injuries from . detailed by Dr. Robert CarterInjuries and fatalities from (Royal Commission cases )Given up at Calcutta and Darjeeling382383384In India soon becomes " putrid " and " septically dangerous " . 384And tubercle - 358, 384And erysipelas 384Goldson , Mr. William .Cases of small- pox after vaccination ( 1804) 114Pleads for further investigation of vaccination question 114Graniteville .Cases of " spurious ” vaccination at 323Grantham , Mr. Justice.Personal experience of small- pox after re- vaccination 215Gray, Dr. J. M.Animal lymph 372Greenhow, Mr. Edward.On small - pox after vaccination ( 1833 ) 151Age- incidence of vaccinated small-pox 151 , 395INDEX . 429Gregory, Dr. George.On Jenner's first publicationJenner's" presumption "PAGE17154Onthe " sanguine pathologists " of 1800 153Repudiates identity ofcow-pox with small -pox 30, 309Onthe "trammels of Jennerian pathology 309Fatal small -pox after vaccination ( 1825) 149, 150On " acknowledged frequency " of small -pox after vaccination - 153Onthe mitigating power of vaccination 179, 180Onthe obscuring of vaccination scars by eruption 192On vaccination scars wearing out 192, 193Vaccination cicatrix as a measure of protection 212Grieve, Dr.Class of patients who take malignant small - pox 191Influence of sanitary measures on small-pox 256Griffin, Dr. F. L.Results of animal lymph- 370Grocers' Company.Offer prize of £1,000 for a pure vaccine lymph ( 1883 ) 269, 270Guy, Dr.Grosvenor , Mr. John.Cases of small - pox after vaccination ( 1801 )War as a cause of disease11379, 80HACKNEY.Small - pox in 1871-72Hadwen, Dr. Walter.Small -pox fatality at Gloucester Hospital ( 1895-96) -Hall, Mr. R." Confluent " chicken -poxHanson , Dr.Communicability of leprosyHarding, Mr. T. M.Cases of small- pox after vaccinationHardy, Mr. Thomas .Attributes a case of small- pox to chicken-poxAfterwards " reluctantly " alters his opinionHardy, Prof.Unpleasant reminiscence of re - vaccinationHarris , Dr. Walter.Small -pox in the seventeenth centuryHarrison, Mr. E.Case of small -pox after vaccination -Harrison , Mr. Thomas.Cases of small- pox after vaccination94,959715932617415916029042, 43112141430 INDEX.Hart, Mr. Ernest .On pre-Jennerian small - poxLeicester system of small -pox preventionOn immunity of vaccinated childrenSmall -pox fatality in vaccinated and unvaccinatedStatistics of small -pox in the Franco- Prussian WarSmall-pox at Douglas ( 1877-78 )Hartlepool.Small -pox in 1871-72Hartpence, Dr. W. M.Results of animal lymph-Haygarth, Dr.System of small -pox prevention at Chester ( 18th century )Judicious counsels respecting vaccinationHeron, Dr.Cases of " malignant " chicken- poxHerrick, Dr. S. S.Kesults of animal lymph-Herschell, Lord .His opinion of glycerinated lymphOn vaccinationPAGE57,58- 88, 89173, 174184237, 239, 240256, 25764371402106, 107160377380, 381396-399Hillis , Mr. John D.Cases of leprosy following vaccination 335-337Hirsch, Dr. August.Habitat of small-pox 258Hoagland, Dr. L. B.Animal lymph 370, 371Holland , Sir Henry .Holmes, Mr.Holt, Dr. Alfred H.Non- realisation of earlier anticipations about vaccination -Cases of vaccino - syphilisResults of animal lymphHooper, Dr. R.Fatal case of small-pox after natural cow-poxHopkirk , Dr. Arthur F.Re- vaccination Law in the German army ( 1834)Statistics of small-pox in the Franco- Prussian WarHoughton-le- Spring .Small -pox in 1871-72House of Commons.Comınittee ( 1802) .Accepts Jenner's " spurious cow-pox " theoryEndorses Jenner's opinion respecting value of vaccination15230537411023423864,9529105House of Commons.Committee ( 1871 ) .INDEX . 431PAGEChairmancompares mortality of small-pox with that of the plagueOn Vaccination Act ( 1867 )3133Howard, John.Insanitary condition of prisons ( 18th century ) 73-75On window-tax in prisons74Hubbard, Dr. George H." Spurious " vaccination in the American Civil War 321 , 322Hugo, Mr. Thomas.Small -pox after vaccination at Crediton ( 1814) 134, 135Hull.Park -space and death -rates from zymotic diseases ( 1870-79 )62Hunt , Dr. Ezra M.Animal lymph369, 370Husband, Dr.Hutchinson , Mr. Jonathan.On blood being omnipresent in vaccine lymphVaccination and skin diseasesVaccination prurigoVaccinal impetigo at St. Pancras WorkhouseCases of vaccino- syphilisOn syphilitic infants sometimes looking perfectly healthy307289292292301-303308Leeds case 314Cases similar to Leeds case 316Diagnosis between the Leeds case and syphilis 314, 315Calf lymph and vaccino-syphilis 317 , 318Escape of co- vaccinees in vaccino- syphilis cases 353,354Case of lupus following vaccination 358Ofplague attendantsImpetigo Contagiosa.IMMUNITY.To small-pox in the unvaccinatedOf small -pox hospital nursesTo zymotic diseases in improved dwellingsAnd vaccinationIndia.Small -pox and vaccinationRe-vaccinated small-pox in the armyGlycerinated lymph a failureIndian Lancet.Case of tetanus following vaccinationInfluenza.Age- incidenceIngenhousz, Dr.Cautions Jenner166-171 , 232 , 233231-233233247291 , 292401226, 410383, 38436149, 50108432 INDEX .Inoculation (small-pox) . PAGEPopular in Turkey - 10Dr. Timoni's letter on 10Introduced into England by Lady Mary Wortley Montagu ( 1721 ) 10Condemned criminals experimented upon IISecures royal patronage ( 1722 ) IIProgress impeded by severity of results IIPractice almost ceased ( 1728 ) - IIRevived ( 1740)11,59Made gratuitous ( 1746) 59Sanctioned by Royal College of Physicians ( 1754 ) IIReformed by Gatti, Sutton, and Dimsdale (1763 ) 11 , 12Diffused small-pox 58-60Prohibition in Paris ( 1763) - 58, 59Effect of its displacement by vaccination - 58-61 , 86, 390Inoculation Test (see Variolous Test) .JACOBS, MR.Personal experience of cow- pox 108 , 109Jaundice.Epidemic at Bremen, from glycerinated lymph ( 1883-84) 381, 382Jenner, Dr. Edward.First interested in cow -pox 9On the " Tradition of the Dairymaids " 9On the symptoms of cow-pox in milkers 270, 271On the immunity of cow-poxed milkers to small -pox 10First vaccination ( 1796) -14Method of applying variolous test 13, 14Variolous test failures15Cautioned by Royal Society 106Theories criticised by Dr. Beddoes - 16His " presumption," Dr. George Gregory on154And his medical confrères 106Has no lymph (end of 1798) 16Uses Woodville's lymph 21On Woodville's lymph finally assuming the nature of vaccine 61Abandons variolous test ( 1804) 26, 389Coins term " spurious cow- pox"26Assertions respecting permanent value of vaccination 105 , 164 , 214 , 267Assertion respecting safety of vaccination 267Disregards Dr. Haygarth's counsels 107Cautioned by Dr. Ingenhousz 108In 1804 advised to come forward and vindicate his doctrines114Reassures his friend Dunning , who had become sceptical 114, 115Conference with Lord Henry Petty 122Rewarded by Parliament 123Jenner and vaccination " again to be put upon their trial " ( 1809 ) 125Accuses Brown of " fraud and artifice" 128On Grosvenor case130Brings forward new doctrine to repel failures 130, 131INDEX . 433Jenner, Dr. Edward. PAGEAnnoyed by the anti-vacks 132Also by Lord Ellenborough's remarks on vaccination ( 1813 ) 132 , 134Disparaging remarks on his discovery by Dr. Thomson ( 1822 ) - 147Disconcerted by criticism in the Edinburgh Review 148On the requisite number of vaccination marks- 204Onmild small -pox in the eighteenth century 189On cow-pox and erysipelas 346, 347Jenner Society.Small -pox and sanitation 241Jeunhomme, Dr.Statistics of small-pox in the Franco- Prussian War 238-240Jones, Dr. Horace E.Results of animal lymph- 372Jones, Dr. J. T.Results of animal lymph- 372Jones, Dr. Joseph .Vaccino- syphilis in the American Civil War 319 , 320Jones, Mr. William.Experiences in the Franco- Prussian War 82, 83Jurin's statistics.Of small - pox fatality in the eighteenth century 180-183 , 408 , 409Criticised by Dr. M'Vail 181The Royal Commission on 183KEIGHLEY .Small - pox in 1893 -Kellett , Mr. R. G.53 , 91 , 97 , 225 , 390, 392 , 393Cases of small - pox after re - vaccination in his familyKilmarnock.216Small-pox in 1728-63 43LAMBETH .Small -pox in 1871-72 95, 96Lancet.Vaccination failures " numerous and discouraging " ( 1853 ) 155Fatality of small -pox ( 1871 ) 184Pock-marked faces ( 1872) 56On the propagation of inoculable diseases by vaccination-Cases of erysipelas after vaccination279349Calf lymph and vaccino-syphilis 366Langworthy and Arscott, Messrs .Experiments, referred to 23, 24Lawbaugh, Dr. A. I.Results of animal lymph- 374434 INDEX .Lebus.Cases of vaccino - syphilis at ( 1876 )Lee, Dr. Robert .Skin diseases attending vaccination -PAGE324286Leeds .Park- space and death-rates from zymotic diseases ( 1870-79)Case of " vaccino- syphilis "62311-319Legge, Dr. T. М.Sanitary works at Berlin, with reduction in mortality259Leicester .Park- space and death- rates from zymotic diseases (1870-79)62Small-pox epidemic, 1892-94 (see Small -pox).System of small - pox prevention 88-91Vaccination returns ( 1885-95) - 87Lennander, Dr.Leprosy.Case of lupus following vaccination -Communicability ofInoculation ofIn-vaccination of ( cases ) -Whether spread by vaccination359325, 326326, 327329-342342-345Lettsom , Dr.Vaccinal injuries at Clapham ( 1800 ) 275Lining, Dr. C. Е.Animal lymph 373Lister, Lord.Small -pox in the Germany army 234-236Little, Dr.Cases of " confluent " chicken-pox 160, 161Liverpool.Typhus in 1839 48Park - space and death-rates from zymotic diseases ( 1870-79 ) 62Llanelly.Small - pox in 1871-72 95, 96Local Government Board .Powers under Vaccination Acts34On pre-Jennerian small -pox 186On the re-vaccination of the army 224Assertion respecting immunity of re - vaccinated soldiers 224On the safety of vaccination 270Encourage practice of vaccinating newly-born infants 281 , 282Assertion respecting vaccino - syphilis 293And the Leeds case312, 314INDEX . 435Local Government Board.Cases similar to Leeds caseInquiry into 132 fatal cases ( erysipelas, etc. ) after vaccinationPromote glycerinated lymphLondon.Population previous to present centurySmall -pox epidemics ( see Small-pox) .Small-pox and fever death - rates ( 1629-1835 )Typhus in 1685-86 , 1741 , 1837-38, 1847, and since 1871PAGE316351379325737-39, 48Insanitary condition in early times 67-73,400Park- space and death - rates from zymotic diseases ( 1870-79 )Squares , dates of construction of6265London Gazette.Pock -marked faces ( 17th and 18th centuries ) 55London Medical Repository.Case of small - pox after vaccination - 135On alarming number of vaccination failures ( 1817 ) 142London Sınall - pox Hospital.Vaccination failures ( 1825 , 1826-65, 1867 , 1871 )Lucas, Mr. Clement.Case similar to Leeds caseLürman , Dr.Jaundice epidemic at Bremen from glycerinated lymphLupus.Following vaccinationLyman, Dr. Henry M.35, 149 , 150, 175316381 , 382358, 359Animal lymph 367Lymph ( Vaccine) .No guarantee of purity ( Mr. Farn) 268, 269Lyttelton , Lord.Introduced Compulsory Vaccination Bill ( 1853 ) 163Promised certainty of vaccination as a preventive of small-pox - 163MACAULAY, Lord.Window-tax 66MacCombie, Dr. John.Small-pox fatality in vaccinated children 173" Good " Onmalignant small-pox- 190marks203, 204Cases of small-pox after re - vaccination 218-220Opinion respecting protective value of re -vaccination 220Macdonald, Dr.On the spreading of leprosy by vaccination 344, 345436INDEX.M'Ghie.Woodville's variolous testsMaclean, Dr. Charles.Vaccinal injuriesMacleod, Dr.Cases of small -pox after vaccinationMacnamara , Mr. C. N.Communicability of leprosyInoculation of leprosyIn-vaccination of leprosyM'Vail , Dr. John C.Age- incidence of small-poxCriticises Jurin's statisticsMaddock, Mr. B.Injurious results of vaccinationMaitland, Mr. Charles (early inoculator)Makuna, Dr.On classification of small-pox cases by vaccination marksCases of vaccino- syphillis reported in his " Inquiry "Malthus, T. R.Vicarious mortalityManchester .Typhus in 1839Small -pox in 1769-74Park - space and death - rates from zymotic diseases ( 1870-79 )Marsh, Dr. E. J.Animal lymphMarson, Mr. J. F.Mild small -pox in the unvaccinatedFatality of corymbose sinall-poxHis method of classifying small -pox casesHis scar statisticsMartin, Dr. Henry A.Case of vaccine généraliséeMartin , Sir Ranald.Leprosy and vaccinationMassey, Isaac.Mild small -pox in the eighteenth centuryMeasles.In Glasgow, takes the place of small-pox ( 1783-1812 )PAGE18278144-146326327, 32833449181275, 27610, 11202, 203303-30583,84434862371189191193, 194204, 205285334,335188-84, 85Medical and Chirurgical Review.INDEX.Cases of post - vaccinal small - pox, with remarks by editors -Case of small- pox attributed to chicken- poxOn Mr. John Ring's prevarications -Injurious results of vaccinationMedical and PhysicalJournal.Review on Mr. Goldson's objectionsMedical Observer.Fatal cases of small -pox after natural cow-pox113 cases with 16 deaths of small- pox after vaccinationSmall-pox mortality after vaccination at Witford ( 1810)Medical Record ( New York).Case of tetanus following vaccinationMedical Times and Gazette.Squalid surroundings of small-pox sufferers ( 1871 )On the transmission of tubercle by animal lymphMelichar, Dr.Epidemic of impetigo contagiosa following vaccinationMerthyr.Small-pox in 1871-72Metropolitan Asylums Board.437PAGE118-122157, 158158276114111125-127128, 129361246357,35829264, 95, 96Small -pox statistics in the Hospitals ( see Small -pox ) .Small-pox immunity in one of the Managers (unvaccinated) 232, 233Cases of small-pox after re - vaccinationMichaels , Mr.216-221 , 223Causes of Montreal small-pox epidemic ( 1885 ) 103Milnes , Mr. Alfred.Age- incidence of typhus and typhoid fevers 49Age- incidence of influenza 49, 50Age- incidence and sanitation 76, 396Mold.Small - pox in 1871-72 53, 93 , 94, 104. 392Montagu , Lady Mary Wortley.Introduces snmall - pox inoculation into England ( 1721 ) 10Montreal .Small - pox epidemic ( 1885) 102 , 103Moore, Mr. James.Moore , Sir William .Woodville's lymph -Effects of small-pox inoculationCommunicability of leprosy21 , 2259326Morland, Mr. W.Cases of erysipelas after vaccination 347,348438INDEX.Morrow, Dr. P. A.Vaccine généraliséeSkin diseases attending vaccinationReluctance of profession to recognise vaccinal injuryAnimal lymphMorton, Dr. Richard.Small-pox in the seventeenth centuryMoseley, Dr. Benjamin.Publication on vaccination failuresMudge, Mr. John.Messrs. Langworthy and Arscott's experimentsMild small-pox in the eighteenth centuryMudie, Dr. P.Acknowledges his prejudice in favour of vaccinationMurchison, Dr. Charles .Typhus fever epidemics ( 1685-86 , 1741 )Murray, Dr.PAGE2852893633734212223, 24188, 18916137326 Communicability of leprosyNAPIER, DR. ALEXANDER.Eruptions from calf lymph 373-377Nash , Brigade-Surgeon.Vaccination and re- vaccination in the army 224, 225Small -pox cases and deaths in the army ( 1860-88) 225National Vaccine Establishment.Founded ( 1807 ) 123Principal function 123Report on the Grosvenor caseCases of small- pox after vaccinationPock-marked faces ( 1821 , 1825)130143-145.14755,56223, 224IINavy.Small -pox after re - vaccinationNettleton, Mr. Thomas ( early inoculator)Neuss.Small-pox after vaccination at ( 1865-73) - 175Newcastle-on-Tyne.Park-space and death- rates from zymotic diseases ( 1870-79) 62Small-pox in 1871-72 64, 95, 96Niemeyer, Dr. Felix von .Dangers ofvaccination 279, 280On vaccination and tubercle355Opinion on compulsory vaccination356Nightingale, Miss Florence.Onthe first canon of nursing 265, 266INDEX.Northampton .Small-pox in 1871-72Norway.The Government of, on the vaccination of young childrenNorwich.Small-pox in 1819 confined to lower classesSmall -pox in 1871-72Park- space and death - rates from zymotic diseases ( 1870-79)Vaccinal erysipelas ( 1882)Nottingham.Fatal case of small-pox after vaccination ( 1809)Park - space and death-rates from zymotic diseases ( 1870-79 )Nurses.Immunity to small -pox and plagueNursing.Influence on small-pox fatalityOGLE, DR. WILLIAM.On age- incidence of zymotic diseasesOldham .Park- space and death- rates from zymotic diseases ( 1870-79 )Oliver , Mr. Richard.On the spreading of leprosy by vaccinationOpen Spaces in Towns.Salutary effect ofPAGET, SIR JAMES.Onthe effects of vaccinationParliament , Acts of.Relating to vaccinationPublic Health Act ( 1875 )Paul, Mr. Alexander.Small-pox age - incidence in recent local epidemicsPearse, Dr. S. H.Animal lymphPearson, Dr. George.439PAGE94, 95283, 2842459562348, 36312962231-233256, 266466234562, 63, 25127233-35 , 412-41554393-395372271120, 132, 13330132162Symptoms of cow-poxCases of small-pox after vaccinationRepudiates identity of cow-pox with small -poxHis " insinuations that vaccination is good for nothing "Peel, Sir Robert.Opinion on compulsory vaccination (reported by Mr. Duncombe)440 INDEX .Percival , Dr. Thomas .On the inoculation of infantsPercival , Dr. W. F." Spurious " vaccination at GranitevillePerron, Dr.Epidemic of impetigo contagiosa following vaccinationPhipps, James.Jenner's first vaccinationPicton, Mr. J. A. (see Royal Vaccination Commissioners) .Piffard, Dr.Case of leprosy following vaccinationPAGE28332329214337, 338Pitt, William .Condition of the poor in 1796 78Plague.Compared with small - pox 31 , 32Immunity of attendants 233Playfair , Lord.Statistics of small -pox in the Franco- Prussian War 237Plomesgate.Vaccinal injuries ( 1878 ) 351Plymouth.Park- space and death - rates from zymotic diseases ( 1870-79 ) 62Pock -marked faces.Pontypridd.Portsmouth .Prevalence in seventeenth and eighteenth centuriesDisappearance avowed by Vaccine Board ( 1821 , 1825 )Frequency deplored by Lancet ( 1872 )Cause of diminished prevalence since 1872Small- pox in 1871-72Park - space and death - rates from zymotic diseases ( 1870-79 )Pourquier , Dr.Epidemic of impetigo contagiosa following vaccinationPractitioner, The.Heifer vaccinationPreston.Severe and fatal small -pox after vaccinationPreston , Staff- Surgeon T. J.Small-pox after re -vaccination on H.M.S. " Audacious "Prince , Dr. M.Results of animal lymphPrisons.Insanitary condition , eighteenth centuryProtze, Dr.Fpidemic of impetigo contagiosa following vaccination5555,565639164, 94, 9562292368123, 12422337573-75292INDEX .Provincial Medical and Surgical Association .Vaccination failures ( 1840)Prurigo following vaccinationPublic Health Act ( 1875 ) , referred toRADCLIFFE, MR. NETTEN.Erysipelas after vaccination at Gainsborough ( 1876)Railway Travelling.Risk compared with that of vaccinationRake, Dr. Beavan.Results of vaccination of lepersRansome, Dr. Arthur.Action ofglycerine on the growth of the tubercle bacillusRaymond, Dr. J. H.Fatal case of small-pox after re-vaccination441PAGE154, 15529254348, 363365328358216136-141277, 278Redhead, Mr. M.Cases of small - pox after vaccinationReece , Dr. Richard .Injurious results of vaccinationRegistrar-General.Classifies small - pox deaths(Vaccinated) 199(Unvaccinated ) 199(No statement) 199Investigates " no statement" deaths from small -pox ( 1871-72) 199, 200Small - pox at Mold ( 1871-72) 93Most of the chicken -pox deaths are very probably " small -pox6645Influence of sanitary measures on small-pox 253Effect of sanitary reform on child mortality 75Causes of decline of fever 41, 42Deaths from vaccination, England and Wales ( 1859-96)Registrars (Metropolitan) .Influence of sanitary measures on small - pox ( 1843 )Re -vaccination.Personal experiences of failureExperience of the Metropolitan Asylums BoardIn the navyIn the armyFatal small -pox after, at Berlin ( 1870-72 )In the German armyRhazes.On varieties of small -poxRice, Dr.Results of animal lymph346, 362247-254214, 215216-221 , 223223, 224224-231231234-236186373Richardson, Sir B. W.On sanitation 259, 26029442 INDEX .Ricketts , Dr.On the obscuring of vaccination scars by eruptionOn vaccination scars wearing outFallacy of classifying small- pox cases by marksPAGE195, 196195195Ricord, Prof.On vaccino - syphilis 293Rigden, Mr.On small -pox being confined to the lower classes245Rijo, Dr. R. G.Case of tetanus after vaccination360Rilliet , Dr.Vaccination and tubercle354,355Ring, Mr. John.Cases of small - pox after vaccination 115-118His prevarications 158Case of " confluent " chicken- pox 159Robinson , Dr.Severe and fatal small -pox after vaccination at Preston123, 124Ross, Mr.Skin eruptions attending vaccination 287 , 288Ross, Dr. George.Case of tetanus after vaccination359Royal College of Physicians .Sanction small -pox inoculation IICondemn " spurious cow-pox " theoryReport favourably on vaccination ( 1807 ) -29123On vaccination and leprosy ( 1867 ) -339Royal College of Surgeons .On vaccinal injuries ( 1807 ) 276, 277Royal Commission on Vaccination. (Cases reported in Appendix ix. )Cases of convulsions after vaccination274Disgraceful case of vaccination of newly-born premature infant 283Cases of vaccine généralisée285Cases of eczema following vaccination 291Cases of impetigo contagiosa following vaccination 292Cases similar to Leeds case316Cases of vaccinal erysipelas351Case of lupus following vaccination359Case of tetanus after vaccinationInjuries and fatalities from glycerinated lymphRoyal Society.CautionJennerRoyal Vaccination Commissioners (Majority of).360, 361383106On Woodville's casesCriticise variolous test18:24INDEX . 443Royal Vaccination Commissioners ( Majority of) .On age- incidence of small -poxJurin's statisticsSmall -pox and sanitationRecent decline of small-pox in the MetropolisOn vaccine lymph containing organismsInjurious results of vaccinationVaccination of infantsSkin affections following vaccinationOn blood being omnipresent in vaccine lymphLeeds caseRelationship of cow-pox to syphilis -PAGE50-53, 392-396183241-244244270271 , 272284286, 287307314316Vaccination and scrofula 354Vaccino-syphilis cases more numerous than recordedCompare risk of vaccination with that of railway travellingCalf lymph363365366, 378Glycerinated lymph 380Recommendations with regard to conscientious nonconformists 385Royal Vaccination Commissioners ( Dr. Collins and Mr. Picton) .Pedigree of Woodville's lymph 19Reject Woodville's cases " as furnishing false evidence, andvalueless as a scientific experiment " 22Age- incidence of small-pox in the unvaccinated 46Small -pox age- incidence, Scotland ( 1871 ) 76Gloucester small-pox epidemic-causes of extension 97-99Small -pox fatality, Metropolitan Asylums Board ( 1870-94) 183On methods of classifying small- pox cases by vaccination marks 202Immunity to small-pox in improved dwellings - 247Vaccinal erysipelas (cases and deaths ) 350, 351Statistics of risk of vaccination, and of railway travelling 365Rühle, Dr.Vaccination and scrofula 356Rügen, Isle of.Epidemic of vaccinal impetigo ( 1885 ) 291 , 292 , 380Russell , Dr. James B.192197On the obscuring of vaccination scars by eruptionSmall -pox fatality at Glasgow ( 1871-72 )SALFORD .Park - space and death -rates from zymotic diseases ( 1870-79 )Sanitation .Influences small -pox ( see Small -pox) .Neglect of, in 17th, 18th , and early in 19th centuriesInfluences age- incidence of disease6267-75, 400Savill, Dr.On vaccination scars wearing out75, 76 , 396 , 398 , 399193Texture of vaccination scars 201 , 202444 INDEX.Savill, Dr.On the obscuring of vaccination scars by eruptionWarrington small -pox ( 1892-93) limited to smaller housesScarlet fever .Decline since 1861-65Schaefer , Prof.On vaccinal injury being greater than recordedScotland .Small-pox age - incidence ( 1871 )Scott, Dr. Anna.On the spreading of leprosy by vaccinationScrofula.And vaccinationSeaton, Dr. E. C.PAGE200246, 24740, 4136476345280, 305, 354-358Vaccination at Mold prior to 1871-72 small-pox epidemicVaccination at Swansea prior to 1871-72 small-pox epidemicSimilarity of vaccination sore to syphilis -Shaftesbury, Lord.9394310, 311On small -pox being chiefly confined to the lowest classImproved lodging-houses might exterminate small -pox245245Sheffield.Park- space and death- rates from zymotic diseases ( 1870-79 ) 62Small- pox in 1887-88 (see Small- pox) .Small-pox after recent vaccination ( 1887-88) 171-173Small -pox after re-vaccination ( 1887-88 ) - 221 , 222"Census" 176, 177Shipman , Dr. N. S.Animal lymph 372Shorter, Mr. John .Effect of inoculation after vaccination 14, 15Short Heath.Small - pox in 1894 92Simon, Sir John.Oncomplete immunity of the vaccinated to small - pox 164, 214Assertions respecting safety of vaccination 268If lymph be not guaranteed pure, vaccination should be optional 268Sims , Dr. John.Case of small- pox after natural cow-pox 108, 109Remarks on the " loathsomeness " of cow- pox 109Skin diseases.And vaccination 285-292And calf lymph 366-370, 372-378INDEX . 445Small-pox ( Variola) .Adisease of the poorAdisease of towns -Blindness fromDisfigurement fromDisplacement of (by measles, etc. )Identity with cow- pox repudiatedInoculation (see Inoculation).In the Franco- Prussian WarPAGE245-247 , 249, 250, 2576126655, 56, 39184, 85, 39630, 30980-83 , 237-240In the German army 234-236Treatment of - 186, 187 , 260-266, 391Age- incidence.In seventeenth century 42,54In eighteenth century 43,54Since 1837-38 44In local epidemics 51-53, 392-396Compared with that of other diseasesCauses of extension .InsanitationAnd vaccination 45, 46, 50-54, 125-129, 151 , 152 , 154, 155 , 392-396Influence of sanitary measures onInoculation (small -pox )Density of population on area and in dwellingsConımercial depression and high prices of wheat46-50, 39676, 396, 39858-61 , 86 , 39065-77, 241-260, 399-40161-65, 248-250, 25277-79War 79-8357, 58, 60, 390Decline.Prior to introduction of vaccinationFrom thence to the 1871-72 epidemicDuring recent yearsEpidemics.Aynho ( 1723-24)Bavaria ( 1871 )Berlin ( 1870-72 )Birkenhead ( 1877 ) -Birmingham ( 1891-94)Bromley ( 1881 )Cairo(1885)35 , 40, 41 , 5335, 36, 40, 41 , 54 , 244, 39143, 44, 181 , 409175, 176175, 198 , 23124692, 175, 178, 185175226-231Cairo ( 1888-89)Chester ( 1774)Cologne ( 1871-73 ) -Dewsbury ( 1891-92)England and Wales ( 1817-19)England and Wales ( 1837-38) -225, 22643, 97, 182 , 18317552, 213, 247,39379, 161 , 17938, 44, 61 , 79, 151 , 152England and Wales ( 1870-72 )31, 32, 34, 35, 41, 52, 54, 63, 83, 94-96, 199, 213, 246, 391-393England and Wales ( 1892-95): :Glasgow ( 1871-72) -199, 201197446INDEX.Small -pox ( Variola).Epidemics.Gloucester ( 1895-96)Keighley ( 1893 ):PAGE51-53, 96-102, 185, 263, 389, 391-39553, 91 , 97 , 225, 390, 392, 393Leicester ( 1892-94) 51-53, 88, 90, 91 , 94, 97-99, 171, 225, 226,London ( 1634 , 1685, 1710, 1714 , 1719 , 1757, 1796 )231 , 244, 390-395, 402, 41132, 77, 78London ( 1817-19) 79, 142-145London ( 1837-38 ) 38, 247-253London ( 1870-72 ) 32, 35, 36, 174, 185, 199 , 255 , 256London ( 1892-93) 36 , 52, 196 , 197 , 394Mold ( 1871-72) 53 , 93 , 94 , 104, 392Montreal ( 1885 ) 102, 103Norwich ( 1819) 245, 264, 265Scotland ( 1871 ) 76Sheffield ( 1887-88) - 52 , 92 , 171-173 , 175-177 , 185 , 206 , 207 , 211 ,221 , 222, 393,394Short Heath ( 1894) 92Sunderland ( 1884) -175Swansea ( 1871-72 ) - - 64,94Warrington ( 1773) - 43Warrington ( 1892-93) 52 , 92 , 175,394,395Willenhall ( 1894)53, 92, 93, 175 , 211 , 389, 393Witford, Hertfordshire ( 1810) - 128, 129Fatality.Pre-Jennerian 180-183, 186-189, 391, 408, 409Post-Jennerian 183, 184Statistics of, in the unvaccinated 185 , 197, 198 , 204, 205In the vaccinated 128 , 129, 173 , 174 , 179 , 180, 196-198, 203-205In the re- vaccinated231Influence of sanitation and treatment on 97-102 , 241-266, 391Immunity.Not in proportion to proximity of vaccination 141 , 151 , 152 , 154, 155In the unvaccinated 166-171 , 232 , 233Of hospital attendants 231-233In improved dwellings 247Prevention.By separation of the sick from the healthy 402Sanitary in provements 245, 247 , 251 , 254 , 256-260, 401 , 402Provision of open spaces in towns 61-65, 251, 402Sir Edwin Chadwick on -257, 258Dr. Southwood Smith on254At Berlin since 1872259Leicester's system 88-91Varieties .DiscreteConfluentMalignantCorymbose186-190, 260-262191-197, 260-262190, 191191INDEX. 447PAGESmall-pox after natural cow-pox - 27, 106-111Small - pox after re-vaccination 214-231Small - pox after vaccination (see Vaccination ).Small-pox by inoculation after vaccination 112 , 121 , 141Smith, Dr. Southwood.Immunity to small - pox in improved dwellings 247Prevention of epidemics - 254Southampton.Small -pox in 1871-72 95, 96South Shields.64, 94, 95281Small -pox in 1871-72Sparling, Dr.Injurious results of vaccinationSpurious cow-poxStevenson , Mr. John .Cases of small-pox by inoculation after vaccinationStockton.Small-pox in 1871-72Stoke Newington.Vaccinal injuries ( 1871 )Sudbury.Fatal vaccinal erysipelas ( 1883 )26-29, 108-111 , 11411264350351Sunderland.Small -pox in 1871-7264, 94, 95Small -pox in 1884 - 175Park- space and death- rates from zymotic diseases ( 1870-79 )62Sutton, Daniel ( inoculator) IISwansea .Small -pox in 1871-7264,94Sweeting , Dr.Hismethod of classifying small -pox cases by vaccination marks202Sydenham, Dr. Thomas.Fever epidemic ( 1685-86) 37Varieties and treatment of small -pox 186, 187 , 260-262Syphilis.And vaccinationNot always easy to detect in vacciniferAnalogy with cow- pox293-324307, 308309-319TAYLOR, DR. FREDERICK .Case similar to Leeds case 318, 319Tebb, Mr. William ." The Recrudescence of Leprosy," referred to 325448 INDEX.Tetanus.And vaccinationInfantile mortality at Calcutta ( 1881-90) -PAGE359-361361Thin, Dr. George.Eczema after vaccination290Thomson, Dr. John.Vaccination failures ( 1817-19) - 147Disparaging remarks on Jenner's discovery 147Thorne, Sir Richard.On calf lymph and tuberculosis 358Thornton, Mr.Variolous test failures 15, 16Thursfield , Dr. W. N.Immunity to small- pox in the unvaccinated 169, 170Tillmanns, Dr.Incubation period of erysipelas 353Timoni , Dr.Letter on inoculation 10Toms, Dr. S. W. S.Case of tetanus following vaccinationToussaint.His experiments , referred toTradition of the dairymaidsTriple vaccination.Failure to protect from small-poxTrobridge, Mr. Arthur.Small-pox in the German armyTubercle.And vaccinationGrowth in culture media favoured by glycerine3613579,403215, 216, 223234, 236354-359358, 384Turkey.Small -pox inoculation 10Typhoid fever.Age- incidence 49Typhus fever.Decline of37-41 , 53,391Causes of decline 40-42, 257 , 258, 400Epidemics ( 1685-86, 1741 , 1837-38, 1847 ) 37-39Epidemics and high prices of wheat 77-79Age-incidence 47-49Immunity in improved dwellings 247UNDERWOOD, DR. MICHAEL.Immunity to small -pox in the unvaccinated 167, 168INDEX. 449Unna , Dr. P. G. PAGECow-pox and erysipelas - 347Unvaccinated.Whether a danger to the community 164, 178Immunity to small-pox 166-171 , 232 , 233Alleged high fatality among 185Drawn from the lower strata of society 197, 25 7Urticaria .Complicating vaccinationVACCINAL ERYSIPELAS.Cases of290, 375And cow-poxVaccination.Jenner first interested in -346-351346, 3479Early experiences of 15, 16Critical position at end of 1798 16Rescued from oblivion by Woodville 17Accepted by profession 18Jenner's assertions respecting permanent value of 105, 164, 214, 267Opinion of some of Jenner's contemporaries 106-109Reports of failures begin to multiply ( 1804) 113Mr. Goldson on ( 1804) 114Investigation demanded by Medical and Chirurgical Review 118 , 119Failures become numerous ( 1806) 122Report of Royal College of Physicians ( 1807) 123Before Parliament 122, 123Established and endowed ( 1807 ) 123Almost abandoned at Preston on account of failures - 123, 124Failures at Cambridge reported by Sir Isaac Pennington ( 1808) 124Opposed by men of education and influence ( 1808) 124, 125Vaccination and Jenner " again to be put upon their trial " ( 1809) 125Criticised by Mr. Thomas Brown ( 1809) - 127, 128Failures at Witford ( 1810) 128, 129Insinuations by Dr. George Pearson ( 1812) 132Criticised by Lord Ellenborough ( 1813 ) 132, 133Failures reported by Mr. M. Redhead ( 1817 ) 135-141Mr. Thomas Harrison's confidence somewhat shaken 141Falls into disrepute at Frampton ( 1817) 142Medical Repository on " alarming " number of failures ( 1817 ) 142Clamour about failures ( 1818 ) 143Hesitation of respectable persons ( 1818) 143Reluctant admissions of National Vaccine Establishment 143-145 , 147Dr. Macleod loses faith ( 1820) 144, 145"Mortifying fallibility of medical opinions " 145Prejudices " not altogether unreasonable"Extensive failures ( 1817-19)147Pretensions " rather too unreservedly " admitted 147147450 INDEX.Vaccination . PAGEDisparaging remarks by Dr. John Thomson ( 1822) - 147Criticised by Edinburgh Review ( 1822) 148Failures on H.M.S. " Phaeton " ( 1825) 149At London Small -pox Hospital(1825) 149, 150Mr. Edward Greenhow on ( 1833 ) 151Reviewer in British Annals ofMedicine ( 1837)(1037)152Earlier anticipations not realised( Sir Henry Holland, 1839 ) 152Dr. George Gregory on ( 1823-52 ) 152-154Lancet on " numerous and discouraging " failures ( 1853 ) 155Made compulsory ( 1853) 162, 163Lord Lyttelton on 163, 164Criticised by Dr. James Copland ( 1858) 165, 166" A very fleeting protection, indeed " ( Dr. William Gayton) 164Lord Herschell on - 396-399Failures in various towns, etc. , since 1852 175Assertions respecting safety 267 , 268 , 270Ofinfants 281-284Risk compared with that of railway travelling 365, 366Injurious results from 267-384Injury greater than recorded 362-366Vaccination Acts 33, 34, 412-415Vaccination Registers 201Vaccination scars .Wear out 192, 193 , 195Obscured by eruption in confluent small -pox 192 , 194-196, 200201201 , 202VarietiesTexture -" Good " and " bad "As a measure of protectionVaccine lymph.Always contains bloodVaccine Pock Institution .Cases of small - pox after vaccinationVaccino- syphilisTables of alleged casesVachell , Dr. C. T.Cases of vaccinal erysipelas ( 1883 )Vacher , Mr. Francis .Method of classifying cases of small -pox202-205201-213307113 , 119 , 120293-324296-298, 306349193On small-pox being confined to the labouring and artisan classes 246Variola ( see Small-pox).Variola Vaccina .Misleading appellation of cow- poxVariolation ( see Inoculation ).30, 308, 309INDEX 451Variolous Test.Applied by Jenner -AppliedbyWoodvilleCriticised by Royal CommissionPAGE13-1517-2524,25Victoria, Select Committee of Legislative AssemblyOnvaccination 280, 281WAGSTAFFE, DR. WILLIAM.Effects ofsmall-pox inoculation58Varieties of small-pox 187, 188Wainwright, Mr. Thomas.Skindiseases attending vaccination 287Walker, Dr. George B.Animal lymph 372Wallace, Dr. T. C.Case of small-pox after triple vaccination 215Walsall .Small-pox-in 1871-72 95War.Effect on small- pox mortality 79-83Ward, Mr. E.Case of vaccino -syphilis 305Warlomont, Dr.Assertion respecting safety of vaccination 267Warrington.Small -pox in 1773 - 43Small-pox in 1892-93Small-pox epidemic ( 1892-93) limited to the smaller housesVaccinal erysipelas ( 1871 )Watson, Dr. Heron.On blood being omnipresent in vaccine lymphWatson, Dr. R. S.Experiences in the Franco- Prussian WarWatson, Sir Thomas.Fever epidemic ( 1838)Oncases of small-pox being ascribed to chicken-poxVaccino-syphilisWatt, Dr. Robert.Decline of small-pox-it's place taken by measles ( 1783-1812 ) - 84, 85Watts, Dr. Giles (inoculator ) - 1252, 92, 175, 394,39524635030780-8239155386, 387Wells, Mr. J. W.Fatal case of erysipelas after vaccination -Wells, Sir Spencer.Infantile mortality from tetanus at Calcutta ( 1881-90)348361Wheat.High prices and small -pox mortality 77-79452 INDEX.Wheeler, Mr. Alexander .Effects of war on small -pox mortalityFatality of malignant small- pox in vaccinated and unvaccinatedOn statistics of small -pox in the Franco- Prussian WarWhite, Dr. Andrew.Small -pox and vaccination at Montreal ( 1885 )Whitehaven.Small -pox in 1871-72Whitehead, Dr. James.Cases of vaccino-syphilisWillan, Dr. Robert .Insanitary condition of London ( 1800)Effects of window - taxInjurious results of vaccinationWillenhall.Small- pox in 1894Willis , Dr. Thomas.Small -pox in the seventeenth centuryWilson , Sir Erasmus .Cases of leprosy following vaccinationWindley, Alderman.On Leicester system of small - pox preventionWindow- tax -Winterbottom, Mr. T. M.PAGE80190238102- 95, 96299-30170-7371276, 287, 36953, 92, 93, 175, 211 , 389, 39342338, 3398965-67 , 71 , 74, 400116, 11762345369Confluent and fatal small-pox after vaccination ( 1805 )Wolverhampton.Park - space and death- rates from zymotic diseases ( 1870-79 )Wood, Dr. C. В.On the spreading of leprosy by vaccinationWood, Dr. Thomas F.Animal lymphWoodforde, Dr. James.Case of small -pox after natural cow- pox IIIWoodville, Dr. William .Receives news of cow- pox outbreak, Gray's Inn Lane ( 1799)Experiments at London Small-pox Hospital1717Three-fifths of " vaccinated " cases had variolous pustules on body 18Dr. Collins' and Mr. Picton's pedigree of his lymph 19His lymph contaminated with small -pox - 21, 389His lymph away from the Small -pox Hospital - 21, 22His variolous tests on the " vaccinated" convince profession - 18, 22Dr. Collins and Mr. Picton on the value of his experiments 22His lymph ultimately assumes the nature of vaccine61World's vaccine , i.e. , Woodville's lymph 22wwwThis book is a preservation photocopy.It is made in compliance with copyright lawand produced on acid- free archival60# book weight paperwhich meets the requirements ofANSI/NISO Z39.48-1992 (permanence ofpaper)Preservation photocopying and bindingbyAcme BookbindingCharlestown, Massachusetts2001
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ACADEMIAEVEHARVARDIANAESIGILLVMCHRISTINNOVVANCSLARHarvard College LibraryFROMPresident CharlesW. ElectERRATΑ .Page 58, foot -note-For " deducted " read deduced.Page 70, line 14-For " actue " read acute.Page 80, line 2-After word " populations " insert foot -note indicator.Page 138 , opposite No. 22-Delete figure " 7. "Page 160, second foot-note-For " 1882 " read 1822.Page 168, last line-For " p. 394 " read p. 364.Page 174, top of table-For " vaccination " read vaccinated.Page 183, line 20-For " 1874 " read 1894.Page 233, line 4-For " 1802 " read 1892.Page 245, line 4-For " stratas " read strata.Page 267, first foot-note-For " Worlomont " read Warlomont.Page 296, first item oftable-For " Undine " read Udine.Page 326, first foot- note , line 5-For " p. 187 " read p. 178.
A CENTURY OF VACCINATION .
A CENTURY OF VACCINATIONAND WHAT IT TEACHES.BYW. SCOTT TEBB, M.A. , M.D. (Cantab. ) , D.P.H.SECOND EDITION.LONDON :SWAN SONNENSCHEIN & CO . , LIM .1899.Med 1858.98.2HAY NISBET AND COMPANY LIMITED ,PRINTERS,GLASGOW AND LONDON .HARVARCOLLEGELIBRARTO MY FATHER,WILLIAM TEBB ,THIS BOOKIS AFFECTIONATELY DEDICATED .
PREFA СЕ .So long as the practice of vaccination remains establishedand enforced by law, it will be the duty of everycitizen, who is also the father of a family, to form ajudgment upon it ; unless, indeed, it is to be held thatthe infallibility of the legislature and of the medicalprofession, which in this instance directed legislation ,is so well assured that enquiry is superfluous, if notculpable. But it is a sounder doctrine that the existenceof the law does not relieve parents of responsibilitytowards their children, and more especially parents(nowadays the majority) who have heard that theefficacy of this operation has been called in question bycompetent men, while its risks, so long denied, are nowon all hands admitted. I am, therefore, not withouthopes that among my readers will be included a fairnumber of the " general public" interested in the subjectby the pressure of compulsion, and anxious before theysubmit a child to vaccination to feel assured that theyare doing the right thing, being also resolved to withholdthe child from the operation if they cannot besatisfied of this.But I here address myself more particularly to twoclasses-to my medical brethren, and to those whosePREFACE.business it is to legislate for the country on this subject.On the former, I desire, with all respect, to urge thefollowing considerations :-Can itbe said that the Jennerian doctrine ofvaccinationhas ever been placed on a truly scientific basis?I specify the "Jennerian doctrine," for there are otheraspects of the vaccination or inoculation theory whichI expressly rule out of my enquiry. It is a generallyreceived opinion that in the case of certain diseases oneattack affords some degree of immunity against asecond. It is certain that there are exceptions to therule, and it is further certain that the rule has neverbeen scientifically established as such . Nevertheless, itis a generally accepted belief, with evidence in itsfavour, and in the pages that follow I do not reject oreven attack that belief. Further, it is a postulate of themodern inoculation doctrine that a mild or modifiedattack suffices to secure this immunity. Whether thisbe so or not, I cannot tell. It is a matter into which Ihave not been led to enquire, and I am willing to grantit for the sake of argument, since it does not really concernthe position which I am calling in question. WhatI do deny, as the result of my enquiries, is that anattack of cow- pox secures immunity against small-pox .To use technical terms in order to make the distinctionclear : while I may allow within limits the truth ofhomoprophylaxy or homoeoprophylaxy, I am satisfiedthat there has never been shown any sort of scientificbasis for heteroprophlaxy. If the reply be made that,granting it is wrong to teach that vaccination is homoprophylactic,it is fair to claim for it that it is homoeoprophylactic,I should deny that such a claim can bePREFACE .sustained ; and, though I am, of course, aware thatvariolous matter can be so modified by being taken atan early stage and passed once or twice through thecalf as to produce, when inoculated, not an attack ofsmall-pox, but local effects similar in appearance tothose of vaccination, yet that is not what is doneevery day by medical men who vaccinate. What theyare doing they really do not know, nor does any oneknow, for the ultimate origin of the vaccine lymph incommon use has long ago been lost sight of ; but if itbe true that that ultimate origin is cow-pox, if, that isto say, when we vaccinate we are carrying out theteaching of Jenner, then, certainly, we are acting as ifheteroprophylaxy had been established scientifically ;for the investigations of Dr. Creighton and ProfessorCrookshank have proved conclusively that cow-pox isa disease radically different from that against which itis said to protect. Effects similar to those of vaccinationcan be produced in a variety of ways, and,therefore, to produce them as Dr. Klein and othersclaim to have done, by means of small -pox virus , attenuatedor in other ways concocted , does not identify thedisease on which Jenner relied for protection with thedisease against which he claimed that it protected, anymore than does the production of a vaccine vesicle fromcattle- plague identify vaccination with that disease.Many of my brethren, while willing to acknowledgethat there is no true pathological relation betweenCOW pox and small - pox, fall back on the allegedevidence of statistics, and claim to find in them ascientific vindication of vaccination. The majority ofthe Royal Commissioners took this view, and ratherPREFACE .deprecated the idea that any other scientific vindicationwas necessary . To the questioning of theposition that trustworthy statistics do provide sucha vindication my pages are partly devoted. I donot deny that the " century of vaccination " synchronisesroughly with a century in which small -pox (in Europe,at any rate) has largely declined. But this coincidenceby no means involves any connection in theway of cause and effect. Small-pox, like typhus, hasbeen dying out since 1780. Vaccination in this countryhas fallen largely into disuse since people began torealise how its value was discredited by the great smallpoxepidemic of 1871-72 . So that, while small-pox hasdeclined during the last one hundred and twenty years ,twenty years may be cut off from each end of thisperiod, as contributing no evidence whatever of thedecline being due to vaccination, and as involving theconclusion that some other causes have been at workto promote this result. I am, of course, only speakingapproximately. To the evidence afforded by detailedcases criticism of another kind is applicable, and to thisI will presently refer. But, first, in passing, I would callattention to the ease with which an alleged protectiveoperation can acquire a great reputation as successful,more especially if its adoption should coincide with adecline from other causes of the disease against which itis supposed to protect. A local epidemic of small-poxis seldom so severe as to attack more than 5 per cent .of the population. If, therefore, a small minority hasadopted some alleged prophylactic, it is very unlikelythat the disease will count among its victims any considerableproportion of those who are thus fortified,PREFACE .particularly as they would be likely to be more thanordinarily careful in matters relating to health. Inthis way their prophylactic will acquire a great reputation,and the vastly greater number who have equallyescaped without having recourse to the protectiveoperation will be overlooked. This is what happens inpretty nearly every epidemic in regard to re- vaccinationand the security it is alleged to provide. In the caseof primary vaccination other but not less misleadinginferences are drawn. Should there be an epidemic ofsmall -pox in a locality where 85 per cent. of the populationare vaccinated, it is obvious that the 95 per cent.of the population who escape the epidemic (assuming, asbefore indicated, a maximum of 5 per cent. attacked byit) will largely coincide with the 85 per cent. vaccinated ;and vaccination thus gains credit. But it will be objected,if the 5 per cent. attacked coincide, in however small adegree, with the 15 per cent. unvaccinated, this is strongtestimony to the risk of being unvaccinated ; and so, nodoubt, it would be, but for the fact that in localitieswhere the vaccination law is vigorously carried out,the unvaccinated , as a class, will be found to consistlargely of the outcasts of society, nomads whom the lawhas failed to reach, and of weakly children who onaccount of their health have been excused the operation .This class, therefore, is likely to furnish a disproportionatenumber of the victims of the epidemic ; andthus again the prophylactic acquires reputation. Addto this the facts, often overlooked , that medical men,even if officials and highly placed, are still liable as mento err, and that their errors will probably accord withtheir cherished beliefs, and it will readily be understoodPREFACE.thatthe evidence ofdetailed cases-which is really theonly evidence on which the credit of vaccination dependscannot be accepted wholesale as if it werenot open to question. A vaccinated patient with novisible signs of vaccination is likely to be described asunvaccinated ifhis case is severe, and especially ifdeathensues; while if the marks are not plainly visible, theexplanation of"not properly performed " is an obviousone; and the patient will be included as " belonging tothe unvaccinated or imperfectly vaccinated class " inthe list of cases, and, tout court, as " unvaccinated " orhaving no marks" in the official summary. I think itwould be advisable for my medical brethren to acceptasauthentic only published and tested cases, or such ashave come under their own personal observation.To those who are about to legislate for the countryonthis vexed question I also address myself particularly.The Queen, in her Speech at the opening of the presentSession of Parliament, called for " earnest consideration "of the subject. Hitherto vaccination bills have beenpassed into law without adequate discussion or debate.Parliament has been assured (incorrectly) that there iscomplete unanimity in the medical profession concerningthe nature, value, necessity, and safety of vaccination ;and that has sufficed. Lords and Commons have atonce bowed before this alleged unanimity, with theresult, as vaccinists claim, but cannot possibly prove ,that small-pox has been practically stamped out, butundoubtedly also with the result that hundreds ofinfants have died from the effects of the operation,that thousands of otherwise blameless citizens have beenfined or imprisoned for their very natural and properPREFACE .Iresistance to this extraordinary law, and hundredsof thousands of pounds of public money have beenspent on what I am satisfied is nothing but a uselessand mischievous fallacy. It is strange that membersof Parliament do not perceive that the strength of thepro- vaccinist party lies in the public endowment of thepractice. Right through the century there has existeda body of officials , ostensibly paid to promote thepractice of vaccination, but also, partly at least, paidto vindicate it theoretically, and to explain away itsfailures and its accompanying disasters. But for thisState aid, vaccination would long ago have been consignedto the same limbo as has received a thousandother similar fads which, fortunately for the public,have not secured official recognition and support.hardly expect that legislators will have time to readthe numerous cases I adduce-some showing thatimmunity from small -pox exists without vaccination ,others that mild attacks of small- pox were recordedlong before there was any alleged mitigating powerin vaccination to which to ascribe them, and, again ,others proving that neither vaccination nor re- vaccinationnor recent vaccination can be depended upon toprotect from small -pox or even from death from thatdisease. But to the cases of injury and death resultingfrom vaccination I trust they will not refuse to givesome attention . This evidence should be enough todetermine any fair- minded enquirer that the enforcementof vaccination by law is indefensible. Take away firstthe compulsory law, and then take away (if vestedinterest is not too strong for you) the endowment ofthe practice, and when this has been effected, medicalPREFACE .men will find themselves for the first time since 1803 .free to discuss the vaccination question as a scientificone on its own merits. To what result that unfettereddiscussion will lead I have myself (now that I havestudied the matter carefully for some years) no sortof doubt.In conclusion, I desire to express my obligationsfor the valuable assistance of Mr. A. W. Hutton, whoseletters on " The Vaccination Question," addressed toMr. Asquith and Mr. Balfour in 1894 and 1895, I canrecommend as an introduction to the rational study ofthis vexed problem .April, 1898.PREFACE TO THE SECOND EDITION .THE interval that has elapsed between the first andsecond editions of this book has witnessed a considerablestrengthening of the position of those whodissent from the popular belief in the value ofvaccination . It is true that the debates in Parliamentshowed how very far the general public is yetfrom a just appreciation of the present position ofthis controversy . So far as I noticed, apart from thevery few newspapers that definitely supported the antivaccinistcause, only one-the Westminster Gazetteadmittedthat there is a real weakness on the other side,viz. , the fact that there exists among medical men themPREFACE.selves a doubt, and a growing doubt, whether vaccinationis, after all, what it professes to be. But it canhardly be questioned that a recognition of this doubtand of its grave significance also underlay the excellentspeeches of Mr. Balfour and of Lord Salisbury, to whomthe passing of the measure into law was largely due.Reasons of expediency had, of course, to be urged insupport of such a measure of relief; but these wouldhardly have sufficed, apart from the weightier considerationthat it is unjustifiable to enforce under penalties amedical doctrine concerning which doctors themselvesdisagree. There is no reason to suppose that either Mr.Balfour or Lord Salisbury has any special knowledge ofthe subject, or has abandoned the current belief concerningit ; but as statesmen, and as thinkers, they couldnot fail to recognise the limits beyond which matters ofopinion cannot be enforced.When the Act itself is administered in the spirit inwhich it is framed it will afford a much- needed relief,and may even do something to retard the progress ofthe movement for the disestablishment and disendowmentof vaccination. But the unfortunate andindefensible provision about " satisfying " two justicespermits men on the bench, who are often, it appears,fanatical believers in vaccination, to use the Act as aweapon of terror against timid conscientious objectors .They actually have the assurance to inform claimantsfor exemption, with all the authority that comeswith a declaration ex cathedra, that if the child inquestion is not vaccinated it will certainly take smallpox,whereas, if it is vaccinated, it will as certainlyescape. No medical man could or would speak thusPREFACE.positively. If this misuse of the new law becomesgeneral, it will shortly be as unworkable as the oldone was ; but it is to be hoped that this deplorablemaladministration will only be temporary.That the movement against vaccination will spreadand will ultimately triumph everywhere is certain. Thealleged unanimity of the medical profession on thesubject-the argument on which pro-vaccinists mostlyrely-is far more apparent than real. That a majorityof medical men would, if polled at this moment, passa vote of confidence in vaccination is probably true .But votes need to be weighed as well as counted ; andI am satisfied that, if the poll were confined to thosepractitioners who have studied the subject, and havehonestly endeavoured to form an independent judgmenton the evidence, the majority would be the other way.Even now very few care to defend the practice openly.And it must be remembered that it has never been theway of the medical profession, as a body, to confess todoubts as to the value of any established medicalpractice. They will allow such practices gradually tofall into desuetude when they no longer commandconfidence ; and this is especially the case when othermethods of treatment can acceptably be substituted ;but a positive declaration against any doubtful practiceis not to be looked for.Nothing would more quickly undeceive the publicthan the rapid and complete abandonment of thepractice of vaccination in rural districts. Small -pox ismainly an urban disease ; and on this point the statisticsare so clear that the firmest believers in the protectivepower of vaccination must admit that in rural districtsPREFACE.it is unnecessary ; but, while townspeople can combineto free themselves from the pressure of the law, countryfolk cannot. Local epidemics will still occur in townswhere the sanitary conditions are defective ; and if, in asingle instance, the town happens to be unvaccinatedas well as insanitary, an epidemic there will render allother evidence nugatory, and throw back the movementperhaps for years. Nevertheless, in spite of such drawbacks,a practice that has been so thoroughly discreditedby competent men on scientific grounds must sooner orlater be consigned to the limbo of discarded superstitions.That the practice has been definitely discredited onscientific grounds is not open to serious question.The investigations of Dr. Creighton and ProfessorCrookshank have been very generally ignored by themedical profession ; but it is true that some effortshave been made to rehabilitate vaccination by bacteriologists, who assert that they have discovered " thespecific organism on which vaccinia depends. " Theirmain object is, of course, to reassure the public inregard to the now admitted risks of vaccination ashitherto practised. We are to have " pure cultures, " towhich it is supposed no one will take any objection.But surely the public will demand something positiveas a scientific demonstration that vaccine really has aprophylactic power against variola, and will not besatisfied with the mere assurance that now at last itwill do no harm. It is not long since it was announcedin the papers that Dr. Klein had identified the vaccinewith the variolous bacillus, but who now believes thathe did ? A later claim, not indeed to have made thisidentification of the bacilli of the two diseases, but to1PREFACE.business it is to legislate for the country on this subject.On the former, I desire, with all respect, to urge thefollowing considerations :-Can it be said that the Jennerian doctrine of vaccinationhas ever been placed on a truly scientific basis ?I specify the " Jennerian doctrine," for there are otheraspects of the vaccination or inoculation theory whichI expressly rule out of my enquiry. It is a generallyreceived opinion that in the case of certain diseases oneattack affords some degree of immunity against asecond. It is certain that there are exceptions to therule, and it is further certain that the rule has neverbeen scientifically established as such. Nevertheless, itis a generally accepted belief, with evidence in itsfavour, and in the pages that follow I do not reject oreven attack that belief. Further, it is a postulate of themodern inoculation doctrine that a mild or modifiedattack suffices to secure this immunity. Whether thisbe so or not, I cannot tell. It is a matter into which Ihave not been led to enquire, and I am willing to grantit for the sake of argument, since it does not really concernthe position which I am calling in question. WhatI do deny, as the result of my enquiries, is that anattack of cow- pox secures immunity against small -pox.To use technical terms in order to make the distinctionclear: while I may allow within limits the truth ofhomoprophylaxy or homoeoprophylaxy, I am satisfiedthat there has never been shown any sort of scientificbasis for heteroprophlaxy. If the reply be made that,granting it is wrong to teach that vaccination is homoprophylactic,it is fair to claim for it that it is homoeoprophylactic,I should deny that such a claim can bePREFACE .sustained ; and , though I am, of course, aware thatvariolous matter can be so modified by being taken atan early stage and passed once or twice through thecalf as to produce, when inoculated, not an attack ofsmall -pox, but local effects similar in appearance tothose of vaccination, yet that is not what is doneevery day by medical men who vaccinate. What theyare doing they really do not know, nor does any oneknow, for the ultimate origin of the vaccine lymph incommon use has long ago been lost sight of; but if itbe true that that ultimate origin is cow- pox, if, that isto say, when we vaccinate we are carrying out theteaching of Jenner, then , certainly, we are acting as ifheteroprophylaxy had been established scientifically ;for the investigations of Dr. Creighton and ProfessorCrookshank have proved conclusively that cow -pox isa disease radically different from that against which itis said to protect. Effects similar to those of vaccinationcan be produced in a variety of ways, and,therefore, to produce them as Dr. Klein and othersclaim to have done, by means of small-pox virus, attenuatedor in other ways concocted, does not identify thedisease on which Jenner relied for protection with thedisease against which he claimed that it protected, anymore than does the production of a vaccine vesicle fromcattle-plague identify vaccination with that disease.Many of my brethren, while willing to acknowledgethat there is no true pathological relation betweenCOW pox and small - pox, fall back on the allegedevidence of statistics, and claim to find in them ascientific vindication of vaccination.the Royal Commissioners took thisThe majority ofview, and ratherPREFACE .deprecated the idea that any other scientific vindicationwas necessary. To the questioning of theposition that trustworthy statistics do provide sucha vindication my pages are partly devoted. I donot deny that the " century of vaccination " synchronisesroughly with a century in which small-pox ( in Europe,at any rate) has largely declined. But this coincidenceby no means involves any connection in theway of cause and effect. Small-pox, like typhus, hasbeen dying out since 1780. Vaccination in this countryhas fallen largely into disuse since people began torealise how its value was discredited by the great smallpoxepidemic of 1871-72. So that, while small-pox hasdeclined during the last one hundred and twenty years ,twenty years may be cut off from each end of thisperiod, as contributing no evidence whatever of thedecline being due to vaccination, and as involving theconclusion that some other causes have been at workto promote this result. I am, of course, only speakingapproximately. To the evidence afforded by detailedcases criticism of another kind is applicable, and to thisI will presently refer. But, first, in passing, I would callattention to the ease with which an alleged protectiveoperation can acquire a great reputation as successful,more especially if its adoption should coincide with adecline from other causes of the disease against which itis supposed to protect. A local epidemic of small-poxis seldom so severe as to attack more than 5 per cent.of the population. If, therefore, a small minority hasadopted some alleged prophylactic, it is very unlikelythat the disease will count among its victims any considerableproportion of those who are thus fortified,PREFACE .particularly as they would be likely to be more thanordinarily careful in matters relating to health. Inthis way their prophylactic will acquire a great reputation,and the vastly greater number who have equallyescaped without having recourse to the protectiveoperation will be overlooked. This is what happens inpretty nearly every epidemic in regard to re- vaccinationand the security it is alleged to provide. In the caseof primary vaccination other but not less misleadinginferences are drawn. Should there be an epidemic ofsmall -pox in a locality where 85 per cent. of the populationare vaccinated, it is obvious that the 95 per cent.of the population who escape the epidemic (assuming , asbefore indicated, a maximum of 5 per cent. attacked byit) will largely coincide with the 85 per cent. vaccinated ;and vaccination thus gains credit. But it will be objected,if the 5 per cent. attacked coincide, in however small adegree, with the 15 per cent. unvaccinated, this is strongtestimony to the risk of being unvaccinated ; and so, nodoubt, it would be, but for the fact that in localitieswhere the vaccination law is vigorously carried out,the unvaccinated , as a class, will be found to consistlargely of the outcasts of society, nomads whom the lawhas failed to reach, and of weakly children who onaccount of their health have been excused the operation.This class, therefore, is likely to furnish a disproportionatenumber of the victims of the epidemic ; andthus again the prophylactic acquires reputation. Addto this the facts, often overlooked, that medical men,even if officials and highly placed, are still liable as mento err, and that their errors will probably accord withtheir cherished beliefs , and it will readily be understoodPREFACE.that the evidence of detailed cases-which is really theonly evidence on which the credit of vaccination depends-cannot be accepted wholesale as if it werenot open to question. A vaccinated patient with novisible signs of vaccination is likely to be described asunvaccinated if his case is severe, and especially if deathensues ; while if the marks are not plainly visible, theexplanation of " not properly performed " is an obviousone ; and the patient will be included as " belonging tothe unvaccinated or imperfectly vaccinated class " inthe list of cases, and, tout court, as “ unvaccinated " or" having no marks " in the official summary. I think itwould be advisable for my medical brethren to acceptas authentic only published and tested cases, or such ashave come under their own personal observation .To those who are about to legislate for the countryon this vexed question I also address myself particularly.The Queen, in her Speech at the opening of the presentSession of Parliament, called for " earnest consideration "of the subject. Hitherto vaccination bills have beenpassed into law without adequate discussion or debate.Parliament has been assured (incorrectly) that there iscomplete unanimity in the medical profession concerningthe nature, value, necessity, and safety of vaccination ;and that has sufficed. Lords and Commons have atonce bowed before this alleged unanimity, with theresult, as vaccinists claim, but cannot possibly prove,that small-pox has been practically stamped out, butundoubtedly also with the result that hundreds ofinfants have died from the effects of the operation,that thousands of otherwise blameless citizens have beenfined or imprisoned for their very natural and properPREFACE .Iresistance to this extraordinary law, and hundredsof thousands of pounds of public money have beenspent on what I am satisfied is nothing but a uselessand mischievous fallacy. It is strange that membersof Parliament do not perceive that the strength of thepro-vaccinist party lies in the public endowment of thepractice. Right through the century there has existeda body of officials, ostensibly paid to promote thepractice of vaccination, but also, partly at least, paidto vindicate it theoretically, and to explain away itsfailures and its accompanying disasters. But for thisState aid, vaccination would long ago have been consignedto the same limbo as has received a thousandother similar fads which, fortunately for the public,have not secured official recognition and support.hardly expect that legislators will have time to readthe numerous cases I adduce-some showing thatimmunity from small-pox exists without vaccination ,others that mild attacks of small-pox were recordedlong before there was any alleged mitigating powerin vaccination to which to ascribe them, and, again ,others proving that neither vaccination nor re-vaccinationnor recent vaccination can be depended upon toprotect from small-pox or even from death from thatdisease. But to the cases of injury and death resultingfrom vaccination I trust they will not refuse to givesome attention. This evidence should be enough todetermine any fair- minded enquirer that the enforcementof vaccination by law is indefensible. Take away firstthe compulsory law, and then take away (if vestedinterest is not too strong for you) the endowment ofthe practice, and when this has been effected, medicalPREFACE .men will find themselves for the first time since 1803 .free to discuss the vaccination question as a scientificone on its own merits. To what result that unfettereddiscussion will lead I have myself (now that I havestudied the matter carefully for some years) no sortof doubt.In conclusion, I desire to express my obligationsfor the valuable assistance of Mr. A. W. Hutton, whoseletters on " The Vaccination Question," addressed toMr. Asquith and Mr. Balfour in 1894 and 1895, I canrecommend as an introduction to the rational study ofthis vexed problem .April, 1898.PREFACE TO THE SECOND EDITION .THE interval that has elapsed between the first andsecond editions of this book has witnessed a considerablestrengthening of the position of those whodissent from the popular belief in the value ofvaccination. It is true that the debates in Parliamentshowed how very far the general public is yetfrom a just appreciation of the present position ofthis controversy . So far as I noticed, apart from thevery few newspapers that definitely supported the antivaccinistcause, only one-the Westminster Gazetteadmittedthat there is a real weakness on the other side,viz. , the fact that there exists among medical men themPREFACE.selves a doubt, and a growing doubt, whether vaccinationis, after all, what it professes to be. But it canhardly be questioned that a recognition of this doubtand of its grave significance also underlay the excellentspeeches of Mr. Balfour and of Lord Salisbury, to whomthe passing of the measure into law was largely due.Reasons of expediency had, of course, to be urged insupport of such a measure of relief; but these wouldhardly have sufficed, apart from the weightier considerationthat it is unjustifiable to enforce under penalties amedical doctrine concerning which doctors themselvesdisagree. There is no reason to suppose that either Mr.Balfour or Lord Salisbury has any special knowledge ofthe subject, or has abandoned the current belief concerningit ; but as statesmen, and as thinkers, they couldnot fail to recognise the limits beyond which matters ofopinion cannot be enforced.When the Act itself is administered in the spirit inwhich it is framed it will afford a much-needed relief,and may even do something to retard the progress ofthe movement for the disestablishment and disendowmentof vaccination. But the unfortunate andindefensible provision about " satisfying " two justicespermits men on the bench, who are often, it appears ,fanatical believers in vaccination, to use the Act as aweapon of terror against timid conscientious objectors .They actually have the assurance to inform claimantsfor exemption, with all the authority that comeswith a declaration ex cathedra, that if the child inquestion is not vaccinated it will certainly take smallpox,whereas, if it is vaccinated, it will as certainlyescape. No medical man could or would speak thusPREFACE.positively. If this misuse of the new law becomesgeneral, it will shortly be as unworkable as the oldone was ; but it is to be hoped that this deplorablemaladministration will only be temporary.That the movement against vaccination will spreadand will ultimately triumph everywhere is certain . Thealleged unanimity of the medical profession on thesubject-the argument on which pro-vaccinists mostlyrely is far more apparent than real. That a majorityof medical men would, if polled at this moment, passa vote of confidence in vaccination is probably true.But votes need to be weighed as well as counted ; andI am satisfied that, if the poll were confined to thosepractitioners who have studied the subject, and havehonestly endeavoured to form an independent judgmenton the evidence, the majority would be the other way.Even now very few care to defend the practice openly.And it must be remembered that it has never been theway of the medical profession, as a body, to confess todoubts as to the value of any established medicalpractice. They will allow such practices gradually tofall into desuetude when they no longer commandconfidence ; and this is especially the case when othermethods of treatment can acceptably be substituted ;but a positive declaration against any doubtful practiceis not to be looked for.Nothing would more quickly undeceive the publicthan the rapid and complete abandonment of thepractice of vaccination in rural districts. Small -pox ismainly an urban disease ; and on this point the statisticsare so clear that the firmest believers in the protectivepower of vaccination must admit that in rural districtsPREFACE.it is unnecessary ; but, while townspeople can combineto free themselves from the pressure of the law, countryfolk cannot. Local epidemics will still occur in townswhere the sanitary conditions are defective ; and if, in asingle instance, the town happens to be unvaccinatedas well as insanitary, an epidemic there will render allother evidence nugatory, and throw back the movementperhaps for years. Nevertheless, in spite of such drawbacks, a practice that has been so thoroughly discreditedby competent men on scientific grounds must sooner orlater be consigned to the limbo of discarded superstitions.That the practice has been definitely discredited onscientific grounds is not open to serious question.The investigations of Dr. Creighton and ProfessorCrookshank have been very generally ignored by themedical profession ; but it is true that some effortshave been made to rehabilitate vaccination by bacteriologists,who assert that they have discovered " thespecific organism on which vaccinia depends. " Theirmain object is, of course, to reassure the public inregard to the now admitted risks of vaccination ashitherto practised. We are to have " pure cultures, " towhich it is supposed no one will take any objection.But surely the public will demand something positiveas a scientific demonstration that vaccine really has aprophylactic power against variola, and will not besatisfied with the mere assurance that now at last itwill do no harm. It is not long since it was announcedin the papers that Dr. Klein had identified the vaccinewith the variolous bacillus, but who now believes thathe did ? A later claim, not indeed to have made thisidentification of the bacilli of the two diseases, but to1PREFACE .have ascertained what is the cause of the vaccinedisease, is due to the researches of Mr. Stanley Kent,and paragraphs have gone the round of the papersproclaiming the immense value of his discovery. Butit is at least doubtful, from the publications which havehitherto appeared on this alleged discovery, whether themethods adopted have been adequate to permit theassertion that this organism, independent of otheragencies, is to be regarded as the vera causa of vaccine,and it is at any rate true that not less emphatic assertionsas to the discovery of such a cause have beenput forward from time to time, only to be discardedor repudiated as the result of maturer investigation .Finally, I should like to bear testimony to the noblepart in this controversy that has been played by myvenerable friend, Dr. Alfred Russel Wallace. It is areproach sometimes levelled against men of science,that, though in principle they admit that their teachingis subject to revision, yet in practice they often showthemselves dogmatic and unteachable. Of Dr. Wallacethis is certainly not true. Whether in physical science,or in psychology, or in politics, he has always kept anopen eye and an open mind ; nor has he ever lackedthe courage to stand by a cause which he believed tohave right on its side. His essay, entitled, " Vaccinationa Delusion, its Penal Enforcement a Crime, " reprintedin his recent work, " The Wonderful Century," is asable as it is outspoken, and cannot fail to convince thosewho read it how unsound is the basis on which thewhole fabric of vaccination legislation has been reared.METHODS OF SMALL- POX INOCULATION. II1721 , Lady Mary, who had returned to London, hadher daughter inoculated by Maitland. In the sameyear this surgeon experimented on some condemnedcriminals at Newgate, and in 1722 variolation wasencouraged by Royalty.Another of the early inoculators was Thomas Nettleton,of Halifax, who recommended long and deep incisions,and the using of matter from ripe pustules. Theseverity of the disease induced was a great bar to theprogress of small -pox inoculation, and by the year 1728the practice had almost ceased. It was revived about1740, and in 1754 was authoritatively sanctioned by theRoyal College of Physicians, who pronounced it to be" highly salutary to the human race." About the year1763 a milder method of procedure came into vogue ;this was first introduced by Gatti, the French inoculator,and was taken up in this country by Daniel Sutton andDr. Dimsdale, the latter of whom has published accountsof his practice. Dimsdale says :-" It seems not improperto add, that the method I now generally use inperforming the inoculation, as believing it to be the bestis simply this : the point of a lancet slightly dippedin the recent variolous matter, which I prefer takingduring the eruptive fever, is introduced obliquely betweenthe cuticula and the cutis, so as to make the smallestpuncture possible, rarely producing a drop of blood. " 1Dimsdale preferred inoculating from mild cases andfrom arm to arm, for he says :-" If neither an inoculatedpatient is at hand, nor anyone in the neighbourhoodhas a distinct kind of the natural disease, a threadmay be used as in the common manner, provided the" Tracts on Inoculation," p. 130. Hon. Baron T. Dimsdale. London. 1781 .12 THE EARLY HISTORY OF VACCINATION .thread be very recently infected." ¹ About the results,he adds " In general, the complaints in this state arevery moderate, and attended with so little illness thatthe patient eats and sleeps well the whole time : a fewpustules appear, sometimes equally dispersed . " 2He also had some very mild cases which not only hadlittle or no pustular eruption on the body or fever, but didnot even present a pustule at the seat of inoculation, therebeing simply local inflammation ; and in his book he givesa list of twelve such cases, which, however, he consideredprotected from any future attack of small -pox.Another writer, Dr. Giles Watts, in referring to thisnew method of inoculation, says :-" To say the truth ,it is a fact well known to inoculators, in this way, andI have sometimes known the same happen in the old,that the patients pretty often pass through the smallpoxso easily as to have no more than five pustules.Nay, it happens every now and then, in this way ofinoculation, that even an adult patient shall pass throughthe distemper without having one, or even so much asa single complaint, other than, perhaps, a slight shivering,chill, or some such trifling disorder, which he wouldhardly have taken the least notice of at any other time. " 3Thus the inoculation- system of Sutton and Dimsdale,which produced such mild results, depended upon gettingmatter from the eruption of small-pox at an earlystage of the disease, using it when fresh, inoculatingfrom mild cases or from arm to arm, taking the smallest" The Present Method of Inoculating for the Small -pox, " p. 29.Thomas Dimsdale, M. D. London. 1767 ." A Vindication of thep. 10. Giles Watts, M.D.2 Ibid. , p. 37.New Method of Inoculating the Small-pox,"London. 1767 .JENNER'S VARIOLOUS TESTS. 13quantity of matter and introducing it by a superficialpuncture. This, it may be noted, is precisely the sortof inoculation Jenner recommended should be used inapplying the variolous test in cases which had beenvaccinated. Jenner says :-" In some of the precedingcases I have noticed the attention that was paid to thestate of the variolous matter previous to the experimentof inserting it into the arms of those who had gonethrough the cow-pox. This I conceived to be of greatimportance in conducting these experiments. " 1 Now, ifwe refer to the case of John Phillips, aged sixty- two ,who had had the cow-pox at the age of nine years, welearn that the matter for inoculation was taken fromthe arm of a boy just before the commencement of theeruptive fever, and instantly inserted. A little furtheron he relates a story of a medical man who used stalesmall-pox lymph for inoculation, with serious results.Then he continues-" As a further cautionary hint, Ishall again digress so far as to add another observationon the subject of inoculation. Whether it be yet ascertainedby experiment that the quantity of variolousmatter inserted into the skin makes any difference withrespect to the subsequent mildness or violence of thedisease, I know not ; but I have the strongest reasonfor supposing that, if either the punctures or incisions bemade so deep as to go through it, and wound the adiposemembrane, that the risk of bringing on a violent diseaseis greatly increased. " ?With regard to these ten cases of casual cow -pox in1 " An Inquiry into the Causes and Effects of the Variolæ Vaccine,”pp. 55 , 56. Edward Jenner, M.D. , F.R.S. London. 1798 .2 Ibid. , pp. 58, 59.14 THE EARLY HISTORY OF VACCINATION .milkers who had been subsequently inoculated withsmall -pox, the method of inoculation then in vogue wasprobably used ; therefore, from the conditions underwhich the test was made, on Jenner's own showing, aslight and trivial result was the most that should havebeen anticipated. Jenner, however, admits a certainamount of local inflammation supervening in all thecases he describes, which , if we make allowance for thegeneral looseness and ambiguity of his statements ,may, not inconceivably, include the appearance of alocal pustule at the seat of inoculation .In 1796 Jenner vaccinated his first case, James Phipps .In less than seven weeks from the insertion of thecow-pox matter Phipps was inoculated with small-pox,with the result that " the same appearances were observableon the arms as we commonly see when a patienthas had variolous matter applied, after having either thecow -pox or the small -pox. " ¹Now, the question is, What appearances did Phippsactually have on his arms as the result of the varioloustest? And to guide us in forming an opinion, there is aletter of Jenner's to a medical man, Mr. John Shorter, whowrote to him about two cases in which he had appliedthe test six months after successful vaccination, with theresult of producing a pustule at the seat of inoculationin each case. Jenner, in his reply, December 29, 1799 ,says :-" Pray, recollect how seldom we find the skininsensible to the action of variolous matter in those whohave previously gone through the small -pox. Thecow-pox leaves it in the same state. The patients you1" An Inquiry into the Causes and Effects of the Variola Vaccina,”p. 34. Edward Jenner, M.D. , F.R.S. London. 1798.THE VALUE OF JENNER'S TESTS . 15mention were not insensible to the local action of thevariolous virus." Thus, if the skin is seldom insensibleto variolous matter after cow- pox or small -pox, andthese cases of Shorter's are samples of the result, itseems not improbable that when Jenner applied thevariolous test in the case of Phipps he got a localpustule at the seat of inoculation; for the same appearances,he says, were produced, as commonly observed,when variolous matter was applied to a person who hadhad either cow- pox or small -pox.Mary James is another of the few cases Jenner isknown to have subjected to the variolous test. This wasapplied eight months after vaccination, with the resultof a local pustule, fever, and the faint appearance of arash about the wrists; matter taken from the arm of thiscase produced small - pox when inoculated on her brother.To sum up the value of these tests. It amounts tothis : that Jenner, in applying them, used a form of inoculationwhich produced little more than a local result,and the appearances he obtained were not very differentfrom what would be produced by that form of inoculationwhen there was no question of cow- pox at all .Apparently the test broke down, not only in the caseof Mary James, but in other instances. Mr. Thornton ,surgeon, of Stroud, published his experience. Thecases are important as being the first independentevidence after the publication of Jenner's " Inquiry."` Medical and PhysicalJournal, vol. iii . , p. 351. ( April , 1800. )2 " Further Observations on the Variola Vaccine , or Cow-pox,"pp. 34-36. Edward Jenner, M.D. , F.R.S. London. 1799.3 Letter dated February 7 , 1799, and published in Dr. Beddoes' " Contributionsto Physical and Medical Knowledge," p. 398. Bristol . 1799.16 THE FARLY HISTORY OF VACCINATION .He vaccinated a Mr. Stanton and four of his childrenfrom a milker on the Stonehouse Farm, a source used byJenner himself. The matter was taken from a purulentpock, the only one which was not degenerated into asordid and painful ulcer. In the four children the inflammationwas severe and protracted, the scabs falling offabout the twentieth day. " From the long continuedlocal excitement," Mr. Thornton adds, " I began to entertaina hope that the virus might imperceptibly have creptinto the habit, and proved a security against the variolousinfection . " So, to relieve his own doubts, and to ensurethe safety of the patients, he inoculated them with smallpox,with the result that " all the children received theinfection , and passed through the different stages of thedisease in the usual slight manner. " Mr. Stanton, inwhom the inflammation had not been so severe, was theonly one who resisted the variolous inoculation .At the end of 1798, six months after the publicationof Jenner's " Inquiry," the case for vaccination stoodthus: Most of the children's arms had ulcerated, andthe variolous test, in the few cases in which it had beenapplied, had produced equivocal results. Moreover, allJenner's stocks of lymph had been lost, so that no furtherexperiments could be made. Dr. Beddoes, of Bristol, inwriting to Professor Hufeland, of Berlin, said :-" Youknow Dr. Jenner's experiments with the cow-pox. Hisidea of the origin of the virus appears to be quite indemonstrable,and the facts which I have collected are notfavourable to his opinion that the cow-pox gives completeimmunity from the natural infection of smallpox.Moreover, the cow-pox matter produces foul ulcers,and in that respect is a worse disease than the mildlyinoculated small-pox. " The celebrated Dr. GeorgeWOODVILLE AND PEARSON. 17Gregory, Physician to the London Small -pox Hospital,in his lectures at St. Thomas's Hospital, has alluded tothe inconclusiveness of Jenner's thesis. " When we wereengaged in tracing the early history of vaccination, youmust have been struck with the extraordinary contrastbetween the absolute scepticism concerning the prophylacticvirtue of cow - pox which prevailed before thepublication of Jenner's first essay and the unlimited confidencereposed in it, within two years afterwards, in allparts of the world. A calm and dispassionate examinationof Jenner's first essay is calculated to awaken somesurprise at this sudden conversion of men's minds. " 1It can thus be quite understood that the professionrequired more satisfactory proof before accepting the newdoctrine; and they shortly afterwards obtained evidencewhich to them appeared to support Jenner's theories.On January 20, 1799, Dr. William Woodville, Physicianto the London Small-pox Hospital, received intelligenceof an outbreak of cow- pox among the cows at a dairy inGray's Inn Lane. The disease on a milker's hand wascompared with Jenner's plates and pronounced genuine.It was then decided to give it a trial ; and the experimentswere conducted by Drs. Woodville and Pearsonat the Small-pox Hospital. The first inoculations weremade from the cow and from the hand of a dairymaid,and the subsequent ones, to the number of five hundred,from arm to arm. With regard to the testing of thecases by small-pox inoculation, Dr. Woodville says : -" Of all the patients whom I inoculated with variolousmatter, after they had passed through the cow- pox ,1 " Lectures on the Eruptive Fevers , " p. 207. London. 1843 .18 THE EARLY HISTORY OF VACCINATION.amounting to upwards of four hundred, none wereaffected with the small-pox. "1 Concerning these tests,M'Ghie says:-" Suffice it to observe, that the trialswhich were made by the profession, to communicatevariola to thosewhom they had vaccinated, completelyfailed. The cow-pox having thus triumphantly undergonethe experimentum crucis, vaccination was soon eagerlyadopted by the unprejudiced and disinterested in everycountry towhich the vaccine lymph was conveyed."2Ifwe analyse these so-called vaccinations, we find thatthree-fifths ofthe patients had pustules about thebodyanditis no longer disputed that these pustular cases werecases ofsmall-pox-and hence the subsequent varioloustests were ofno value in settling the question ofthe protectivevalue of cow-pox. Let us now consider the remainingtwo-fifths, which only presented a local pustuleatthe seat ofinoculation; and to do this it is importantto discuss the means by which Woodville's cases becamecontaminated. As the Vaccination Commissioners havepointed out, small-pox may have been introduced-(1) By infection at the Hospital or at the patients'homes.(2) Bythe inoculation of small-pox; several patientsbeing purposely inoculated with small-pox afew days after " vaccination. "(3) The lymph with which the patients were " vaccinated"may have become contaminated withsmall-pox.1"Reports of a Series of Inoculations for the Variola Vaccina, orCow-pox," p. 155. William Woodville, M.D. London. 1799."Thoughts on Vaccination," p. 11. Dumfries. 1827 .3 Final Report, Royal Commission on Vaccination, Appendix i. , p. 147.sTi,sf"mWHpcotto"hstoaoeoonhhhfhorltodsnleeoewaltdiptywioevgiiinwrirtnnilaeugnleleged'st-.spswpuuhmiobsartxjtloheuluclgtehssG.ILCRNAOANNWYE'STCB......ERPPRMo.u.aae.lcyydlknndileeinagnnrgiddge S,.dRaairicarehymaidS. topped1 1Talley.Brown.Price .Stopped .Wise ..StoppedP. ink.)p(1u7s0tules.Stoppedi...HBFauornxrkiesr ..DCernonuicshStopped . Stopped.Pedder Hoole Hickland .Morton Munday George Butcher Dorset .Stopped S.TlarardaentS.toppedStopped .C...KMCoeoolyrwesgmaann's .TurnerS.topped....SHHHJHBWW..uuue.u.elllwmllslepltus.Stopped S(uppliedtloymphJ.)ennerFontoihtveersaussedV. accinifersS.topped.TurnerS. treeton .Smith .Meacock..).()()(pp13C3Muu00r5.ss50o0ttuuuclleehssCR'.,.s5DVSoCe0iaootnocscmyamtsctmamieieilionnmsnstaesistnieiitonootnnnersS. topped20 THE EARLY HISTORY OF VACCINATION.This pedigree shows that Woodville's lymph passedexclusively through Collingridge, inoculated direct fromthe cow, and Streeton, Smith, and Meacock, inoculatedfrom a cow at one remove, from a pustule on the handof a dairymaid at the Gray's Inn Lane dairy. Allhad a large number of small-pox pustules, and henceWoodville's cases were from first to last hopelesslycontaminated with small-pox.In the case of Buckland, " vaccinated " direct from thecow, on the seventh day two pustules exactly resemblingthose of small- pox appeared near to the inoculated part ,and on the tenth, several pustules on different parts ofthe body ; the symptoms strongly suggesting that thepatient was inoculated when he was supposed to havebeen vaccinated. In Streeton, Smith, and Meacock thefacts are consistent with the small-pox being acquiredin the same manner as in the case of Buckland.Besides these three persons, Collingridge was the onlyother case through which Woodville's strain continued.She was inoculated at the same time and with the samematter as Buckland, and the margin of the inoculationswelling, was beset with minute confluent pustules, suggestinginoculated small-pox. The difficulty, however ,in this case is that on the fifth day after " vaccination "she was purposely inoculated with small-pox (on theopposite arm to the " vaccination "), and the pustuleswhich appeared about the body on the thirteenth daymay possibly have been due to this inoculation. Theusual day for the eruption to appear in ordinary inoculatedsmall - pox was the tenth or the eleventh, and thusthe pustules on the thirteenth day were rather late ifdue to the first inoculation, and early (eighth day) ifdue to the second ; and therefore it is just as likely" VACCINATION " WITH VARIOLOUS LYMPH. 21as not that Collingridge was variolated on her firstinoculation.Hence it is probable that the whole of Woodville's" Hospital matter " was contaminated at its sources, andthe absence of pustules in two-fifths of the cases does notprove that these were of other than variolous origin ; for,as Dr. Collins and Mr. Picton¹ say, " on the assumptionthat Woodville was dealing with arm- to - arm variolation,he only succeeded in obtaining what inoculatorsbefore and since claimed to have obtained when workingwith undoubted small-pox matter. " There is the furtherargument that matter from secondary small -pox pustulesin several instances produced only a local pustule in thenext remove.Woodville's lymph, when used by others away fromthe Hospital, produced eruptions : thus Jenner was suppliedwith a thread from Bumpus, who had three hundredand ten variolous pustules. In the first case inoculatedby him, " spots " appeared on the face; and in thesecond, the local vesicle assumed " more perfectly thevariolous character than is common with the cow-poxat this stage," and the areola was studded over with" minute vesicles. " Baron tells us that " the eruptionswhich attended many of the early cases of vaccination inLondon were unfortunately also propagated in differentparts of the country, where the contaminated matter hadbeen distributed by Dr. Pearson. " 3 Moore says :—" Variolous matter, under the denomination of vaccinelymph, was spread widely through England, and trans1 Royal Commission on Vaccination .Statement , section 50.2 Baron's " Life of Jenner," vol. i. , p. 245.Dissentient Commissioners'* Ibid. , p. 339.22 THE EARLY HISTORY OF VACCINATION .ported to Germany, and even to the Island of Madeira ,where a physician described the vaccine as a pustulardisease." 1Woodville's lymph, or the " world's vaccine, " as it hasbeen called, had an enormous circulation both in Englandand abroad, at a time when Jenner had no stocks ; itwas this lymph, in fact, which convinced the world ofthe efficacy of vaccination .aIn summing up the value of the Woodville evidence,Dr. Collins and Mr. Picton say :-" It is, therefore,probable that the whole of Woodville's five hundredcases, which appeared to confirm Jenner's thesis, andsecured the support of professional authority, were, infact, only a series of mild variolations. It is certainthat they were, from first to last, contaminated withsmall - pox. We agree with Professor Crookshankthat, in either case, they must be set aside for thepurpose of arriving at decision as to whetheruncontaminated cow- pox confers immunity towardssmall-pox. Woodville's cases, therefore, which did somuch to establish the practice of vaccination, and whichfor nearly a century have been cited as demonstratingthe truth of Jenner's doctrine, must be rejected asfurnishing false evidence, and valueless as a scientificexperiment. " Although at first some of the casesinoculated with Woodville's lymph were undoubtedlyinfectious, after a time, whether from attenuation ordilution of the original matter, from the selection ofmild cases, or from other causes, the number of pustules" History of Vaccination," p. 36.2 Royal Conımission on Vaccination. Dissentient Commissioners' Statement,section 51 .OPINION OF THE ROYAL COMMISSION . 25slight local appearances, whereas in the later ones theresults of the tests are for the most part given collectively,and we obtain such vague expressions as " no diseaseensued ; " concerning Nos. 89, 90, and 91 we read, " noneof the above three patients took the small-pox, " ¹ and inreferring to sixty-seven tests (Nos. 132 to 200, omittingNos . 193 and 194), all the information we have is that" the above patients had variolous matter insertedin their arms but it produced no disorder. " 2 IfWoodville had given details in each instance, it seemsprobable that a considerable number would have beendescribed as presenting some local manifestation, andif, as suggested by the Commissioners, we are tomake allowance for the expectant attitude of mindbetrayed by the sanguine experimenter, these cases wereevidently not so immune as generally believed ; but, asshown above, even if we accept the position that thewhole of Woodville's four hundred cases were immuneto inoculated small-pox, this proves nothing in favour ofJenner's thesis.Instances of the variolous test breaking down werenot uncommon. Thus a surgeon, named Boddington ,found in the case of his own child that the inoculationtest produced not only a local pustule, but also a generalsmall - pox eruption. He wrote to Jenner on the subject,who replied , " How a gentleman, following a professionthe guardian angel of which is Fame, should have socommitted himself as to have called this a case of smallpoxafter cow-pox, is not only astonishing to me, butmust be so to all who know anything of the animal1 " Reports of a Series of Inoculations for the Variola Vaccina , or Cowpox,"p. 86. William Woodville , M. D. London. 1799. 2 Ibid. , p. 113 .314 THE EARLY HISTORY OF VACCINATION .milkers who had been subsequently inoculated withsmall -pox, the method of inoculation then in vogue wasprobably used ; therefore, from the conditions underwhich the test was made, on Jenner's own showing, aslight and trivial result was the most that should havebeen anticipated. Jenner, however, admits a certainamount of local inflammation supervening in all thecases he describes, which, if we make allowance for thegeneral looseness and ambiguity of his statements ,may, not inconceivably, include the appearance of alocal pustule at the seat of inoculation.In 1796 Jenner vaccinated his first case, James Phipps.In less than seven weeks from the insertion of thecow-pox matter Phipps was inoculated with small-pox,with the result that " the same appearances were observableon the arms as we commonly see when a patienthas had variolous matter applied, after having either thecow- pox or the small-pox. " ।Now, the question is, What appearances did Phippsactually have on his arms as the result of the varioloustest ? And to guide us in forming an opinion, there is aletter of Jenner's to a medical man, Mr. John Shorter, whowrote to him about two cases in which he had appliedthe test six months after successful vaccination, with theresult of producing a pustule at the seat of inoculationin each case. Jenner, in his reply, December 29, 1799,says :-" Pray, recollect how seldom we find the skininsensible to the action of variolous matter in those whohave previously gone through the small-pox. Thecow- pox leaves it in the same state. The patients you1 " An Inquiry into the Causes and Effects of the Variola Vaccina,”p. 34. Edward Jenner, M.D. , F.R.S. London. 1798.THE VALUE OF JENNER'S TESTS . 15mention were not insensible to the local action of thevariolous virus." Thus, if the skin is seldom insensibleto variolous matter after cow-pox or small -pox, andthese cases of Shorter's are samples of the result, itseems not improbable that when Jenner applied thevariolous test in the case of Phipps he got a localpustule at the seat of inoculation ; for the same appearances, he says, were produced, as commonly observed ,when variolous matter was applied to a person who hadhad either cow- pox or small -pox.Mary James is another of the few cases Jenner isknown to have subjected to the variolous test. This wasapplied eight months after vaccination, with the resultof a local pustule, fever, and the faint appearance of arash about the wrists ; matter taken from the arm of thiscase produced small- pox when inoculated on her brother.To sum up the value of these tests. It amounts tothis : that Jenner, in applying them, used a form of inoculationwhich produced little more than a local result,and the appearances he obtained were not very differentfrom what would be produced by that form of inoculationwhen there was no question of cow-pox at all .3Apparently the test broke down, not only in the caseof Mary James, but in other instances. Mr. Thornton,surgeon , of Stroud, published his experience. Thecases are important as being the first independentevidence after the publication of Jenner's " Inquiry."Medical and PhysicalJournal, vol. iii . , p. 351. (April, 1800. )2 " Further Observations on the Variola Vaccine, or Cow- pox, "pp. 34-36 . Edward Jenner, M.D. , F.R.S. London. 1799.3 Letter dated February 7 , 1799, and published in Dr. Beddoes' " Contributionsto Physical and Medical Knowledge," p. 398. Bristol . 1799.16 THE EARLY HISTORY OF VACCINATION.He vaccinated a Mr. Stanton and four of his childrenfrom a milker on the Stonehouse Farm, a source usedbyJenner himself. The matter was taken from a purulentpock, the only one which was not degenerated into asordid and painful ulcer. In the four children the inflammationwas severe and protracted, the scabs falling offabout the twentieth day. " From the long continuedlocal excitement," Mr. Thornton adds, "I began to entertaina hope that the virus might imperceptibly have creptinto the habit, and proved a security against the variolousinfection. " So, to relieve his own doubts, and to ensurethe safety of the patients, he inoculated them with smallpox,with the result that "all the children received theinfection, and passed through the different stages of thedisease in the usual slight manner. " Mr. Stanton, inwhom the inflammation had not been so severe, was theonly one who resisted the variolous inoculation .At the end of 1798, six months after the publicationof Jenner's " Inquiry," the case for vaccination stoodthus: Most of the children's arms had ulcerated, andthe variolous test, in the few cases in which it had beenapplied, had produced equivocal results. Moreover, allJenner's stocks of lymph had been lost, so that no furtherexperiments could be made. Dr. Beddoes, of Bristol, inwriting to Professor Hufeland, of Berlin, said :-" Youknow Dr. Jenner's experiments with the cow- pox.idea of the origin of the virus appears to be quite indemonstrable,and the facts which I have collected are notfavourable to his opinion that the cow-pox gives completeimmunity from the natural infection of smallpox.Moreover, the cow-pox matter produces foul ulcers,and in that respect is a worse disease than the mildlyinoculated small -pox. " The celebrated Dr. GeorgeHisWOODVILLE AND PEARSON . 17Gregory, Physician to the London Small-pox Hospital,in his lectures at St. Thomas's Hospital, has alluded tothe inconclusiveness of Jenner's thesis. " When we wereengaged in tracing the early history of vaccination, youmust have been struck with the extraordinary contrastbetween the absolute scepticism concerning the prophylacticvirtue of cow - pox which prevailed before thepublication of Jenner's first essay and the unlimited confidencereposed in it, within two years afterwards, in allparts of the world. A calm and dispassionate examinationof Jenner's first essay is calculated to awaken somesurprise at this sudden conversion of men's minds . " 1It can thus be quite understood that the professionrequired more satisfactory proof before accepting the newdoctrine; and they shortly afterwards obtained evidencewhich to them appeared to support Jenner's theories.On January 20, 1799, Dr. William Woodville, Physicianto the London Small-pox Hospital, received intelligenceof an outbreak of cow - pox among the cows at a dairy inGray's Inn Lane. The disease on a milker's hand wascompared with Jenner's plates and pronounced genuine.It was then decided to give it a trial ; and the experimentswere conducted by Drs. Woodville and Pearsonat the Small-pox Hospital. The first inoculations weremade from the cow and from the hand of a dairymaid,and the subsequent ones, to the number of five hundred,from arm to arm . With regard to the testing of thecases by small - pox inoculation, Dr. Woodville says : -"Of all the patients whom I inoculated with variolousmatter, after they had passed through the cow-poх,1 " Lectures on the Eruptive Fevers," p. 207. London. 1843.18 THE EARLY HISTORY OF VACCINATION.amounting to upwards of four hundred, none wereaffected with the small-pox. " 1 Concerning these tests,M'Ghie says:-" Suffice it to observe, that the trialswhich were made by the profession, to communicatevarioia to thosewhom they had vaccinated, completelyfailed. The cow-poxhaving thus triumphantlyundergonethe experimentum crucis, vaccination was soon eagerlyadopted by the unprejudiced and disinterested in everycountry to which the vaccine lymph was conveyed."2Ifwe analyse these so-called vaccinations, we find thatthree-fifths ofthe patients had pustules about the bodyanditis no longer disputed that these pustular cases werecases ofsmall-pox-and hence the subsequent varioloustestswere ofno value in settling the question of the protectivevalue of cow-pox. Let us now consider the remainingtwo-fifths, which only presented a local pustuleat the seat of inoculation; and to do this it is importantto discuss the means by which Woodville's cases becamecontaminated. As the Vaccination Commissioners havepointed out, small-pox may have been introduced-(1) By infection at the Hospital or at the patients 'homes.(2) By the inoculation of small - pox ; several patientsbeing purposely inoculated with small -pox afew days after " vaccination."(3) The lymph with which the patients were " vaccinated" may have become contaminated withsmall-pox.1" Reports of a Series of Inoculations for the Variola Vaccine, orCow-pox, " p. 155. William Woodville, M.D. London. 1799."Thoughts on Vaccination, " p. II . Dumfries. 1827 .3 Final Report, Royal Commission on Vaccination, Appendix i . , p. 147 .mT,is"fHWpctoso"hstaoooeohnhfhorltsodneloeawltpditywioeivgiinwtrirnnialeugnlleeged'sTt-.spswpuuhmiobsartxjtlhoeuluclgtehssG.ILCRNAOANNWYE'SB.....CERPRMo..uae.lcydlkndileinagnnrgiddgeTalley .Brown .S. topped.Price S..WtiospepedS. toppedP. ink dS,.Raaiircraeyhmaid.p)1(u7s0tulesS. toppedPedder .Hoole Hickland .Morton Munday .George Butcher .Dorset .Stopped .1.Slade T. arrantS. topped...HBFauornxrkiesr C..Drenonuicsh.Stopped S. toppedS. toppedTColeman'sCow.Keys.Morgan.Turner .S. toppedW..SHHJHBW..uue..uellwmllespltus.Stopped S(uppliedltyomphJ.)enner|FontoihtveersaussedV. accinifersS. topped.Turner.Streeton S. mith M. eacockp..()..)(()p1C33Muu0r50.ss5o00ttuuucllheessR'.,、Ds5VSCoCie0oatonosccyammstcatmmeiileiinonmstsnaesistneiiitnoootnnnersS.toppedTHE EARLY HISTORY OF VACINATIONThis pedigree shows that Woodrille's lymph passedexclusively through Collingridge, inoculated direct fromthe sow, and Streeton, Smith and Meacock, inoculatedfrom a cow at one remove, from a pustule on the handof a dairymaid at the Gray's Inn Lane dairy. Alfare a large number of small-pex pustules, and hencees cases were from first to last hopelesslyexcreted with small-pox.In the case ofBuckland, "vaccinated " direct from thecow on the seventh day two pustules exactly resemblingwave of small-pcx appeared near to the inoculated part,and on the tenth, several pustules on different parts ofthe body; the symptoms strongly suggesting that thesacient was inoculated when he was supposed to haveLeser vaccinated. In Streeton, Smith, andMeacock theFacts are consistent with the small-pox being acquiredthe same manner as in the case of Buckland.Besides these three persons, Collingridgewas the onlyOther case through which Woodville's strain continued.She was inoculated at the same time andwith the samematter as Buckland, and the margin of the inoculationswelling, was besetwith minute confluent pustules, suggestinginoculated small-pox. The difficulty, however,in this case is that on the fifth day after " vaccination "the was purposely inoculated with small-pox on theopposite arm to the " vaccination "), and the pustuleswhich appeared about the body on the thirteenth daymay possibly have been due to this inoculation. Theusual day for the eruption to appear in ordinary inoculatedsmall-pox was the tenth or the eleventh, and thusthe pustules on the thirteenth day were rather late ifdue to the first inoculation, and early (eighth day) ifdue to the second; and therefore it is just as likely" VACCINATION " WITH VARIOLOUS LYMPH. 21as not that Collingridge was variolated on her firstinoculation .66Hence it is probable that the whole of Woodville'sHospital matter " was contaminated at its sources, andthe absence of pustules in two-fifths of the cases does notprove that these were of other than variolous origin ; for,as Dr. Collins and Mr. Picton¹ say, " on the assumptionthat Woodville was dealing with arm - to - arm variolation,he only succeeded in obtaining what inoculatorsbefore and since claimed to have obtained when workingwith undoubted small-pox matter. " There is the furtherargument that matter from secondary small -pox pustulesin several instances produced only a local pustule in thenext remove.Woodville's lymph, when used by others away fromthe Hospital, produced eruptions : thus Jenner was suppliedwith a thread from Bumpus, who had three hundredand ten variolous pustules. In the first case inoculatedby him, " spots " appeared on the face ; and in thesecond, the local vesicle assumed " more perfectly thevariolous character than is common with the cow- poxat this stage," and the areola was studded over with" minute vesicles. " Baron tells us that " the eruptionswhich attended many of the early cases of vaccination inLondon were unfortunately also propagated in differentparts of the country, where the contaminated matter hadbeen distributed by Dr. Pearson. " 3 Moore says : —" Variolous matter, under the denomination of vaccinelymph, was spread widely through England, and trans1 Royal Commission on Vaccination .Statement, section 50.2 Baron's " Life ofJenner," vol . i. , p. 245.Dissentient Commissioners '* Ibid. , p. 339.22 THE EARLY HISTORY OF VACCINATION.ported to Germany, and even to the Island of Madeira,where a physician described the vaccine as a pustulardisease." 1Woodville's lymph, or the " world's vaccine," as it hasbeen called,had an enormous circulation both in Englandand abroad, at a time when Jenner had no stocks; itwas this lymph, in fact, which convinced the world ofthe efficacy of vaccination .aIn summing up the value of the Woodville evidence,Dr. Collins and Mr. Picton say :-" It is, therefore,probable that the whole of Woodville's five hundredcases, which appeared to confirm Jenner's thesis, andsecured the support of professional authority, were, infact, only a series of mild variolations. It is certainthat they were, from first to last, contaminated withsmall - pox. We agree with Professor Crookshankthat, in either case, they must be set aside for thepurpose of arriving at decision as to whetheruncontaminated cow-pox confers immunity towardssmall-pox. Woodville's cases , therefore, which did somuch to establish the practice of vaccination, and whichfor nearly a century have been cited as demonstratingthe truth of Jenner's doctrine, must be rejected asfurnishing false evidence, and valueless as a scientificexperiment. " Although at first some of the casesinoculated with Woodville's lymph were undoubtedlyinfectious, after a time, whether from attenuation ordilution of the original matter, from the selection ofmild cases, or from other causes, the number of pustules1 " History of Vaccination," p. 36 .* Royal Conımission on Vaccination . Dissentient Commissioners' Statement,section 51 .OPINION OF THE ROYAL COMMISSION . 25slight local appearances, whereas in the later ones theresults of the tests are for the most part given collectively,and we obtain such vague expressions as " no diseaseensued ; " concerning Nos. 89, 90, and 91 we read, " noneof the above three patients took the small-pox," ¹ and inreferring to sixty- seven tests (Nos. 132 to 200, omittingNos. 193 and 194), all the information we have is that" the above patients had variolous matter insertedin their arms but it produced no disorder. " 2 IfWoodville had given details in each instance, it seemsprobable that a considerable number would have beendescribed as presenting some local manifestation, andif, as suggested by the Commissioners, we are tomake allowance for the expectant attitude of mindbetrayed by the sanguine experimenter, these cases wereevidently not so immune as generally believed ; but, asshown above, even if we accept the position that thewhole of Woodville's four hundred cases were immuneto inoculated small-pox, this proves nothing in favour ofJenner's thesis.Instances of the variolous test breaking down werenot uncommon. Thus a surgeon, named Boddington,found in the case of his own child that the inoculationtest produced not only a local pustule, but also a generalsmall -pox eruption. He wrote to Jenner on the subject,who replied , " How a gentleman, following a professionthe guardian angel of which is Fame, should have socommitted himself as to have called this a case of smallpoxafter cow-pox, is not only astonishing to me, butmust be so to all who know anything of the animal1 " Reports of a Series of Inoculations for the Variola Vaccina , or Cowpox," p. 86. William Woodville, M. D. London. 1799. 2 Ibid. , p. 113 .326 THE EARLY HISTORY OF VACCINATION .Ultieconomy." Baron refers to this as a sample of Jenner'smethod of dealing with " rumours " of this kind.mately Jenner discarded the test, for in 1804 hewrites :-" I will just remark that the fairest of all testsis exposure to variolous contagion. This is the naturaltest; inoculation is not. Who does not know (all medicalmen ought to know) that the insertion of the variolouspoison into the skin of an irritable person will sometimesproduce great inflammation, disturbance of the system ,and even eruptions ? " 2Any other evidence brought forward by Jenner isentirely discounted by his invention of the term" spurious cow-pox." This was first used to describecases of cow-pox which did not originate from greasein the horse, and subsequently as an excuse when it wasdiscovered that the vaccinated were liable to be attackedby small-pox. In his paper on " The Origin of theVaccine Inoculation," he gives the following ingeniousexplanation :-" In the course of the investigation of thissubject, which, like all others of a complex and intricatenature, presented many difficulties, I found that some ofthose who seemed to have undergone the cow-pox, nevertheless,on inoculation with the small - pox, felt itsinfluence just the same as if no disease had been communicatedto them by the cow. This occurrence ledme to enquire among the medical practitioners in thecountry around me, who all agreed in this sentiment,that the cow- pox was not to be relied upon as a certainpreventive of the small-pox." This for a while damped, but did not extinguish,1 Baron's " Life ofJenner," vol. i. , p. 445.2 Letter from Jenner to Dunning, July 22, 1804. Baron's " Life ofJenner," vol. ii . , p. 339.SPURIOUS COW- POX. 27my ardour ; for as I proceeded, I had the satisfactionto learn that the cow was subject to some varieties ofspontaneous eruptions upon her teats : that they wereall capable of communicating sores to the hands of themilkers ; and that whatever sore was derived from theanimal , was called in the dairy the cow-pox." Thus I surmounted a great obstacle, and in consequence,was led to form a distinction between thesediseases, one of which only I have denominated the true,the others the spurious cow-pox, as they possess nospecific power over the constitution. " ¹I may here remark that Jenner never gave any signs bywhich the true and spurious cow -pox could be distinguished,and the mystery remains unsolved until this day.66In some concluding remarks of the Inquiry," herelates the cases of Hannah Pick and Elizabeth Sarsenet,who contracted cow-pox with all the other servants ata farm in the parish of Berkeley. These cases fairlypuzzled him ; for Hannah, when inoculated with smallpox,was found protected ; but Elizabeth, on exposureto the infection, contracted the disease. In the lattercase, although there were multiple vesicles , there was noglandular or constitutional affection. Jenner says :-" This impediment to my progress was not long removedbefore another, of far greater magnitude in its appearances,started up. There were not wanting instances toprove that, when the true cow- pox broke out among thecattle at a dairy, a person who had milked an infectedanimal , and had thereby apparently gone through thedisease in common with others, was liable to receive thesmall -pox afterwards . "1 " The Origin of the Vaccine Inoculation," pp. 2 , 3. Edward Jenner ,M.D. , F.R.S. London . 1801 .28 THE EARLY HISTORY OF VACCINATION.Baron observes-" Most men would, at this stage,have abandoned the investigation in despair. It wasnot so with Jenner. " ।Jenner continues-" This, like the former obstacle,gave a painful check to my fond and aspiring hopes ;but reflecting that the operations of Nature are generallyuniform, and that it was not probable the human constitution(having undergone the cow-pox) should in someinstances be perfectly shielded from the small -pox, andin many others remain unprotected, I resumed mylabours with redoubled ardour." The result was fortunate ; for I now discovered thatthe virus of cow-pox was liable to undergo progressivechanges, from the same causes precisely as that of smallpox;and that when it was applied to the human skin inits degenerated state, it would produce the ulcerativeeffects in as great a degree as when it was not decomposed,and sometimes far greater : but, having lost itsspecific properties, it was incapable of producing thatchange upon the human frame which is requisite torender it unsusceptible of the variolous contagion ; sothat it became evident a person might milk a cow oneday, and having caught the disease, be for ever secure ;while another person, milking the same cow the next day ,might feel the influence of the virus in such a way as toproduce a sore or sores, and in consequence of this mightexperience an indisposition to a considerable extent ;yet, as has been observed, the specific quality being lost,the constitution would receive no peculiar impression. " 21 Baron's " Life of Jenner," vol . i. , p. 132 .2 " The Origin of the Vaccine Inoculation," pp. 3 , 4. Edward Jenner,M.D. , F.R.S. London. 1801 .CONDEMNED BY THE COLLEGE OF PHYSICIANS. 29Only think of the absurdity of it. One day, matterfrom the nipple of the cow, when inoculated on ahuman being, produces true cow-pox , and renders thatperson for ever afterwards secure from small -pox ; thevery next day, matter from the same cow will produceidentical symptoms, but the cow-pox having lost itsspecific properties, the second person remains entirelyunprotected !The " spurious cow-pox " cry contributed largely toestablish vaccination ; for before the Committee appointedby the House of Commons to consider Jenner'sclaim for reward, some of the leading medical mengravely asserted that cases of failure must have beendone with spurious matter.It is only fair to mention that this explanation wascondemned by the College of Physicians. " Somedeviations from the usual course have occasionallyoccurred, which the author of the practice has calledspurious cow- pox, by which the public have beenmisled, as if there were a true and a false cow-pox. "This condemnation, however, came too late to arrestthe mischief, for cow-poxing had already become anestablished practice.It was also unfortunate that the early opponents ofvaccination were almost entirely an interested opposition,being pledged to small -pox inoculation ; and it wasespecially unfortunate that if they had questioned thevalidity of the variolous test they would have exposedtheir own nostrum, which , as I have shown, was in somecases little else than an imposture.1 " Report of the Royal College of Physicians of London on Vaccination , "p. 5. ( Ordered to be printed, by the House of Commons, July 8 , 1807. )30 THE EARLY HISTORY OF VACCINATION .Another thing which largely contributed to establishvaccination was the misleading name of “ variolavaccina," or small -pox of the cow, given to the diseaseby Jenner ; and this, giving as it did a truly scientificring, most materially assisted the cow-pox propagandistsin their innovation. The theory that cow- pox was smallpoxof the cow was quite new to the veterinary surgeonsand other practical people of that time, and was objectedto by one of Jenner's leading contemporaries, Dr. GeorgePearson, on the ground that " cow-pox is a specificallydifferent distemper from the small-pox in essential particulars,namely, in the nature of its morbific poison, andin its symptoms." 1 Dr. George Gregory, a more recentauthority, was also entirely opposed to the identitytheory. " On all these grounds, I demur to the theoryof identity, and hold that small-pox and cow-pox areantagonistic affections that cow- pox, instead of being,as Dr. Baron maintains, of a variolous, is, in fact, of ananti- variolous nature-that it alters and modifies thehuman constitution so as to render some individualswholly, others partially, and for a time, unsusceptible ofsmall - pox . " 2 The total unlikeness of cow - pox to smallpoxin all respects, save their names, has been muchdwelt upon by several modern pathologists, to whosewritings I refer my readers .1 " An Inquiry concerning the History of the Cow- pox, " p . 109. GeorgePearson , M.D. , F.R.S. London. 1798 .2 " Lectures on the Eruptive Fevers, " p. 207. London. 1843 .36" Vaccine et Variole, " p. 100. Chaveau. Paris. 1865. " Human andAnimal Variola," p. 4. George Fleming , F.R.C.V.S. London. 1881 ." The Natural History of Cow-pox and Vaccinal Syphilis. " CharlesCreighton , M. D. London. 1887. " History and Pathology of Vaccination." Edgar M. Crookshank, M. B. ( 2 vols. ) London. 1889.CHAPTER II .THE DECLINE IN SMALL- POX SINCE THE INTRODUCTIONOF VACCINATION .THE argument that small-pox has declined since theintroduction and more efficient enforcement of vaccinationis an important one. It is commonly assertedthat in former times this disease raged like the plague, ¹but a careful examination of the London Bills of Mortalitywill show the absurdity of the claim. In thewhole history of small-pox it never raised the totaldeaths so as to make them stand out conspicuouslyamong surrounding years ; but this was very far frombeing the case with the plague.Burials within the London Bills of Mortality from plague and" all causes " for the plague years 1603, 1625, 1636, and 1665. "Years. Deaths from plague. Deathsfrom all causes.1603 ...... 30,561 ...... 37,2941625....35,417 ..... 54,2651636 ...... 10,400 ...... 23,3591665 ...... 68,596 97,306" Your Committee, however, believe that, if vaccination hadnot been general, this epidemic ( 1871-72 ) would probably have becomea pestilence, raging with destructive force, like the plague of the MiddleAges. " ( Draft Report proposed by the chairman of the Select Committeeon the Vaccination Act, 1867. )• Second Report, Royal Commission on Vaccination, pp. 289, 290.32 THE DECLINE IN SMALL- POX .For the non - plague years, 1604-24, the averageannual number of deaths from all causes was 8,548 ;for the years 1626-35 , 8,986 ; and the years 1637-64,12,554. It is thus evident that the plague made anenormous difference to the total mortality, which wasnever the case with small -pox.Let us now see what small-pox was at its worst.The only continuous set of figures we have extendingover a long period of time are those for London, and, inthe absence of any reliable information about the population,we are forced to the imperfect method of comparingthe ratios of deaths from small-pox to those forall causes. The following figures give the highest yearsfor small-pox in the seventeenth, eighteenth, and nineteenthcenturies :-Years.DeathsfromDeathsfromsmall -pox. all causes .Ratio per 1,000fromsmall-pox.Seventeenth century ( 1634) 1,354 10,400 130Eighteenth century ( 1796) 3,548 19,288 184Nineteenth century ( 1871) 7,912 80,430 98Although there is not a great difference between themaxima of the seventeenth and nineteenth centuries ,a sensible decline has nevertheless taken place, forthe small-pox epidemics appear at much less frequentintervals than formerly.Since the commencement of the Registrar- General'sreturns in 1838 we have the advantage of exact figures ,and the interval from this date to the present time maybe conveniently divided by the great epidemic of 1871-72 .It was during the first of these periods that most of theimportant laws relating to vaccination came into force.In 1840 an Act (3 and 4 Victoria, cap. 29) was passedmaking it the duty of Guardians to provide facilitiesTHE VACCINATION ACTS. 33for vaccination ; but it was not until 1853 ( 16 and 17Victoria, cap. 100) that neglect of vaccination was madepunishable by fine, or imprisonment in default of distress.The effect of this law was seen in the large increase ofthe number of vaccinations in 1854. By the Act of 1861(24 and 25 Victoria, cap. 59), Guardians were authorisedto appoint officers to institute and conduct proceedingsfor the purpose of enforcing obedience to the law. Themost important Act of all, however, was that of 1867(30 and 31 Victoria, cap. 84), which imposed on theGuardians the duty of seeing that children were dulyvaccinated, and empowered them to pay any officerappointed by them to prosecute persons charged withoffences against the Act. It also introduced a provision(section 31 ) to secure the vaccination of childrenborn before the Act came into force ; but the most importantprovision of all was that relating to repeatedpenalties for the non-vaccination of the same child, andthis harsh process of the law could hardly fail, in the thenstate of public opinion, to greatly increase the numberof vaccinations . Referring to this Act, the SelectParliamentary Committee 2 say :-" Your Committee areglad to find that wherever the Guardians endeavour tocarry out the law, it is very generally, and indeed almostuniversally, enforced ; " and they proposed an amendmentto the effect that the appointment of vaccination officers1 Dr. Seaton informed the House of Commons' Committee of 1871 thatof two hundred and sixty Unions inspected in 1870, only one hundred andtwenty were reported as not having vaccination officers ; a large number ofthese , however, had appointed officers since ( before May, 1871 ) .2 " Report from the Select Committee on the Vaccination Act ( 1867 ) , 'p. xiii . ( Ordered to be printed, July 13, 1871. )34 THE DECLINE IN SMALL- POX.should be made obligatory-a suggestion which wasembodied in the Act of 1871 (34 and 35 Victoria ,cap. 98).The Act of 1871 made other alterations. By the27th section of the 1867 Act, it was provided that theGuardians shall make inquiry, and " if they find thatthe provisions of the Act have been neglected, shallcause proceedings to be taken against the persons indefault. " This clause was repealed by the Act of 1871 .The repeal of this section absolved the Guardians fromthe duty of prosecuting for the time being ; but in1874 an Act was passed ( 37 and 38 Victoria, cap. 75 )empowering the Local Government Board to make" rules , orders, and regulations prescribing the duties ofGuardians and their officers in relation to the institutionand conduct of proceedings to be taken for enforcingthe provisions of the said Acts ( 1867 and 1871 ). " TheLocal Government Board have acted on this power, andin their General Order, dated October 31 , 1874, haveintroduced a clause (art. 16) which takes the place ofthe repealed 27th section of the Act of 1867.If we refer to the diagram in the Appendix, whichgives the proportion of public vaccinations under oneyear of age to the births, from 1845 to 1896, we find thatthe Act of 1853 doubled the number of vaccinations ;after this the number diminishes, to increase again in1863-64. This increase was probably due to an outbreakof small-pox. After another decline, there is anincrease of vaccinations in 1868-69, which may be attributedto the Act of 1867 ; and a still further rise in1871 , due, no doubt, to the great epidemic of small -poxthen prevailing. The effect of the legislation of 1871SMALL- POX AND VACCINATION SINCE 1872. 35is not apparent, for there is no further increase in thenumber of vaccinations in 1872, when the Act cameinto operation .Another method of testing the increasing efficiency ofthe Vaccination Acts is the proportion of the small - poxcases vaccinated. The figures for the London Small -poxHospital work out as follows : -Years.Percentage of small -poxcases vaccinated.1826-341835-451845-551855-6518671871354464788492An examination of the diagram referred to showsthat with the gradually increasing proportion of thepopulation vaccinated there is no diminution in smallpox,and the epidemic of 1871-72, coming whenEngland was thoroughly vaccinated, points forcibly tothe inutility of the operation.Let us now examine the history of small -pox andvaccination subsequent to the great epidemic. Thesame diagram shows that the infantile public vaccinationsremained practically stationary until 1881 or 1882 ,when they began to decline ; from 1881 to 1896 theydecreased from 57.3 to 34.9 per cent. of the births ,which is a considerable reduction. It will be seen thatsince the great epidemic ( 1871-72), and coincident withthe decline in vaccination, small-pox has diminished ,and quite recently, markedly so .An examination of the statistics for London, since theopening of the hospitals of the Metropolitan Asylums36 THE DECLINE IN SMALL- POX .Board, also shows conclusively that the enormous declinein the small-pox mortality in recent years cannotbe attributed to vaccination. The figures are takenfrom the published reports of the Metropolitan Asylumsand Local Government Boards.Estimatedpopulation in themiddle of each .year.Percentage of birthsnot finally accountedfor in regard tovaccination .No return.Years.Deaths fromsmall-pox .Small-poxdeath-rateper million.1871 3,267,251 7,912 2,4211872 3,319,736 1,786 5378.81873 3,373,065 113 33 8.71874 3,427,250 57 16 8.81875 3,482,306 46 12931876 3,538,246 736 207 6.51877 3,595,085 2,551 709 711878 3,652,837 1,417 387 711879 3,711,517 450 120 7.81880 3,771,139 471 124 701881 3,824,964 2,367 617 5.71882 3,862,876 430 110 6.61883 3,901,164 136 34 6.51884 3,939,832 1,236 3076.81885 3,978,883 1,419 347 701886 4,018,321 24 5 7.81887 4,058,150 9 2 901888 4,098,374 92 10.31889 4,138,996 1161890 4,180,021 4 I 13.91891 4,221,452 8 2 16.4.1892 4,263,294 41 10 18.41893 4,306,411 206 48 18.21894 4,349,166 89 22 20.61895 4,392,346 55 131896 4,421,955 9 2Thus it will be seen that with an increasing proportionof the population vaccinated, up to the great epidemicDECLINE OF TYPHUS FEVER. 37of 1871-72 , there was no corresponding decline in thesmall-pox mortality, and more recently, while the reductionin small-pox has been enormous, the vaccinationshave also declined .As pointed out above, however, if this century becompared with the two previous ones, a large decline insmall-pox has taken place ; and this has been accompaniedby an equal if not a greater decline in anotherzymotic disease, which is spread by overcrowding andinsanitation-viz.: typhus fever. In 1685-86 the countrysuffered from a severe epidemic of a fever which hasbeen described by Sydenham, and, according to Dr.Murchison, ¹ presented all the symptoms of typhus-viz.:headache, pains in the limbs, dry brown tongue, delirium ,and an eruption resembling that of measles, and oftenaccompanied by true petechiæ. According to theLondon " Bills " there were 3,832 deaths from feverin 1685 , or a rate of 165 per 1,000 of the total deaths(23,222) in the year; and 4,185 deaths in 1686, or oneof 185 per 1,000 (total deaths, 22,609) .The most severe fever year was in 1741. In London7,528 died, or a rate of 234 per 1,000 from all causes(32,169). This considerably exceeds the figures forsmall -pox, which, at its worst, in 1796 , had only a rate of184 per 1,000 total deaths. Dr. Murchison, in speaking ofthe fever epidemic in 1741 (p. 34), says :-" In London itis said to have broken out among the poor, who had beenhalf- starved for two years, and obliged to eat uncommonand unwholesome things. In all the accounts mentionis made of the eruption : in some cases it is described1 " The Continued Fevers of Great Britain," p. 30. (Second edition. )1873.38 THE DECLINE IN SMALL- POX .as like that of measles , in others as like so many smallflea-bites, while in a few instances it is said to have beenmixed up with petechiæ and vibices." From the descriptiongiven by one of the writers at the time-Barker, ¹ ofSalisbury-there can be but very little doubt that thisepidemic was one of true typhus. The patient, afterhaving languished for several days, was seized withrigors or cold chills , and with a heavy pain in the foreheador over the eyebrows, which rendered him stupidand dejected. About the seventh day petechiæ or spotssometimes appeared upon the breast or arms ; thesewere commonly of a pale red colour, like measles, andsometimes purple, like so many small flea-bites. In avery few the eruption was of a deep violet colour, and inothers very broad, like scurvy spots or bruises. In thelater stages the patient became delirious, the breathingwas often laboured, and there was also convulsivetwitching of the tendons, and fumbling with the bedclothes.In 1837-38 , epidemics of small-pox and typhus tookplace simultaneously. In England and Wales , duringthe eighteen months ending December 31 , 1838, 27,822died from typhus, and 22,079 from small-pox ; while inthe Metropolis during the same period, there were6,011 deaths from typhus, and 4,580 from small-pox.In London we know that this epidemic of fever wasalmost wholly typhus. Of sixty cases in 1837-38, ofwhich notes were kept by West, under Latham, atSt. Bartholomew's Hospital, none that died and wereexamined post-mortem had ulcerations of Peyer's patches1 " An Inquiry into the Nature, Cause, and Cure of the presentEpidemic Fever," pp. 39-42. J. Barker, M.B. London. 1742 .DECLINE OF TYPHUS FEVER.39pathognomonic of enteric or typhoid fever, althoughsome had congestion of Peyer's patches, the casesbeing all reckoned typhus exanthematicus.¹ Sir ThomasWatson has also testified to the nature of this epidemic:-" Fever is very rife in St. Giles's and inother crowded parts of this town, just now ( 1838).Our wards at the Middlesex are full of it ; andscarcely a case presents itself without these spots.We speak of it familiarly as the spotted fever, or (from theresemblance which the rash bears to that of the measles,hereafter to be described ) as the rubeoloid fever. " 2The 1847 epidemic of fever in England was almostentirely one of typhus, there being 30,320 deaths, or anumber considerably exceeding any year for smallpoxover the whole period of registration. Since thisepidemic, typhus fever has largely diminished ; but ithas been noticed that at the London Fever Hospital allthe great annual rises in the deaths from fever inLondon since 1849 (after which year enteric feverand typhus were first separated in the returns of theHospital) have corresponded to a greatly increasedadmission of typhus, and not of enteric cases.In the returns of the Registrar-General it was separatedfrom enteric fever in 1869 ; and from 1871-75 to1891-95 the average annual typhus death-rate in Englandand Wales has declined from 81 to 4 per million, ora fall of 95 per cent. on the earlier rate. The fact thatthis complaint, which was formerly more prevalent thansmall -pox , should have diminished to such an extent as1 " A History of Epidemics in Britain," vol. ii. , p. 194. CharlesCreighton, M.A. , M.D. Cambridge. 1894." Lectures on the Principles and Practice of Physic," vol. ii . , p. 732 .(Third edition. ) 1848.40 THE DECLINE IN SMALL- POX .to have become practically extinct, has a very importantbearing on the decline of small-pox, for it is admittedthat typhus fever is a disease which is spread by overcrowdingand insanitation, and in subsequent chaptersit will be seen also that small-pox is largely disseminatedin the same manner.The following table shows the decline that has takenplace in small -pox, fever, typhus fever, and scarlet feversince the commencement of registration. It is dividedinto five-year periods .England and Wales.-Average annual death-rate per millionliving, from small-pox, fever, 1 typhus fever, and scarlet fever,in five-year periods from 1838-95.2Years. Small-pox.3 Fever. Typhus fever. Scarlet fever.1838-42 576 1,0531847-50(4years)292 1,2461851-55 248 9831856-60 198 8421861-65 219 922 9821866-70 105 850 9601871-75 408 599817591876-80 82 380 346801881-85 83 273 23 4361886-90 16 202 7 2411891-95 24 185 4182Over the whole period it will be found that thesmall -pox death-rate declined 96 per cent. , while feverdeclined 82 per cent. But the most extraordinary featureof the table is the large small -pox death-rate in 1871-75 ,1 The term " fever " includes typhus , typhoid , and simple and ill-definedfevers.From 1843-46 the causes of death were not abstracted .3 The figures for small-pox include chicken-pox.CAUSE OF DECLINE OF FEVERS. 41twenty years after vaccination had been made compulsory.Thus, between 1838-42 and 1871-75 the deathratefrom small-pox had only abated 29 per cent. , whilefever diminished 43 per cent.; and, therefore, since thecommencement of registration there was practically noimportant decline in small- pox until after the 1871-72epidemic, although the death-rate from fever had materiallydiminished. Let me call attention to what hashappened with the other diseases in the table. Since1871-75 , typhus (for which we have no State- enforcedpreventive inoculation) has declined 95 per cent. , or afall as great as there has been in small- pox over thewhole period of registration ; and scarlet fever showsthe important reduction of 81 per cent. since 1861-65 .An objection has been made to the fever figures, onthe ground, it is said, that formerly fever included otherdiseases, such as pneumonia, influenza, etc. , which nowappear under their respective headings. The followingquotation, however, from the Registrar-General's fortysecondannual report ( 1879) proves that this is not thecase to any large extent. The cause of the decline isalso explained. The Registrar- General says ( p. xxx.) :-" Had the deaths from one or more of this group ofcauses fallen , while those from others in the same grouphad risen, or had the fall been trifling, or the totals dealtwith insignificant in amount, it might have been suspectedthat the alteration was a mere alteration in name.as the deaths under each heading have declined, as thefall in the death- rate from them has been enormous62.4 per cent. in the course of ten years-and as thetotals are by no means small, it may be accepted asan indisputable fact that there has in truth been aBut442 THE DECLINE IN SMALL- POX.notable decline in these pests, and it may be fairlyassumed that the decline is due to improved sanitaryorganisation. "I will now allude to the alterations that have takenplace from time to time in the age-incidence of thesmall -pox mortality. Dr. Creighton has pointed outthat, in all probability, in the seventeenth century smallpoxwas more a disease of adults than in the eighteenthcentury, when it was largely a disease of children ; atany rate, it was on account of its incidence on adultsthat the disease obtained its evil repute. In the diaryof John Evelyn, we read that he himself had small-poxwhen a young man. His two daughters died of it inearly womanhood within a few months of each other ;and a suitor for the hand, of one of them died of it aboutthe same time. Among the medical writers, Willis givesfour cases, all in adults ; and Morton, sixty-six clinicalcases of small-pox, twenty -three of which were undertwelve and the rest over twelve years of age.¹Again, in their writings the physicians of that timeindicated that small-pox was a mild disease in infants.Willis says, " There is less danger if it should happen inthe age of childhood or infancy ; " again, " the sooner thatanyone hath this disease, the more secure they are, whereforechildren most often escape. " 2 Dr. Walter Harris, ina treatise on the acute diseases of infants , says :-" Thesmall-pox and measles of infants, being for the most parta mild and tranquil effervescence of the blood, are wontto have often no bad character, where neither the helping1 " A History of Epidemics in Britain , ” vol . ii . , pp. 443, 444. Creighton .2 Thomas Willis , M.D. , on " Fevers ." Translation by S. Pordage ,pp. 139, 142. London. 1681 .AGE - INCIDENCE OF SMALL- POX . 43hands of physicians are called in, nor the aboundingskill of complacent nurses is put in requisition. " ।In the eighteenth century, on the contrary, the incidenceof the small-pox mortality, especially in themanufacturing towns, was almost entirely on infants andyoung children, as is shown in the following table 2 :-Sınall-pox Percentagedeaths under under five years Years.Small-poxdeaths atall ages. five years of age . ofage.Kilmarnock , 1728-63 622... 563 90.5Manchester, 1769-74 ... 589 559 94.9Warrington, 1773 209 197 94.3Chester, 1774 202 180... 89.1Carlisle, 1779-87 ... 241 229 950In country districts, however, where small -pox appearedat less frequent intervals, there was time for thechildren to grow up without having the disease ; andthus, in some instances, there were very few cases anddeaths in the early years of life. Aynho, a smallmarket town in Northamptonshire, is an instance inpoint. The following figures are recorded by the rectorof the parish for fifteen months in 1723-243 :-Ages. Cases. Deaths .0-11-22-3 3 23-4 4 I4-565-10 15 110--15 33 315-20 14 I20-25 16325-30 9 3" A History of Epidemics in Britain, " vol . ii. , p. 441. Creighton .2 Ibid. , pp. 527 , 536 , 538 , 554. 3 Ibid. , p. 520.44 THE DECLINE IN SMALL- POX .Ages. Cases. Deaths.30-40 12...40-50 103450-60 4 160-70 4 2Above 70 2 I...Totals, 132 25Thus, in the eighteenth century, although there mayhave been exceptions in some country districts, in townsthe rule was for small-pox to be almost entirely achildren's disease. This continued to be the case untilafter the 1837-38 epidemic. The Registrar-General firstseparated ages for all England in 1847, and the followingtable gives the proportion of small-pox deaths under fiveyears of age from that time.England and Wales. For small-pox¹ the deaths at all ages andunder five, and the percentage of deaths under five to deathsat all ages in five-year periods from 1847-95 .Percentageunderfive years of age.Small-pox deathsYears. atSmall-pox deathsunderall ages. five years of age.1847-50(4 years)20,439 14,307 7001851-55 22,801 15,09166.21856-60 ... 19,270 11,010 57 11861-65 23,007 12,477 54.21866-70 11,779 6,403 54.41871-75 47,696 14,929 31'31876-80 10,243 2,938 28.71881-85 11,025 3,002 27.21886-90 ... 2,32082035.31891-95 ... 3,515 1,313 37.41 These figures include chicken-pox ; if this disease be omitted from thecalculations , 26.9 per cent. of the total deaths from small-pox were underfive years of age in the period 1891-95 , or a percentage reduction of 62since 1847-50 .INCREASE IN ADULT MORTALITY OF SMALL- POX. 45The figures in this table are corrected for chicken-pox ;this disease was included with small-pox until 1874, butsince that date chicken- pox deaths have been separatelyclassified. My authority for adding them is containedon page x. of the fifty- second annual report of theRegistrar - General ( 1889) : -" There were, however,eighty-three deaths ascribed to chicken-pox, and it isvery probable that most of these were in reality cases ofmodified small -pox, true chicken-pox being an ailmentthat is rarely, if ever, fatal." It will be seen from thetable that over the whole period the percentage of deathsfrom small -pox under five years of age has declined from700 to 37.4, or a percentage reduction of 47 .Not only has the children's share of the small -poxdeath-rate diminished, but at ages above ten the mortalityhas actually increased ; that is to say, there hasbeen an age-shifting of the small - pox death- rate. This isshown by the following figures taken from the forty- thirdannual report of the Registrar- General ( 1880, p. xxii.).England and Wales. Mean annual deaths from small- pox atsuccessive life-periods, per million living at each life-period._Age-periods.Under5.Vaccination optional, 1847-53 ... 1,617Vaccination compulsory, 1872-80 3235- 10- 15- 25-45andupwards.337 94 109 66 22186 98 173 141 58The increase in the adult mortality of small-pox duringthe period of compulsory vaccination has been urged byDr. Bridges as a sufficient ground for altering the law.He thought that, if these facts had been generally knownat the time, the Legislature would have hesitated beforemaking vaccination compulsory. Dr. Collins and Mr.46 THE DECLINE IN SMALL- POX.Picton have also shown that since the last century therehas been an alteration in the share borne by children ofthe small -pox deaths independently of vaccination.From 1881 the Registrar-General has classified thesmall -pox deaths into three groups-the vaccinated, theunvaccinated , and those in which there is no statement.In the unvaccinated class, from 1881-93 , there were in all3,746 deaths, 1,483 , or 39.5 per cent. , of which were underfive years of age ; during the last century, as pointed outabove, the proportion under five years of age was morethan double this figure. It is not easy to understandhow vaccination can have brought about this change inthe unvaccinated .Comparisons have been instituted with other diseases.In this connection Dr. Ogle, the late Superintendent ofStatistics to the Registrar-General, informed the RoyalCommission (Q. 516 and 518) that the zymotic diseaseswere the better ones with which to compare small -pox ;but he said , " It is impossible to make similar comparisonsin the case of scarlet fever or measles, and diseases thatonly affect children. Fever is the only one of thezymotic headings that you can take, because it is theonly one that affects all ages to any extent. Fever is ,therefore, the only one which it is possible to subject tothis kind of investigation. "The following table gives the children's proportionof deaths for fever in five-year periods from 1847-95.Corrections have been made for remittent fever.1869 to 1880 the deaths from remittent fever, under fiveyears of age, were classed with typhoid, and therefore IFrom1 Royal Commission on Vaccination. Dissentient Commissioners ' Statement,section 147 .AGE - INCIDENCE OF TYPHUS FEVER . 47have added these deaths to fever for the other years inthe table-viz.: from 1847-68 and from 1881-95.Englandand Wales.-For fever the deaths at all ages and underfive, and the percentage of deaths under five to deaths at allages in five-year periods from 1847-95.Fever deathsYears. atFever deathsunderPercentageunderall ages. five years of age. five years of age.1847-50(4years) J88,093 15,880 1801851-55 92,440 19,539 2111856-60 82,847 19,072 23.01861-65 95,723 19,166 20.01866-70 94,057 17,352 18.41871-75 70,109 12,994 18.51876-80 47,524 8,375 17.61881-85 37,005 4,692 12.71886-90 28,698 2,908 1011891-95 27,628 2,180 7.9Over the whole period the children's proportion ofdeaths from fever has declined from 18 to 7.9 per cent. ,or a percentage reduction of 56. This is greater or lessthan the figure for small-pox, according to whether thechicken-pox deaths are included or not in the smallpoxtotals.Not only has there been an alteration in the ageincidenceof fever as a whole, but there is every reasonto believe that the same change has taken place in theseveral diseases composing the group. Except in quiterecent years this is difficult to prove in the case oftyphoid fever; but in typhus there is very little doubt thatsuch has been the case. In order to compare presentdaytyphus with some former period, it is necessaryto find, not only years of undoubted typhus, but also48 THE DECLINE IN SMALL- POX .years in which the ages are separated. The epidemicyears, 1837-38, are out of the question, because deathswere not classified at different ages ; but the epidemictook place later in the North of England, and for 1839we have the figures for Manchester and Liverpool. Ialso give the statistics for all England and London forthe epidemic of 1847, which was almost exclusivelytyphus fever.Deaths from typhus fever at all ages and under five, with percentageunder five years of age, for Manchester and Liverpoolin 1839, and for England and Wales and London in 1847 .Percentageunder fiveyears of age .Years.Typhusdeaths atTyphus deathsunder fiveall ages. years of age .Manchester 1 1839 323 51 15.8Liverpool ¹ ... 1839 305 46 151England and Wales 1847 30,320 4,364 144England and Wales(excluding London)Vales 1847 27,136 3,823 141London " 1847 3,184 541 170In 1869 the typhus deaths were separated fromtyphoid in the returns of the Registrar- General. Thefollowing gives the figures for typhus from 1871-95 forEngland and Wales and for London :-Typhusdeathsatall ages.Percentageunderfive yearsofage.TyphusYears.deaths underfive yearsofage.England and Wales 1871-95 18,206 1,040 5.71England and Wales 1871-95(excluding London ) j15,955 848 5.31London ... 1871-95 2,251 192 8.531 Third Annual Report of the Registrar- General , pp. 194 and 206 .Tenth Annual Report of the Registrar- General .AGE - INCIDENCE OF INFLUENZA. 49Thus it would appear that there has been a greatalteration in the age- incidence of typhus fever from thecommencement of registration. Since the separationof typhus and typhoid fevers in the returns of theRegistrar-General , both diseases have shown a changein this particular. The percentages under five years ofage are as follows :-TyphusTyphoid1871-75 . 1876-80. 1881-85 .6.4 613.517.4 160 1121886-90. 1891-95 .3.4 518.4 6.6In typhoid, there has been a marked change inthe age-incidence ; but in typhus, the quinquennium,1891-95 , shows only a slight decline in the children'sshare of deaths as compared with the earlier period,1871-75.The age-shifting of the small-pox death-rate-thatis to say, the lessened death-rate in children combinedwith an increased death-rate in adults-has beenclaimed as a " phenomenon " which is " without a parallelin the history of human mortality. " 2 Mr. AlfredMilnes³ has, however, pointed out that a similar " phenomenon" has occurred in the case of influenza. TheRegistrar-General, in his fifty-fourth annual report(1891 , p. xx. ) , gives the death-rates per million living1 The figures up to 1890 are those given by Mr. Alfred Milnes in theVaccination Inquirer for February, 1893. The last column has beencalculated by me from the returns of the Registrar-General. The typhoidfever percentages have been corrected for remittent fever deaths under fiveyears of age.2 " Vaccination Vindicated, " p 18. John C. M'Vail, M.D. 1887 .3 The Vaccination Inquirer, May, 1893.50 THE DECLINE IN SMALL- POX .at different ages in the influenza epidemics of 1847-48and 1890-91 .Under5.5- 10- 15-25-_Age-periods..35- 45- 55- 65- 75- 85-1847-48 ... 713 80 49 51 79 139 284 809 2,372 5,510 11,2431890-91 ... 306 55 46 115 197 347 595 1,060 1,985 3,355 4,821On comparing this table with that on page 45, it willbe seen that both small-pox and influenza show adecline up to ten years of age. In the next age -period,10-15 , the death - rate at both periods is nearly the same,while from fifteen onwards the later period shows agreater mortality from both diseases ; but the influenzamortality in persons aged sixty- five and upwards showsa decline in the later epidemic of 1890-91 as comparedwith the earlier one of 1847-48 .6Before leaving the subject of age- incidence, I woulddraw the attention of my readers to a table in section171 of the Final Report of the Royal Commission.It gives for England and Wales the deaths from smallpoxat certain age-periods to 1,000 deaths from smallpoxat all ages. The figures under one year of age areas follows :-Deaths from small-pox under oneyear ofage to 1,000 deaths fromsmall -pox at all ages.Years.1848-54 ... ... 2511855-59 ... ... ... 2311860-64 2371865-69 ... ... 2311870-74 ... ... ... 1431875-79 1121880-84 ... ... ... 1131885-89 112...1890-94 166AGE - INCIDENCE OF SMALL - POX. 51From 1848-54 to 1855-59 the proportion of infantilesmall -pox deaths declined from 251 to 231 , or a reductionof 8 per cent. The successful public vaccinations ofinfants under one year of age are given in the Appendix.1On calculation it will be found that from 1848-54 theyaveraged 36.9 per cent. of the births , and from 1855-59,51.5 per cent.; that is to say, that between the twoperiods the proportion increased from 36.9 to 51.5 percent. , or a percentage increase of 39.6. By a similarcalculation, from 1865-69 to 1870-74 they increasedfrom 48.5 to 55.6 per cent. , or a percentage increase of14.6. Between the latter periods the proportion ofsmall- pox deaths under one year of age declined from231 to 143 , or a reduction of 38.1 per cent. To put itin tabular form :From the period1848-54 to 1855-591865-69 to 1870-74...Percentage increasein the proportion ofsuccessful publicvaccinations underone year of age tothebirths.39.614.6Percentage decline in theproportion of small- gxdeaths under one yearof age to 1,000 deathsfrom small-pox at allages.8.038.1It is obvious from the above that there is some causeother than vaccination contributing to the alterationthat has taken place in the age- incidence of the smallpoxmortality.There is another point on which the Commissionershave laid considerable stress . They show that at Leicesterand Gloucester the proportion of small-pox deaths1 It will be observed in the Appendix that the returns are made up toSeptember 29, but for the purposes of these calculations, the proportion ofsuccessful public vaccinations under one year of age to the births has beenestimated to December 31 for the years in question .52 THE DECLINE IN SMALL- POX.under ten years of age is greater than in the wellvaccinatedtowns of Sheffield and Warrington. Thefigures given are as follows :-Epidemics.Small-poxdeathsatall ages.Small-pox deathsunder tenPercentageunder ten yearsyears ofage. ofage.Warrington, 1892-93 62 14 22.5Sheffield, 1887-88 500128 25.6London, 1892-93182 67 36.8Dewsbury, 1891-92 110 57 51.8Gloucester, 1895-96 434280 64.5Leicester, 1892-93 2115 {(or 66:6)71.41If the reader will consult the diagram in the Appendix,he will find that England and Wales, for seventeenyears previous to the epidemic of 1871-72, wasvery well vaccinated. In that epidemic there were42,220 deaths from small-pox, of which 20,094, or 47.6per cent. , were under ten years of age. This is doublethe proportion at Warrington and Sheffield , and verynearly the same as at Dewsbury, where, according tothe Commissioners, vaccination had been greatly neglected.In 1892, the second year of the Dewsburyepidemic, the percentage of children born and notfinally accounted for with regard to vaccination was37.7 . In England and Wales, in 1872 , the default wasonly 5.1 per cent .As the Commissioners have, in two of the townsnamed, based their conclusions on a small number of1 The 66.6 per cent. is an alternative figure put forward by the Commissionersin their desire to state the case fairly, and is obtained bysubtracting certain deaths which resulted from small-pox taken in consequenceof the proximity of a scarlet fever ward to the hospital in whichsmall-pox cases were treated.AGE - INCIDENCE OF SMALL- POX . 53deaths, perhaps I may be forgiven if I add the following:-Small-poxdeathsatall ages.44Small-pox deathsunder fiveyears ofage.Percentageunder five yearsofage.Epidemics.1Mold, 1871-72Willenhall , 1894Keighley, 1893 ...47715 34116 3400 00I shall have occasion to refer to Mold and Willenhallin subsequent chapters. It is sufficient to say here that,at the time of their respective epidemics, both were verywell-vaccinated districts. With regard to Keighley ,there is no reason to believe it to be better vaccinatedthan Leicester or Gloucester; indeed, evidence pointsto the contrary. I do not wish to infer from the experienceof these districts that vaccination increases theshare of the small-pox mortality borne by children ;the figures are too small for accurate inferences, as alsoare those of the Commissioners .To sum up the contents of the present chapter, it willappear that, although there has been a marked declinein small-pox since the last century, there has beenan equal, if not a greater, reduction in typhus fever.It has also been shown that since the commencement ofregistration the vaccination of a gradually increasingproportion of the population previous to the great1 'The local Registrar has kindly supplied me with the figures for theregistration sub-district of Mold.At Leicester , in 1892-93 , of twenty- one small -pox deaths , nine wereunder five years of age. If the deaths of those children who sufferedfrom the proximity of the scarlet fever ward to the hospital in whichsmall -pox cases were treated be left out of the calculation, 412 per cent .of the total deaths from small-pox at Leicester were under five years ofage, a proportion not much higher than that of Willenhall or Mold.54 THE DECLINE IN SMALL- POX .epidemic of 1871-72 had very little effect on the smallpoxdeath - rate, although there was an appreciablediminution in fever. From this epidemic to the presenttime, with an increasing neglect of vaccination since1881 , an enormous decline in small-pox has taken place,and a corresponding diminution in typhus and scarletfevers ; the reduction in all three diseases being due, nodoubt, in large measure to the sanitary improvementsintroduced by the Public Health Act of 1875 .With regard to the age- incidence, when small -poxfirst began to be much known, in the Stuart period, itwas chiefly as a malady attacking adults ; as it becamemore generally diffused, in the eighteenth century(except in a few country districts where epidemicscame infrequently), it was almost entirely a disease ofchildhood ; and more recently it is recognised again asa disease attacking adults as well as children. Thatthis is not due entirely, or even principally, to vaccination,seems clear from the fact that a similar alterationof incidence has taken place in the unvaccinated.Another notable point is that, since the commencementof registration, the most important decline in the proportionof infantile small-pox deaths has not coincidedwith the period representing the greatest increase inthe public infantile vaccination ; nor is there sufficientevidence to show that the children in well- vaccinatedtowns suffer less than in those districts where vaccinationhas been largely neglected. When we come tocompare the behaviour of other diseases in this particular,we find that in the only group which are fairlycomparable with small-pox a similar change has beenobserved .POCK -MARKED FACES. 55Before concluding the chapter, I must allude to afavourite argument in defence of vaccination, whichseems to weigh with a large number of people that is,the rarity of pock-marked faces at the present time,as compared with some former period . As to thedisfigurement of the population in the seventeenth andeighteenth centuries, there is little or no evidence ; butit is significant that in the issues of the London Gazette,from 1667-1774, of one hundred advertisements forrunaway apprentices, servants who had robbed theirmasters , horse-stealers, highwaymen, etc., only sixteenwere described as more or less marked with small-pox,four being black men or boys. This consecutive hundredincluded only those who were so particularlydescribed in feature that pock-marks would have beenmentioned had they existed. Apparently pock -markedfaces were not so common as is generally imagined .The argument that vaccination has lessened the numberis an old one, for in their annual report for 1821 theNational Vaccine Board say :-" We appeal confidentlyto all who frequent the theatres and crowded assembliesto admit that they do not discover in the rising generationany longer that disfigurement of the human facewhich was obvious everywhere some years since. "In the report for 1825 we read :-" What argumentmore powerful can be urged in favour of vaccination,than the daily remark which the least observant mustmake, that in our churches, our theatres, and in everylarge assemblage of the people, to see a young personbearing the marks of small -pox is now of extremely1 " A History of Epidemics in Britain, " vol . ii. , p. 454. Creighton .56 THE DECLINE IN SMALL- POX .rare occurrence ? " Half a century afterwards, in 1872 ,the Lancet, of June 29 (vol. i. , p. 907), lamented " thegrowing frequency with which we meet persons in thestreet disfigured for life with the pitting of small-pox.Young men and, still worse, young women are to beseen daily whose comeliness of appearance is quitecompromised by this dreadful disease."Thus, while with the limited vaccination of 1825 thedisfigurement of the young was extremely rare, yet,after nineteen years of compulsion, pock-marked faceshad conspicuously increased. It is difficult to constructany scientific theory of protection from these facts,and we may therefore conclude that the argument sooften brought forward as conclusive is illusory anduntrustworthy.CHAPTER III .SOME OF THE CAUSES OF THE DECLINE IN THESMALL - POX MORTALITY.IN the last chapter attention was directed to the factthat although some of the epidemics of small -pox inthe present century have been nearly as severe asthose of the two previous ones, yet they took placeat longer intervals ; and thus there has been an importantreduction in the mortality from this malady.The disease began to subside, however, before theintroduction of vaccination, and was part of a generalimprovement in the public health which was takingplace about this time. This is seen in the followingtable compiled by Dr. Farr.London. Average annual death-rates per 100,000 living at sixdifferent periods, from 1629-1835.1All causes. Small -pox.2 Fever.1629-35 5,000 189 6361660-79 8,000 417 7851728-57 5,200 426 7851771-80 5,000 502 6211801-10 2,920 204 2641831-35 3,200 83 III1 " M'Culloch's Statistical Account of the British Empire," vol. ii. ,p. 579. (Second edition. ) London. 1839.*In a pamphlet by Mr. Ernest Hart , entitled , " The Truth About Vaccination" ( 1880, p. 35), it is stated that " In Dr. Farr's valuable article onVital Statistics in ' M'Culloch's Account of the British Empire,' it is shownthat in the twenty-seven years , 1629-35 and 1660-79, the annual mortality558 CAUSES OF DECLINE IN SMALL- POX .Commenting on these figures, Dr. Farr says :-" Smallpoxattained its maximum mortality, after inoculationwas introduced. The annual deaths of small -pox registered1760-79 were 2,323 ; in the next twenty 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."Considering, also, that since the commencement ofregistration small-pox has completely ignored thefluctuations in the amount of vaccination, it is beggingthe question to assume that this is in any way relevantto the diminution that has been recorded. I propose,therefore, in the present chapter, to indicate someof the causes which have led to the decline of thedisease.It will be convenient at this juncture to consider theeffect produced on the small-pox mortality in the displacementof small-pox inoculation by vaccination. Asit was only in rare instances that the inoculated weresubjected to any form of isolation, it cannot be deniedthat they must often have acted as centres of infectionand have diffused the disease. Dr. Wagstaffe,¹ writing in1722, related an instance where, in consequence of a fewinoculations, small-pox was spread in the town of Hertford,and occasioned a considerable mortality. In Paris,in 1763 , the unusual severity of small-pox was attributedfrom small- pox in London was equal to nearly 16,000 per million personsliving ; and in the forty years, 1728-57 and 1771-80, to nearly 18,000 permillion living." It is not at first sight apparent how these high rates havebeen deducted from Dr. Farr's figures.1 A Letter to Dr. Freind, p. 38. London. 1722.SMALL- POX DIFFUSED BY INOCULATION . 59to increased infection from inoculation, and a decreewas issued prohibiting the practice. The advocates ofvaccination were almost unanimous in their opinionthat inoculation was responsible for much loss of lifefrom small-pox; thus Moore¹ declared that the neglect oftheprecaution ofpreventing the spread of infection fromthe inoculated had occasioned the loss of millions oflives." The last statement must, however, for obviousreasons, be received with caution.If we consult the London Bills of Mortality, we findthat the small-pox mortality in the eighteenth centuryexceeded that of the seventeenth century. There arereasons, however, for believing that other causes besidesinoculation must be sought for to explain the highsmall-pox rates in the eighteenth century. One ofthese is, that small-pox rose to a higher level of mortalityabout the year 1710 ; whereas inoculation wasnot introduced into this country until 1721. Dr.Creighton informs us, that " from 1721 to 1727 theinoculations in all England were known with considerableaccuracy to have been 857 ; in 1728 they declinedto 37 ; and for the next ten or twelve years theywere of no account." In London inoculation wasrevived about 1740, and after a few years became alucrative branch of surgical practice, but was restrictedalmost exclusively to the well-to-do. Gratuitous inoculationcommenced with the opening of a hospitalin 1746 ; but it was not till 1751-52, that any consider-1" History of Small-pox," pp. 232, 233. James Moore. London." A History of Epidemics in Britain," vol . ii. , p. 504.1815.60 CAUSES OF DECLINE IN SMALL- POX .able number of people were inoculated in connectionwith the charity.According to the London Bills it does not appearthat the few inoculations which took place during theyears 1721-28 had any appreciable effect on the smallpoxmortality, nor should we expect them to do so ; butif a diagram be prepared showing year by year the ratesof small-pox deaths to those for all causes, it will befound that from 1751 to 1781 a still higher level ofsmall-pox mortality was reached than that whichprevailed from 1710 to 1751 ; this seems to suggestan inoculation factor in the case. After 1781 smallpoxwas certainly at a lower level than that obtainedbetween 1751 and 1781 (although in the one year,1796, it touched the highest point in the century) .This diminution, as Dr. Farr has pointed out, was associatedwith a decline in the general death -rate, and wasno doubt brought about by the sanitary improvementsintroduced at that period ; and thus small -pox becameless prevalent, in spite of the fact that inoculation stillremained in full operation .To sum up the case, it is evident that the largemortality from small-pox in the last century cannot bewholly attributed to inoculation ; but from the facts herepresented I am led to believe that the augmentationwhich took place in 1751 , and continued for a largenumber of years, might with fairness be put down to thiscause. The first sign of any diminution in the small -poxdeath- rate commenced after 1781. This cannot be dueto any falling off in the amount of inoculation, but mustbe associated with a general improvement in the publichealth then observable ; the further decline after theFLUCTUATIONS IN SMALL- POX MORTALITY. 61introduction of vaccination was in part probably broughtabout by the substitution of a non- infectious process.¹One of the causes of the spread of small-pox is overcrowdingand want of air-space in and around houses.The fifth annual report of the Registrar-General givesthe country and the town mortality from various causesfor the four years 1838-41 ; in the case of small -pox theformer is 507, and the latter 1,045 per million ; for allcauses the figures are 19,300 and 27,073 respectively.This shows that small-pox is much more influenced bythe aggregation of the population than by all othercauses of disease combined. The mortality from smallpoxappears to vary according to the greater or lesserproportion of open spaces in towns.table illustrates this point.The following1As most of the lymph with which the early " vaccinations " were performedwas of variolous origin, it is important to show that after a timethe cases inoculated with Woodville's lymph ceased to be infectious Thefollowing , in a letter from Jenner to Lord Egremont (Baron's " Life ofJenner," vol. i. , p. 342), is very much to the point. Referring to thethreads distributed by Dr. Pearson, Jenner says :-" In many places wherethe threads were sent , a disease like a mild small-pox frequently appeared ;yet, curious to relate, the matter , after it had been used six or seven months,gave up the variolous character entirely , and assumed the vaccine ; thepustules declined more and more, and at length became extinct. I nadesome experiments myself with this matter, and saw a few pustules on myfirst patients ; but in my subsequent inoculations there were noneود62 CAUSES OF DECLINE IN SMALL- POX.For twenty large towns¹ the acres of town area to one acre ofpark, and the average annual death-rate per 1,000, for the tenyears 1870-79, from small-pox, measles, scarlet fever, fever,and whooping- cough.Acresof Average annual death-rate per 1,000 living,for the ten years 1870-79.town areato one acre Smallofpark.ScarletMeasles. Fever.Whoopingpox.fever. cough.Bristol 10...21... 45 99 50 54LiverpoolBrighton10... 58 76 1.35 95-88... ...22 13 '29 472649London ... ... 23 *48 52 71 42 79Leicester ... ... 32 33 *38 84 *48 49Bradford 34 09 46 112 65 58Manchester ... 34 19 57 1'02 69 88Birmingham ... 38 37 42 115 48 84Leeds ... ... 47 18 *48 I'II 73 65PlymouthNottingham... ... 63 39 71 32 49 7366 ... 40 30 65 69 34Salford ... ... 74 5581 9768 86Oldham ... ... 78 1653 1.53 *48 66Sunderland ... 115 92 33 119 74 72Hull ... ... 117 25 27 84 83 48Newcastle-on-Ty 153 65 '30 119 67 55Sheffield ... ... 249 42 40 1.50 8566280...1,067PortsmouthNorwichWolverhampton ( no parks)This table indicates generally, that towns with thegreatest amount of park space have low small - poxdeath - rates, and vice versa. Liverpool appears to be anexception, but it will be noticed that in this town therates for the other zymotic diseases are also very high,52 38 62 75 40702655 52 5768 31 93 56 601 Fortieth and Forty-second Annual Reports of the Registrar- General .SALUTARY EFFECT OF OPEN SPACES.2563due to overcrowding and sanitary neglect. It must beremembered, that with regard to air supply, small townswould have the advantage of large ones. A singledwelling would be surrounded on all sides with air ; butsuppose we have a group of houses of equal sizesarranged symmetrically in the form of a square, withfive houses to a side, there will be sixteen outside houseswith twenty-five altogether, and the fraction willrepresent the external aerial supply ; with one hundredhouses to a side, this will be shown by the smallerfraction 396 and hence the difference in the externalventilation of the two groups of houses wouldbe very large, being represented by the differencebetween the two fractions and 1 Thus,independently of park space, a small town would havebetter external ventilation for its houses than a large one ;this may to some extent explain several exceptions inthe table.100006400 39610000It may be that there are other causes than theamount of park space to account for the difference inthe small-pox mortality in the several towns specified,but the figures, in comparison with those of theother zymotic diseases, appear to be so striking as tosuggest that external ventilation really exercises animportant influence on the prevalence and mortalityof this disease.The epidemic of 1871-72, which largely dominates thesmall -pox figures in the last table, was conspicuouslysevere in the mining districts, which, as a rule, are mostovercrowded. Durham was one of the most devastatedcounties, eleven of the thirteen registration districtshaving enormous small-pox death-rates .64 CAUSES OF DECLINE IN SMALL- POX .... ... 40,812... ... 99,705Registrationdistricts.DarlingtonStocktonPopulationin 1871.Deathsfromsmall-pox inthe 1871-72epidemic.Small-poxdeath-ratepermillion.152 3,724432 4,333Hartlepool ... ... 39,970 175 4,378Auckland ... ... 69,159 536 7,750Durham ... ... 91,978 835 9,078Easington ... ... 33,694 293 8,696Houghton-le-Spring .. 26,171 193 7,375Chester- le- Street ... 33,300 209 6,276Sunderland ... 112,643 1,011 8,975South Shields ... 74,949 744 9,927Gateshead ... ... 80,271 514 6,403Dudley, in Staffordshire, had a small-pox deathrateof 8,977, Newcastle one of 6,456, and Bedwellty,Pontypridd, Merthyr, Swansea, Abergavenny, rates of8,520, 7,492 , 6,380, 5,627, and 4,768 per million respeс-tively. Thus we see that small-pox picks out itsvictims from thickly - populated centres, and moreespecially towns which are imperfectly aerated, andwhere, as in mining districts, the industrial conditionspredispose to overcrowding.That our ancestors had a less plentiful supply of freshair in and around their houses goes without saying. Itis a well-known fact that our towns have increased inarea quite out of proportion to the increase in the population.Mr. John Timbs observes that the majority ofthe London squares were the growth of the last century,and that few of those in the western district existedbefore 1770, their sites being then mostly sheep-walks ,1 The epidemic was not limited to the years 1871 and 1872, in somecases it extended over several years ." " Curiosities of London, " pp. 746 , 747. John Timbs, F.S.A. 1867 .INCREASE OF METROPOLITAN AIR - SPACES. 65paddocks, and kitchen - gardens ; but we know thatseveral of the London squares existed in the seventeenthcentury, and there is a reference to BloomsburySquare in " Evelyn's Diary," under the date February 9,1665 :-" Dined at my Lord Treasurer's, the Earle ofSouthampton , in Blomesbury, where he was building anoble square or piazza, a little towne; his owne housestands too low, some noble roomes, a pretty cedarchapell, a naked garden to the north, but good aire. "At the beginning of the eighteenth century Grosvenor,Cavendish, and Hanover Squares were laid out, the lasttwo about the year 1718. Portman, Manchester, Finsbury,and Fitzroy Squares were constructed at the endof the last century ; and at the beginning of thepresent century, about 1804, Russell Square, one ofthe largest in London, was finished, and about thistime, also, Bedford and Euston Squares were opened.In 1829 a variety of important improvements weremade immediately around St. Martin's Church ;a whole labyrinth of close courts and small alleyswere swept away, a district including places knownas the Bermudas, the Caribbee and Cribbe Islands,and Porridge Island, notorious for its cook - shops ; ¹this wholesome and wholesale clearance prepared thesite for the construction of Trafalgar Square. Othersquares, such as Lowndes and Woburn Squares, weremade about 1836 ; while Blandford, Harewood, andDorset Squares are of more recent construction .Besides a deficient aeration of towns , our ancestorssuffered under an insanitary tax upon light and air,1 See Cassell's " Old and New London," vol. iii. , p. 141 .66 CAUSES OF DECLINE IN SMALL- POX .known as the window-tax. This was imposed in orderto make good the deficiencies of the clipped money.Its origin, in 1695, has been described by LordMacaulay :-" It was a maxim received among financiersthat no security which the government could offer wasso good as the old hearth -money had been. That tax,odious as it was to the great majority of those whopaid it, was remembered with regret at the Treasuryand in the City. It occurred to the Chancellor of theExchequer that it might be possible to devise an imposton houses, which might be not less productive nor lesscertain than the hearth-money, but which might pressless heavily on the poor, and might be collected by aless vexatious process. The number of hearths in ahouse could not be ascertained without domiciliaryvisits. The windows a collector might count withoutpassing the threshold. Montague proposed that theinhabitants of cottages, who had been cruelly harassedby the chimney men, should be altogether exemptedfrom the new duty. His plan was approved by theCommittee of Ways and Means, and was sanctionedby the House without a division. Such was the originof the window-tax, a tax which, though doubtless agreat evil, must be considered as a blessing whencompared with the curse from which it rescued thenation . " ¹The tax first fell largely on the landlord, but by the20th of George II . ( 1746) it was levied upon the severalwindows of a house at so much per window, and consequentlyfell more cruelly upon the tenants of the1 " History of England," vol . iv. , p. 641. Macaulay.THE WINDOW-TAX. 67tenement houses. By the 21st of George II . , cap. 10,all skylights, the lights of staircases, garrets, cellars , andpassages , were to count for the purpose of the tax ; andit was further enacted ( 11th section) that " no windowor light shall be deemed to be stopped up unless suchwindow or light shall be stopped up effectually withstone or brick, or plaister upon lath, etc. " The law wasenforced by a corrupt machinery of commissioners,receivers - general, and collectors , who were paid byresults , and thus could hardly fail to act injuriously.In 1803 the law was altered, the houses being rated as awhole according to the number of their windows, andat the same time the tax for tenement houses was maderecoverable from the landlord ; it thus became a sort ofmodern house-tax rated on windows.¹The great speculative builder of the Restoration wasNicholas Barbone, and his method of procedure maybe inferred from the following :-" He was the inventorof this new method of building by casting of groundinto streets and small houses, and to augment theirnumber with as little front as possible, and selling theground to workmen by so much per foot front, and whathe could not sell, built himself. This has made groundrents high for the sake of mortgaging ; and others, followinghis steps, have refined and improved upon it,and made a superfoetation of houses about London. " 2" In these mazes of alleys, courts or ' rents,' " Dr.Creighton says, " the people were, for the most part,1 For the above description of the window-tax, I am indebted to Dr.Creighton's " History of Epidemics. "* Quoted by Dr. Creighton from " Lives of the Norths." "A Historyof Epidemics in Britain," vol. ii. , p. 86.68 CAUSES OF DECLINE IN SMALL-POX .closely packed. Overcrowding had been the rule sincethe Elizabethan proclamation of 1580, and it seems tohave become worse under the Stuarts. On February24, 1623 , certain householders of Chancery Lane wereindicted at the Middlesex Sessions for sub-letting, ' tothe great danger of infectious disease, with plague andother diseases. ' In May, 1637, one house was foundto contain eleven married couples and fifteen singlepersons ; another house harboured eighteen lodgers. Inthe most crowded parishes the houses had no sufficientcurtilage, standing as they did in alleys and courts.When we begin to have some sanitary informationlong after, it appears that their vaults, or privies , wereindoors, at the foot of the common stair. In 1710,Swift's lodging in Bury Street, St. James's, for which hepaid eight shillings a week, had a ' thousand stinks init,' so that he left it after three months. The House ofCommons appears to have been ill-reputed for smells ,which were specially remembered in connection withthe hot summer of the great fever -year, 1685. "In the days of the Tudors and the Stuarts, the personalhabits even of the upper classes left much tobe desired. Fresh linen being a luxury, the clotheswere seldom changed, and the dyer was more often inrequisition than the laundress. Sir John Falstaff thusdescribes the contents of the buck or linen-basket :-" Foul shirts and smocks , socks, foul stockings, andgreasy napkins ; that, Master Brook, there was therankest compound of villainous smell that ever offendednostril . " ¹1 " The Merry Wives of Windsor," act iii. , scene v.DOMESTIC INSANITARY CONDITIONS. 69From a washing tally found behind some oakpanelling in the old chaplain's room at Haddon Hall ,in Derbyshire, it would appear that towels had notalways belonged to the domestic arrangements of thisestablishment, for in place of that word, which wasscratched out, " laced bands " had been written on thehorn of the tally.Some interesting relics called " scratch- backs " havecome down to us, the name sufficiently indicating thehabits of the aristocracy of the time. A scratch -backis a hand or claw set in a long handle, which was sometimesmade of silver elegantly chased, and there is oneinstance where a ring on the finger of the hand is setwith brilliants. At one time these implements were asindispensable to a lady of fashion as her fan or herpatch -box. They were kept in her toilet, and carriedwith her even to her box at the play. They belong toa period when personal cleanliness was not consideredessential, when the style of dress worn was anythingbut conducive to comfort and ease, and when ladieswore immensely high head -dresses, which, when oncefixed, were frequently not disturbed or altered for amonth, and not until they had become almost intolerableto the wearer and to her friends .In the sixteenth and seventeenth centuries, the stateof the public health in London was at a very low ebb.The town ditch was a receptacle for all kinds of rubbishand decomposing organic matter ; the streets were unpaved,and saturated with slops and other filth . Insteadof regular highways, the out- parishes were reached bya maze of narrow passages and alleys. The dwellingsof the poor were as bad as they well could be ; the70CAUSES OF DECLINE IN SMALL- POX.houses projected over the roadway, which was so narrowthat they almost met at the top ; there was no attemptat ventilation, and up to and even beyond the timeof Queen Elizabeth, the floors were strewn with rushes,and, if we may trust to an epistle from Erasmus tohis friend Dr. Francis, physician to Cardinal Wolsey,it would appear that these were seldom thoroughlychanged, and, the habits of the people being uncleanly,the smell soon became intolerable. He speaks of thelowest layer of rushes (the top only being renewed) assometimes remaining unchanged for twenty years, areceptacle for beer, grease, fragments of victuals, excrementaland other organic matter. To this filthiness ,Erasmus (one of the most actue observers ) ascribed thefrequent pestilences with which the people were afflicted.Even as late as the beginning of the present centurythings were very different to what they are now. Thus,Willan, writing of fever, says :-" Among the poor the mortality from this cause(contagious malignant fever) was nearly one in fourof all persons affected, notwithstanding the attentiveadministration of proper articles of diet, and of suitableremedies, with plenty of wine." The good effects of all these applications are almostwholly superseded by the miserable accommodations ofthe poor with respect to bedding, and by a total neglectof ventilation in their narrow, crowded dwellings. It willscarcely appear credible, though it is precisely true, thatpersons of the lowest class do not put clean sheetson their beds three times a year ; that, even where nosheets are used , they never wash or scour their blanketsand coverlets, nor renew them till they are no longerDOMESTIC INSANITARY CONDITIONS. 71tenable; that curtains, if unfortunately there should beany, are never cleaned, but suffered to continue in thesame state till they drop to pieces ; lastly, that fromthree to eight individuals, of different ages , often sleepin the same bed ; there being, in general, but one room ,and one bed for each family. To the above circumstancesmay be added, that the room occupied is eithera deep cellar, almost inaccessible to the light, and admittingof no change of air, or a garret, with a low roof andsmall windows, the passage to which is close, kept darkin order to lessen the window-tax, and filled not onlywith bad air, but with putrid, excremental, or otherabominable effluvia from a vault at the bottom of thestaircase. Washing of linen, or some other disagreeablebusiness, is carried on while infants are left dozing, andchildren more advanced kept at play whole days on thetainted bed ; some unsavoury victuals are from time totime cooked. In many instances idleness, in others thecumbrous furniture or utensils of trade with which theapartments are clogged, prevent the salutary operationof the broom and whitewashing brush, and favour theaccumulation of a heterogeneous , fermenting filth . Therooms do not change their condition till they changetheir tenants. Often, indeed, so little care is taken thatenough of the old leaven reinains to infect all theinmates who successively occupy the same premises.I recollect a house in Wood's Close, Clerkenwell,wherein the fomites of fever were thus preserved fora series of years ; at length a friendly fire effectuallycleared away the nuisance. A house notorious for dirtand infection, near Clare Market, afforded a furtherproof of negligence ; it was obstinately tenanted till the72 CAUSES OF DECLINE IN SMALL- POX.walls and floor giving way in the night crushed to deaththe miserable inhabitants. From all these causes combinedthere is necessarily produced a complication offoetor, to describe which would be as vain an attemptas for those to conceive who have been always accustomedto neat and comfortable dwellings." The above account is not exaggerated. For thetruth of it I appeal to the medical practitioners, whosesituation, or humanity, has led them to be acquaintedwith the wretched inhabitants of some streets in St.Giles's parish, of the courts and alleys adjoining LiquorpondStreet, Hog Island, Turnmill Street, Saffron Hill ,Old Street, Whitecross Street, Grub Street, GoldenLane, the two Brick Lanes, Rosemary Lane, PetticoatLane, Lower East Smithfield, some parts of UpperWestminster, and several streets of Southwark, Rotherhithe,etc." It cannot be wondered at, that in such situationscontagious diseases should be formed, and attain theirhighest degree of virulence. The inhabitants of thesecond storey in houses occupied by the poor areusually better accommodated, and therefore experience ,during sickness of any kind, the best effect from publicand private charities. But persons thus stationed sufferfrom contiguity, and from their friendly attentions tothose above them, or to the tenants of the cellars ; sothat in whatever part of the house a fever commences ,it is soon diffused among all the inmates and theiroccasional visitors, especially in seasons which favourits progress like the last autumn and winter.is a melancholy consideration that in London and itsvicinity hundreds, perhaps thousands of labourers , headsItEIGHTEENTH CENTURY PRISONS . 73of families, and in the prime of life, are thus consignedto perish annually, being often so situated that medicalapplications or cordial diet cannot in any wise alleviatetheir distress. " 1The sanitary condition of the prisons in the lastcentury, as discovered by the great prison reformer,John Howard, gives some indication of the ignorancethat prevailed in regard to the public health at thattime. In the Introduction to his book, he tells us thatin his inspection of gaols, he noticed a complication ofdistress, but his attention was principally arrested bythe gaol fever and the small-pox, which he saw prevailingto the " destruction of multitudes," not only offelons in their dungeons, but of debtors also. On page 8 ,in describing the air in prisons, he says :-" My readerwill judge of its malignity, when I assure him that myclothes were in my first journeys so offensive, that in apost-chaise, I could not bear the windows drawn up,and was therefore often obliged to travel on horseback.The leaves of my memorandum book were often sotainted, that I could not use it till after spreading it anhour or two before the fire ; and even my antidote, avial of vinegar, has, after using it in a few prisons ,become intolerably disagreeable. I did not wonderthat in those journeys many gaolers made excuses , anddid not go with me into the felons' wards ." From hence anyone may judge of the probabilitythere is against the health and life of prisoners, crowded1 Dr. Willan's " Observations on Diseases in London. " Medical andPhysical Journal, vol . iii . , pp. 298-300. (April , 1800. )" The State of the Prisons in England and Wales." (Second Edition . )1780. John Howard, F.R.S.674 CAUSES OF DECLINE IN SMALL- POX .in close rooms, cells, and subterranean dungeons, forfourteen or sixteen hours out of the four-and -twenty.In some of those caverns the floor is very damp ; inothers there is sometimes an inch or two of water,and the straw, or bedding, is laid on such floors ,seldom on barrack bedsteads. Where prisoners arenot kept in underground cells, they are often confinedto their rooms, because there is no court belongingto the prison, which is the case in most city andtown gaols."There was much overcrowding. On page 21 weread :-" Debtors crowd the gaols (especially those inLondon) with their wives and children . There are oftenby this means ten or twelve people in a middle-sizedroom , increasing the danger of infection. " John Howardobserves the effect of the window-tax (p. 9) :-" One causewhy the rooms in some prisons are so close, is perhapsthe window- tax, which the gaolers have to pay ; thistempts them to stop the windows, and stifle theirprisoners."Concerning the water supply and drainage, we read(pp. 8, 9) :-" Many prisons have no water. This defect isfrequent in bridewells and town gaols. In the felons'courts of some county gaols there is no water ; in someplaces where there is water, prisoners are always lockedup within doors, and have no more than the keeper orhis servants think fit to bring them. In one place theywere limited to three pints a-day each-a scanty provisionfor drink and cleanliness ! Some gaols have nosewers, and in those that have, if they be not properlyattended to, they are, even to a visitant, offensive beyondexpression. How noxious, then, to people constantlyAGE - INCIDENCE AND SANITATION . 75confined in those prisons ! " Under these conditions,is it to be wondered at, that typhus and small -poxprevailed to the " destruction of multitudes " ?Howard's attention was arrested by the insanitarystate of the prisons, but it is doubtful whether the poor,especially in the large towns, lived in a much healthieratmosphere than the prisoners. Dr. William Buchan ,in his work on " Domestic Medicine," says :-" Wheneverair stagnates long, it becomes unwholesome ; hence theunhappy persons confined in jails not only contractmalignant fevers themselves, but often communicatethem to others . Nor are many of the holes, for we cannotcall them houses, possessed by the poor in great townsmuch better than jails. These low, dirty habitations,are the very lurking-places of bad air and contagiousdiseases. Such as live in them seldom enjoy goodhealth, and their children commonly die young. " ¹Thus, Dr. Buchan connects the high mortality ofchildren in the last century with overcrowding and filth .From these facts we may infer, that sanitary reformwould tend to alter the age - incidence of zymotic disease.This has been fully recognised by the Registrar- General inthe following notable words :-" That the sanitary effortsmade of late years should have more distinctly affectedthe mortality of the young is only what might be naturallyanticipated ; for it is against noxious influencesto which the young are more especially sensitive thatthe weapons of sanitary reformers have been chieflydirected . " 21 " Domestic Medicine," p. 86. ( Tenth edition. ) 1788. WilliamBuchan , M. D.2 Forty- second Annual Report of the Registrar - General , p. xxiii. 1879.76 CAUSES OF DECLINE IN SMALL-POX.There is no reason to believe that small-pox is anyexception to this general law, and in this connection thefollowing table quoted by Dr. Collins and Mr. Picton isnot without interest.¹Fatal small-pox in Scotland, 1871.Small-pox PercentageSmall -poxdeaths atall ages.deathsunder fiveyears ofunder fiveyears ofage.age.Principal towns (population above ) 88625,000)19522.0... ... ..10,000 to 25,000)Large towns (population from 14332 22.3Small towns (population from 2,000 209 55to 10,000Mainland rural districtsInsular rural districts... 183 2526.313.6II 0 ΟΟThe larger proportionate small -pox mortality of childrenin the towns, compared with rural and insular districtsis certainly not due to any difference in the amount ofvaccination , and it is difficult to resist the conclusionthat the young are more injuriously affected by overcrowdingand other insanitary conditions associated withtown life than adults.2While discussing the subject of sanitation, it is necessaryalso to allude to the influence of burial-grounds onmortality. In the last century it was usual to establishthese in the midst of populous towns, and there can beno question, that the constant inhalation of effluvia fromdead bodies , had a deleterious effect on the living .1 Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 148.2 See Paper read by Mr. Alfred Milnes before the Statistical Society,June 15 , 1897 .BURIAL - GROUNDS AND MORTALITY. 77Buchan observes (p. 85 ) : " Certain it is, that thousandsofputrid carcases, so near the surface of the earth , in aplace where the air is confined, cannot fail to taint it ;and that such air, when breathed into the lungs, mustoccasion diseases. " With the growth of sanitary institutions,reforms have been made with regard to the disposalof the dead, and, in nearly all urban districts, the deadare now buried in outlying cemeteries. The nextgeneration will no doubt witness a great extension ofthe still more sanitary practice of cremation, alreadyintroduced in London, Glasgow, Manchester, Liverpool,and other places .Besides insanitation, other causes have probably hadtheir effect on the small-pox mortality.1A number of typhus and small-pox epidemics havebeen intimately associated with periods of scarcity andwant. The winter of 1683-84 was very severe. This wasfollowed by a long drought in the summer of 1684, andanother severe winter in 1684-85 , and not until the springof 1685 was there plentiful rain. In 1685-86 the countrywas visited by a terrible epidemic of fever, and in 1685small -pox was above the average, with 2,496 deaths inLondon, or a rate of 107 per 1,000 deaths from allcauses . The winter of 1708-09 was excessively severe,frost lasting all over Europe from October to March.This was followed by a bad crop of cereals in 1709, theprice of wheat per quarter running up from 27s. 3d. onLady- day, 1708, to 81s. 9d. on Lady-day, 1710.2 In1710, the proportion of small-pox deaths was 127 per 1,000" A History of Epidemics in Britain," vol. ii . , p. 23. Creighton.2 Ibid. , pp. 54, 55-78 CAUSES OF DECLINE IN SMALL- POX.1deaths from all causes ( 3,138 small-pox deaths). 2,810died from small -pox in 1714, or a rate of 106 per 1,000from all causes . This followed a rise in the price of wheat .In 1718 the harvest was a bad one ; and about thistime there was scarcity of employment amongst theweavers in the east end of London ; during the year1719, there were 3,229 deaths from small-pox in London,or a rate of 114 per 1,000 from all causes. Up to themonth of February, 1756, the season had been a forwardone, but the early promise of spring was blighted by cold.This was succeeded by a wet summer and autumn ; thefruit crop was ruined, and the corn harvest spoilt bylong, heavy rains ; dearth and bread riots followed.1757, the proportion of small- pox deaths rose to 155 per1,000 from all causes ( 3,296 small -pox deaths).InA bad harvest in 1794 raised the price of wheat to 55s.(January 1 , 1795 ) ; by August, 1795, it rose to 108s. , fallingin October to 76s. , owing to the action of the Government,in order to avert famine, causing neutral ships-bound to French ports with corn-to be seized andbrought to English ports. In the spring of 1796, theacme of distress was reached, wheat being sold for 100s.per quarter. Mr. Pitt admitted in Parliament that thecondition of the poor " was cruel , and such as could notbe wished on any principle of humanity or policy ; inthis year, the mortality figures showed the largestnumber of small -pox deaths of any year within theLondon Bills , being 3,548, or 184 per 1,000 deaths fromall causes. The harvest in 1816 proved deficient in14" A History of Epidemics in Britain, " vol . ii. , pp. 62 , 64. Creighton .2Ibid. , p. 125. $ Ibid. , pp. 158 , 159 .Eighth Annual Report of the Registrar-General , p. 12.COMMERCIAL DEPRESSION . 79quantity, and inferior in quality. Prices rose from 66s.a quarter in 1815, to 78s. in 1816, and 98s. in 1817. Thiswas succeeded by epidemics of small -pox, relapsingfever , and typhus in 1817-19 .From the Registrar-General's eighth annual report welearn that the year 1837 was one of great commercialdepression. In referring to joint stock banks, MajorGraham says :-" Many of the companies were got upby speculators, for the sole purpose of selling shares.The signal of collapse was given by the failure of theAgricultural Bank of Ireland in November, 1836. TheBank of England assisted the Manchester Northern andCentral Bank in December, the large American housesin February and March, 1837. It was in vain. Commercialcredit fell to its lowest point of depression inthe first half of the year 1837." 2 Again-" In 1837 theprice of bread rose rapidly, while trade was depressed,and speculation sat exhausted in the midst of ruin. " 3During the several years commencing in 1837, one ofthe most disastrous small -pox epidemics of the nineteenthcentury occurred , and also a very severe epidemicof typhus.Another cause of the diffusion of small -pox, as well asof typhus and dysentery, is probably war. Dr. , Guywrites :-" War is a special cause of that more generalcondition of overcrowding, so destructive to health, soproductive of disease. It consists in bringing one crowdof trained, armed, and disciplined men into collision withanother, under circumstances highly unfavourable tohealth . It reaches its climax in civil war, in prolonged1 Eighth Annual Report of the Registrar-General , p. 16 .2 Ibid. , p. 23 . Ibid. , p. 24.80 CAUSES OF DECLINE IN SMALL- PΟΧ .1siege operations, and when armies are quartered amongcivil populations. " The shock of battle also, with itsattendant anxiety, and the high tension of the organism ,are important and undeniable factors in the productionof epidemic diseases .Mr. Alexander Wheeler pointed out before the RoyalVaccination Commission (Q. 7,994) that during almostthe whole of the last century Europe was one hugebattle-ground, and wars continued on and off until theyear 1815. The fact that small -pox was decliningduring the opening years of the present century, doesnot exclude war as one of the causes of this disease .As to the effects of war. In a work by Mr. William F.Fox, entitled " The Losses of the American Civil War, " weread :-" 110,070 were killed , 249,458 died of other causes ,making 359,528 in all in the Northern army. " In speakingof the 249,458 who died from disease, Mr. Fox says :" One-fourth died from fever, principally typhoid ; onefourthfrom diarrhoea or other forms of bowel complaint ;one-fourth from influenza and lung complaints ; and onefourthfrom small-pox , measles, brain diseases , erysipelas,and various other forms of disease common to themasses . " 2With regard to the Franco- Prussian War, Mr. Wheeler,in his evidence before the Royal Commission, quotedsome of the commissioners sent to Eastern France to aidthe peasantry. One of these, Dr. Robert Spence Watson ,has published his experiences, from which the followinghave been extracted. I may state that in 1870 there1Journal of the Statistical Society, December , 1882 , p. 579.2 Third Report , Royal Commission on Vaccination, Q. 8,056 .3 " The Villages Around Metz. " Newcastle-on-Tyne. 1870.THE EFFECTS OF WAR. 81was not more small -pox than usual until the later monthsof the year. Its increase was at the time of the terribleslaughter following the invasion of France." November 6, 1870. Then I went to Lessy andChatel St. Germain, hearing everywhere the same stateof distress. All the crops gone, all the winter's firewoodgone, many houses destroyed, and numbers needing helpin every village. When the mare's hoofs sunk deep,she knocked up bits of flesh, and the stench was so sickeningthat I should have fainted but for my smelling salts.It was a strange and sad sight ; sometimes twenty- fiveheaps of graves within sight at once. These graves arein a bad state, many of them were too shallow to beginwith . The heavy rains have caused them to sink in, andthey are covered with an inch or more of black, oilywater, which has, when disturbed, a most disgustingstench " (pp. 22, 23)." November 7th. All men and officers alike speakof the terrible loss of blood. At Rezonville, and inits neighbourhood, the people say 18,000 Germans areburied . This I doubt, but the number must be enormous" (p. 25) ." November 9th. Metz was literally crammed withsoldiers. The Germans strong, hearty, conscious ofvictory ; the French-cowed, worn, starved, and miserable.In one place there were fifteen long streetsof railway vans, filled with typhus patients ; in anotheras many streets of canvas tents, also filled with sick. Ivisited these places, and found them in the filthiest state ;but the Germans had begun to put them into order. Atfirst , you might see soldiers, in full small -pox, walkingabout the streets, but this was soon forbidden " (p. 28 ).82 CAUSES OF DECLINE IN SMALL- POX.Dr. Watson concluded his last letter with the observationthat " unless England puts forth her hand liberallyand wisely, the coming winter must see in that beautifuland fertile land an amount of misery, famine, and plaguewhich it is too dreadful to contemplate " (p. 36).Another commissioner has kindly furnished me withthe following statement :-" Mr. William Jones, of Sunderland,was one of those who went out on behalf ofthe Society of Friends to relieve the sufferings of thepeople. He was present at Metz when Marshal Bazaine'sarmy surrendered. The main body were encampedoutside the walls of Metz , on low ground near theMoselle, the wetness of the season having convertedthe camping-ground into a morass. In some placesthe impress of the men's bodies was left as a cast in themud in which they had lain. Their clothes and theirblanket were saturated with mud. Their food for weekshad only been a biscuit and a bit of horseflesh withoutsalt. Dysentery was universal, and typhus and smallpoxraged. Over a wide area around the camp thecarcases of dead horses were left to rot and contaminatethe air. On the 29th of October, 1870, Mr.Jones and his companion, Mr. Allen, were permitted toenter the city, which had opened its gates to admit theGerman army, which marched through in triumph. Thenarrow streets were crowded with French soldiers disarmed, and looking diseased and hunger-bitten. Numbersof them were going about the streets with confluentsmall -pox fully out over their faces. Black typhusraged in the hospitals. Ultimately the worst cases wereremoved into 320 railway vans drawn up in the ' GrandePlace.' No one was allowed to pass the GermanMALTHUS DISCOVERS A NEW PRINCIPLE . 83sentries into the square, but the constant cry of thewretched sufferers for water was distinctly heard by Mr.Jones outside the square in which they were isolated.It was stated that all these black typhus patientsperished, and were buried in huge trenches outsidethe walls of the city." Mr. Jones's companion, Mr. Allen, who was vaccinated,and, he believes, re -vaccinated , took the small - pox,and his own sister, who came over to nurse him, caughtthe disease from him and died there, and was buried inthe cemetery at Plantières outside the walls of Metz." N.B.-Mr. John Bellows, of Gloucester, who followedMr. Jones to Metz , states in his pamphlet, ' The Track ofthe War round Metz,' that, of the twelve commissionersof the Society of Friends who were present in Metz, eightwere at one time ill, five being down with small -pox ,and one ( Miss Allen) died of small -pox . "There is, indeed, some reason to believe that this warwas the starting point of the great European pandemicof small-pox in 1871-72 .Another cause of the decline in small- pox during thepresent century, especially among children, remains tobe told. Malthus, in 1803, wrote :-" For my own part,I feel not the slightest doubt, that, if the introduction ofthe cow- pox should extirpate the small- pox, and yetthe number of marriages continue the same, we shallfind a very perceptible difference in the increasedmortality of some other diseases. " Malthus, thus early,clearly saw that even if cow- pox had possessed all the1 " An Essay on the Principle of Population," p. 522. T. R. Malthus.London. 1803.84 CAUSES OF DECLINE IN SMALL- POX .virtues that were claimed for it, the reduction in the mortalityfrom one zymotic disease would, other things beingequal , have no appreciable effect on the death- rate.This principle was first worked out experimentallyby Dr. Robert Watt, lecturer on the theory and practiceof medicine at Glasgow. He examined the Glasgowburial registers over a space of thirty years, from 1783-1812 , and divided the thirty years into five periods ofsix years each. The following table gives his figuresfor small-pox, measles, and whooping-cough, as percentagesof the deaths from all causes¹ :-Ofthe total deaths ,the percentageUnder tenFromTotal deathsPeriods.years offrom all causes .small-pox.Fromneasles .age.Fromwhoopingcough.1783-88 9,994 53.48 19.55 0.93 4.511789-94 11,103 58.07 18.22117 5131795-1800 9,991 54.48 18.70 210 5.361801-06 10,034 52.03 8.90 3.92 6.121807-12 13,354 55.69 3.90 10.76 5.57These statistics proved that while small-pox haddiminished, measles and to a lesser extent whoopingcoughhad increased, so that a child had no betterchance of reaching its tenth year in the last period thanin the first. Dr. Watt was somewhat staggered at theresult. He says (p. 6) :-" Taking an average of severalyears, I found that more than a half of the human species1 An Inquiry into the Relative Mortality of the Principal Diseases ofChildren , and the numbers who have died under ten years of age , inGlasgow, during the last thirty years ( p. 49) . Robert Watt, M. D. 1813 .2 Dr. Watt remarks that in Glasgow during the last period ( from 1807-12)vaccination may be said to have been pretty fully established , " perhaps,as much so , as in any other city in the Empire. "THE ZYMOTIC DISEASES REPLACE EACH OTHER. 85died before they were ten years of age, and that of thishalf more than a third died of the small - pox, so thatnearly a fifth part of all that were born alive perished bythis dreadful malady. I began to reflect how differentthe case must be now ! In eight years little more than600 had died of the small-pox ; whereas, in 1784, thedeaths by that disease alone amounted to 425, and in1791 to 607, which, on both occasions, exceeded thefourth of the whole deaths in the year." To ascertain the real amount of this saving ofinfantile life, I turned up one of the later years , and byaccident that of 1808, when, to my utter astonishment, Ifound that still a half or more than a half perishedbefore the tenth year of their age ! I could hardlybelieve the testimony of my senses, and therefore beganto turn up other years, when I found that in all of themthe proportion was less than in 1808 ; but still, on takingan average of several years, it amounted to nearly thesame thing as at any former period during the lastthirty years."Dr. Farr was a firm believer in Watt. He writes :-" The zymotic diseases replace each other ; and when oneis rooted out it is apt to be replaced by others, whichravage the human race indifferently wherever the conditionsof healthy life are wanting. They have thisproperty in common with weeds and other forms of life :as one species recedes , another advances. By improvingthe hygienic conditions in which men live, you fortifythem against infection ; and further, by isolating theinfected, the chances of attack are diminished. " ¹1 Thirty- fifth Annual Report of the Registrar-General , p. 224 .86 CAUSES OF DECLINE IN SMALL- POX .In this chapter, I have attempted to deal with some ofthe principal causes of the diminution of small-pox.Firstly, I have shown that a part of the decline, andespecially that part which has taken place in children , isnot necessarily a saving of life, but only a shifting of themortality on to some other disease, such as measles orwhooping - cough, which happens for the time being tobe more predominant .The residue of the diminution is a real gain, and isprobably due partly to the displacement of small-poxinoculation by a non-infectious malady ; and to thisextent was vaccination an advantage as compared withthe old variolous inoculation. Other causes have beendue to the more abundant air supply in and aroundhouses ; the greater cleanliness of the people in theirpersons, their houses, and their towns ; and last, but notleast, the greater material prosperity and freedom fromwar, which has been the lot of those who have beenfortunate enough to be born into the present century.CHAPTER IV.THE INCIDENCE OF SMALL- POX ON VACCINATED ANDUNVACCINATED COMMUNITIES.THE experience of Leicester has proved conclusivelythat small -pox can be kept from spreading in unvaccinateddistricts. In 1872 , Leicester was a wellvaccinatedtown, and had an epidemic of small -pox,with 346 deaths registered from the disease . Thisfailure to protect led to a revolt against the practice.The default commenced after 1874, and since 1885 thepercentages of vaccinations to births have been asfollows¹ :-Years. Births.Primaryvaccinations .Percentage of vaccinationsto births .1885 4,682 ... 1,842 39.31886 4,858 1,122 23.11887 ... 4,689 ... 474 ΙΟΙ1888... 4,787 ... 3146.61889 ... 4,789 ... 172 3.61890 ... 4,699 1312.81891 4,790 92 1.91892 5,816 ... 133 ... 2.31893 ... 6,006 249 ... 411894 ... 5,995 1332.21895 ... 5,962 ... 75 13As far as the children are concerned, therefore,Leicester is practically unvaccinated. Let us see what1 Report of the Medical Officer of Health for the year 1895 , pp. 31 , 38 .88 SMALL - POX INCIDENCE AND VACCINATION .has been their small -pox record since 1872, when thepopulation was about half what it is at the present time.Year.1872Small-pox deaths.346Year.1884Small -pox deaths .01873 2 18851874 Ο 18861875 I 18871876 Ο 1888 ...1877 6 ... 1889 0...1878 I ... 1890 Ο...1879 0 ... 1891 ..1880 0... 1892 6 ...1881 2 ... 1893 1518825 1894Ο1883 ... 3 1895 0 ...The above figures up to the year 1889 have been takenfrom a table handed in by Mr. Biggs, and published inthe Fourth Report of the Royal Commission (p. 438) .They include two deaths not given by Dr. Priestley inhis recent report, viz. , one in 1875 and another in 1877 .Over a period of twenty- two years, from 1874 to 1895,which embraces the recent epidemic in the town, in spiteof forty-nine separate importations from vaccinateddistricts, notably Sheffield, there were only thirty -ninedeaths from the disease, or an average annual small-poxdeath- rate of 12.6 per million, against 47 per millionduring the same period in better-vaccinated Englandand Wales.Certain objections have been raised to the Leicestersystem, but they are all totally irrelevant. One ofthese is given by Mr. Ernest Hart in his letter tothe Times of August 31, 1894 : " That wherever noncompulsionmakes head in the matter of vaccination , aTHE LEICESTER SYSTEM . 89great variety of forms of severe compulsion are thenecessary and accepted sequence and corollary-as, forexample, compulsory removal to hospital, compulsoryisolation and disinfection, compulsory quarantine anddetention from business of the persons in contact withthe small-pox patients prior to their removal. All theseforms of compulsion, and others connected therewith, arerampant in Leicester, the home and typical centre ofnon- compulsion and non-vaccination. "The answer to this is that there is no more interferencewith the liberty of the subject than the ordinarylaws allow. Alderman Windley, chairman of theLeicester Sanitary Committee, writing to the Times ofOctober 15 , 1887, says :-" Will you permit me to say :( 1 ) That the Sanitary Committee of this Corporation, intheir treatment of small-pox cases, when they occur, actunder the powers of the Public Health Act, 1875, whichapply to the country generally ; (2) that if the suffererhas not ' proper lodging and accommodation ' he is removedto the Fever Hospital, and the house in whichhe was found is disinfected and limewashed ; (3 ) that,whenever we can, we induce the persons found at thehouse, who have been in contact with the patient, to gointo the quarantine ward at the hospital for a fortnight,making their sojourn there as pleasant as practicable.In one instance we had a refusal, and in that case ourinspector made daily visits to the house, in order toascertain whether any other case had fallen of the disease.We have no power of forcible removal, and shouldhardly apply it if we had. " With regard to the power ofremoving quarantines, the Lancet of June 5, 1886 (vol. i . ,p. 1091 ) , admits that " actual legal powers do not exist ; "790 SMALL- POX INCIDENCE AND VACCINATION.-and in the recent epidemic it was not found necessary toremove them, for of 1,261 patients quarantined, 1,026, or81 per cent. , were quarantined in their own homes ; andthe medical officer adds : " I am satisfied that inan epidemic of small-pox, quarantining of persons whohave come into contact with the disease can be carriedout satisfactorily at their own homes-more efficiently,and at a much less cost, than in a special building orbuildings built for the purpose. " ¹The cost has been brought forward as an argumentagainst the system . The total expenditure on theepidemic was £4,500, which includes the cost oferection of new wards for the nurses. The amount ismodest in comparison with the £32,000 spent indealing with the epidemic in the well-vaccinated townof Sheffield, which sum, we learn, proved but a fractionof the total money loss caused to the inhabitants.Another argument is that Leicester, notwithstandingits widespread insurrection against the Vaccination Acts,owes its protection after all to vaccination, or ratherre- vaccination. Dr. J. G. Glover, in a letter to the Timesof September 11 , 1894, puts the case thus :-" The firstline of their defence is a cordon of re-vaccinated personsround every case that occurs in the town. The medicalofficer is re-vaccinated ; the sanitary inspectors are revaccinated;the nurses are re- vaccinated; and tell it notin Gath!-the other persons in the house of the small-poxcase are not only compelled (not by law) to keep themselvesto themselves , but are re-vaccinated. " With regardto the quarantines, the medical officer, on page 12 of hisreport, informs us that of 1,261 persons quarantined in the1 Report on the Epidemic of Small- pox, 1892-93 , p. 14.COMMENDED BY THE MEDICAL OFFICER. 911892-93 epidemic, 51, or 4 per cent., were vaccinated,and 72, or 5.7 per cent. , were re-vaccinated in quarantine.This disposes of the re-vaccination of the quarantines.On page 24, Dr. Priestley gives the hospital staff, allincluded, at 40 ; besides these, eight other sanitaryofficials must be added to make up the " cordon.”Among these, five took small-pox, or an attack -rate of104 per 1,000. Thus, this well-protected " cordon " hadan attack-rate fifty-five times that of the unvaccinatedpopulation among which they lived (attack-rate of population= 1.9 per 1,000), and it is not easy to understandhow it came to shield the town from small -pox.In defence of the Leicester system , I cannot do betterthan quote the words of the medical officer in the prefaceto his annual report for 1893 :-" You are entitledto great credit-more especially in the case of small -pox ,which, by the methods you have adopted, has been preventedfrom running riot throughout the town, therebyupsetting all the prophecies which have again and againbeen made. I need only mention such towns as Birmingham,Warrington, Bradford, Walsall, Oldham, and theway they have suffered during the past year from theravages of small-pox, to give you an idea of the resultsyou in Leicester have achieved, results of which I, asyour medical officer of health, am, justly I think, proud."The following are the attacks and deaths, with theirrespective rates, for the unvaccinated towns of Leicesterand Keighley in the recent epidemics :-Attack-rate Death-rateSmall-pox epidemics. Population. Attacks. permillion.Deaths. permillion.Keighley, 1893 ... 32,070 72 2,245 7 218Leicester, 1892-94 ... 184,547 355 1,924 21 11492 SMALL - POX INCIDENCE AND VACCINATION .If these be compared with epidemics that have takenplace in admittedly well-vaccinated towns, the result isvery striking.Small-pox epidemics.Willenhall , 1894Attack-rate Death-ratePopulation. Attacks. permillion.Deaths. permillion.... 17,684 842 47,614 47 2,658Sheffield, 1887-88 ... 312,793 7,066 22,590 679 2,171Warrington, 1892-93 674 12,481 65 1,2046,352 248 50454,000Birmingham, 1891-94 492,301 3,127At Short Heath, near Willenhall, in 1894, out of apopulation of 2,667, there were 90 cases and six deathsfrom small-pox, or an attack -rate of 33,746, and a deathrateof 2,250 per million. In the case of Sheffield ,Warrington, and Short Heath we have valuable evidenceabout the vaccination. At Sheffield, for a large numberof years previous to the epidemic of 1887-88 , over 80 percent. of the births had been vaccinated ; and in 1862, atan inspection of borough school children,¹ it was foundthat 86 or 87 per cent. were found " protected " in the likefashion. At Warrington, at the time of the epidemic, anexamination of 7,522 school children revealed the factthat 7,135 , or 94.9 per cent., were vaccinated ; and atShort Heath , in 1893, 89 per cent. were found to bevaccinated . But, in making an estimate of the vaccinationof the population, an allowance must be madefor the fact that school children would, if anything, beslightly better vaccinated than the rest of the population.At Willenhall and Birmingham, the large proportionof small -pox cases vaccinated is sufficient evidence thatthese towns were well " protected," being 89.3 and 88-8per cent. respectively ; for, as I have pointed out in a1A total of 1,409 school children were examined. ( Sixth Report of theMedical Officer of the Privy Council , p. 165. )SMALL- POX AND VACCINATION AT MOLD. 93letter to the British Medical Journal of November 9,1895, the population cannot very well be vaccinated toa lesser extent, or we should have to admit that smallpoxpicked out the vaccinated for its victims. In thecase of Willenhall, not only were a large proportion ofthe population vaccinated, but they were very efficientlyvaccinated, for 78 per cent. of the vaccinated cases exhibitedthree or four marks.Not only may well -vaccinated towns be affected withsmall -pox, but the most thorough vaccination of a populationthat it is possible to imagine may be followed byan extensive outbreak of the disease. This happenedin the mining and agricultural district of Mold, in Flintshire.On the 9th May, 1871 , Dr. Seaton informed theSelect Committee of the House of Commons, that from1853 to 1871 all the children born and remaining in thedistrict of Mold had been vaccinated, and he gave thefigures for thirteen years ending September 30, 1866.Of 6,601 births, 5,784 had been successfully vaccinated ;202 had left the district before vaccination ; 600 haddied previous to the operation ; 4 had had small-poxprevious to vaccination ; and II remained over for thenext year's vaccination. He added : " Of course it isa work of years to build up a district to the state inwhich Mold is." In 1871-72, fifty persons died ofsmall - pox , or on the population ( 13,834) a rate of 3,614per million.¹ Compare this with the immunity of1 The Registrar- General has courteously supplied me with the populationand deaths from small-pox, in the registration sub-district of Mold. Thenumber of small -pox deaths is slightly in excess of that given by the localregistrar ( see p. 53) , but even adopting the latter's figures, if calculatedon the population of the Registrar-General, the small-pox death- ratefor Mold in 1871-72 will be over 3,000 per million.94 SMALL - POX INCIDENCE AND VACCINATION .aLeicester in the late epidemic. Leicester, with thepopulation under ten years of age practically unvaccinated,¹ had small - pox death - rate of 114 permillion ; whereas Mold, with all the births vaccinatedfor eighteen years previous to the epidemic, had oneof 3,614 per million .Dr. Seaton informed the Committee that a greatdeal was done in Swansea to secure vaccination, andthe Lancet of August 6, 1870 (vol. ii. , p. 205 ), refersto the report of the medical officer of health, whereinit was stated that nine-tenths of the population wasvaccinated ; and this is borne out by the Local GovernmentBoard returns for 1872 , which give 91 per cent. ofthe births as vaccinated ; yet, in 1870-73 , there were 379deaths from small-pox, or, on the population of 1871(67,357), a death-rate of 5,627 per million. The followingtable specifies those towns which, in the epidemicof 1871-72 , had rates exceeding 6,000 per million .Registrationdistricts.South ShieldsHackneyNorthamptonDeathsfrom Small -pox Percentage of Percentage ofPopulation small-pox death-rate vaccinations vaccinationsin1871 . to births in to births in1892.per inthe1871-72 million.epidemic.1872.74,949 744 9,927 83.2 74.7124,951 1,231 9,852 78.6 43 250,743 467 9,203 79.7 6.2Durham 91,978 835 9,078 77.4 84.2Dudley 134,125 1,204 8,977 81.3 83.7Sunderland 112,643 1,011 8,975 85.2 84.0Easington 33,694 293 8,696 84.2 86.5Bedwellty 51,763 441 8,520 82.2 78.4Auckland 69,159 536 7,750 80.679.0Caistor 48,885 371 7,589 71.5 83.6Dover 35,249 265 7,518 84.9 74 IPontypridd 51,921 389 7,492 81.8 82.31 Medical Officer's Report for 1893 , p. 67.Registrationdistricts. inthe per1871-72 million.SMALL- POX AND VACCINATION IN 1871-72. 95Deathsfrom Small -pox Percentage of Percentage ofPopulation small-pox death-rate vaccinations vaccinationsin 1871. to births in to births in1872. 1892.epidemic.Houghton- le- Spring 26,171 193 7,375 87.2 84.4Walsall 71,834 527 7,336 83.1 60.9Bideford 19,506 141 7,229 86.4 917Norwich 80,386 562 6,991 81.5 26.2Southampton 48,055 312 6,493 750 78.4Newcastle 131,198 847 6,456 83.2 81.9Gateshead 80,271 514 6,403 75.2 64.5Merthyr 104,239 665 6,380 88.3 84.9Lambeth ... 208,342 1,324 6,355 77.6 69.8Chester-le- Street 33,300 209 6,276 85.8 83.7Llanelly 34,732 216 6,219 90°4 82.3Whitehaven 47,572 294 6,180 86.1 88.3In nearly all of the twenty- four towns, the epidemictook place in the years 1871 and 1872, but in several itcontinued over three or four years. The small -poxdeaths were distributed as follows :-Registration districts. 1870. 1871. 1872. 1873. 1874. Total .South Shields9 603 132 744Hackney 16 868... ... 313 2113 1,231Northampton 57 410 467Durham...30 43926234 70 835Dudley I ... 10 1,128 58 7 1,204Sunderland 2 ... 933 75 I 1,01 1Easington ... 183 110 293Bedwellty ... 172 265 3 I 441Auckland ... 9 150 371 I5 536Caistor ... 2 283 47 38 1 371Dover ... 16 .. ... 247 2 265Pontypridd ... 7 319 38 25 389Houghton-le -Spring ... 110 83 193Walsall 16 ... 502 2 7 527Bideford 36 105 141Norwich 245 316 I 56296 SMALL- POX INCIDENCE AND VACCINATION .Registration districts . 1870. 1871 . 1872. 1873. 1874. Total.Southampton 3 305 4 312Newcastle 8 702 132 5 847Gateshead ... I... 409 101 I 2 514Merthyr ... ... 2 32 538 58 35 665Lambeth 28 972 295 24 5 1,324Chester- le-Street ... I 106 93 7 2 209Llanelly ... 24 171 21 216Whitehaven... 3 294 7 163 105 16I have given the percentages of vaccinations to births forthe years 1872 and 1892 ; and it will be seen that most ofthe towns showed a higher rate of vaccination of infantsin the earlier than the later year ; some allowance must,however, be made for the epidemic of 1871-72 increasingthe vaccinations, but there is no reason to believe thatany of these towns were badly vaccinated.Gloucester has quite recently experienced an outbreakof small-pox exceeding the rates in any of these towns,enormous as they are, and as the town is one in whichvaccination has of late years been largely neglected, theoccurrence has been seized upon by the press all overthe country, with the result that numbers of Boards ofGuardians, which had allowed the Vaccination Acts tofall into abeyance, have been stimulated to reimposeproceedings. The attack- incidence of the epidemic isheavy, being 48 per 1,000, or about the same as that forthe well -vaccinated town of Willenhall in 1894 ; but it1 The rate for Gloucester is 10,548 per million .2 In 1895-96 611 per cent. of the cases of small-pox were vaccinated,and , therefore, the population must, on any theory of protection, havebeen vaccinated to this extent. The proportion is larger than at Leicester(55.7 per cent. ), and considerably larger than at Keighley (43.1 per cent. )in the recent epidemics in these towns.SMALL - POX AT GLOUCESTER . 97is the case-mortality of 21.8 per cent. of those attacked ,which has made it one of the most remarkable epidemicsof modern times. To explain this by want of vaccinationis merely to beg the question ; for at Chester, in1774 , where all the deaths were under ten years of age,and all , of course, unvaccinated, the fatality was 14.6per cent.; and recently in the unvaccinated towns ofKeighley and Leicester the fatality was 9.7 and 5.9 percent. respectively. From certain statistics, published bythe committee appointed by the Gloucester Board ofGuardians, it appears that the fatality at the hospitalwas much greater than among cases treated at home.Cases . Deaths . Fatality per cent .In hospitalAthome7301,30619924427.318.7These figures treat of the whole epidemic ; but it must beremembered that the hospital administration was takenover by Dr. Brooke, of the Thames Ambulance Service,towards the end of April, and, consequently, the casemortality( 27 per cent.) is considerably mitigated by theaddition of cases with a low fatality, due to the reformsinstituted under Dr. Brooke's regime. Dr. WalterHadwen has pointed out that the total number of completedcases under treatment for the twelve monthsprior to Dr. Brooke's arrival was 277, of which 151 ,or 54 per cent. , were fatal.¹ This tremendous hospitalfatality, when compared with the 59 per cent. atLeicester, where the cases were nearly all treated in thehospital , suggests certain influences at the hospitalwhich were deleterious to the vitality of the patients.The Dissentient Commissioners report (section 261 ) that1 An Address by Dr. Hadwen at Weston- super- Mare, October 22, 1896.98 SMALL- POX INCIDENCE AND VACCINATION .they learn from Dr. Coupland, that the following circumstancescontributed to the extension of the disease.1. "A main factor was the introduction of the diseaseinto some of the public elementary schools ."2. The large and increasing proportion of cases retainedat home ; especially as " quarantine, " which inthe early periods was under supervision, came to bemore a matter of advice than of control. Dr. Couplandbelieves that " the facilities of intercourse between neighbourswill account for a great deal-in other words, thefailure of isolation ."3. The hospital is situate within the city, and wascrowded to excess, there being at one time two and evenfour in a bed ; it is possible that the hospital contributedto the spread, but it is difficult to prove this. On theother hand, " there had been aroused a deep feelingagainst the hospital ; the mortality amongst the childrenadmitted into it had been very high, and this feelingcould not be eradicated , although the accommodationwas extended and the organisation improved. Thus ithappened that the majority of persons remained in theirhomes up to the last weeks. "4. The small sanitary staff was overtaxed ; and Dr.Coupland reports there were serious defects in hospitaladministration.5. The hospital accommodation was afterwards increased,and the administration improved. That theseefforts were not more immediately successful was owingto the unwillingness of the people to enter the hospital ,which had so suffered in reputation.6. Dr. Coupland, in comparing the experience ofGloucester with that of Leicester, points out thatDR. BROOKE'S REPORT ON THE HOSPITALS. 99Leicester has the advantage of being better organisedin its sanitary department, and its medical officer is not,as at Gloucester, engaged in private practice. There ismore " sanitary vigilance " at Leicester, and its sanitarystaff is more numerous .At the quarterly meeting of the Gloucester CityCouncil, held on Tuesday, January 26, 1897, the followingreport of Dr. Brooke was handed to the pressfor publication : -Gentlemen,-Stroud Road, Gloucester,May Ist, 1896.To the Sanitary Committee.In accordance with an arrangement made on the 20thult. with the Metropolitan Asylums Board, my services, undercertain conditions, have been temporarily lent to the SanitaryCommittee of the City of Gloucester, for the purpose of takingentire charge and control of the small-pox hospitals .In accordance with this arrangement I made a preliminary visitof inspection to the said hospitals on the 21st ultimo, and at asubsequent interview with the Chairman of the Sanitary Committeeand Mr. Alderman Powell, I made several suggestions ; one,which I deemed of the first importance, and which I suggestedfurther should be carried out at once, viz., the appointment of athoroughly experienced matron who must also be a trained nurse.Having obtained the consent of these gentlemen, I at once tooksuch steps as were necessary. I issued an advertisement in threedaily papers, The Lancet, and The Hospital, with the result thatamongst a great number of applications I was fortunate enoughto find the application of Miss E. Walker, late Assistant Matronat the London Hospital, and, more recently, Lady Superintendentof the Hill Road Infirmary, Liverpool, an infirmary with eighthundred beds. I engaged Miss Walker as matron, temporarily, at asalary of £4 4s. per week, with the usual allowances ; and I considerthat the city of Gloucester is to be congratulated on having100 SMALL- POX INCIDENCE AND VACCINATION .obtained the services of a lady who, from her past experience andtraining, is so eminently fitted to discharge the responsible dutiesand combat the difficulties attaching to her present post.Acting upon an instruction conveyed in an urgent telegramfrom the Chairman of the Sanitary Committee, asking that Mr.Pitt might be relieved from the great pressure of work, I engaged,temporarily, Dr. C. K. Bond, late Resident Physician, St. Georgeand St. James Dispensary, King Street, Golden Square, W. , at asalary of £5 5s. per week. Dr. Bond is a gentleman who has hadalready considerable experience in small-pox. I also engaged twocharge nurses-Nurses Wright and Wilkins, both of the HospitalShips, near Dartford.By the courtesy of the Clerk to the Metropolitan AsylumsBoard, I was allowed the use of the chief offices of the Board totransact all business and interview all candidates ; this was of thegreatest possible service and convenience to me.I came into residence at the house of Mr. M'Crea on the 28thult. I have since my arrival, and accompanied by Miss Walker,made a thorough inspection of the Stroud Road Hospital, and weare of opinion as to the absolute unsuitability ( 1st) of the site, assuch ; ( 2nd) of the structural arrangement, which is devoid of anyplan, system, or method, and renders the satisfactory working ofthe hospital an impossibility .The sexes, as perhaps you know, should in all hospitals beabsolutely separated in a separate building situated in a differentpart of the ground ; to separate them now with the existing buildingswould be practically impossible.We find also, that, from a sanitary point of view, the wholeadministration of the hospital has been shockingly neglected.One of the greatest defects is the deficient laundry accommodation,and the additional laundry which is in process of erectionwill not be nearly sufficient to meet the requirements. We areinformed at the hospital, that it is impossible to obtain a sufficientsupply of clean linen, and that they are already a month behindwith the washing.I considered it my duty, on visiting the hospital this morning,to direct Mr. Hall's attention to the fact that the gas stoves in thenew kitchen should be placed on iron plates, and that there shouldHOSPITAL DEFECTS IN GLOUCESTER . ΙΟΙalso be an iron plate over the match-boarding at the back, whichis scorched and browned by the heat, and there is great danger offire. This draws my attention to the fact, that there is, with theexception of a fire hose in centre of ground, a total absence offire-extinguishing appliances attached to the wards, and no firebuckets.Two additional men should be immediately engaged to clearthe grounds and the various nooks and corners throughout theplace, of the great accumulation of rubbish.The ambulance shed near the main block is very foul and dirty,and smells most offensively ; and round many of the wards I foundheaps of decaying animal and vegetable matter-bones, bread,vegetables, etc. and sometimes a heap of foul linen and soileddressings soaked in discharges. At any rate, in one of the wardswe found neither kitchen, scullery, nor pantry, and in the bathrooma miscellaneous collection of dirty dinner things, patients' clothing,and soiled linen .Our recommendations are :-( 1st) the appointment of two mento clear the ground of the refuse and keep it clean, and to performthe ordinary duties of a hospital porter ; ( 2nd) the appointmentof a gate porter at a salary of 25s. per week, and his board andlodging ; and that a gate book should be kept, and that no oneshould be admitted but those connected directly with the hospitalwithout a pass, to be obtained from the medical superintendent. Inotice that the gate is left open and that people are allowed inside .With regard to the Hempsted Hospital , I venture to say thatthe Sanitary Committee are incurring a great and serious responsibilityin continuing to keep this hospital open, and to allow patientsto be admitted. With regard to this, I state definitely that I havefound abundant evidence that both patients and staff are detainedthere at a grave risk.I can only add, that upon the whole question of the hospitalaccommodation, I am of opinion, in the interests of the inhabitantsof this city, and, perhaps, not only this city, but also in theinterests and welfare of the patients, that both hospitals should beclosed as soon as possible, and that immediate steps be taken toform a camp by means of tents at a considerably greater distancefrom the town .102 SMALL - POX INCIDENCE AND VACCINATION .At the present time, only the brick foundations have beenreached in the process of the erection of the building, which Isuggested ten days ago should be immediately put up for myaccommodation. I now suggest that this building, when completed,should, in at any rate a temporary way, be used for theaccommodation of the matron, as it is most essential that sheshould reside on the hospital grounds. I am, Gentlemen, yoursobediently,F. B. BROOKE,Medical Superintendent.These facts are of so serious a character, that it is to behoped there will be an official inquiry into the matter,as also into the sanitary condition of the city, regardingwhich there have been many complaints.Apparently the epidemic at Gloucester, although it hasbeen much commented upon in the press, is not by anymeans the most devastating epidemic of modern times.We have it on Dr. Edward Seaton's authority that,during the year 1885 , the inhabitants of Montreal sufferedto the extent of 3,000 deaths from small - pox, i.e. , on thepopulation ( 160,000), a small-pox death- rate of 18,750per million. It has been alleged that this epidemic wasoccasioned by the neglect of vaccination among theFrench Catholic population. In this connection, it issufficient to quote from the late Dr. W. B. Carpenter, who,in referring to the 1874-75 epidemic of small -pox, and theresistance exhibited towards the proposed vaccination1 The Times , December 10, 1886.2 The allegation has been revived quite recently ( 1896) by Dr. AndrewWhite, late President and Professor of History at Cornell University, inhis interesting work, entitled " A History of the Warfare of Science withTheology in Christendom " ( vol . ii . , p. 60. )THE MONTREAL EPIDEMIC. 103law, says :-" I made a point of enquiring during my staythere, in August last, as to what had been the subsequentcourse of affairs. I learned on the very best authoritythat the objections of the French Catholics had beencompletely overcome. Vaccination being now( 1883 ) as well carried out in Montreal by its officers ofhealth as in the other great cities of the Dominion,small-pox has become almost entirely extinct. " 1The causes of the epidemic in 1885 were not farto seek. Towards its close a member of the staffof the Montreal Herald interviewed Dr. Garceau, ofBoston, a supporter of vaccination, but who was declaredby the editor to be one of the best- informed sanitarianson the American continent. When asked to what causehe attributed the extent of the epidemic, Dr. Garceaureplied " One cause is the fact that the people havenot been properly vaccinated, but I attribute the chiefcause to the frightful system of cesspits which prevails ,and the insanitary condition of the place generally. Itis unclean ; and unless some action is taken to clean theprivy vaults and remove all garbage, the city will nextseason be in excellent shape for cholera, or any otherequally contagious disease. " The Secretary of theCitizens' Committee (Mr. Michaels) appointed to inquireinto the epidemic, said-" The streets and lanes are in adisgraceful condition. Not only in the distant portionsof the city, but within the most aristocratic quartersand in the heart of the commercial portion, the lanes,and even portions of the streets , are reeking with filth. "1A Letter to the Right Hon. Lyon Playfair, C.B. , pp. 13 , 14. 1883 .2 Vaccination Inquirer, vol. viii . , p. 179. ( February , 1887. )104 SMALL- POX INCIDENCE AND VACCINATION .In the present chapter, I have dwelt on the fact thatunvaccinated towns may, by means of personal andmunicipal sanitation, be kept comparatively free fromsmall-pox, and I have also pointed out, as in the caseof Mold, that the most complete vaccination of a districtpossible, may be followed by an epidemic, with a smallpoxmortality thirtyfold that of an unvaccinated community. On the other hand, recent experience has alsoproved, that towns where vaccination has been neglectedmay be seriously afflicted with the disease in preciselythe same way as well - vaccinated districts. The moral tobe derived from such occurrences is that small-pox, incommon with other zymotic diseases, is largely influencedby overcrowding and insanitation , and until theprofession awake to these important facts, we shall stillcontinue to pay a heavy price for our ignorance andmisdirected energy.CHAPTER V.DOES VACCINATION PREVENT SMALL- POX ?FOR a disease in the cow to afford protection against aradically dissimilar disorder in man, is a proposition sostrange, that we should demand the most completeevidence before subscribing to it. According to Jennera vaccinated person is for ever afterwards secure fromthe infection of small-pox, and this opinion was absolutelyendorsed by the Committee of the House of Commonsin 1802 ; 1 in fact, as Baron informs us, if cow-pox hadonly been a temporary security, " it would have deprivedthe discovery of nearly all its value. "2 Of course, nobodyat the present time believes in the life-long protection ofvaccination , or revaccination would not be so urgentlydemanded, but the statement was quite unwarranted even1 " The result, as it appears to your Committee, which may be collectedfrom the oral testimony of these gentlemen ( with the exception of three ofthem) is, that the discovery of vaccine inoculation is of the most generalutility, inasmuch as it introduces a milder disorder in the place of theinoculated small- pox , which is not capable of being communicated by contagion;that it does not excite other humours or disorders in the constitution; that it has not been known, in any one instance, to prove fatal ; thatthe inoculation may be safely performed at all times of life (which is knownnot to be the case with regard to the inoculation of the small-pox), in theearliest infancy, as well as during pregnancy, and in old age ; and that ittends to eradicate, and, if its use become universal , must absolutelyextinguish, one of the most destructive disorders by which the human racehas been visited " (pp. 3, 4).2 Baron's " Life of Jenner," vol. ii. , pp. 18, 19.8106 DOES VACCINATION PREVENT SMALL- POX ?in Jenner's day, and this no doubt explains the action ofthe Royal Society. When the subject was laid beforethe President, "Jenner was given to understand, that heshould be cautious and prudent ; that he had alreadygained some credit by his communications to the RoyalSociety, and ought not to risk his reputation by presentingto the learned body anything which appeared somuch at variance with established knowledge, and withalso incredible. " 1Baron informs us, that Jenner used to bring the subjectbefore the medical society to which he belonged. "Allhis efforts were, however ineffectual : his brethren wereacquainted with the rumour, but they looked upon it asone of those vague notions from which no accurate orvaluable information could be gathered, especially asmost of them had met with cases in which those whowere supposed to have had cow-pox, had subsequentlybeen affected with small-pox. " 2The celebrated Dr. Haygarth wrote and advised circumspection.He says : " Your account of the cow-poxis indeed very marvellous ; being so strange a history, andso contradictory to all past observations on this subject,very clear and full evidence will be required to render itcredible. You say that this whole rare phenomenon issoon to be published ; but do not mention whether byyourself or some other medical friend. In either case, Itrust that no reliance will be placed upon vulgar stories.The author should admit nothing but what he has provedby his own personal observation, both in the brute andhuman species. It would be useless to specify the doubts1 Baron's " Life of Jenner," vol . ii. , p. 168 . 2 Ibid. , vol. i . , p. 48.JUDICIOUS COUNSELS DISREGARDED. 107which must be satisfied upon this subject before rationalbelief can be obtained. If a physician should adopt sucha doctrine, and much more if he should publish it uponinadequate evidence, his character would materiallysuffer in the public opinion of his knowledge and discernment." 1 It is needless to remark that Dr. Haygarth'sjudicious counsels were disregarded by Jenner, as Baronand other authors repeatedly show.In the first chapter of this volume, I have alluded tothe fact that Jenner himself had instances of small-poxafter cow -pox, and also to the ingenious explanationsthat he invented to account for failures. This happenedin the following case, reported by Dr. Ingenhousz, whowas distinguished as a man of science as well as aphysician . He had made a particular study of smallpoxinoculation under Dimsdale, and had been summonedto the Court at Vienna, and appointed Physicianto the Emperor. Shortly after the appearance of the"Inquiry " he visited the Marquess of Lansdowne atBowood, and took the opportunity of writing to Jenneron the subject of cow- pox. Dr. Ingenhousz informedhim that the first person he addressed was a Mr. Alsop,practitioner at Calne. This gentleman introduced himto a farmer of the name of Stiles at Whitley, near Calne,who, thirty years before, had bought at a fair a cowwhich was found to be infected with cow-pox ; thedisease soon spread through the whole dairy, and Stileshimself caught the complaint in a very severe way.After he had recovered and the sores dried up, he was1 Baron's " Life of Jenner, " vol. i . , pp. 134 , 135 .Letter from Ingenhousz to Jenner, October 12, 1798. Baron's " Lifeof Jenner, " vol. i. , pp. 291-293 .108 DOES VACCINATION PREVENT SMALL- POX ?inoculated for the small-pox by Mr. Alsop. Stiles tookthe disease, had a number of eruptions, and communicatedit to his father, who died of it. Dr. Ingenhouszbesought Jenner to inquire further into the subject, beforedeciding in favour of a doctrine which might do greatmischief, should it prove erroneous.Jenner was in great trepidation, for in writing to hisfriend Gardner he said : " It is a matter of real moment ;a matter on which perhaps much of my future peacemay rest-indeed, my existence. " 1 But in reply toDr. Ingenhousz he takes a very lofty tone-" Truth,believe me, sir, in this and every other physiologicalinvestigation which has occupied my attention, has everbeen the object which I have endeavoured to hold inview. Should it appear in the present instancethat I have been led into error, fond as I may appear ofthe offspring of my labours, I had rather strangle it atonce than suffer it to exist, and do a public injury. " 2But what sort of explanation did Dr. Ingenhouszreceive of the case ? We read in " Further Observations "that the cows gave out " an offensive stench from theirudders, " that Jenner had heard of other cases of the sort ,and that he hoped the general observations he had tooffer in the sequel would prove of sufficient weight torender the idea of their ever having had existence, but ascases of " spurious " cow-pox , extremely doubtful.Dr. John Sims, a London physician of repute, contributedto the first number of the Medical and PhysicalJournal³ the experience of a Mr. Jacobs, a solicitor of1 Letter from Jenner to Gardner. Baron's " Life of Jenner," vol . i. , p. 296 .2 Ibid. , p. 294.* Medical and PhysicalJournal, vol. i . , pp. 11 , 12. ( March , 1799. )A LOATHSOME DISEASE. 109Bristol, who began life as a milker on his father's farm .Mr. Jacobs had twice suffered from cow -pox, and, onbeing inoculated for small-pox, had it in so greatabundance that his life was for some time despaired of.He described the cow- pox as the most loathsome ofdiseases, and added that his right arm was in a stateof eruption, both the first and second time, from oneextremity to the other ; the pain was excessive, and hisfingers so stiff that he could scarcely move them .Dr. Sims added :-" What this gentleman remarks of theloathsomeness of the disease, although a circumstanceentirely overlooked in Dr. Jenner's account, appears tobe in itself a formidable objection to its introduction,even should it be found to answer the purpose for whichit has been recommended . But, if in one case, and thatwhere the patient has been twice so severely afflictedwith it, it has already been found to be ineffectual inpreserving from the infection of the small-pox, it willsurely make us hesitate in recommending the introductionof a hitherto nearly unknown disease."When Jenner read this he remarked, in a letter to hisfriend Gardner :-" I am beset on all sides with snarlingfellows, and so ignorant withal that they know no moreof the disease they write about than the animals whichgenerate it. The last philippic that has appeared comesfrom Bristol, and is communicated by Dr. Sims , ofLondon . Sims gives comments on it in harsh andunjustifiable language." ¹ Sims appears to have lackedthe courage of his convictions, and afterwards admittedthat the case was " spurious," and in a year's time hisconversion was complete, for his name appeared near1 Baron's " Life of Jenner," vol. i. , p. 321 .110 DOES VACCINATION PREVENT SMALL- POX ?the top of a list of London physicians and surgeons whorecommended cow- pox to the public.There were other cases of the same description, andsome of these found their way to the medical journals.Thus Mr. Charles Cooke,¹ an apothecary of Gloucester,related the case of a Mrs. Carter, of Longney, aged50. At the age of eighteen, she lived in a dairy farm ;at that time the cows were affected with chapped andsore teats, and all the servants who stripped them hadinflammation and boils upon their hands. She was soill with fever and with these boils, that she could notwork for a week ; her hands and arms were dreadfullyswollen, and she kept her bed for two days. She wastold by a medical man that the disease she suffered fromwas a very bad attack of cow-pox. When inoculated forsmall -pox by Mr. Cooke, in December, 1798 , she tookthe disease, had " rather a burthen of pustules," andrecovered without any variation from the commoncourse of inoculated small-pox .Another case is reported by Dr. R. Hooper, of theMary- le- bone Infirmary. Thomas and William Pewsey,brothers, in the service of a farmer who lived nearDevizes , were seized with painful eruptions on differentparts of their bodies, and suffered very considerably ;they acquired the complaint in consequence of milkingcows affected with a pustular disease. Five yearsafterwards one of the brothers, Thomas, was taken illwith confluent small - pox and died. The usual form ofexcuse was forthcoming, this time from the Rev. T. D.1 Dr. Beddoes' " Contributions to Physical and Medical Knowledge,"pp. 387-392 . Bristol. 1799.* London Medical Review and Magazine, vol . i . , pp. 505-508. (July , 1799. )" SPURIOUS " COW- POX. IIIFosbrooke , M.A. , curate of Horsley, Gloucestershire,who, in a later number of the Review ( August, 1799,p. 628), said that the case appeared plainly to be oneof " spurious " cow-pox.Dr. James Woodforde,¹ of Castle - Cary, reluctantlypublished a case which seemed " to militate against thepermanent preventive influence of the variolæ vaccinæ."A patient-Mrs. Dredge, aged 55-took small-pox ofthe distinct sort ; she informed him that she did notexpect the disease, having taken cow-pox twenty-eightyears previously from milking cows affected with theShe observed that the cow-pox was very severe ;she had numerous pustules on her hands and fingers, losttwo nails, had considerable swelling in the arm-pit, andgreat fever.same.There is a case, given in the third volume of theMedical Observer, of a person who had cow-pox in thenatural way, accompanied by much constitutional affection.About nine months afterwards he took small-poxand died .So much for cases of small-pox after natural cow-pox.Jenner had a number of failures of this sort broughtto his notice, quite in the early days, and he and hisfriends attempted no sort of explanation, except thatthese cases had somehow or other managed to get inoculatedwith a " spurious " form of the disease ; theonly proof of spuriousness, however, being that they hadhappened to take small-pox afterwards.When vaccination came to be more extensively practised,there were a large number of instances recorded1 Medicaland PhysicalJournal, vol . v. , pp. 151 , 152. (February, 1801. )* The Medical Observer, vol . iii. , p. 200. (August, 1808. )112 DOES VACCINATION PREVENT SMALL- POX ?both of mild and severe small-pox, even within theshortest periods of the operation. Mr. E. Harrison, ¹ ofHorncastle , related the case of Fanny Allington, who,when exposed to variolous inoculation six months aftervaccination, was attacked with mild small-pox withmoderate eruption. Mr. Harrison remarks that severalwho were vaccinated from this case resisted the infection.Thus we are invited to entertain the strange notionthat " Fanny communicated a security against the smallpoxto others, although she herself remained liable to itsinfluence. "Mr. John Stevenson, of Kegworth, did not feel " perfectlysatisfied " that the cow -pox was " universally andinfallibly an antidote to the small-pox ; " and on readinghis case, it is quite evident that he had substantial groundsfor his heresy. Two children were vaccinated in June, 1800.According to the account given by Mr. Stevenson, thevaccination was perfectly correct. Six months afterwards,both these children were inoculated with recentvariolous matter, to remove all doubts in the minds ofthe parents about the efficacy ofcow- pox. Mr. Stevensonsays :-" You may conceive my confusion and chagrinwhen, on the eighth day, I received a message requestingme to visit my young patients, who complained ofheadache, chilliness, sickness, and the other precursorysymptoms of small-pox. On my arrival, I found, to mysincere regret, that there was little doubt of their havingthe genuine variolous fever; the pustules on the arms ofboth were fully distended with purulent matter, and considerablyinflamed around , their margins. In MasterMedical and PhysicalJournal, vol. v. , pp. 108-111 . ( February, 1801. )* Ibid. , vol . vi. , pp. 121-124. (August, 1801. )FATAL SMALL - POX AFTER VACCINATION. 113Edward, on the following day, a full crop of eruptionssupervened ; with respect to his brother, the eruptivefever was much milder. That this secondarydisease was the real small -pox, admits not of a doubt,since many children were inoculated successfully withmatter taken from Master Edward. "In the report on the cow-pox inoculation from thepractice at the Vaccine- Pock Institution during theyears 1800-02, we read (p. 66), " The distressing informationwas lately given of two children in one familytaking the small-pox casually, of which they died,although they were supposed to be in security, byhaving been inoculated for the cow-pox two yearsbefore."The following letter, dated March 27, 1802 , from Mr.John Grosvenor, of Oxford, to the Chairman of theHouse of Commons Committee, is printed in theAppendix to the Report 1 :-" I beg leave to informyou that, in the latter end of March, last year, twochildren were inoculated for the cow-pox by a younggentleman, a pupil of mine, and that I saw thechildren in the progress of the disorder, and theyappeared to have received the infection properly, andwere judged by us to be secure from the variolousinfection. A few months afterwards they were seizedwith the natural small-pox, of which one of them died.They were the children of a servant of Sir DigbyMackworth, of this place."From about 1804, as Baron² informs us, the reports of1 Report from the Committee on Dr. Jenner's Petition respecting hisdiscovery of Vaccine Inoculation. Appendix, p. 40. (Ordered to beprinted, May 6 , 1802. )" Baron's " Life of Jenner, " vol . ii . , pp. 13 , 14.114 DOES VACCINATION PREVENT SMALL- POX ?failures had begun to multiply, and one of Jenner'scorrespondents, who was seriously alarmed for hisreputation, wrote a long letter full of doleful anticipationsof the ill effects likely to arise from the " sinisterrumours propagated by the anti- vaccinists, " and advisedhim to come forward and vindicate his doctrines. Thecases which made the most stir were those communicatedby Mr. Goldson to the Portsmouth MedicalSociety. He wrote a pamphlet¹ on the subject, andconcluded with the following sensible remarks (p. 62) :-" It is far from my wish to provoke controversy. Ionly ask for further investigation. Vaccine inoculationmust stand by its own merits, or fall from its ownimmediate defects. To suffer zeal for the discoveryto shut their eyes to conviction, and, by deeming everyfailure spurious, to conceal it, is beneath the dignityof the profession. " The reviewer in the Medical andPhysical Journal observed, that " the objections of Mr.Goldson, if valid, would go to the entire abolition ofvaccine inoculation taken from the human subject. "These cases were the starting point of a very determinedopposition to vaccination, and even Jenner'sfaithful henchman, Dunning, admitted that some of thefailures looked " ugly, " and it required all Jenner'singenuity to keep him true to the cause. " But whileI am fighting the enemy of mankind, it will be vexatiousto see my aides-de-camp turn shy. Among the foremostin the field, I have always ranked Richard Dunning.1 " Cases of Small-pox subsequent to Vaccination. " William Goldson ,M.R.C.S. Portsea. 1804.2 Medical and PhysicalJournal, vol . xii . , p. 85. (July, 1804. )3 Letter from Jenner to Dunning, October 25, 1804. Baron's " Life ofJenner," vol . ii . , p. 341 .AN INGENIOUS EXPLANATION . 115No one has been more obedient to the commands ofhis general, or wielded the sword against the foe withgreater force and dexterity. But shall I live to seemy friend dismayed at the mere shadow of fortuneon the side of the enemy; will he who has led suchhosts into the field, and found them invulnerable, startif, in the continuation of the combat, he should see aman fall ? Enough of metaphor. The moral of allthis is, that I see you are growing timid. "The failures in Goldson's practice were such, however,as were beginning to be reported all over the country.Thus Mr. William Forbes,¹ of Camberwell, contributedthe case of Stephen Brown, a young man, who wasvaccinated in December, 1802. The vaccination, weare informed, must have been perfect, because mattertaken from his arm produced the same disease inanother case from whom two children were vaccinated,whose arms exhibited " beautiful" specimens of thecow-pox. Stephen Brown took the small-pox inFebruary, 1805, and had a considerable number ofsmall -pox eruptions, though of a mild kind. Mr.Forbes , who appears in ingenuity to rival Jenner himself,attributed the failure not " to a defect in thepreventive power of the vaccine virus, but to thecircumstance of his constitution not having undergonethat change which is necessary to secure it from thefuture contagion of the small-pox, notwithstanding theperfect appearance of the pustule upon his arm."In the same journal, Mr. John Ring mentioned a" clear case " of small-pox two years after one of his1 Medical and PhysicalJournal, vol. xiii. , pp. 517-520. (June, 1805. )" Ibid. , vol . xiv. , p. 6. (July , 1805. )116 DOES VACCINATION PREVENT SMALL- POX ?own vaccinations. On examination he found thatthere were the remains of a pustular eruption, whichappeared to be variolous, and was in some degreeconfluent ; he explained the case by saying, that whenthe child was vaccinated it was suffering from ringworm,which prevented the cow-pox from producing the fulleffect on the constitution.Mr. Blair, ¹ surgeon to the Lock Hospital , alsoreported the case of a child vaccinated on May 7, 1803 ;the vaccination left a cicatrix on each arm. On June 3 ,1805 , he was asked to see the child , whom he found" covered with a distinct variolous eruption, small in size,but fairly maturated." Dr. Adams, of the InoculationHospital , agreed that it was certainly a case ofsmall-pox.In the same number² (July, 1805), Mr T. M. Winterbottom,of South Shields, related four cases of small - poxafter supposed vaccination, as occurring in the practiceof Mr. G , surgeon in the town.John Gait was vaccinated on the 5th of December,1804. The arm inflamed regularly, and the pustuleswere full , leaving an indelible mark. He took confluentsmall -pox on March 3, 1805-that is to say, threemonths after vaccination-and died on March 14.Robert Thompson, vaccinated on March 5 , 1804.The inflammation and other symptoms were regular,On the 10th March, 1805 , he took discrete small -poxof a mild type,Richard Hall, vaccinated on December 17, 1804.The vaccination was regular, and he had four or fivepustules on other parts, caused by scratching. Small-1 Medical and PhysicalJournal, vol . xiv . , pp. 21 , 22. Ibid. , pp. 23, 24.MR. RICHARD DUNNING'S CASES. 117pox developed on February 24, 1805 ; he had a largenumber of pustules, but they were not confluent.Elder was vaccinated on December 20, 1804,and took small -pox of a confluent and bad kind inApril, 1805 .What failure could be more conclusive than thesefour cases ? One took the small-pox two months aftervaccination, and had a large number of pustules ; another,three months, and died of it ; a third, four months aftervaccination, with a confluent and bad kind of small -pox ;while the fourth, who had been vaccinated a year, had amild variety of the disease.In the Medical and Physical Journal for October ,1805 , are two cases reported by Mr. Richard Dunning.The first, two and a half years old, was vaccinated byMr. Dunning on October 8th, 1803, the cicatrix on onearm being distinctly if not strongly marked. In lessthan two years (29th July, 1805,) the patient wasattacked with small-pox, the pustules amounting tomany hundreds, and were situated principally on theface and extremities . In the other case he had vaccinatedthe child more than two years previously,and the patient had from fifty to one hundred pustules.In this case Mr. Dunning was not satisfied with thevaccination , as the child had torn both the vaccinevesicles on the seventh or eighth day with its nails ,although he observed that nothing could be moreregular and correct than the progress of the earlyvesicles, and the cicatrices on the arms were not unusuallysmall, and were in many respects satisfactory.In the November number of same volume (pp. 403, 404),1 Medical and Physical Journal, vol. xiv. , pp. 308-310.118 DOES VACCINATION PREVENT SMALL- POX ?Mr. John Ring mentioned the cases of two childrenvaccinated by him who had slight attacks of small-poxafterwards , and also a case in the practice of a Dr.Nelson ; and he explains : " I am now inclined tobelieve that these, and some other well-authenticatedcases of a similar kind, are to be ascribed to the greatersusceptibility of small-pox in some habits than inothers."In the Journal¹ for December, 1805 , Mr. Walter Drewrelated the case of a child whom he had vaccinated inthe spring of 1804. The arm , we are informed, exhibitedall those criteria by which vaccination is recognised,such as the hardened phlegmonic base, and inflammatoryareola encompassing the pustule from the ninth tothe eleventh day, and its gradual change to a dark brownprominent scab, which adhered a long time, and leftbehind an indelible impression on the arm, such as inappearance to " enable me to warrant safety from smallpoxinfluence. " In September, 1805 , however, the childwas seized with an eruptive fever to very high degree,and this was followed by a small-pox eruption of thedistinct kind.A number of cases are recorded in the eleventhvolume of the Medical and Chirurgical Review. Theeditors say " that late failures (real or supposed) ofthe vaccine inoculation to secure the constitutionagainst future small-pox have, as was to have beenexpected, excited a great sensation in the public mind,and which is not likely to be allayed till the subject hasundergone the fullest and most impartial investigation.Medical and PhysicalJournal, vol . xiv . , p. 537 .“ Medical and Chirurgical Review, vol . xi . , p. Ixii . (January, 1805. )FURTHER FAILURES OF VACCINATION . 119Speaking abstractedly, it is of no moment in whichway the question respecting the vaccine practice isultimately determined, but it is of infinite importancethat the true state of the case be made out, whether ittell for or against the practice."The following case, taken partly from the minutesof the Vaccine-Pock Institution, appears in pp. xxx.(September, 1804, ) and lxv., lxvi. (January, 1805, ) of theeleventh volume of the Review. The child, about fiveyears of age, was vaccinated on each arm in October ,1803 ; both places took well, and mahogany scabs wereformed, which, on separating, left pits. In July, 1804,nine months after vaccination, the child was taken illwith small -pox ; the pustules were distinct and attendedwith purple spots, and it died on the eighth day of thedisease. The two medical men who vaccinated thepatient saw it before death, and were satisfied that itwas a case of small-pox.The Review¹ gives two cases which were also verythoroughly investigated, viz., the children of Mr. Hodges ,stay- maker, residing in Fulwood's Rents, Holborn. Bothchildren were vaccinated by Mr. Wachsel , the residentsurgeon at the Small-pox Hospital. He witnessed theappearance of the vaccinated parts, and expressed himselfas perfectly satisfied of their regularity, and of affordingpermanent security against future variolous infection.In the younger child (two and a half years vaccinated),the small-pox was mild ; but in the elder (vaccinatedfour years previous to attack), the eruption was verygenerally over the body, face, and limbs, and proceededMedical and Chirurgical Review, vol. xi. , pp. liii. - lvi . ( November,1804) ; and pp. lxiii. -lxv. (January , 1805 ) .120 DOES VACCINATION PREVENT SMALL- POX ?in the customary manner of small-pox to maturationand scabbing. The patient was very ill, and for somehours delirious ; the eruption was exceedingly copious ,some of the pustules running together ; there was swellingof the face, occasioning temporary blindness, andthe patient was much pitted.The editors¹ also related five cases of small-pox aftervaccination, and pledged themselves for the accuracy ofthe statement in every material point (see opposite page).In the Medical and Chirurgical Review, further instancesare recorded, some of these being extractedfrom the minutes of the Vaccine- Pock Institution. Dr.Pearson, at the request of Dr. Benjamin Moseley, anopponent of vaccination, examined a case of small-poхin a patient who had been vaccinated fifteen monthspreviously, and on whom a distinct scar was left as theresult of the operation. There were several hundrederuptions, in greater proportion on the face, and Dr.Pearson had no doubt of its being a case of small -pox,although Mr. Griffiths, and Dr. Willan, who also saw thechild, supposed it to be chicken-pox ; it is to be noted,however, that another child was inoculated from thispatient, and the local result was described by Dr. Pearsonas " unambiguously variolous " (p. xxi. ). The editors³furnish particulars of seven instances of failure on theirown responsibility ; the disease was caught between twoand six years of vaccination. None of the cases weredescribed as mild, and several of the patients werevery ill ; one, who took the disease two years after1 Medical and Chirurgical Review, vol . xi . , pp. cxxv. -cxxviii. (May, 1805. )2 Ibid. , vol . xii . , pp. xvi. , xvii. ( July, 1805. ) * Ibid. , pp. xxiv. -xxvii .Name . Age .Thomas Bainbridge5Harriet Bainbridge3Mary Hart3Vaccination .Vaccinated intwo places onFebruary24th ,1800 ,by Mr. Wachsel ,atthe Small -pox Hospital .Thevaccination regular and satisfactory.Scabs fell off about thetwenty -sixth day and left "cicatricesasstrongly marked as.u"sualVaccinated atSmall -pox HospitalinOctober ,1802. Cicatricesstrongly marked ,and child declaredsecure from future smallpox.Vaccinated atSmall -pox HospitalinOctober ,1802. Wentregularlythrough thedisease with Nature ofthe small -pox .cD-sopMomenoanavxrflecllluheonptedM.,,11d2a98inant0eddrh5dchInoculated with variolous matter onMarch12th ,1805. Thirty or forty eruptionsappeared ,which ripened into pustules ,inevery respect resembling small -pox ,though ofsmall size .InMarch ,1803 (five months after vaccination),took small -pox inthe natural way .About forty pimples appeared ,several ofwhich maturated .Vaccinated when three months |Inoculated with variolous matter onMarch.sucsauraslJohn Kay4Jw,dMoRbelroiyh-.dhnongvcttbalhoecaecriendations. atisfactory16th ,1805. There was considerable constitutionaldisturbance ,with eruption ofpimples ,some maturating .The fifth case inthe practice ofMr. Forbes Surgeon ,ofCamberwell ,was that ofayoung man who took smallpox"inaconsiderable degree "when inoculated with variolous matter two years after vaccination .6122 DOES VACCINATION PREVENT SMALL- POX ?vaccination, " had it very full, so as to leave manymarks " (p. xxvii. ).The reports of failure at length became so numerous,that it was found necessary to take action. In a letterto Mr. Dunning in reference to Dr. Benjamin Moseley'spublication of failures, Jenner expresses the opinion thatnothing would " crush the hissing heads of such serpentsat once " but a general manifesto with the signatures ofmen of eminence in the profession, unless Parliamenthad a mind to take the matter up again. It was aboutLondon where the " venom of these deadly serpents "chiefly flowed. " I know very well," Jenner said, " theopinion of the wise and great upon it (vaccination) ; andthe foolish and the little I don't care a straw for ; " andtherefore he turned to those in authority. He had aconference with Lord Henry Petty (afterwards Chancellorof the Exchequer) at Hampstead, who expressedhis determination to bring the subject forward in theensuing session. Consequently, in 1806, an addresswas voted to His Majesty by the House, praying " thatHis Majesty will be graciously pleased to direct hisCollege of Physicians to inquire into the state of vaccineinoculation in the United Kingdom, and to report theiropinion and observations upon that practice, theevidence which has been adduced in its support, andthe causes which have hitherto retarded its generaladoption ; and that His Majesty will be graciously1 The progress of the vaccine pock was deemed regular by Mr. Nicholson ,apothecary at St. Bartholomew's Hospital , and it left the ordinary mark onthe arm.2 Baron's " Life of Jenner," vol. ii . , p. 354.3 Ibid. , p. 352. * Ibid. , p. 14.DR. ROBINSON'S ADMISSIONS.123pleased to direct that the said report, when made, maybe laid before this House.¹The College reported favourably, and Jenner wasawarded £20,000 (the sum total he received being£30,000), and the National Vaccine Establishment wasfounded with a Vaccine Board of eight, each having asalary of £ 100 a-year. Although the profession andParliament had been practically committed to vaccinationat the time of Jenner's Petition ( 1802) , this wasthe first instance of the establishment and endowmentof the practice, and the natural tendency was to stifleopposition ; indeed, it may be said that one of theprincipal functions of the National Vaccine Establishmentwas to explain away the failures of cow- pox toprotect from small - pox.In some towns the failures were such as to lead to adiscontinuance of the practice ; thus, in the appendix ofDr. Willan's book, is a report on vaccination by Dr.Rutter, physician to the Liverpool Dispensary, whogives Dr. Robinson's account of the state of vaccinationat Preston . " Vaccination was first practised in thistown by one or two gentlemen in the year 1798 or1799, soon after its introduction by Dr. Jenner. A fewchildren only were inoculated at that time, but theywere supposed to have gone through the disease in theregular way." The practice afterwards became more general, untilthe small -pox raged epidemically. It was then observed1 Hansard's Parliamentary Debates, first series, vol. vii. , pp. 883 and899. (July 2 , 1806. )" On Vaccine Inoculation. " Appendix, p. xxvi. Robert Willan ,M.D. London. 1806 .124 DOES VACCINATION PREVENT SMALL- POX ?that many of the children who had been previouslyvaccinated, and were supposed to be secure, caught thecomplaint ; some of whom died, and others recoveredwith difficulty. The frequent occurrence of theseuntoward events alarmed the public mind, and prejudicedthe vulgar against the practice so entirely, thatfor a time it was nearly laid aside, except among themore enlightened. " Thus, we have an early admissionof the fact, which can no longer be denied, that againstepidemic small - pox vaccination is of little or no avail.¹Sir Isaac Pennington, Regius Professor of Physic atCambridge, laid before the Royal College of Physiciansan account of twenty- five cases of small- pox after vaccination,which he had visited in the town of Cambridge.Most were strongly marked, six only being mild. Insome, the vaccination had been of seven or eight years'standing ; and in others, not of so many weeks. In all ,the cicatrix was very distinguishable ; and at the timethey were vaccinated, the inoculator declared they hadgone through the disease in a proper manner. Sir Isaacsaid he had not seen any fatal cases where he had reasonto suppose the vaccination had succeeded properly.In 1808, about ten years after the introduction ofvaccination, the opposition became very strong, theopponents being men of education, and many of thembelonging to the medical profession. Discussions onthe subject took place in public, and according to1 See extracts from recent official sanitary reports from India, quoted byDr. Collins and Mr. Picton . Royal Commission on Vaccination, DissentientCommissioners' Statement , section 227 .* Letter from Sir Isaac Pennington. Medical Observer, vol. iv. , p, 246.(December, 1808. )FATAL SMALL- POX AFTER VACCINATION . 125Jenner, many professional men, some holding importantpublic stations, were concerned in diffusing " wretchedand pernicious trash, " and we also learn from Baron that" the walls of London " were placarded with " falsehoods. " 1About a year later we find him writing that " Jennerand vaccination were again to be put upon their trial. " 2In the Medical Observer³ for November, 1809, theeditor selected cases of failure from those formerlypublished and known to be authentic. Of 113 instancesgiven, 16 died, or a case- mortality of 14.2 per cent. Thedetails given in fourteen of the fatal cases are asfollows :-1. A child was vaccinated by Mr. Robinson, surgeonand apothecary, at Rotherham, towards the end of theyear 1799. A month later it was inoculated withsmall-pox matter without effect, and a few monthssubsequently took confluent small-pox, and died.2. A woman-servant to Mr. Gamble, of Bungay, inSuffolk, had cow-pox in the casual way from milking.Seven years afterwards she became nurse to the YarmouthHospital, where she caught small-pox, and died.3 and 4. Elizabeth and John Nicholson, three years ofage, were vaccinated at Battersea in the summer of 1804.Both contracted small-pox in May, 1805, and died.They were attended by Dr. Moseley and Mr. Roberts.5. Mr. J. Adams, of Nine Elms, contracted casualcow- pox , and afterwards died of confluent small -pox.6. The child of Mr. Carrier, Crown Street, Soho,was vaccinated at the institution in Golden Square ,and had small - pox three months afterwards, and died.1 Baron's " Life of Jenner," vol . ii . , pp. 110, 111. 2 Ibid. , p. 128 .* Medical Observer, vol. vi. , pp. 387-398.* Two of the deaths have been described elsewhere in this chapter.126 DOES VACCINATION PREVENT SMALL- POX ?7. Mary Finney's child, aged one year, died of smallpoxin July, 1805, five months after vaccination .8. The child of Mr. Blake's coachman, living atNo. 5 Baker Street, died of small-pox after vaccination .9. Mr. Colson's grandson, at the " White Swan,"Whitecross Street, aged two years, was vaccinatedby a surgeon at Bishopsgate Street, in September,1803. He died of confluent small -pox in July, 1805 .10. Mr. Brailey's child, aged two years and eightmonths , was vaccinated at the Small-pox Hospital,and forty weeks afterwards died of confluent small-pox.11. Mr. Hoddinot's child, No. 17 Charlotte Street,Rathbone Place, was vaccinated 1804, and the cicatrixremained. In 1805 it caught small-pox, and died.12. C. Mazoyer's child, No. 31 Grafton Street, Soho ,was vaccinated at the Small-pox Hospital. Died ofsmall -pox in October, 1805 .13. The child of Mr. R died of small -pox inOctober, 1805. The patient had been vaccinated,and the parents were assured of its security. Thevaccinator's name was concealed.14. The child of Mr. Hindsley at Mr. Adam's office,Pedlar's Acre, Lambeth, died of small - pox a yearafter vaccination .In five of these fourteen deaths ( Nos. 2, 5 , 8 , 12, 13),the length of time which had elapsed since vaccinationis not given. In No. 2 the small-pox was contractedseven or more years afterwards; in No. 8 the patientwas a child ; and Nos. 12 and 13 were both children,and as they took small-pox in 1805, it is not possiblethis could have supervened more than five or six yearsafter vaccination. Of the nine remaining deaths, eight,OPINIONS OF BROWN OF MUSSELBURGH . 127with one possible exception ( No. II ), were affectedwith the disease within a year of vaccination, and theremaining death (No. 9) was within two years of theoperation .1In 1809, Brown, of Musselburgh, published notes offorty- eight cases of small -pox, all of which had occurredwithin nine years of vaccination, most of them withinmuch shorter periods. Brown was originally a convertto the Jennerian doctrine, but he says (pp. 279, 280) :—“ Іam also convinced, from what has passed under my ownobservation for the last three or four years, that we havebeen all guilty of rejecting evidence that deserved moreattention, in consequence of the strong prepossessionswhich existed, from the very persuasive proof of its(vaccination) resisting inoculation and exposure to theepidemic, and from our judgment being goaded andoverpowered with the positive and arbitrary opinionsof its abettors. I am now perfectly satisfied, from mymind being under the influence of prejudice, and blindto the impressions of the fairest evidence, that the lasttime the small-pox was prevalent, I rejected, and explainedaway many cases which were entitled to themost serious attention, and showed myself as violentand unreasonable a partisan as any of my brethren inpropagating a practice which, I have now but littledoubt, we must ere long surrender at discretion. " 2Brown allowed that it might keep off small- pox for atime, and that there was reason to believe it tended1 " An Inquiry into the Anti-variolous Power of Vaccination. " ThomasBrown, surgeon, Musselburgh. Edinburgh. 1809.* Brown somewhat modified his opinions in a later work published in1842.128 DOES VACCINATION PREVENT SMALL- POX ?to make the disease milder ; in fact, he held what wouldbe about the average medical opinion of to-day. Ofcourse he was hopelessly before his time, and came infor a great deal of abuse. Jenner, writing to Baron, andreferring to a letter written by Brown to one of theLondon papers, says :-" His letter, under the veil ofcandour and liberality, is full of fraud and artifice, forhe knows that every insinuation and argument he hasadvanced has been refuted both by the first medicalcharacters in Edinburgh and Dublin, and, indeed,by many others. " ¹ The more reasonable of Brown'sopponents, however, ultimately adopted his views, forin the Edinburgh Medical and Surgical Journal ofJuly, 1818, we read :-" Before we conclude, we must,in justice to ourselves, pay the amende honorable to Mr.Brown, of Musselburgh, whose opinions we strenuouslycontroverted in 1809, because we did not think themsupported by the evidence then brought forward, orconsistent with our knowledge of vaccination at thattime ; and to which we now, in 1818, confess ourselvespartly converts, in consequence of increased experienceand observation . "The Medical Observers for August, 1810, states thatat Witford, Hertfordshire, the poor of the parish werevaccinated some time previously by Mr. Farrow, apothecaryat Hadham, with matter procured from Dr. Walkerof the London Cow-pox Institution. During theprevalence of the variolous epidemic, of the sixty- ninevaccinated, twenty-nine contracted small-pox, nine of1 Baron's " Life of Jenner, " vol. ii . , p. 47 .2 Edinburgh Medical and SurgicalJournal, vol . xiv. , p. 387.3 Medical Observer, vol . viii . , pp. 81 , 82.MORTALITY AT WITFORD . 129whom died. The editor gives the names and ages ofthose who died, as follows :-Name.William BartonMary CatmoreAnn CatmoreEmma PriorMartha WrennWilliam CatmoreCharles WybrowJohn Fitstead... ... ...... ... ...... ... ...James Thoroughgood... ...Age.5 years .13 years .13 years .6months.6 years.3 years .6 months .1 year.2 years.Thus these vaccinated cases of small-pox in the parishof Witford had a fatality of 31 per cent. , and seven ofthe nine deaths (78 per cent.) were under ten years ofage. This can hardly be regarded as a successfulexperience of the protective or mitigating powers ofvaccination ; and to make matters worse, two of thechildren originally vaccinated were reported to havedied from the effects of the operation .The Edinburgh Medical and SurgicalJournal for July,1810, refers to the Third Report of the NottinghamVaccine Institution, in which it is stated, that " duringthe virulence of the epidemic, one of the subjects, whosecase was marked in the register as perfect or satisfactory,fell a victim to the small-pox. " ¹ The boy wasoperated on in September, 1806, the vaccination beingdismissed as satisfactory. On the 31st of January, 1809,he contracted small-pox, and died on the eighth day.About this time several failures took place in highlife, and consequently attracted much attention. Thecase of the Hon. Robert Grosvenor was an instance inEdinburgh Medical and SurgicalJournal, vol . vi. , p. 385.2 See Baron's " Life of Jenner," vol. ii. , pp. 155-158 .130 DOES VACCINATION PREVENT SMALL- POX ?point ; he took confluent small-pox and nearly died, tenyears after vaccination by Jenner's own hands. This wasvery awkward, especially as the case got noised abroad ;but the National Vaccine Establishment were quiteequal to the occasion, and issued a special report on thisand other cases, from which it appeared that the boywould have died outright had he not been vaccinated.The Grosvenor case evidently made some impression,for we find Jenner admitting, in a letter to a correspondent,that it was " a speck, a mere microscopic speck onthe page which contains the history of the vaccinediscovery, " ¹ and in a letter to Baron, about this time, wefind the following :-" The noise and confusion this casehas created is not to be described . The vaccine lancetis sheathed ; and the long concealed variolous bladeordered to come out. Charming ! This will soon curethe mania. The town is a fool, an idiot ; and willcontinue in this red-hot, hissing-hot state about thisaffair, till something else starts up to draw aside itsattention. I am determined to lock up my brains, andthink no more pro bono publico ; and I advise you, myfriend, to do the same ; for we are sure to get nothingbut abuse for it. It is my intention to collect all thecases I can of small-pox, after supposed security fromthat disease. The best plan will be to push outsome of them as soon as possible. This would not benecessary on account of the present case, but it will provethe best shield to protect us from the past, and thosewhich are to come. " 2Here we have a new doctrine which was broughtforward by Jenner to repel failures, viz., that cases of1 Baron's " Life ofJenner," vol. ii. , p. 158 . Ibid. , p. 161 .FURTHER PROOFS OF FAILURE . 131small -pox after small -pox were not uncommon, andthat vaccination could not be expected to do more thansmall -pox itself. In a letter to Mr. James Moore, wefind the extraordinary statement that " thousands ( ofsuch cases) might be collected, for every parish in thekingdom can give its case." It is important to notethat this admission-that small-pox takes place aftersmall - pox although undoubtedly true, was onlybrought forward when the failures of cow-pox to protecthad become so numerous and notorious that it wasimpossible to invent further excuses .Another case was that of the son of Sir Henry Martin.The medical man, Mr. Arthur Tegart, who vaccinatedand also attended the boy, gives a description of the casein the Medical and Physical Journal for September,1811. With regard to the vaccination , Mr. Tegart says,"A strong and marked eschar now remains on the armvaccinated, and Sir Henry Martin tells me, that aneminent professional gentleman saw the child during itsprogress through the disorder, and considered it as avery fine specimen of the complaint. " The diseaseattacked him ten years after vaccination ; at first theeruption conveyed to Mr. Tegart the idea of an aggravatedkind of chicken-pox, but afterwards he says, " Ibegan (reluctantly enough, I admit,) to consider thedisease as the small-pox. " There were upwards of ahundred pustules on the face, and about twice thatnumber on the extremities. Dr. Heberden, who wascalled into consultation, hesitated but little in pronouncingthe disease to be small-pox ; but Mr. James1 Baron's " Life of Jenner, " vol. ii . , p. 363 .* Medical and PhysicalJournal, vol. xxvi . , pp. 177-181 .132 DOES VACCINATION PREVENT SMALL- POX ?Moore, director of the National Vaccine Establishment,entertained " some doubts" on the subject.In February, 1812, opposition apparently ran ratherhigh, for we read that Jenner " was particularly annoyedby the atrocious falsehoods of the anti-vaccinists ; " ¹ andsome friends were inclined to urge him to seek redress ina court of law. Again, later in the year, in a letter to JamesMoore, we read that " the anti-vacks are assailing me, Isee, with all the force they can muster in the newspapers .The Morning Chronicle now admits long letters . "The Medical and Physical Journal for August, 1812(vol. xxviii. , pp. 111-114), gives extracts from the minutesof the Vaccine- Pock Institution regarding cases in onefamily who were vaccinated at the Institution, and visitedby Drs. Domeir and Pearson. (See opposite page.)Dr. Pearson remarks (p. 114), " It does not appear thatthe children had the subsequent small-pox mitigated inany proportion to the degree of affection by vaccination. "Apparently Dr. Pearson did not have a high opinion ofvaccination at this time, for Jenner, in a letter datedNovember 18, 1812, refers to his " insinuations thatvaccination is good for nothing. " 3In consequence of the revival of small-pox inoculation,Lord Borington, in 1813, at the instance of the NationalVaccine Board, brought in a bill to check this practice.Lord Ellenborough, the Lord Chief Justice, after ridiculingsome of the provisions of the bill, made someremarks on the subject of vaccination. " No doubt," heobserved, " it was of some use, but he did not concur inall the praise bestowed upon it in this bill ; but if the1 Baron's " Life of Jenner," vol. ii . , p. 181. 2 Ibid. , p. 383. 3 Ibid.N. ame A. geMAAnancrneyll12LAnucceyll-7V. accinationV.,31oM18anas0crt1ccihnatedvttWahhecerncoitungahtionirwomaeninagtenuhnlearrf.vlieansreigceleVS,3oarencdpctienmabteerd1scwH8ihea0xal5drl.acteri.,,vtveshiserzidecelesTwte.aheawrrecomehres.dsiucsbatbsisenqcutentonN.-tsophmafoeatxlulrep,-Ae2aSopr6opmnrutpaxiphelltaliroend1n,dvEb8ieruu1srutm2-ype.trioounsst."1tshOMi2hcananteavcyhbitsngftan,ioshotahfphanolfapesewlteeanrsvauldstfeicehrrpfsaerotmotryminnctv."accinationSa,-e2Apor9pmponutrapxphiletllairoend1lpoShna8aufhau1rsedm2g-.bererst,.htpwTiuehohhslraciteenkcesrshw,fctwoaaaoheenrncnerrmdefeesluentob,ivokaaneflrinsandiddcduelrayrslpobfheafaryuvrgomnetmspgrsahlst.tfewaTwhayhanhecoesedeelsmlenct.f1odauOMol2rwapnartooyhsyedvnstaf"cahrroacreowrecmseinationlpoautoaeehnnprfreetdomcneivablet.r"ihgehtJohn Ancell9V.,21Jo4a8ant0cnh4cuianraytedTdvfweioehsureitrercilnecestsa.stuahcsnteuadiabslsfactoryA.,-1s2Dpop8m7eon1atrvx2lhielllopedeN;itotmnhrthooiuhartrpentetryionsr."p1twMOer2heansetrlptyheletecytsdlstvfoaeichanrrfsaecotmtrcmisinncatt."asnireooeewnncyAuA,,icfftGasnhoeonanheganiunmaecvoemlrtireardedrlslcgaylcecitneadtedsa.-dpminoaexdldl134 DOES VACCINATION PREVENT SMALL- POX ?noble lord considered it a complete preventive of thesmall -pox, he differed with him in opinion. At thesame time he had shown his respect for the discovery,for he had had eight children vaccinated. He believedin its efficacy to a certain extent ; it might prevent thedisorder for eight or nine years, and was desirable ina large city like this, and where there was a large familyof children. " ¹ Lord Ellenborough also remarked thatvaccination was " perhaps, sometimes, apt to introducedisorders into the constitution . " The bill was withdrawn,but the remarks of the Lord Chief Justice, whichtended to damn vaccination with faint praise, wereannoying to Jenner, and it was also unfortunate thatthis was the opinion of one of the " wise and great, "and consequently Jenner felt the matter somewhatacutely. " I have seldom," said Baron , " seen Jennermore disturbed than he was by this occurrence, and notcertainly because he had any fears that the unsupportedassertion of his lordship would prove correct, but becauseit unhappily accorded with popular prejudices, and whenuttered by such a person, in such an assembly, wascalculated to do unspeakable mischief. " SMr. Thomas Hugo, of Crediton, in the Journal forDecember, 1814, said that at Crediton the cases offailure became at length so numerous and decisive thatthey could not fail to excite alarm, and to engage theserious attention of medical practitioners. He instancedtwenty- five cases of small -pox in persons who, from the¹ Baron's " Life ofJenner," vol . ii. , p. 196.2 Hansard's Parliamentary Debates, first series, vol. xxvi. , p. 989.(June 30, 1813. )3 Baron's " Life of Jenner," vol. ii. , p. 197.* Medical and PhysicalJournal, vol . xxxii . , pp. 478-481 .MR. HUGO'S CASES . 135regular progress of the vaccine vesicles, were consideredsecure. He alluded only to those cases attended bymedical practitioners, and where the evidence was consideredin all respects conclusive. The fever, we aretold, in its attack and progress was commonly violent ;the heat was excessive, the pulse very quick, universallanguor, pain in the head and loins, frequent vomiting ,occasional delirium in the night, and sometimes convulsions.These symptoms, after having occasioned considerablealarm for three or four days, were succeeded by adistinct and mild eruption, which dissipated all apprehensionof danger. Mr. Hugo adds (p. 480) , " I believethat vaccination has nowhere been practised with morescrupulous attention to the characteristic appearanceof the vesicle, and I have in no case which had beenentrusted to my own care, neglected to ascertain theconstitutional affection by the test of a second vaccination.It is impossible, I conceive, therefore, to explainthese unsuccessful cases on the supposition that thepreceding vaccination had been spurious and irregular. "In the London Medical Repository¹ for April, 1816, acase of failure is given in a girl , nine years of age, whowas vaccinated in Batavia, and, as far as could be judgedfrom the cicatrices on the arms as well as from theaccount of her mother, in a manner quite satisfactory.The eruptive fever was exceedingly violent, and theeruption, though distinct, was very considerable.In the MedicalandPhysicalJournal for January, 1817,Mr. Thomas Harrison, of Kendal, contributes some casesfrom the practice of Mr. M. Redhead, Ulverston (pp. 5-7).1 London Medical Repository, vol . v. , pp. 295, 296.2 Medical and Physical Journal, vol . xxxvii. , pp. 2-12.No. Name .wAhgeen.vaccinatedBywhom .AwgheeninfectedwithNature ofthe small -pox .s-.pmoaxllIJRtoownboeesr'tschildrenInfants Mr. Redhead2Elizabeth James Infant Mr. Harrison12J3Joasmeepsh RIMnref.dahntead154William James InfantMr.Carter5PWairlkleiram4Mr. Close ,Dalton 18FE6ellilzabeth3Mr. Briggs12c,1oShw8ap0oumhonotnairdxtlcnilhynuedsw;fsondiienreoavxeltryenyes.mbamchOehyaandidnelidcalcdffoeoaunvuryesrisrindgerableep.ttrrohueepvtiioouns8Very feverish .Pustules distinct .Awellmarkedcase ofsmall -pox .Very feverish ,and thought dangerouslyill for afew days .Eruption not sofull aswith Elizabeth .Had them (eruptions )milder than thetwo former .Continued out afew days .Delirious two days before the eruptionappeared .Pustules numerous ,andcontinued out seven oreight days .Considerable fever previous tothe eruption,which was ofthe distinct kind .7SMtaarbilae10Mr. Carter19Feverish before the eruption ,whichwas ofasmall horny kind ,and soondisappeared .w.,sewsaHlreoanaiulosdgpdlnhttionfahadBfoebaeturoygerusrattenen.sMiasrteirass,,dwFleuieilctvgichehrertieudmedpg.foanbiurfuynsemetabutleersAfew small horny pox ,which continuedout about five days .Small horny pox .p.itaShbBlobmooeeloarxgulnatlynafbT.haforehtroroettrnmhiaegrshtFeverish three days ,with delirium .Facefull ofpustules ,and many onher body ;small horny kind ,which disappearedinfive orsix days .Feverish .Not somuch indisposed asBetty ;had fewer pustules ,but larger .Very feverish .Had afull crop ofsmallhorny pox .Face swelled .Blind threedays .Much fever .Very full of pustules ,andismuch marked .Very feverish .Had large distinct pox .Has marks on the face .8Mary Stable InfantMr.Edmondson,Keswick149Charles Hodge InfantMr.Harrison91BJ0roihsncoe3Mr. Redhead 16IIThomas Briscoe Infant Mr. Redhead912 Mary A. Briscoe InfantMr.Redhead613Betty Turner Infant Mr. Redhead614 Alice Turner InfantMr.Redhead1215Rob .Braithwaite's Infant Mr. Carter14daughter16Mr. Rawlinson's son Mr. Briggs17Ellen Physaclea Infant Mr. Redhead1310No. Name .Awhgeenv. accinatedB.wyhomAwgheeninfectedwiths.-pmoaxll.-tsoNphmfaoeatxlulre1LM8oanrgy4CMarr.terΙΟ1BW9aiilnleisam IMRnref.dahntead3W2Mi0olnlkihaomuse2CMarr.ter21BCeltartky ICMnarfr.atnetr7NJ2io2chhnolson'sdaughter.2WR3ooobdhouse'sdaughterHMarr.rison'sassistant7wIoAnlonfdmanatn1324William Tyson2Mr. Briggs925 John Kirkby InfantMr.BriggsIIdM,,ftwdeehiauvlrtyceeihsrerhiumsh.sbpTumoyohcarxelcnleyededdp,fdtaoiihaonnfseyxdtahppeared.lltamaoeehrannfgemrdtssksillness ,succeeded by Hadthreedays'illh.,siedwpinnoahoxcryixrnscuyhstedN.Ptiomuhnfousedtctiushlpeossedh.ifokBnoroiefunrcerdncaytmeedfv.awifaevtceeeckrisnationFE,.ftbduehrualvrutyleepsertiisohndrw,ttaiehhensgerndtuotilunagcrthsp-.sotmfoaxglelsS.fodoSnlefefmuivgamgerlbhrelteerip..FnaodvxiosuproasbeldydV.fsfBeeaeeuvvywrteesyrriaslhps,.rauepnscedtoeuvdleyersysA.ihtdneehativeygeshntI.tdotHnharwordyoreisnesyposede.,iddfanriaeusywpastpipoenared.||5TC3M2BaaW.ar6ennrm.nddtjearminKirkby2JK7oisrekpbhy RIMnref.dahnetad528 Sarah Bond InfantAtLiverpool1229 Jane Ellis InfantMr.Lodge,IngletonII,leWowaTarinanhrulsdegpletiriaomn.rtlctTehoohhsennaetgtnseiernuedifctwwnohweefuioreerlekcdstreedna.vPtofauhftcseectriunlaetsionh.koinrdnyt.etcGahhoosermtioplulygahintw,.fdmHMeieaauvtlnecdihrryhium,ptoskhwuhfoiohseonritndncuyhlesd. isappeared;,fficraHuanrealcomltdparkably.ioccownfoanacmkesrpeulsettaetionR,ipwbmserueueltccltothvyered..acammWobaoanornsfuktitehndedWB3ae0lttseyrs HIMnarfr.arnitson14dpc.soaHiumrfassaottdlpiulnlcets31 IDsiaxboelnla HIMnarfr.arnitsonΙΟ,.frIbcmaHuesuraal-torldpkedc.weolvleredMD3ai2rxgoanret RIMnref.dahnetad12B3Ge3atrtnyet CIManrrf.taenrt1434 Christ .Troughaire's Mrs.Dixonfour children Mr. CarterP..fdpvNuieueolsrsrlttftyieunclctetlsyR.weelcloveredW.iapDthntuiheasseisttguihlntecstwrd.,eaeieanlgcydlhostveredf)(etotHarhfhauveepodmtuiroanbslyf..dckahOuirianlsonldetpdinctMr. Briggs140 DOES VACCINATION PREVENT SMALL- POX ?Although there are no deaths in this list, the casesare by no means all of the mild variety, and in five ofthe number the patients were pitted. Again, they donot support the theory that the severity is in proportionto the length of time elapsed since vaccination. Let uscompare cases in the same family which would probablybe under much the same conditions.William James ( No. 4), who had been vaccinated abouteight years, had a milder attack than the other twoJames's (Nos. 2 and 3), vaccinated twelve and fifteenyears . In the case of Maria Stable, however, vaccinatedonly nine years before attack, the small -pox wascertainly not milder than that of her sister Mary,vaccinated fourteen years before attack (Nos. 7 and 8).Then, in the three children, John, Thomas, and MaryBriscoe ( Nos. 10, II , and 12) : in John, who had beenvaccinated thirteen years, the disease was as mild, if notmilder than the other two, vaccinated nine and sixyears. Also Betty Turner (No. 13), six years aftervaccination, took small-pox more severely than hersister ( No. 14) , vaccinated twelve years previously.the four Kirkbys ( Nos . 25 , 26, and 27) : although Josephand John had been vaccinated five and eleven years, theeruptions were larger and continued longer in William,who was infected four weeks after vaccination. Lastly,there were the two Dixons (Nos. 31 and 32). Isabella,ten years after vaccination, had a full crop of pustules ,and was marked ; whereas, in the case of Margaret,vaccinated twelve years prior to attack, the disease wasnot so severe.InTaking all these cases in conjunction, they afford nosupport to the theory that the disease is modified inMR. REDHEAD'S CASES. 141proportion to the proximity of the vaccination ; nordoes the incidence of small-pox seem to be regulatedin this manner, for the National Vaccine Board says : -" It appears to us to be fairly established, that the dispositionin the vaccinated to be thus affected by thecontagion of small-pox, does not depend on the timethat has elapsed after vaccination ; since some personshave been so affected who had recently been vaccinated ;whilst others, who had been vaccinated eighteen andtwenty years have been inoculated, and fairly exposed tothe same contagion with impunity. " This evidence is ,I venture to suggest, more valuable than present -day experience,for these theories of prevention and mitigationhad not then obtained the same hold on the medical mind.Mr. Redhead also gives several instances of small - poxbeing taken by means of inoculation after vaccination .One of these, James Shepherd, was vaccinated at fiſteenmonths of age by Mr. T. Carter, and when a year and ahalfold, i.e. , three months after vaccination, was inoculatedwith matter from Elizabeth James, above - mentioned .Mr. Redhead notes that the patient was very feverish ,the arm much inflamed, but the pustules not very large.Mr. Harrison, in referring to Mr. Redhead's cases, says(p. 10) :-" We cannot but feel our confidence in thepreventive power of the cow-pox to be somewhatshaken . " He also relates three instances in one family ;these excited considerable interest among medical men,from one of them having been vaccinated at a publicinstitution in London by Jenner himself, who, afterhaving inspected the vaccination, pronounced the childsecure from small -pox .1 Report of the National Vaccine Establishment for 1819.142 DOES VACCINATION PREVENT SMALL- POX ?There is every reason to believe that about this timevaccination was rapidly falling into disrepute. Thus,Jenner's old friend, Gardner, writing to him fromFrampton, on May 21 , 1817, says :-" From some unaccountablecauses, the fame of vaccination seems todecline in this part of the country : I find my offers ofgratuitous service very frequently rejected even by thosewhose former children have undergone the operation. " ¹In the London Medical Repository for July, 1817, theeditors, Dr. G. M. Burrows and Mr. A. T. Thomson, intheir observations on prevailing diseases, say : " Variola,above all , continues and spreads a devastating contagion .However painful, yet it is a duty we owe to the publicand the profession to apprise them, that the numberof all ranks suffering under small-pox who havepreviously undergone vaccination, by the most skilfulpractitioners, is at present alarmingly great. This subjectis so serious , and so deeply involves the dearestinterests of humanity, as well as those of the medicalcharacter, that we shall not fail in directing our utmostattention to it . " 2In the August number the editors remark : " Generally,the diseases of last month partake of that nature usualto the season ; hence there is nothing but variolaparticularly demanding notice. Small-pox, however,still forces itself upon our observation. It has, webelieve, been more prevalent than for many years past,and has assumed a more than usually virulent character ;many of the cases having been of the confluent kind.This may in some degree account for so many, whoBaron's " Life of Jenner, " vol . ii. , p. 203.2 London Medical Repository , vol . viii. , p. 95.1OFFICIAL EXCUSES FOR FAILURE . 143had previously undergone vaccination, being infectedby small -pox, as we remarked in our last report ; andwe are concerned to find, from the increasing testimoniesof medical practitioners, that these instanceshave been much and widely extended. So little modifiedhas the disease in some cases appeared to have beenby the influence of the vaccine inoculations, that deathhas ensued ; an effect which, as far as our informationgoes , was never before produced by small- pox, after thepatient had been subject to the action of the vaccinevirus . " ¹Baron informs us that in 1818 " there was greatclamour about the prevalence of small-pox after vaccination,"and that "the greatly exaggerated statements onthe subject of the vaccine failures, and the hesitatingmanner in which respectable individuals spoke on thesubject, threatened to lead to a considerable abandonmentof the practice. " 2About this time we even find failures recorded bythe National Vaccine Establishment, coupled withingenious but far-fetched explanations. Thus, in thereport of 1818 , we read :-" Five cases have been reportedto the Board, of vaccinated persons who havesubsequently died of small -pox. In one of these cases,it was clearly ascertained, that the only vaccine vesiclewhich had been excited, was disturbed and broken inits progress, which there is great reason for believinghas been a frequent cause of the insecurity of vaccination:in the other cases, no detail respecting thevaccination could be obtained, and they were, moreover,1 London Medical Repository, vol . viii . , p. 183 .2 Baron's " Life of Jenner, " vol. ii . , pp. 237, 238 .144 DOES VACCINATION PREVENT SMALL- POX ?all vaccinated at a period of time when the mode ofvaccination , and the management of the vesicle, werenot well understood . "In the report of 1819 it is stated :-" The testimoniesof some of our correspondents in this country, are byno means so favourable. They concur in showing, thatgreat numbers of persons who had been vaccinated,have been subsequently seized with a disease presentingall the essential characters of small-pox ; but that inthe great majority of such cases, the disease has been ofcomparatively short duration, unattended by symptomsof danger. In several of these cases, however, themalady has been prolonged to its ordinary period ; andin eight reported cases it has proved fatal. "In the London Medical Repository for August, 1819,Mr. William Gaitskell, surgeon of Rotherhithe, was" truly sorry to report two cases of malignant smallpoxsubsequent to vaccination." The first, a stoutyoung man, eighteen years of age, contracted small -poxtwo years after vaccination , and died on the twelfth day,a mass of putrefaction . The second, about twenty-twoyears old, took small-pox of a very malignant description,twelve years after vaccination , but recovered .Both patients were supposed to have gone through aregular vaccination ; they were pronounced safe (accordingto their own statement), and presented distinctimpressions of the disease on their arms .In the Medical and Physical Journal for July, 1820,Dr. Macleod, physician to the Westminster GeneralDispensary, contributed a communication, entitled1 London Medical Repository, vol . xii . , pp. 113, 114.2 Medical and PhysicalJournal, vol . xliv . , pp. 1-12DR. MACLEOD'S EXPERIENCES . 145"Remarks on the Small-pox, as it has occurred inLondon subsequent to Vaccination." He gives thefollowing cases (pp. 10-12) illustrating some of theappearances assumed by small-pox after vaccination.(See next page.)Dr. Macleod says (p. 6) :-" I have seen too manyinstances of small -pox in children vaccinated in London,where that process was carried on in the way whichthe National Vaccine Establishment has recommendedas the most efficacious, to retain much faith in itspreventive powers, in whatever manner conducted. "Again he remarks (pp. 8 , 9) :-" The history of vaccinationaltogether forms a severe satire upon the mutability ofmedical doctrines. In the first ardour of discovery, notcontented with its blessings to mankind, its benefitswere also extended to the brute creation. It was toannihilate small- pox, prove an antidote to the plague,to cure the rot in sheep, and preserve dogs from themange. These good-natured speculations , however ,were soon abandoned ; and more recently all hadagreed in acknowledging its anti-variolous powers,which, we were told , were as well established as anythinghuman could be."But the present epidemic shows too clearly the mortifyingfallibility of medical opinions, though foundedon the experience of twenty years, and guaranteed bythe concurring testimony of all the first physicians andsurgeons in the world. "In 1820 we have also further official admission ofvaccine failures. " It is true, indeed, my Lord, thatwe have received accounts from different parts ofthe country of numerous cases of small -pox havingN. ameAwgheen.infectedLTuhcoamsas5SDeolviena9OHlednfireyld7SLtuicllywell22William Pyrhe 8Robert Page.Vaccination.soaVmwifgaohxecnectnihnsatedV,ayosawtefeaghavceerecsnninatedt.IiJHnnheosenltnbieotruritnaionnHV-aStpoatmhoscaexpcliiltnaaltedw,pofamhaeleoahrdwndeftenchts.ctoaihnrcematrix,tapyV1otrea4teacavrccisikonuasted.cptaahoaiehnanrcreddmaftercitxV-aHtSptoahmosecaxpcliiltnaaltedw,ofmahaleonahdwnddetnhsp.ctoaeihnrcremaftercitx2,tVshmah1oauaoancpvndcpetiohnssaetdedm.sidtaanihatseniensafesaerctory-Page3h,tVsahoaaunacpvddcpeionsaetdeds.idtamanihatseniesnafseaerctoryN.-stopmhafoaetxlulreS,fpecfbeuroomyvsuplaetpilrrutootliuwaoserndlo.,,fcnaahienncemcdesbktsh,.fdwACaeeietonvltatpdeihdairracickuhemedo,pcfeeaouahurxnnsceutsdtespruttelimaoirntc..pftEoiaahrrnerceuostepwitcdiuelodanrlyp,feCtaouerohnnsvunedtepsrutilidaoernrsable.,,fcbaahancecdeskt,-fcbiuwSpeounsimovnthtaxesehlrirldeedrable.iotpwnnfhoaucecsmokbnsseirderable,,fdVhaaeeiecnvloacdeildorreamincputhameniedb.fresoaAiexcfnytsstrdtreleaemsmseinnegsscdpeaoiourpnfspupftipeeutoarliueraosnerntdp.fettowbOaarhhefonrcueerdetpeystions,cetturamoyhhnononeeedudufsentlrdhuent.ipcotopaMnahotfonarehcdnteksrysentftwsnwoaohiuaenretrrehreraooruwmnsded,apgptaoruihupfesverpotipelunlaalgereasnce.acSptoofreeehffrinvteosteemirrcneahgliæf.ftpawpwilhuioeluertcrliphekdedlse,fdifuwaTeinosinhvslhtdeeelehraorsweeedds.rrmdabTeaeeayhvssayeehessrmlabellsingc,rfvcaaeeehonnsvsinddteiltlrcdieiunsslsuhaerde,cdwaoreeipnnuptptprherteaaisrlosenidosns.fvpatowbaTieehpfeahrsa-esrceitrekcllyes.,apoabmfepneotaadcrerqaeraumwneaecredsa,cndsaToboiynhnatdmdsetpteittoumtsional;otcsbchouecenpcasveaseurmilvoseeninaoelndsm,sctttadaehehhbionvineeoerdeltuderdhte.itodlhfaleynesss,haitbbamWiifnoruaamsfotnietslnchateererrddisease milder .COW- POX FAILURES EXTENSIVE. 147occurred after vaccination ; and we cannot doubt thatthe prejudices of the people against this preventiveexpedient are assignable (and not altogether unreasonablyperhaps) to this cause. These cases the Boardhas been industriously employed in investigating ; andthough it appears that many of them rest only onhearsay evidence, and that others seem to have undergonethe vaccine process imperfectly, some years since,when it was less well understood, and practised lessskilfully than it ought to be, yet, after every reasonablededuction, we are compelled to allow that too manystill remain on undeniable proof, to leave any doubtthat the pretensions of vaccination to the merit of aperfect and exclusive security in all cases against smallpox,were admitted at first rather too unreservedly. " ¹It was the small-pox epidemic of 1817-19 which,however, demonstrated the failure of vaccination on alarge scale, for a majority of the cases were admittedly" protected . " Dr. John Thomson writes :-" It is tothe severity of this epidemic, I am convinced, that weought to attribute the greatness of the number of thevaccinated who have been attacked by it, and not toany deterioration in the qualities of the cow - pox virus ,or to any defects in the manner in which it has beenemployed. Had a variolous constitution of the atmosphere,similar to that which we have lately experienced ,existed at the time Dr. Jenner brought forward hisdiscovery, it may be doubted whether it ever could haveobtained the confidence of the public. " *1Report of the National Vaccine Establishment for 1820." Historical Sketch of Small-pox, " p. 394. John Thomson, M.D. ,F.R.S.E. London. 1822 .148 DOES VACCINATION PREVENT SMALL- POX ?Dr. Thomson's publications on the subject called forthan article in the Edinburgh Review, which opens thus :-" Vaccination, we are perfectly persuaded, is a very greatblessing to mankind ; but not quite so great a blessing,nor so complete a protection, as its early defendersconceived it to be. The proof of this has been admittedwith great reluctance ; but it has unfortunately becometoo strong for denial or resistance. The first answersgiven to the instances of failure, with which the friendsof vaccination were pressed, were, either that the diseasewhich had occurred after vaccination was chicken-pox,and not small-pox ; or that the process of vaccinationhad been unskilfully or imperfectly conducted ; or thatit was one of those very rare cases which occurred inthe times of inoculation , and from which vaccinationitself did not pretend to be wholly exempt. " ¹This does not appear to be strongly condemnatory ofvaccination, but apparently Jenner was much disconcerted." I have an attack," he says, " from a quarterI did not expect, the Edinburgh Review . These peopleunderstand literature better than physic ; but it will doincalculable mischief. I put it down at 100,000 deaths,at least. Never was I involved in so many perplexities." About two weeks after writing this, the unhappyman died in the midst of his difficulties.Dr. William Maxwell, in a paper read before theDumfries Medical Society, remarked that " it must beallowed, that the world has been grievously disappointed,Edinburgh Review, vol. xxxvii . , pp. 325 , 326. ( November, 1822. )* Letter from Jenner to Gardner, dated January 13, 1823. Baron's " Lifeof Jenner, " vol . ii. , p. 433.FAILURES ON H.M.S. " PHAETON." 149in the hope that this discovery (vaccination) would beperfect security against variolous disease." 1In a communication from the Admiralty, which wasprinted with the Report of the National VaccineEstablishment for the year 1825 ( pp. 10-13), is areport by Dr. W. Burnett, one of the Medical Commissionersof the Victualling Board, relating to an outbreakof small -pox on His Majesty's ship " Phaeton " in herpassage to America. Amongst other cases is one of apatient, J. Munns, aged twenty- seven, who was vaccinatedon June 24, 1825, attacked with small-pox onJuly 8, i.e. , fourteen days after vaccination, and whonearly died of the disease.Two others , J. Sutton and T. Avenall, aged twelveand thirteen respectively, who were vaccinated in May,1825 , presented perfect cicatrices , and contracted smallpoxon the 7th of July, i.e. , about two months aftervaccination ; but they " completed the stages in a verymild manner."In the case of John Reid , A.B. , aged nineteen, vaccinatedon the 24th of June, who was attacked withsmall-pox on the 4th of July, and who died on the30th of the same month, it may be objected that thepatient was vaccinated during the incubation of smallpox; but no possible objection can be raised to thethree instances previously mentioned.The Sunday Times of February 12 , 1826, furnishes anaccount of a meeting of the Governors of the LondonSmall -pox Hospital, with the Duke of York in the chair.The number of admissions in 1825, and the particulars of1 Edinburgh Medical and SurgicalJournal, vol . xxii . , p. 9. ( April , 1824. )150 DOES VACCINATION PREVENT SMALL- POX ?each case were read . The account stated that in thelast year twelve persons had died of small - pox whosedeaths were presumed to be subsequent to vaccination.The Duke of York here interposed, and observed thatthe fact of the cases having previously been vaccinatedwas distinctly stated in copy of the report sent to him ;and the Home Secretary, Mr. Peel, who was alsopresent, said that, after reading his copy of the report,he became uneasy about his own children, all of whomhad been vaccinated .Dr. Gregory, the physician to the hospital, stated thatthe copies alluded to by his Royal Highness had beensent before they had been finally settled by him . Hewished to add notes, but finding that the copies hadbeen made, and that the words could not be introducedwithout the making of fresh copies, he did not think theomission of any great consequence, and therefore he letthem go as they were. He regretted he had not inscribedthe word "presumed," but one reason was that itwas not a term generally used by the profession .It is fairly evident what Dr. Gregory thought of thecases . They were, however, the subject of inquiry bythe National Vaccine Establishment, ¹ and, as we mighthave expected, the result was so satisfactory, " as toleave no cause to doubt that these individuals had notbeen properly vaccinated. "From this time onwards medical criticism becameless acute, but neither then nor at any other time hasit subsided, and there was a strong undercurrent ofscepticism amongst able and trustworthy observers atBaron's " Life of Jenner," vol . i. , pp. 273, 274.UNMITIGATED BY PREVIOUS VACCINATION. 151the period with which we are engaged. Thus, in a letterfrom Mr. Edward Greenhow, of North Shields, to theLondon Medical Gazette of February 2, 1833 , vol. xi. ,p. 590, we read :-"And not only is the small -pox aftervaccination becoming much more frequent, but it isbecoming also much more virulent. It is true, in thegreater number of cases, the disease is modified , oftenturning on the fifth and sixth day ; but cases are by nomeans rare where the disease is confluent, and runs itsfull course, unmitigated by the previous vaccination,and death occasionally ensues." From what I have above stated, it would appearthat vaccination is losing its protective influence ; andit becomes a matter of serious consideration to ascertainto what causes we are to attribute this failure. Is itthat its protective power wears out after a certainnumber of years, and that it becomes necessary torepeat the operation ? Or is it that the vaccine virusloses wholly, or in part, its virtues, by passing so repeatedlythrough the human system ? The latter isthe opinion that has forced itself upon my conviction,because the disease has principally attacked youngpersons, and such as have been vaccinated within thelast ten or twelve years, and by far the largest portionhave been done much within that period, so that thenumbers attacked are in the inverse ratio to thenumber of years which have elapsed since they werevaccinated. " I may observe that the age- incidence ofthis disease did not begin to alter very much untilafter the epidemic of 1837-38, which would account forthe large proportion of young persons attacked at anearlier date. The same fact was noticed by one of Dr.152 DOES VACCINATION PREVENT SMALL- POX ?John Thomson's correspondents, Mr. William Gibson, ¹in his experience at New Lanark, where, of 251 vaccinatedcases of small-pox, 191 , or 761 per cent. , took thedisease at intervals up to ten years after vaccination.In 1837 the reviewer in the " British Annals of Medicine,"in criticising certain statements about vaccination,pertinently inquired, " Will it not be better to collectfacts patiently, and to remain a little longer in suspense,than assume a dogmatical tone, or assert a blind belief,and thus silence inquiry ? " *Sir Henry Holland, in his " Medical Notes andReflections, " writes (p. 401 )-" Not only in GreatBritain, but throughout every part of the globe fromwhich we have records, we find that small-pox has beengradually increasing again in frequency as an epidemic ;affecting a larger proportion of the vaccinated ; andinflicting greater mortality in its results. " Again , hesays ( p. 414)-" It is no longer expedient, in any sense,to argue for the present practice of vaccination as acertain or permanent preventive of small- pox. Thetruth must be told, as it is, that the earlier anticipationson this point have not been realised. "Dr. George Gregory was also known to be somewhatsceptical as to the merits of vaccination, and this factcomes out clearly in his writings. In 1823 he wrote,1 Letter from Mr. William Gibson to Dr. John Thomson, datedJanuary 11 , 1819. " An account of the varioloid epidemic which haslately prevailed in Edinburgh, and other parts of Scotland," pp. 251-258.John Thomson, M.D. , F.R.S.E. London. 1820." British Annals of Medicine , Pharmacy, Vital Statistics , and GeneralScience, " vol . i. , p. 235. (February 24, 1837. )3 " Medical Notes and Reflections." Henry Holland, M.D. , F.R.S.London. 1839.OVER -SANGUINE PATHOLOGISTS. 153" The acknowledged frequency of cases of small-pox,subsequent to vaccination, in all parts of the country, issuch as to have excited, in no inconsiderable degree, thefears of many, and the anxieties of all. No one canlook back upon the history of the last few years withoutfeeling sensible that these unpleasant occurrences areon the increase. " ¹ In 1837 he says, " Many of thephysicians and surgeons who flourished at the commencementof this century, and to whose generousefforts in behalf of vaccination the world is deeplyindebted, are passed from this scene. A few stillsurvive, who when they call to mind the strong hopeswhich were held out, in their day, of the ultimateextermination of small -pox, will probably be surprisedto find that, after the lapse of thirty-six years, smallpoxstill prevails ; that the same necessity exists nowas formerly for studying its various aspects ; and thatthe benevolent anticipations of 1800 receive no countenancefrom the facts of 1836. It is impossible to deny,and useless to conceal, that these bright prospects wereoriginally built upon very slender foundations. Thewish was father to the thought. " 2In 1840 Dr. Gregory writes :-" It is often noticedthat persons (vaccinated persons, for instance,) who .resist small - pox in common years, though fully exposedto the contagion, are attacked by it in years ofepidemic prevalence. These and other facts, whichbear on the epidemic origin and diffusion of small -pox,were overlooked by those sanguine pathologists, who1 " Medico- Chirurgical Transactions , " vol . xii. , p. 324. ( 1823. )2 " British Annals of Medicine, Pharmacy, Vital Statistics, and GeneralScience ," vol . i. , p. 193. (February 17 , 1837. )11154 DOES VACCINATION PREVENT SMALL- POX ?imagined that in vaccination nature had provided uswith means adequate for the complete exterminationof small -pox from the earth. " ¹Increased experience does not appear to have modifiedDr. Gregory's views, for twelve years later we findhim writing, " When we look around us, when we observethe quantity of small-pox, now (at the close ofthe first half century from the promulgation of vaccination)diffused through this and other countries,-when we see the practice of re-vaccination almostuniversal on the continent of Europe, and greatlyincreasing in this country, we are led irresistibly to theconclusion, that these broadly-urged claims in favourof vaccination have not been substantiated. Small-poxdoes invade the vaccinated, and the extirpation of thatdireful disorder is an event as distant now as when itwas first heedlessly (and, in my humble judgment, mostpresumptuously) anticipated by Jenner. " *In the Report of the Vaccination Section of theProvincial Medical and Surgical Association, it isstated-" It will be observed in subsequent parts of ourReport, that failures are noticed at all periods, froma few weeks after vaccination up to thirty or moreyears. It has been supposed that they are mostcommon at and after the age of puberty ; but this iscertainly not the opinion of our correspondents ingeneral. Some, it must be admitted, do affirm thatsmall -pox has more frequently occurred in personsArticle by Dr. Gregory on " Small-pox " in Tweedie's " Library ofMedicine, " vol . i. , p. 310. London. 1840.* Medical Times and Gazette, new series, vol. iv. , p. 633. ( June 26,1852. )ADMISSIONS OF THE " LANCET." 155recently vaccinated, than in those at a remote period,while others assert that time makes no difference. " 1Even the Lancet, which has generally been known asa thorough-going advocate of vaccination, reluctantlywrites : " In the public mind extensively, and, to amore limited extent, in the profession itself, doubtsare known to exist as to the efficacy and eligibility ofthe practice of vaccination. The failures of the operationhave been numerous and discouraging. It hasfailed frequently by producing no effect at all ; it hasfailed by producing a vesicle by no means clearlyindicative of the existence of the vaccine disease ; andit has failed in protecting persons so vaccinated froma future attack of small-pox. " 2Thus, in the early epidemics, the cases of smallpoxafter vaccination were numerous ; but, in estimatingthe number, we must take account of some of thecases which have been ascribed to chicken-pox. SirThomas Watson, writing in 1848, said, " These mildand irregular forms of variola, both parents and medicalmen, wishing, I suppose, to believe nothing in disparagementof the protecting power of vaccination, arevery apt to consider, and to call chicken-pox. " 3 In theearly days, however, it was by no means only the mildcases that were thus designated .In a report on the cow- pox inoculation from thepractice at the Vaccine-Pock Institution, during the" Transactions of the Provincial Medical and Surgical Association, "vol. viii . , pp. 35, 36. ( 1840. )2 The Lancet, vol . i. , p. 476. (May 21 , 1853. )3 " Lectures on the Principles and Practice of Physic," vol . ii . , p. 805 .(Third edition. ) 1848 .156 DOES VACCINATION PREVENT SMALL- I'OX ?years 1800-02, we read (pp. 19, 20) :-" It may bealso useful to notice that we have been alarmed two orthree times with the intelligence of the small-poxoccurring several weeks or months after our patientshad undergone the cow- pock. We thought it our dutyto visit and examine these patients, and also to inquireinto their history among their attendants, and by thesemeans we obtained the completest satisfaction that thepretended small-pox was generally the chicken-pox. "They gave the following instance as an illustration inwhich the eruptions were, by their resemblance, mistakenfor small-pox by the friends of the patient, andeven by a medical practitioner, " who accordingly gavea representation of the case by no means advantageousto the Institution. " The child was vaccinated on April1 , 1800 ; a genuine vaccine scab was formed, whichfell off and left a cicatrix. Four months afterwards thechild was attacked with fever, followed by an eruption,which , when seen at the Institution, presented over onehundred eruptions of blackish scabs and red spots," apparently the chicken -pox, in the scabbing state. "Small pits were observed some months afterwards .Dr. John Walker, the resident vaccinator of theRoyal Jennerian Society, related that a father called onhim and informed him that, of two children he hadvaccinated the previous spring, one was now coveredwith small-pox, and the other sickening, and that he(the father) was advised to advertise it. On consultingthe register, Dr. Walker found both the cases markedperfect, and he told the father that it was impossible forMedical and PhysicalJournal, vol . xii . , p. 543. (December, 1804. )CASES ATTRIBUTED TO CHICKEN - POX . 157either of the children to be infected with small-pox ; hethen called on the vice- president, Mr. John Ring, andchallenged him to come and detect his (Dr. Walker's)failure. " He had the goodness to accompany me,and on our seeing the child, he immediately declaredit chicken -pox."Dr. William Farquharson, Mr. James Bryce, and Mr.A. Gillespie, of Edinburgh, in a joint letter to Dr.Walker, remark on many children who had passedregularly through the process of vaccination, but onwhom eruptions appeared at different periods afterwards,which by some ignorant people were supposedto be variolous ; but which, upon investigation, uniformlyturned out to be chicken-pox. In some of these casesthe eruptive fever was very severe, sometimes evenattended with convulsions ; and the consequent eruptionsvery numerous, and in a few cases the last ofthe pustules did not disappear until the fifth or sixthday. " These cases," they add , " were repeatedly visitedby many medical practitioners of this place, as well asby ourselves, and none of them entertained any doubtof the disease being chicken -pox.2A case is recorded in the Medical and ChirurgicalReview. A child was operated on by Mr. Ring inMay, 1804, who expressed himself as perfectly satisfiedwith the progress of the vaccination, saying that " hewould forfeit a hundred guineas if the child ever tookthe small -pox afterwards. " A distinct scar was lefton each arm as the result of the operation. In October or* Medical and PhysicalJournal, vol. xiii . , pp. 286, 287. ( March, 1805. )* Medical and Chirurgical Review, vol. xi . , pp. cvi . - cviii. ( March,1805. )158 DOES VACCINATION PREVENT SMALL- POX ?November of the same year it was taken ill, and thepustules were pretty numerous, particularly on thescalp, two of them leaving pits; the patient was seenrepeatedly during the progress of the eruption by Mr.Ellis, apothecary, of Drury Lane, who asserted it to besmall -pox. The child was next taken to Mr. Soley,apothecary , in Bloomsbury Square, about the ninth day.He declared immediately, and without hesitation, that itwas undoubtedly small-pox, and he chided the motherfor not having taken means to prevent it by vaccination .She replied that she had done all in her power byhaving the child vaccinated by Mr. Ring. " Then," saidMr. Soley, " it cannot be small-pox, for small-pox neveroccurs after cow-pock. It must be a rank kind ofchicken-pox ; " and he sent her to Mr. Ring. Oncalling at Mr. Ring's house, she first saw his assistant,who declared it to be small-pox, and upbraided themother for not having had the child vaccinated. WhenMr. Ring was informed of this unusual circumstance,and on seeing the child, he remarked that it could notbe small-pox, for this disease was never attended byitching, nor did it appear in clusters, as in this case.He told the mother she might rest satisfied that it wasnot small - pox , and he begged her to say nothing aboutit, as it might excite alarm. In a foot-note on p. cvii . ,the editors remark on the above case :-" This attemptto conceal everything that appears unfavourable, sofrequently resorted to by certain pretended friends ofvaccination, cannot be too much reprobated. It showsthe business to have got into very bad hands.truth their only object, they would court investigation,not endeavour to suppress it.WereCASES OF CONFLUENT CHICKEN - POX . 159Mr. John Ring, in the Medical and Physical Journal,gave a description and drawing of a case of confluentchicken-pox in a boy four years of age, who had beenvaccinated some time before. He added : " When thechicken - pox broke out in so formidable a manner, it wasmistaken for the small -pox. "In the Medical and Physical Journal for November,1805 , Mr. R. Hall, of Clement's Inn, related instances inthe family of a Mr. Ross. An eruption appeared ontwo of his children, one of whom had been vaccinatedabout a year before. In both cases, the eruption wasextremely copious, but the pustules were much largerand more confluent in the one which had not beenvaccinated. Mr. Hall says : " In both, the pustules soexactly resembled in form, figure, and other circumstances-those of small-pox, that, had we founded ouropinion on the external character alone, we should mostunquestionably have deemed them both cases of genuinesmall -pox ; but, as they neither went through theregular course, nor were attended with any of thosesymptoms which uniformly accompany violent cases ofsmall -pox , we did not hesitate to consider themas cases of confluent varicella . "In the twentieth volume of the Medical and PhysicalJournal, on pp. 257, 258 (September, 1808), Mr. ThomasHardie relates the case of a patient who, four yearsafter he had vaccinated her, was much indisposed, andhad a considerable eruption, which he supposed to bethe chicken-pox, until the fourth day of the eruption,1 Medical and PhysicalJournal, vol . xiv. , pp. 141 , 142. ( August , 1805. )Ibid. , pp. 410-412 .160 DOES VACCINATION PREVENT SMALL- POX ?when the phenomena, both local and general, inducedhim " reluctantly " to alter his opinion.Mr. Richard Pew, of Sherborne, ¹ also saw a postvaccinalcase, in which the pustules " bore so general aresemblance to real small-pox, that anyone acquaintedwith the subject must immediately acknowledge themto be a branch of the same family."In 1818 there was published the Substance of aCorrespondence between the Directors of the Cow-pockInstitution , Sackville Street, Dublin, and their subscribersor other medical practitioners ; and also with the IrishMedical Staff and Militia Surgeons, being replies tocertain queries circulated by the Directors, occasioned byalleged failures in vaccination. A number of thereplies testified to the occurrence of chicken - pox aftervaccination.Mr. Heron, of Lucan , remarked "that in the summerand autumn of 1810 a very bad kind of pustular eruptionmade its appearance among the children about Banagherand its neighbourhood, which many of the practitionersin these places took for small- pox , and inoculated withmatter from it as such. From observations, however,then made, it appeared to Mr. Heron to be nothingmore than a malignant chicken-pock, of which somedied." 2Dr. Little, of Ballina, stated that, " about three yearsago, the regiment to which he belonged, being quarteredin Tuam, a very severe form of confluent varicellaprevailed epidemically, and he was repeatedly calledMedical and PhysicalJournal, vol . xxi . , p. 250. ( March , 1809. )* " Historical Sketch of Small -pox," p. 252. John Thomson, M.D. ,F.R.S.E. London. 1882.DR. P. MUDIE'S EXPLANATION. 161upon to see children as well of the townspeople as thesoldiers, whom he had vaccinated, and who were markedin his journal as having gone regularly through thedisease ; but in no instance could he hesitate as to thenature of the disease, which, though often of a mixednature, was genuine, and of the conoidal form , asdescribed by Dr. Bateman. " 1Dr. P. Mudie, in a letter to Dr. Thomson, datedOctober, 18 , 1818, freely acknowledges a bias in hisown mind with regard to the prevalence of small -poxafter vaccination. " Of late years," he says , " I haveremarked, that the disease called chicken -pox has beenmuch more severe than it used formerly to be, andmany of the cases, occurring after vaccination, so muchresembled small-pox, that if my mind had not beenprejudiced against the possibility of such an occurrence,I would have pronounced the eruption to have been of avariolous nature. " 2Thus there were a large number of vaccine failuresin the early years of the century; and, if we includesome of the chicken-pox patients, there must have beenthousands of such cases in the epidemic of 1817-19.Secondly, these failures took place at all periods aftervaccination , even within a few weeks or months of theoperation. Thirdly, post- vaccinal small - pox, accordingto these early records, did not seem to be an especiallymild disease ; and lastly, there did not appear to be any1 " Historical Sketch of Small - pox , " pp. 252, 253. John Thomson,M.D. , F.R.S.E. London. 1822 .•An account of the varioloid epidemic which has lately prevailed inEdinburgh and other parts of Scotland, p. 240. John Thomson, M.D. ,F.R.S.E. London. 1820.162 DOES VACCINATION PREVENT SMALL- POX ?relation between the severity of the disease and thelength of time which had elapsed since the operation .Vaccination was first made compulsory in 1853. Itis difficult at this day to understand how the promotersof vaccination managed to get this Act on our StatuteBooks, except on the assumption that the overwhelmingevidence of the early failures of vaccination had beenoverlooked or forgotten.Mr. George Canning declared, in. 1808, that althoughhe considered the discovery (vaccination) to be of thevery greatest importance, he could not figure any circumstanceswhatever that could induce him to followup the most favourable report of its infallibility, whichmight be brought forward, with any measure of a compulsorynature.¹2We have it on the authority of Mr. T. S. Duncombe,M.P. for Finsbury, that in 1840, Sir Robert Peel, beingurged to make vaccination compulsory, expressed hisopinion that such a course would be repugnant to thehabits and feelings of the British people, and to thatfreedom of opinion and action to which they were wellaccustomed. Mr. Duncombe quotes Sir Robert assaying that " The proposal to make it compulsorywas so contrary to the spirit of the British people, andthe independence in which they rightly gloried, that hewould be no party to such compulsion. " 3 Sir RobertPeel , however, died in 1850, and in 1853 a measureinvolving an enormous curtailment of the liberty of the1 Hansard's Parliamentary Debates, first series, vol. xi . , p. 844.(June 9 , 1808. )* Ibid. , third series, vol. cxliii. , p. 552. (July 10, 1856. )3 Ibid. , vol . clxiv. , p. 674. (July 10, 1861. )VACCINATION MADE COMPULSORY. 163subject, without any demand for such legislation, andwithout previous inquiry, was passed through bothHouses of Parliament with very little discussion.Lord Lyttelton introduced the Bill into the House ofLords, and, on the motion to go into Committee,explained that, having no scientific knowledge of thesubject himself, he was indebted for almost all hisinformation to some able and learned members of theEpidemiological Society. " It was unnecessary, " heinformed the House, " to speak of the certainty ofvaccination as a preventive of the small-pox, that beinga point on which the whole medical profession hadarrived at complete' unanimity. " 1If we refer to the Return on " Small-pox andVaccination," prepared by the Committee of the EpidemiologicalSociety, and from which Lord Lytteltonobtained his information, we find certain extraordinaryand wholly unwarrantable statements (p. 4). " Smallpoxis a disease," say the authors, " to which everyperson is liable, who is not protected by a previousattack or by vaccination." Again : " Every case of itis a centre of contagion, and every unvaccinated orimperfectly vaccinated population is a nidus for thedisease to settle in and propagate itself."1 Hansard's Parliamentary Debates, third series, vol . cxxv. , p. 1002.(April 12 , 1853. )* Copy of " Letter from Dr. Edward Seaton to Viscount Palmerston,with enclosed Copy of a Report on the State of Small - pox and Vaccinationin England and Wales and other Countries, and on Compulsory Vaccination,with Tables and Appendices, presented to the President and Councilof the Epidemiological Society by the Small-pox and Vaccination Committee,the 26th day of March, 1851. " ( Parliamentary Paper, No. 434.Ordered, by the House of Commons, to be printed, 3rd May, 1853. )164 DOES VACCINATION PREVENT SMALL- POX ?The two latter propositions, we are seriously informed," do not admit of being controverted. " Wewill suppose, for the sake of argument, that none ofthese propositions are capable of refutation. We thenread : " If it admit of doubt, how far it is justifiable inthis free country to compel a person to take care of hisown life and that of his offspring, it can scarcely bedisputed that no one has a right to put in jeopardy thelives of his fellow-subjects."Here the question presents itself, If vaccination is apreventive of small-pox, as asserted by Lord Lyttelton ,how could the unvaccinated put in jeopardy the livesof their protected fellow- subjects ? Thus, there is noargument for compulsion, even if it be admitted thatvaccination protects for life ; if vaccination does notprotect for life, and it is evident, from the numerouscases I have quoted, that it does not do so, then theprofession should show how long its protective valuelasts. Of the various medical experts who have beenexamined before the recent Vaccination Commissionit is important to remember that none have endorsedthe opinion of Jenner, Sir John Simon, and others,that vaccinated persons are for ever afterwards securefrom the infection of small -pox. Although some havemaintained that vaccination protects for considerableintervals, one prominent official expert, Dr. WilliamGayton, thinks that " primary vaccination is a veryfleeting protection indeed. As to the time that thatprimary protection lasts, I do not know, but I think it isa very short time" (Q. 1,755). Another authority , Dr.R. A. Birdwood, with an experience of 12,000 casesof small -pox, emphatically stated that vaccination cannotDR. JAMES COPLAND'S VIEWS. 165be relied on as an absolute protection up to any agewhatever (Q. 31,191 ) . And lastly, there have beenwitnesses of the very highest professional standing andscientific attainments, who have maintained that vaccinationexerts no specific protective influence at all. Whenthe profession are agreed on this important point,then the vaccinated will be able to make themselvessecure by periodical re-vaccinations, and their lives willnot be placed in peril by anti- vaccinists .It is interesting to note that the first compulsoryAct of Parliament entirely failed to remove the honestdoubts of some distinguished members of the medicalprofession. Thus Dr. James Copland expressed theopinion that vaccination " will never be generallyadopted, and that, if it were so adopted, it could neveraltogether banish small -pox, nor prove a complete orlasting preventive of variolous infection. " ¹Again he writes (p. 829) :—“ At the time of my writingthis , just half a century has elapsed since the discoveryand introduction of vaccination ; and after a quarterof a century of most transcendental laudation of themeasure, with merely occasional whisperings of doubt ,and, after another quarter of a century of reverberatedencomiums from well-paid vaccination boards , raisedwith a view of overbearing the increasing murmuringsof disbelief among those who observe and think forthemselves, the middle of the nineteenth century findsthe majority of the profession, in all latitudes andhemispheres, doubtful as to the preponderance of1 " A Dictionary of Practical Medicine," vol . iii . , part ii . , p. 831 .James Copland, M.D. , F.R.S. London. 1858.166 DOES VACCINATION PREVENT SMALL- POX ?advantages, present and prospective, to be obtainedeither from inoculation or from vaccination . "I now propose to show that the unvaccinated whenexposed do not necessarily take small-pox, and also ,that since the population has been more largely" protected," it is the vaccinated who form not only anoverwhelming proportion of the sufferers, but in a largenumber of instances they are the means of propagatingthe disease.Some very remarkable cases are recorded by Dr.William Baylies in his little book entitled, " Facts andObservations Relative to Inoculation in Berlin " ( 1781 ,pp. 132-144) . The King of Prussia having given hissanction to inoculation in February, 1775 , eight orphanchildren were chosen to commence the series , and onlythose were selected who were perfectly free from allmarks or signs of their having gone through the smallpoxbefore ; a thread was used, which had been chargedwith fresh variolous matter at the London Small- poxHospital ; the matter was inserted into both arms ofthe patients, and Dr. Baylies had not the least doubtthe disease would come on as it ought to do ; yetwe are informed that " neither fever nor any othersymptom followed in consequence of it, though thearms of two of them, on the third or fourth dayfrom the operation, had a degree of inflammation fora day or two " (p. 138).He then used a thread of much older matter, andre- inoculated these eight children, and also inoculated ,for the first time, four others, with a similar result ; andlastly, having learnt that the child of a baker was downwith the disease, he resolved to inoculate them with freshDR. MICHAEL UNDERWOOD'S OPINIONS. 167variolous matter. The twelve children before-mentioned,with seven others, were conducted to the baker's house,and they were all inoculated with warm fluid matterfrom ripe pustules, and for nearly an hour the childrenwere kept in the infected atmosphere, and " not one ofall the nineteen children manifested the least symptomof the disease in consequence of it" (p. 143 ) .As Dr. Baylies was a practised inoculator, we areforced to the conclusion that either the children had hadsmall-pox before-the conclusion arrived at by Dr.Baylies himself-or that they were naturally immune tothe disease ; but, considering that the most careful examinationwas made for marks of small-pox, the latterview appears to be the more probable.In this connection some remarks made by Dr.Michael Underwood, in his work on the diseases ofchildren, are not without interest. Dr. Underwoodobserves :-" Though the small-pox is a complaint soincident to the early part of life, that comparativelyfew children living to the age of eight or ten years,are found to escape it, yet it is not so readily communicatedin the state of early infancy, as hath beengenerally imagined, unless by immediate infection.The poor furnish frequent instances of the truth ofthis observation. I have attended where children bornin an air, saturated, as it were, with the miasma (orinfectious particles) of this disease (as well as of themeasles), and even lying continually in a cradle inwhich another child has died a few days before, have,nevertheless, escaped the disease, and sometimes, whenthey have slept together in the same bed with oneloaded with it. Hence it appears, that highly tainted168 DOES VACCINATION PREVENT SMALL- POX ?air, and even personal contact, are often insufficient tocommunicate the poison. Yet we know that infantsare very easily infected, receiving the small-pox byinoculation as readily as adults ; though neither are atall times equally susceptible of it. "¹In the Medical and Physical Journal for April, 1803 ,Mr. C. Dennett, of Soho Square, related the followinginstances :-In August, 1800, Mr. had two childrenwho were laid up with confluent small-pox, one of whomdied ; an infant, three weeks old, was exposed to theinfection the whole time, being always in the same room,and sometimes in the same bed. Mr. Dennett says hecould not persuade the parents to have the baby inoculated,and to vaccination they positively objected. Itdid not take the infection ; later in the year, the childwas inoculated with fresh variolous matter withouteffect, and this was repeated three times with no bettersuccess .Another child in the same family, born later, escapedthe disease, although it had slept in the same bed withthe former child, who had now contracted confluentsmall-pox . Mr. Dennett inoculated the infant on fourseparate occasions with small-pox matter without effect.These cases were evidently not very uncommon, for Mr.Dennett remarked that "every practitioner must havemet with cases when, under some peculiar constitution,the habit is not susceptible of the disease, either byinfection or inoculation" (p. 394).1 " A Treatise on the Disorders of Childhood, and Management ofInfants from the Birth," vol . i. , pp. 299-301 . Michael Underwood, M.D. ,Physician to Her Royal Highness the Princess of Wales. London. 1797.2 Medical and Physical Journal, vol . ix. , p. 365.DR. COUPLAND'S REPORT. 171Two other persons, aged fourteen and twenty, who hadnever been vaccinated, and who slept with the others,did not contract small-pox."The above instances appear to show that immunityin the unvaccinated, even when strongly exposed tosmall-pox, is not nearly so rare as has been generallybelieved . It is also instructive to note that Dr.Coupland, in his report on the Leicester outbreak,shows, with regard to 193 invaded households, that atseveral specified age-periods, the small-pox attack-rateswere much the same, although, according to his censusof the inmates, the proportion of the unvaccinated atthese age-periods vastly differed. The figures cited areas follows :-Ofthe total inmates ,the percentage.Age-periods.Totalinmates. 2 Unvaccinated. Attacked.Under 1 year 33 910 2121-10 years 328 740 28.910-30 years 534 15.5 28.130 years and upwards ... 330 2.7 20.5With these figures before him, it is not surprising thatDr. Coupland should have come to the conclusion that"the natural liability to small-pox, unaffected by vaccination,was not so great as has been supposed."To resume our inquiry into the question as towhether vaccination prevents small-pox, the followingcases, extracted from the Sheffield Report, are of importanceas showing that recent vaccination of the mostapproved fashion will not secure immunity from thisdisease. ( See next page.)1 Final Report, Royal Commission on Vaccination, Appendix vi. , p. 3 .2 In nineof the inmates the age was not ascertained .Page ofReport .District.No. Name .Age whenattacked .Vaccination.Results of vaccination .c,foFionocveuae-trartiecdesh.iaisnanrqceluahfare,cpoFilnocaeuai-trnricesh.iisananqrlcuefhaare41Brightside.27 Mary H.iinnfancy10months Vaccinated Five foveated cicatrices ,twothirdssquare inch inarea .41Brightside-41 Sarah C. 6months Vaccinatediinnfancy42 Brightside -102SLA.anrnah V1ma0ocnctihnsatediinnfancy62 North Sheffield 79ErnestC.. 9months VaccinatediinnfancyS9Sho7euftfhield 2Ge9rtrudeHoskins M.150NHeatlhlearm 1SF.8rank150Nether Hallam 57HedleyV.H.c,.fFoiooncvueaetrartiecdesh.isainaqnrlucefaahreCharacter-.spomofaxllVery slight ,notpitted .,snVloeitrghytp.ittedV, eryslightindeed.pniotttedV,moienlerdyp. itpS,-,.cpenVom2Oilliioanoncaitgtcenaeitghcttenhtirdhthinsxatedwhenow6ledekss.iainqrneucahare,cfVtFm6ioawoocvcounaec-trtairhtinescadetsedwhen .tisaihnqrniuecraahdrseow6ledeksiinnfancyc,fVmT8ioaohcvcnraectteairhetinsecadetsedo-tiishnnqnicuerhadrea. rea,spVlleiargyyh-teatalhbdleout,.pntioittmteed,inmVloieltlrdya,.apnltioltttedFATAL SMALL- POX IN VACCINATED CHILDREN . 173Examples of more absolute failure to protect couldhardly be imagined than these seven cases contractingsmall -pox from a fortnight to seven or eight monthsafter vaccination of the most correct type. Altogetherthere were about 450 vaccinated cases under ten yearsof age at Sheffield in the 1887-88 epidemic, and yet aprominent defender of compulsory vaccination deliberatelymaintained that " vaccinated children under tenyears of age are wholly and entirely immune fromsmall - pox , and cannot be infected . " ¹Since writing the above, it appears that the editorof the British Medical Journal has somewhat shiftedhis ground, for in a recent article on "Vaccinationas a Branch of Preventive Medicine," he maintainsthat in certain epidemics (referred to) "vaccinatedchildren under ten have been almost immune fromdeath by small-pox," which I venture to suggest is aconsiderable modification of his original statement. Itis a pity that Mr. Ernest Hart did not have an opportunityof consulting Dr. John MacCombie's article on" Small-pox " in the same volume (Allbutt's " System ofMedicine," vol. ii.), for he would then have discoveredthe following figures (p. 221 ) : -Age -periods.Under 5 years5-9 yearsVaccinated.Cases. Deaths.Fatalitypercent.3851,46830 7.859 40It must also be presumed that Mr. Hart's attention hasnot been arrested by the following experience of the1Letter ofMr. Ernest Hart to the Times ofAugust 31, 1894.*Allbutt's " System ofMedicine," vol. ii. , p. 664. London. 1897.174 DOES VACCINATION PREVENT SMALL- POX ?Metropolitan Asylums Board in the epidemic of1870-72 :-Age-periods.Under 5 years5-10 yearsVaccination .Numberadmitted.Number ofdeaths.Fatalityper cent.195 38 19.5786 60 7.6These two tables prove that " vaccinated children "under five years of age (let alone ten years ) are noteven " almost immune from death by small-pox. "What could be more emphatic than the followingexperience of Mr. T. Massey Harding ? " " Allpractitioners are acquainted with cases disproving theimmunity of the vaccinated, such as the following :-Iattended a man, aged 40, with confluent small- pox, ofwhich he died. He had been vaccinated twice, accordingto his own statement. In the house were his sister,her husband, and two children, all unvaccinated. Ivaccinated them all, and it took effect. In threeweeks from the day of vaccination, the woman, Mrs.G. , and one of her children had small-pox, distinct, butslight. "Nor can it be truthfully said that epidemics originatewith the unvaccinated , for in a number of notableinstances the first unvaccinated case is a long waydown the list. Thus, at Neuss , in Germany, from1865-73 , there were 247 cases of small-pox, all of1 " Report of the Committee appointed on the Ist June, to collate andreport upon the Returns obtained from the several Hospitals of theManagers, with regard to the cases of Small-pox treated therein. " Presentedto, and adopted by, the Managers of the Metropolitan AsylumsDistrict , at their meeting on the 13th July, 1872. P. 5 ; Table 2.2 British MedicalJournal, p. 974. ( November 21 , 1857. )STATISTICS OF VACCINATED SMALL- POX. 175them vaccinated ; at Bromley, in 1881 , 43 cases, allvaccinated ; and in the 1870-72 epidemic at Bonn,the first unvaccinated case was forty-second on thelist.¹The following table shows the large proportion ofvaccinated cases in some well-vaccinated districts : -Vaccinated Percentageattacks.Small-pox epidemics . Years. Attacks." ofattacksvaccinated.Bavaria 3 1871 30,742 29,429 95.7Berlin 4 1871-72 20,391 17,038 83.6Cologne41871-73 2,282 2,248 98.5Neuss4 ... 1865-73 247 247 1000London Small -pox Hospital5 1852-67 13,581 10,661 78.5Hospitals "Metropolitan Asylums Board) 1870-86 50,668 41,061 810Bromley 7 188143 43 1000Sunderland 8 1884 100 96 96.0Sheffield 1887-88 7,066 5,891 83.4Warrington 1892-93 674 601 89.2Birmingham 1893-94 2,945 2,616 88-8Willenhall 1894 828 739 89.3In an epidemic, it is not possible, on any theory ofprotection, for the population to be vaccinated to any1 " Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung,"p. 143. Berlin . 1888 .2 Cases in which there was a doubt about the vaccinal condition of thepatient have been excluded .Second Report, Royal Commission on Vaccination . Q. 1,489.4" Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung,"pp. 152, 154 , 168. Berlin . 1888.Report from the Select Committee on the Vaccination Act ( 1867 ) ,p. 237. 1871 .6 Third Report , Royal Commission on Vaccination , Appendix, p. 204,Table L.7 Lancet , vol . ii . , pp. 372, 373. (August 27 , 1881. )8 Lancet , vol . i . , pp. 363 , 364 . ( February 23 , 1884. )176 DOES VACCINATION.PREVENT SMALL- POX ?lesser extent than the cases of small -pox , or it wouldshow that small-pox picked out the vaccinated for itsvictims. The figures for Bavaria and Cologne, with95.7 and 98.5 per cent. of the cases vaccinated respectively,hardly leave any margin for the population to bevaccinated to a greater extent. Considering that inthese two instances the proportions approximate soclosely, there is every reason for scrutinising very carefullyany estimate of the vaccination of the populationwhich differs largely from the ratio of the vaccinatedcases of small -pox.Such estimates have been made for Sheffield by Dr.Barry, and for the houses invaded by small-pox atWarrington, Dewsbury, and Leicester, by medical menappointed by the Vaccination Commission. As, in thelatter instances, there was no opportunity for examinationof these experts, it will be more satisfactory if Iconfine myself to the case of Sheffield.In his report on the Sheffield epidemic, Dr. Barryestimated that 97.9 per cent. of the population wasvaccinated. It was pointed out to him before the RoyalCommission, that the house-to- house inquiry, on whichhis estimate was based, was taken after the epidemichad reached its height, during the course of which atransfer had been taking place from the unvaccinatedto the vaccinated class. A new estimate was thereforemade, which is included in the Report of the RoyalCommission, at 97.3 per cent.; but even this cannotbe justified. In his examination before the RoyalCommission, Dr. Barry admitted that in the SheffieldUnion, the house-to-house inquiry was enumerated bymen under the supervision of the vaccination officersTHE SHEFFIELD “ CENSUS. " 177(Q. 2,389), and that its primary object was to secure,as far as possible, the discovery of all unvaccinatedchildren (Q. 2,390). These were reported to the vaccinationofficers, whose duty it was to take steps tosecure their vaccination (Q. 2,391). The " census, " Dr.Barry informs us, was a " secondary affair " ( Q. 2,390) .This inquiry, therefore, was instituted in order to huntup the unvaccinated , and it is obvious that a censusconducted on these lines could not have the slightestpretension to accuracy. It would have been thesimplest matter in the world for the householder toomit the mention of the unvaccinated, and, as theinquiry lasted nearly six weeks , to evade the enumerators,who , in the Sheffield Union, were not evensupplied with the names of the occupiers. Moreover ,in 764 houses, information was altogether refused, and11.8 per cent. of the population, or over six timesthe " unvaccinated enumerated," were left out of thecalculation altogether, For these and other reasons,it is impossible that the population could have beenvaccinated to the extent that was claimed ; and, therefore,the calculations that are based on this estimateare misleading.It has been shown that the unvaccinated may beexposed to small -pox without taking the infection, andalso that the most recent and efficient vaccination ofindividuals will not prevent the complaint, and consideringthat such a large proportion of sufferers areamong the vaccinated, who, in most instances, startand spread the epidemic, the statement so often promulgatedthat an unvaccinated individual is a sourceof infection and a danger to the community, is178 DOES VACCINATION PREVENT SMALL-POX ?It has also been pointed out, that evenif vaccination was a complete protection against smallpox,this would be no argument for legislation ; for, inthe words of Dr. J. H. Bridges, " non-vaccinated peopleare not a source of injury to their neighbours ; for theirneighbours can get themselves vaccinated. " ¹ It follows,therefore, that the law, which was first passed on theassumption that the unvaccinated are a danger tosociety-even if there were no other evidence againstvaccination-should be immediately abrogated. "erroneous .¹ Positivist Review , vol . iv. , p. 226. (November, 1896. )* If vaccination mitigates small- pox , as maintained by some, it is noargument for compulsion. The Medical Officer of Health for the City ofBirmingham ( Report for 1893 , p. 45) alleges that one of the causes of therapid spread of small-pox in the recent epidemic was due to " the mildnessand modification of the attacks in vaccinated persons, making it mostdifficult in some cases to decide the nature of the illness , and causing it tobe mistaken for chicken-pox and other trivial affections , and arousing nosuspicion of its being small- pox until severer forms of the disease subsequentlyappeared in the same family."CHAPTER VI .THE MITIGATION THEORY.WHEN it was discovered, in the epidemic of 1817-19 ,that small -pox attacked such a large number of thevaccinated, the theory of mitigation was promulgated.From the cases detailed in the last chapter, it doesnot appear that small-pox was very conspicuouslymitigated by vaccination in the early years , nor doesthere appear to have been any relation between theseverity of the attack and the length of time whichhad elapsed since the operation. It will be profitableto proceed to enquire whether the later experienceshows results more favourable to the mitigation theory.Dr. George Gregory has indicated the measure of themodifying powers which, in his opinion, may be attributedto vaccination. " Vaccination," he says , “ does notappear to lessen the violence, or shorten the duration, ofthe first or eruptive stage of fever, which is generally assevere, and even sometimes severer and longer in itsduration than that of the casual confluent small-pox.It does not appear in like manner to influence thequantity of eruption upon the skin, so much, at least, ashas been generally imagined. It is true, that, in manycases of small-pox, subsequent to vaccination, the eruptionhas been very scanty; but, in a large number also,I have seen it very copious, more particularly about the180THE MITIGATION THEORY.face, breast, and upper extremities, and occasionallyfully equal, in point of quantity, to what is seen in theworst kinds of confluent or coherent natural small -pox. " 1The great power of vaccination, he thought, consisted inmodifying the progress of inflammation in the variolouseruption on the skin and in the throat; but he added :" It is curious to observe that it does not always affectthe course of the disease, when the variolous poisonfixes itself on other parts, more particularly on thebrain. It is in this manner that small-pox, after vaccination,occasionally proves fatal. "2 In a foot- note onp. 331 , he explains that " the eruption on the skin andthroat is only one of the effects of the poison. Another,at least equally important, both with reference to pathologyand practice, is that which is excited upon thebrain and nervous system ; the chief evidences of whichare delirium, inflamed eyes, stupor or restlessness, anddisposition to erysipelas and gangrene. "There are several ways of testing the mitigationquestion, one of which would be to compare the casemortalityor fatality of small-pox before and after theintroduction of vaccination. In the Appendix will befound a table taken from Dr. Creighton's " History ofEpidemics. " It consists of censuses of small -pox epidemicsduring the years 1721-30, the fatality rangingfrom 9.1 to 36.4 per cent. , there being in all 13,192cases, with 2,264 deaths, or an average fatality of 17.2per cent.The principal objection that has been raised to these1 " Medico - Chirurgical Transactions, " vol. xii. , pp. 328 , 329. ( 1823. )2 Ibid. , pp . 330, 331 .JURIN'S STATISTICS. 181statistics is, that in the censuses of small-pox epidemicspassing under the name of Jurin, which largely dominatethe figures in Dr. Creighton's list, Jurin is said tohave " not knowingly set down any deaths under twoyears old as due to small -pox, and that someof his correspondents, in furnishing him with statistics ,followed the same rule." 1The ostensible grounds for this assertion are :-( 1 ) That the Aynho census, to which I have referredin a previous chapter (pp. 43, 44), contains no casesunder two years of age.The Aynho census, a copy of which is to be found inthe archives of the Royal Society, was made by therector of the parish, and the cases are given in theorder of time, just as they occurred over a period ofsome fifteen months, three in one family, two inanother, and so on . There is no suggestion of infantsbeing excluded, and the fact that there were only threeaged two years, and four aged three years , out of atotal of 132, makes the absence of cases in infants notonly credible, but probable. The epidemic was mainlyamong young people and adults , and was quite intelligiblefor a country place where epidemics took placeinfrequently.(2) The other ground of objection is founded on anargument used by Jurin in his letter to Dr. Cotesworth.2 " It is notorious, that great numbers, especially“1Article on Small -pox and Vaccination," by John C. M'Vail, M.D. ,in Stevenson and Murphy's " Treatise on Hygiene and Public Health,"vol . ii . , p. 399. London. 1893 .2 A Letter to the learned Caleb Cotesworth , M.D. , p. 11. James Jurin ,M.D. , Secretary to the Royal Society. London. 1723 .182 THE MITIGATION THEORY.of young children, die of other diseases, without everhaving the small-pox, " etc.The statement that a number of young children diedof other diseases, without ever having the small -pox;has no reference to the censuses which were taken toshow the fatality -rate of natural small -pox as contrastedwith the inoculated. It was part of an argument toshow that the real hazard of dying of small-pox inLondon was greater than the Bills of Mortality showed ,inasmuch as the excessive London infantile mortalitycut off an immense number from other causes (such asconvulsions, infantile diarrhea, etc.,) before small -poxcould attack them. But Jurin admits (p. 12) that inall probability some infants, " very young children, or atmost not above one or two years," went through thesmall -pox, which is sufficient evidence that he had nointention of counting them out, or ignoring them, in thepercentages of fatalities to attacks. His argument,such as it was, applied only to London, but there wereno statistics for London in the censuses, which are allfrom the provinces, many of them made by Nettletonof Halifax, and none of them made, nor even controlled, by Jurin himself.aThe incidence of small-pox in the eighteenthcentury, as pointed out in former chapter, wasalmost entirely on the young ; for instance, at Chester, ¹in 1774, of 1,385 cases, 202 died, or a fatality of14.6 per cent. , the ages at death being as follows(p. 150 ; Tables II . and IV. ) :-1 " Philosophical Transactions," vol . lxviii. , p. 151. ( Dr. Haygarth'sObservations on the Population and Diseases of Chester in the year 1774. )OPINION OF THE ROYAL COMMISSION .Under 1 month ΟBetween I and 3 months ... 3" 3 and ود 6... ... 46 and 12 ..... 44" I and 2 years ... ... ... 38" 2 and 3..... ... 42" 3 and 5 " 495 and 10 22Over 10 yearsTotal 202183The contention, therefore, that the last century fatalityof 17 or 18 per cent. is lower than it should be, becauseof the deliberate omission of young children from thecensuses , is groundless, and ought never to have beenraised.¹Let us now see what is the fatality of small -pox sincea large proportion of the cases have been vaccinated.Dr. Collins and Mr. Picton quote the experience of theMetropolitan Asylums Board's Hospitals, where, from1870 to 1874, 60,855 cases were treated , with a fatalityof 167 per cent. , and among 50,668 of these admissions,the vaccinated were 41,061 , or 81 per cent.During this period the figures have varied considerably.In the year 1896, the fatality was 401 percent.; whereas, from December 1 , 1870, to February 3 ,1 The Royal Commission say ( section 53)--" It has been urged that thedeaths of those dying under two years of age were excluded from Jurin'sstatistics , and that this must have led to the omission of many deaths , asthe mortality in that class was high. The evidence relied on to show thatcases under two years of age were excluded certainly cannot be regardedas establishing it."* Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 97 .184 THE MITIGATION THEORY.In1871 , it was as high as 20.81 per cent. This highfatality in the earlier years may in part be due to thelimited accommodation at the hospitals, when the tendencywould be to admit the more serious cases.this epidemic ( 1870-72), however, the fatality was high ,for the Lancet of July 15, 1871 (vol. ii., p. 94) , estimatedthe fatality of small-pox at 17.5 per cent.; and hence,the large proportion of vaccinated cases¹ does notappear to have diminished the severity of the disease,as compared with the last century.The other method of testing the question is to comparethe fatality in the two classes. Dr. Davies, theMedical Officer of Health for Bristol, in the BristolMercury of April 2, 1896, states the case thus : " Theunvaccinated die at the rate of thirty or forty deathsper hundred cases, the vaccinated at something lessthan five per hundred cases. " This agrees approximatelywith Mr. Ernest Hart's figures in his summary ofdifferent towns during recent epidemics. The claim isthat vaccination mitigates small-pox in the bodies ofthose who have taken the disease, and this is practicallythe whole case for the observance of the operation ; andthe evidence is chiefly to be derived from the reports ofmedical officers of health and others in official position,from which the following have been taken : -1 In the epidemic of 1870-72, a total of 14,808 cases of small-pox wereadmitted into the hospitals of the Metropolitan Asylums Board. Of these ,11,174 , or 75.5 per cent. , were in vaccinated persons .* British MedicalJournal, vol. i. , p. 487. (March 2 , 1895. )FATALITY STATISTICS .Unvaccinated Fatalities-1836-96.Report of Hospital or MedicalOfficer of Health .185Years. Cases. Deaths.Fatalityper cent.Highgate 1836-51 2,654 996 37.5Highgate¹ ... 1871 74 4966.2Dublin ( HardwickeHospital )Feb. 1871 toMarch 1872 )70 55 78.6Homerton 1871-77 1,243 570 45.9Hampstead 1876-78 847 397 46.9Dublin ( Cork Street ) 1876-80 448 288 64.5Fulham .. 1877-79 374 176 47.1Deptford ... 1878-79 258 121 46.9Sheffield..1887-88 1,173 392 33′4Birmingham 1893-94 329 107 32.5Gloucester 1895-96 781 317 40.6Hence, in these instances, the proportion of deaths toattacks among the unvaccinated is stated to have rangedfrom 78 to 32 per cent. Most of these figures are,however, impossible, for the simple reason, that in thelast century, as already shown, before the introductionof vaccination, the average fatality of small-pox wasonly about 17 or 18 per cent.In making a critical examination of the fatalitystatistics in the two classes, it is obvious that theiraccuracy would depend on whether the statementas to vaccination could be absolutely relied upon ;and secondly, on whether the two classes were perfectlycomparable in every respect ; and to do thisit is necessary to say a word or two about thedifferent types of small-pox, and also the method ofclassification.British Medical Journal, vol . 1. , p. 171. ( February 10, 1872. )2 Ibid. , p. 682. (June 22, 1872. ) These figures include four doubtful cases.13186 THE MITIGATION THEORY.A prominent feature in medical and official publicationsadvocating vaccination¹ has been to paint thehorrors of small-pox in its natural state in the mostvivid colours. I have already dwelt on the fact that,in the last century, the average fatality of small-poxwas only about 17 or 18 per cent. of those attacked,and in many epidemics the proportion was much less.Different forms of small-pox have been distinguishedfrom the time of Rhases, and it may be said thatSydenham's main success in his treatment of thedisease was due to the fact that he recognised adiscrete and confluent variety, in the former of whichthe patient, if left alone to Nature, invariably recovered .The following quotations from Sydenham bear onthis point :-" As it is palpable to all the world, howfatal that disease (small-pox) proves to many of allages, so it is most clear to me, from all the observationsthat I can possibly make, that if no mischief be done,either by physician or nurse, it is the most slight andsafe of all other diseases . " 3Sydenham observes that in 1669 small -pox " appeared1 See Mr. Ernest Hart's " Truth about Vaccination," pp. 2-8 ( 1880) ,and also " Facts concerning Vaccination for Heads of Families, " a tract" revised" by the Local Government Board, and " issued with theirsanction," in which it states (p. 4)-" The disease (small-pox) used torage unchecked, killing a very large proportion of those whom it attacked,and maiming, blinding , and disfiguring those whose lives it spared. "" A Treatise on the Small-pox and Measles. " Translation from theoriginal Arabic by Dr. W. A. Greenhill, and printed for the SydenhamSociety, 1848 , pp. 71-73 .3 Letter to Mr. Robert Boyle, dated Pall Mall, April 2, 1688. TheWorks of Thonias Sydenham , M.D. Translation from the Latin Editionof Dr. Greenhill, with a life of the author , by R. G. Latham, M.D.Printed for the Sydenham Society , 1848, vol . i. , pp. lxxii . , lxxiii .SYDENHAM'S CLASSIFICATION OF SMALL- POX . 187in some few places, but in a mild and manageableform." 1"Now, the confluent small-pox is as much worse thanthe distinct, as the plague is worse than the confluent. " ?" As for the distinct sort, even if it can be seenbeforehand, bed is so much out of the question, thatinjunctions against it are superfluous. The scantynumber of the exanthemata makes matters safe eitherway." 3" With few pustules, and those of the distinct sort,the treatment is immaterial ; provided there is no grosserror. The disease is a slight one. The ignorance ofthe physician, who aims at nothing so much as thepromotion of heat, can alone make it dangerous.Dangerous , too, it has been made ; since in such casesthe doctor, though unconsciously, helps the disease. " 4In referring to the treatment of small-pox, " all thisapplies to the confluent small-pox only. With thedistinct sort, they have nothing to do. Those whoboast about curing cases where the rash has beenscanty, deceive themselves and others. If they reallywish to test their skill, let them take a confluent casein a young subject who has drunk hard ; and not so farblunder as to fancy that, in their easier practice, theyhave saved the lives of patients whom it would havebeen a hard matter to have killed. " 5Other authorities testify to the mildness of someforms of the disease. Thus Wagstaffe, in a letter to1 " Medical Observations."vol . i. , p. 160.Printed for the Sydenham Society , 1848 ,2 Letter to Dr. Cole . Ibid. , vol. ii . , p. 58.3 Ibid. , p. 65. * Ibid. , p. 71 . 5 Ibid. , p. 79.188 THE MITIGATION THEORY.Dr. Freind, observes-" There is scarcely, I believe, sogreat a difference between any two distempers in theworld, as between the best and worst sort of small -pox,in respect to the danger which attends them . Sotrue is that common observation, that there is one sortin which a nurse cannot kill, and another which even aphysician can never cure. " 1 Sir Richard Blackmore, inhis remarks on the treatment of small-pox, says :-" Inthe most favourable sort of the distinct small-pox,which are few in number and mild in quality, Natureherself, as I have before observed, is able to cure the distemper,and needs not call the physician in aid. " 2 IsaacMassey, the apothecary to Christ's Hospital, thus giveshis experience :-" Here is the natural small-pox, but onein forty-nine died, and, I can assure the reader, that upona strict review of thirty years' business, and more, notone in forty small-pox patients of the younger life havedied, i.e. , about five, and under eighteen. " Mr. JohnMudge, a surgeon of Plymouth, writing in 1777, says-" There is not perhaps a disease to which the human raceis exposed, that differs more from itself at different timesthan the natural small-pox. We soinetimes see thisdisorder so mild and benign, as scarcely to expose thepatient to more danger than a common cold ; and atothers, exasperated by a degree of malignity and1 A Letter to Dr. Freind showing the danger and uncertainty ofinoculating the Small-pox, pp. 9, 10. W. Wagstaffe , M.D. , F.R.S.London . 1722 .2 " A Treatise upon the Small-pox," p. 42. Sir Richard Blackmore,M.D. , F.R.C.P. London. 1723.3 " Remarks on Dr. Jurin's Last Yearly Account of the Success ofInoculation ," p. 7. Isaac Massey. London. 1727 .CONFIRMED BY JENNER. 189virulence, little, or perhaps not at all, inferior to theplague itself. " 1The matter has also been alluded to by Jenner.Of course Jenner never dreamt in the first ardour ofhis discovery, that the advocacy of vaccination wouldbe reduced to a mere plea for mitigation, and thuswe obtain the following interesting confirmation ofthe painstaking and carefully recorded experience ofSydenham. " There are certainly more forms thanone," he says, " without considering the common variationbetween the confluent and distinct, in which thesmall -pox appears in what is called the natural way.-About seven years ago a species of small -pox spreadthrough many of the towns and villages of this partof Gloucestershire : it was of so mild a nature, that afatal instance was scarcely ever heard of, and consequentlyso little dreaded by the lower orders of thecommunity, that they scrupled not to hold the sameintercourse with each other as if no infectious diseasehad been present among them. I never saw nor heardof an instance of its being confluent. "More recently also we have the corroboration ofMr. Marson, who says " The death- rate from distinctsmall-pox among the unvaccinated is only four percent. , and even those four per cent. die of convulsions,or some other disease to which children are liable." 31 " A Dissertation on the Inoculated Small - pox, " pp. 1, 2. JohnMudge, Surgeon . London. 1777 ." An Inquiry into the Causes andp. 54. Edward Jenner, M.D. , F.R.S.3Q. 4,316, Report from the SelectAct ( 1867 ). 1871 .Effects of the Variola Vaccine,"London. 1798.Committee on the Vaccination$190 THE MITIGATION THEORY.And Dr. William Gayton, medical superintendent ofthe North- Western Fever Hospital, has admitted thatdiscrete small- pox is a comparatively mild disease evenin the unvaccinated .Another variety of small- pox, viz. , malignant orhæmorrhagic, is of a different type. Regarding this,Dr. MacCombie² states ( 1 ) That it is by no meansrare ; ( 2 ) that the majority of attacks occur in vaccinatedpersons ; and (3 ) that recovery does not takeplace. This last statement accords with the experienceof Dr. Gayton, who informed the Royal Commission(Q. 1,818), that malignant or hæmorrhagic small -poxwas almost uniformly fatal whether the person hadbeen vaccinated or not. The following table, compiledfrom the hospital reports by Mr. Wheeler, 3demonstrates the point conclusively :-Malignant Small-pox.Vaccinated. Unvaccinated.Attacks. Deaths. Fatality Attacks. Years. Deaths. Fatalityper cent. percent.Homerton 1871-77 163 139Hampstead ... 1876-78 127 10585.3 153 15382.7 127 115100090.6Fulham 1877-79 26 18 69.2 44 3988.6Deptford 1879 21 21 1000 10 10 1000Dublin ( Cork )Street)1876-80 163 113 69.3 103 93 90.3Total ... 500 396 79.2 437 410 93.81Q. 1,816, Second Report , Royal Commission on Vaccination .* Allbutt's " System of Medicine," vol . ii . , pp. 203, 204. London.1897.3 Third Report, Royal Commission on Vaccination, Appendix, p. 206(Table Q. ) .VARIETIES OF SMALL-POX. 191As vaccination apparently has no influence on thisform of the disease, Dr. Grieve, medical superintendentof the Hampstead Small-pox Hospital, was probablycorrect when he stated that it was " but too commonin people who had lived in defiance of all sanitarylaws, or who by intemperance have debilitated theirconstitutions. " 1Another particularly fatal, but rare variety, termedcorymbose small-pox, has been observed. This wasdescribed by Mr. Marson as presenting two or threepatches or clusters about the size of the palm of a hand,upon which the eruption is as thickly set as it possiblycan be, while the skin around for 'some distance isalmost, if not entirely free. Mr. Marson gives thefigures for 104 cases of this variety, which came underhis observation : 29 were unvaccinated, of these 13 or44.8 per cent. died ; and 74 were vaccinated, of which32 or 43.2 per cent. died. Thus, the fatality in thetwo classes of this variety of the disease, is practicallyidentical .The only remaining type of the disease for us toconsider is the confluent, and from the above it will beevident that the huge difference in the rates of thevaccinated and unvaccinated must take place in casesof this description. In this variety of the disease, thepustules coalesce, so as to render the features hardlyrecognisable, and it can easily be understood that marksof vaccination may be and are readily obscured, so that1 " An Analysis of eight hundred cases of Small -pox. " The Lancet,vol . i . , p. 371. ( March 18 , 1871. )*Article on " Small- pox, " by Mr. J. F. Marson.of Medicine, " vol. i. , p. 438. London. 1866.Reynolds' " System192 THE MITIGATION THEORY.it is impossible to determine from an examination ofthe arm whether they exist or not.This difficulty has been recognised by the leadingauthorities. Thus, Dr. Gregory says-" Great difficultieswere necessarily experienced in determining whohad been really vaccinated, of those who assumed tohave undergone that process . The cicatrix was ourchief guide, but this often failed us, from the swollen andpock-covered condition of the arm at the time of thepatient's admission. " Dr. James B. Russell remarks-" Sometimes persons were said to be vaccinated, but nomarks could be seen, very frequently because of theabundance of the eruption. In some of those caseswhich recovered, an inspection before dismissal discoveredvaccine marks, sometimes ' very good.' Thosewho died, or who were not so examined, are placed ina separate column as ' said to be vaccinated, but V.M.not visible . ' I do not observe in the reports on smallpox,as observed in London and Dublin, any allusion tothis difficulty. Even the best vaccine mark is readilyobscured, or even hidden, by a copious eruption, andunless such special means, as I have described, areadopted, it is impossible accurately to ascertain thefacts of small - pox in the vaccinated . " 2Not only may the scars be obscured by eruption, butthere is no doubt also that they may wear out. Dr.George Gregory says-" The absence of a cicatrix is notdecisive against either the present or prior existence ofvaccine energy in the system, because in many cases," Medico - Chirurgical Transactions," vol. xxii . , p. 97. ( 1839. )* Glasgow MedicalJournal, vol. v. , p. 6. (November, 1872. )CLASSIFICATION OF SMALL- POX PATIENTS . 193the specific inflammation is moderate, and the resultingscar wears out in the progress of life, as other scars dowhich are not the result of a specific poison. " 1 In his" Observations on the Variola Vaccina, " Mr. RobertCeely, of Aylesbury, says-" Inspection of many scars,caused by this lymph, shows that in a few months littleis to be learned in many subjects, with thin skins, ofthe degree to which the vaccine influence has beenexerted on them. " 2A Committee appointed by the EpidemiologicalSociety (" Epidem. Soc. Trans. , " vol. v. , p. 153 , 1885-86)recognised that " not every cicatrix which is oncefoveated will always retain its condition of foveation,and, further, that not every cicatrix will permanentlyexist. " Dr. Savill in his report on the Warringtonoutbreak has also called attention to the fact thatvaccination scars tend to become obliterated with age,and to alter in character with time.3Let us now see what has been the practice withregard to the classification of small - pox patients.Mr. Francis Vacher, Medical Officer of Health forBirkenhead, candidly observes-" The mere assertionsof patients or their friends, that they were vaccinated,counted for nothing, as about 80 per cent. of thepatients entered in the third column of the table( ' unknown ') were reported as having been vaccinatedin infancy. " Mr. Marson informs us-" Patients were1 London Medical Gazette, vol . xxv. , pp. 289 , 290. (November 15, 1839. )" Transactions of the Provincial Medical and Surgical Association ,"vol . viii . , p. 416 , foot- note. ( 1840. )* Final Report, Royal Commission on Vaccination, Appendix v. , p. 42.+ " Notes on the Small-pox Epidemic at Birkenhead in 1877," p. 9 ..:194 THE MITIGATION THEORY .never entered in the register as vaccinated, unless theaccount of the vaccination was a tolerably clear one. " ¹And Dr. William Gayton, in the Homerton Reportfor 1875 , observes ( p. 58)-" I have always classed as' vaccinated ' those upon whom any mark supposed toresult from vaccination has existed, and as ' unvaccinated' when no scar presumably arising from theeffects of vaccine lymph could be discovered. Individualsare constantly seen who state that they havebeen vaccinated, but upon whom no cicatrices of anydescription can be traced. In a prognostic and statisticpoint of view it is better, and, I think, necessary,to class them as unvaccinated . "The fallacies of this method of classification havebeen pointed out by Dr. Birdwood and Dr. Ricketts.Dr. Birdwood, with an experience of twelve thousandcases of small-pox, stated, before the Royal Commission,that in his opinion the evidence of primaryvaccination , collected in small-pox hospitals , shouldnot be relied on . Because-" ( 1 ) On the outbreak of an epidemic there isnecessarily much administrative confusion, and manyuntrained observers. The early observations are incompleteand faulty." (2) In the worst instances the eruption may be sufficientto, and does obscure the scars." (3) The statement of parents as to primary vaccination,and of adult patients as to re-vaccination, shouldbe accepted even when scars are not seen ." Medico - Chirurgical Transactions," vol. xxxvi. , p. 374. ( 1853. )2 Sixth Report , Royal Commission on Vaccination. Q. 31,221 .DRS. BIRDWOOD AND RICKETTS ' EVIDENCE. 195" (4) Scars produced in infancy grow with the growthof the body ; as was pointed out, I understand, by SirJames Paget." (5) In such statistics insufficient allowance is madefor other circumstances, such as occupation, intemperance,and the existence of other diseases. An altogetherdifferent death -rate might be anticipated if small -poxbroke out in a public school, or in the infirm and agedwards of a workhouse. A typhoid fever patient, or anill - fed baby, catching discrete small -pox and dying,would be counted a death from small-pox, obviouslyneither vaccination nor its neglect having anythingto do with it." (6) The accurate observation and record of clinicaldetails is one of the most difficult duties requiredof medical men employed in hospitals for infectiousdisease."Dr. Ricketts ' says-" In some of the earlier statisticson vaccination only two classes of cases were considered,viz. , those vaccinated and those unvaccinated ; apparentlythe only evidence as to vaccination that wasaccepted being the presence or absence of scars. Anabsolute reliance, however, ought not to be placed onthis evidence. There is no doubt that cases occur inwhich vaccination has been successfully performed,although cicatrices are not present when the attackof small - pox supervenes . There is a small class, too,but naturally a very fatal class, in which the rash istoo abundant over the upper part of the arm for anassertion to be made that scars are absent. " On Table1 Report of the Metropolitan Asylums Board for 1893 , p. 136 .196 THE MITIGATION THEORY.B. pp. 144, 145, he gives twenty-six cases, with thirteendeaths, in which the absence of scars could not beasserted because of the abundant eruption ; and intwenty- five of these, the patient was stated to havebeen vaccinated ."noLet us see how Dr. Ricketts' figures work out. OnTable II.c, pp. 185-188 of the same report, there areforty-two vaccinated deaths, and forty-four in whichthere is " no evidence " as to cicatrices. On p. 138 , hedescribes an age-distribution he has made of theevidence " cases. He puts it in the form of a diagram ,and on comparing it with similar diagrams for thevaccinated and for cases in which the vaccinationcicatrix was " absent," he finds that the diagramcorresponds much more nearly with the former thanthe latter. There were ninety- four deaths in whichthe vaccination cicatrix was " absent," but it will benoticed that forty- four of these are in the first threeyears of life, in which there are no cases or deaths inthe other two classes . In all fairness these shouldbe therefore struck off ; we then get fifty deaths inthis class, and if we add the " no evidence " deaths tothe vaccinated ( I am aware that I am slightly overstatingthe case), we have eighty-six vaccinated deaths,and fifty in which the cicatrix was " absent. " Thus,over three years of age, there are, if we include the" no evidence " cases with the vaccinated, 63.2 per cent.of the deaths vaccinated .But there are further allowances to be made, for, onp. 134, Dr. Ricketts says of his class, in which thevaccination cicatrix was " absent," that he is not ableto describe these cases as all " admittedly unvacSOURCESOF FALLACY. 197cinated." Another source of fallacy is pointed outin the British Medical Journal of October 23 , 1880(vol. ii. , p. 672). The editor says-" It is probable thata larger proportion of unvaccinated persons is to befound among the ignorant, dirty, and wretched inhabitantsof the slums of London, and very few indeedamong the educated and better fed members of society."And Dr. Gayton admitted before the Royal Commission(Q. 1,843) that this would be likely to operate detrimentallyby way of raising the unvaccinated mortality.This applies to all places vaccinated up to the usualaverage. When allowance is made for these fallacies,it will be found that the proportion of deaths vaccinatedwill not be very largely different from that of thevaccinated population, which in London, from theamount of default that has taken place in recent years ,would not be very high .It is only fair to mention that other reports agreein not assigning such a large proportion of deaths tothe unvaccinated. In the Glasgow Medical Journal ofNovember , 1872 (vol. v., p. 12), Dr. Russell classifieshis cases according to the eruption. He found thatin discrete cases the fatality in both classes was nil,and in confluent small-pox the fatality of the vaccinatedexceeded that of the unvaccinated. Thus,among seventy-one vaccinated confluent cases therewere forty - nine deaths, or a fatality of 69 per cent. ,and of one hundred and sixteen unvaccinated confluentcases, sixty- four, or 55.2 per cent. , died.But the most striking figures come from Prussia,and they show that up to ten years of age there ispractically no difference in the fatality in the two198 THE MITIGATION THEORY.classes. The following table gives the figures for Berlin'in the 1871-72 epidemic :-Vaccinated. Unvaccinated.Ages. Cases. Deaths.Fatalityper cent.Cases. Deaths.Fatalityper cent.O- I 259 136 52.5 977 570 58.32-5 1,244 437 35 1 1,359 564 4156-10 737 163 22 I251 77 30.7If the difference between 52 and 58 per cent. is allthe mitigation that can be fairly claimed on behalfof vaccination within a year of the operation, even themost enthusiastic champions of vaccination will agreethat we must look to other and more scientific methodsfor the extirpation of small- pox.To recapitulate the facts briefly :-Figures have beenput forward showing an enormous difference in therates of the vaccinated and unvaccinated . It has beenshown that these are open to suspicion, because therates in the unvaccinated considerably exceed thoseof the last century before vaccination was discovered .When we come to analyse them, we find that thedisparity obtains principally in cases of confluent smallpox,in which, according to the leading authorities, thevaccination marks are readily obscured ; and when it isremembered that it has been the practice to classify thecases according to marks, whether discernible or not, itis evident that the results have been largely fallacious.Other sources of fallacy are the different conditionsunder which the two classes labour, and also the age.Of course, when the different ages are separated as" Beiträge zur Beurtheilung des Nutzens der Schutzpockenimpfung, "p. 168. Berlin. 1888.INVESTIGATION BY THE REGISTRAR -GENERAL. 199in the reports of the Metropolitan Asylums Board, thisobjection would not hold, but in the majority ofinstances , all ages are taken together, or separatedonly into those under and over ten ; and consideringthat the unvaccinated more largely consist of younginfants, who normally have a high small-pox fatality,this method naturally raises the rates for this class.The Government returns of small - pox deaths wouldappear to be one way of settling the question, but herewe are met with the difficulty that in death - certificatesof cases of small -pox, medical men in a large proportionof instances make no statement about thevaccination, although they have been repeatedly urgedto do so by the Registrar-General, and also by themedical press . In England and Wales, in 1892-95 ,there were 2,931 deaths from small -pox, of which 391,or 13.3 per cent. , are reported in the vaccinated ; 596, or20.3 per cent. , in the unvaccinated ; whereas, in 1,944,or 66.3 per cent. of the whole, there is no statement asto whether the patient was vaccinated or not. Thefollowing from the British Medical Journal of March17, 1877 ( vol. i. , p. 330), appears to throw some lighton the matter :-" It may not be generally known thatthe Registrar-General, during the epidemic of smallpoxin London in 1871-72, attempted to obtain morecomplete information as to the vaccination of personsdying of small-pox than was furnished in medicalcertificates. Then, as now, no information as to vaccinationwas given in a large proportion of medicalcertificates." The Registrar-General, therefore, requested the localregistrars, in cases where the medical certificate was200 THE MITIGATION THEORY.silent on the point, to endeavour to ascertain from theinformants of the deaths (almost invariably relatives),and to insert in the Register, whether the deceased hador had not been vaccinated." Information derived in this way certainly yieldedresults very similar to those obtained by the antivaccinationiststhemselves ; relatives almost invariablyasserted that the deceased had been vaccinated ; but, asinquiries of the medical attendants in a large numberof these ' not stated ' cases elicited the fact that thedeceased, the statements of relatives notwithstanding,bore no marks of vaccination, registrars were subsequentlyinstructed to insert in the Register no facts asto vaccination unless certified under the hand of aregistered medical practitioner. "It need hardly be said that this inquiry of theRegistrar- General is very important. In these " notstated " deaths, the medical men presumably are unableto decide the fact of vaccination. The difficulty nodoubt is great, for as Dr. Savill has pointed out in hisreport on the Warrington epidemic, " in nearly all fatalcases the eruption is profuse and tends to hide thevaccination scars if they exist. " Dr. Birdwood, as Ihave shown, is also alive to the difficulty, and recommendsthat the statements of parents as to primaryvaccination should be accepted. The relatives in thecases I am referring to almost invariably asserted thatthe patients had been vaccinated, and thus I cannothelp thinking that the most important part of the casefor vaccination has been given away, for if in the recent1 Final Report , Royal Commission on Vaccination, Appendix v . , p. 34.CLASSIFICATION BY MARKS . 201cases epidemic ( 1892-95), we add the " not stated "to the vaccinated, nearly 80 per cent. of the totaldeaths from small-pox will be found in the vaccinatedclass.It seems a pity that the vaccinal condition of patientssuffering from small-pox has not more often been determinedby reference to the vaccination register.Dr. Birdwood informed the Royal Commission (Q.31,250-51 ) that the Metropolitan Asylums Board usedto forward a list of patients to the Local GovernmentBoard for this purpose, but that he knew of nopublished results of their inquiries. If the LocalGovernment Board would undertake investigations ofthis nature, they would doubtless receive the cordialco-operation of both parties in the vaccination controversy,and the results would prove interesting, if notinstructive.It has been urged that the protection afforded byvaccination is in proportion to the number and thequality of the marks. In the first place, cicatricesresulting from the same lymph of good quality varyconsiderably. They may be smooth, striated, puckered,pitted, and so on ; in fact, a French observer, Decanteleu,has figured no less than seventy different varieties ofscars. Dr. Savill points out that " the foveation ofvaccination scars does but follow the same laws whichgovern other lesions involving only the superficial layersof the skin ; " and he figures the arm of a girl to show1 Professor Crookshank's Evidence. Fourth Report , Royal Commissionon Vaccination. Q. 11,892.2 Final Report, Royal Commission on Vaccination , Appendix v. ,p. 42.14202 THE MITIGATION THEORY.the similarity of foveate texture in a scar resulting froma superficial burn on the shoulder, and in some primaryvaccination cicatrices. Thus, it would appear that thetexture of the vaccination cicatrix depends on theamount of the local inflammation, on the method ofperforming the operation, on the age, surroundings,and general health of the individual, and on otherfactors.It is also worthy of notice that in classifying casesof small-pox according to vaccination marks, differentmethods are adopted by different observers. Thus Dr.Gayton informed the Royal Commission (Q. 1,700-06)that when he found one good mark and three imperfectones, he might class them as a case of two good marks,or he would ignore the three imperfect marks, and classthe case as one of a single good mark. Of 10,403 casesof small-pox admitted to the hospitals of the MetropolitanAsylums Board during 1870-84, Dr. Gayton 1classified 2,085, or 20 per cent. , as " vaccinated with goodmarks ; " whereas, at another hospital of the same Board,during the years 1880-85 , Dr. Sweeting placed only39 out of 2,584, or 1.5 per cent., in the category of" good vaccination. " The Dissentient Commissioners,Dr. Collins and Mr. Picton, observe (section 129)-" Itis evident that such a difference indicates a wide marginfor personal discrimination as to what is and what isnot ' good vaccination. " It is, therefore, not altogethersurprising to learn, on the authority of Dr. M. D.Makuna, when medical superintendent of the Fulham1 Second Report, Royal Commission on Vaccination, Appendix, p. 245.2 Ibid. Q. 3,689." GOOD " AND " BAD " MARKS.203Small -pox Hospital, that " what one will call an indifferentmark, another will call fair, a third moderate,and a fourth bad, and so on, till the confusion is worstconfounded." 1،،The following testimonies appear to show that even" good vaccination " is far from securing a perfect immunityagainst small -pox. Thus, Dr. J. J. Bigsby, in anepidemic of small -pox at Newark, found that someof the worst cases (of small-pox) had remarkably goodscars ." 2 In the British Medical Journal of April 1 ,1871 , Dr. Atthill is reported to have stated that " hedid not think that a good mark insured protectionmore than an ill - defined one. "Dr. B. Browning, Medical Officer of Health to Rotherhithe,gives particulars of 469 cases of post-vaccinalsmall - pox, of which 100, or 21.3 per cent. , died."Many of these sufferers, " he says, " showed goodvaccine marks of the kind that would be deemedworthy of an extra grant from the GovernmentInspector (at least I used formerly to receive suchgrants for doing similar looking work), and yet theytook small -pox-some within six days, some withinsix months, and some within six years of their vaccinationdate. " And lastly, I may quote the valuabletestimony of Dr. John MacCombie, who, on June 12,1878 , stated before the Epidemiological Societythat " the evidence afforded by the cases admitted1 Report of the Fulham Small -pox Hospital for the year 1878 , pp. 11 , 12 .2 London Medical Gazette , vol . xxv. , p. 18. (September 28 , 1839. )3 British MedicalJournal, vol . i. , p. 352 ." Transactions of the Society of Medical Officers of Health ( Session1881-82 ), " p. 29.204 THE MITIGATION THEORY.into the Asylum Boards Hospitals goes to showthat the good and bad marks are equally protectiveagainst attacks of small-pox," ¹ and he further remarksthat " good vaccination protects absolutely against noform of small-pox. " 2In considering the theory that the protection is inproportion to the number of marks, it may be mentionedthat, if we are to be guided by Jenner, " a single cowpoxpustule is all that is necessary. " But this, as wellas other theories promulgated by Jenner, has beendiscarded, and the orthodox number of marks at thepresent time is four. It is not pretended that thistheory has any scientific basis, but it appears to restmainly on certain figures compiled by Mr. Marson,surgeon to the London Small-pox Hospital . Theresults he obtained are given in the following tables :-Cases. Deaths.Fatalitypercent.UnvaccinatedVaccinated ( no scars)Vaccinated ( scars)... 2,883 1,006 34.89... 259 102 39.38... 10,293 685 6.66I scar ... 2,584 357 13.822 scars 3,138 242 7.713 scars ... 2,139 65 3.044 scars ... 2,432 21 861 Paper on " Comparison of Small-pox Statistics, Epidemics 1871 and1876, " by John MacCombie, M.A. , M.B. , Medical Superintendent tothe Deptford Small-pox Hospital. Transactions of the EpidemiologicalSociety ( Sessions 1877-78 and 1878-79 ) , vol . iv. , part 2, p. 190.2Ibid. , p. 192.3 " Further Observations on the Variola Vaccina, or Cow-pox. " p. 38.London. 1799.* Report from the Select Committee on the Vaccination Act ( 1867 ) ,pp. 236, 237. 1871 .MR. MARSON'S STATISTICS.Good scars . Indifferentscars .Scars. Cases. Deaths.FatalityCases. Deaths .per cent.Fatalitypercent .I1,530 328 21 44 1,054 29 2.752 1,838 224 12.19 1,30018 1.383 1,151 55 4.78 988 10 ΙΟΙ4 1,179 20 170 1,253 I 08627 1100 4,595 58 1.26205Total ... 5,698To obtain the above figures, Mr. Marson deducteddeaths for superadded disease, thus :-Totaldeaths.Deathsdeducted.Percentage ofdeaths deducted.UnvaccinatedVaccinated ( scars)Indifferent scars.... 1,043 37 3.5790 105 13'3Good scars .Total Deaths Percentage Total DeathsPercentageScars . ofdeaths ofdeathsdeaths. deducted. deaths. deducted.deducted. deducted.I 353 25 71 34 5 1472 25228 III 24625.03 65 10 15′4 14 428.64 37 17 45.9 II IO 90.9Total 70780113 83 25 301This shows that he deducted a larger proportion ofdeaths for the vaccinated than for the unvaccinated,for good scars than for indifferent scars, a larger proportionfor two scars than one scar, for three scarsthan two scars, and for four scars than three scars ,the climax being reached with four good scars, inwhich class, with eleven deaths altogether, he deductedten before making his calculations, and these, forsooth,are the figures on which the notorious marks theorylargely depends !206 THE MITIGATION THEORY.Mr. P. M. Davidson, the Medical Officer of Health toCongleton, has drawn attention to the strange conclusionsto which we should be driven were we toaccept some of the figures in Dr. Barry's SheffieldReport. Table CXIV. (p. 212) shows the fatality andtype of disease with one, two, three, and four or morescars in cases treated at the Borough Hospital, WinterStreet.Under 20 years of age . Above 20 years of age .Conditions as tovaccination .Cases. Deaths. Fatality Cases. Deaths . Fatalityper cent. per cent.No visible primarycicatrix, or I cica- 22 Ο 00 73 13 17.8trixonly ...2 primary cicatrices 94 3 3.2 165 21 12.73 primary cicatrices 187 316 185 18 974 or more primary)cicatrices67 00 32 2 6.2With regard to the type of disease under twentyyears of age, there was one confluent case, and thathad four marks. The only conclusion to be deducedfrom these figures is, that under twenty years of age,no visible mark, or one mark only, secures the greatestimmunity from death and severe disease ; whereaswhen a person reaches the age of twenty and upwards ,one-mark cases have the greatest fatality, the fatalitygradually diminishing with two, three, and four marks,and thus twenty years must elapse before the influenceofplurality of marks comes into play. Dr. Barry surelydid not intend us to believe that this was the case,but it is unquestionably what his figures tend to show.Again in Table CXV. (p. 214), Dr. Barry gives statisticsfor the Ecclesall Bierlow Union Workhouse Hospitalat all ages , as follows :-MR. DAVIDSON'S CASES. 207Scars. Attacks. Deaths.I or 23 or more1411872Fatality per cent.50017These percentages are seriously set forth to show thealarming difference in fatality between one or two andthree or more marks, Dr. Barry and those who suppliedhim with the statistics apparently forgetting that thefatality he gives for one or two marks is nearly threetimes the average fatality of the unvaccinated in thelast century, and even much larger than the figureshe himself gives for his own unvaccinated class, andif they show anything at all they show that the onemarkvaccination which was fashionable during the firsthalf of the century was provocative of a fatal issue ifattacked, and that most of the private vaccination atthe present time is in the same plight, and that Mr.Ernest Hart is giving the best of advice when he says-" Better by far let such applicants (for one or two smallinsertions ) depart with their children unvaccinated thanplace them in a state of false security. " ¹Mr. P. M. Davidson, besides criticising Dr. Barry'sfigures, has given us the result of his own painstakingand valuable experience of a small outbreak he hadto deal with at Congleton, and the following has beenextracted from a table he gives of these cases, onp. 27 of his report.2 ( See next page. )1 Allbutt's " System of Medicine," vol. ii. , p. 676. London. 1897 .2 Special Report on the Recent Outbreak of Small -pox in Congleton.1889.No. Name . Age . Resultsofvaccination.Character of small -pox .IGT.eorge 182HB.enry43S,.,-,ppcsosdFonaiiocneeienunttnaevevemmdstfr-epeieelsrlrdueyeonutsi.itsanhnqricuerhaadresDw;,,-,ptsvsmnoOuihiceqionnptisarulreeetrcryadrkidrrfneeiegdtciealinch in area . throughoutillness.3GeorgeW.26 Three scars (one deeply pitted ,two Semi -confluent ,very few pits .q,-)psoauiqnntauedtraetrdeer.iiannrceha-B4E.mma40s;,-sptDovmstnhTuichineiqwoawptiaslrluodetrrocyydaridsrrfnseigetcieal.iiannrceha .;istanbnpwbeeoeovdtneustrty5Annie S.25 p,)(ssttFiucwwoptaoouetrrresfdiciali.-hisaonanqrnlcueefhaare.,pDvmniieiotsrltcydirnegteBR6.andel32 ,(pstdoFichenotareeutrepreseldyi,-.)tpisathninqrwictueorhtaadersdeC,,pesdixoeettvneteefpenrlld-euyentc;sfp,aiaeonvcrmdeem-laynently.pcloevteerleyd7Harry B. 26PJ8.ohn19sc.,(),sppsCEtiuiiocoiwxpttanngoettrsfhreesiltfddduiecerinaatlbly.iiasonnrqnceuehaarep,-,tespCdaoThxcioeennwitatnredeorertfpmdnsellasduynieevnnetltylys.iianqnrcuehaare .pitted-CD9.aniel2710J-C.ames20IICJ.ohn192555Three scars (one pitted ,two superficial ),|Discrete ,very mild ,no pitting .one -fifth square inch inarea .Four scars (two deeply pitted ,one Discrete ,some pitting .sqt,-,)pouhuinparteeterreetfdeircsiala.iisnrnqceuhaare.,,,p(spsCdotFmieicoenwoutvtaneeouctetrfperrheslldeduyent,),spsouiqnptueetarerfdeicial.aiinrnceahssD.-,,pptsfaoFliciihqenotiatisuweusgrtrcahresdrrtdeetea.iinrnecahpcS.,,(sps-dooTlioicenenhitntaeeemrgtftrphieelesltdudelyeynt,,-)stpoouhinnpiteeertrdefdicialsquare inch inarea .Three scars (one deeply pitted ,twosuper- Discrete ,very mild ,two orthree pits .ficial ),four -fifths square inch inarea .Two deeply pitted scars ,three -quarters Discrete ,severe slightly .square inch inarea .1812TW.illiamS1T.3homas1PA.4nnieC1M.5rs.431TM6.argaret40sively ;the most severe case .1AS7.arah27One deeply pitted scar ,one -third square Discrete ,very mild ,no pitting ;mildestinch inarea . of all except Cases 2and 4.Four deeply scars ,three -quarters Confluent ,hæmorrhagic ,pitted extensquareinch inarea .210 THE MITIGATION THEORY.Thus five of the cases (Nos. 6, 7, 8 , 11 , and 16) wereconfluent, three semi-confluent (Nos. 1, 3, and 13 ), andnine discrete (Nos. 2, 4, 5, 9, 10, 12, 14, 15, and 17).All the confluent cases, except No. 7, had well-pittedvaccination scars . One of them (No. 7) had eightscars, three (Nos. 6, 11 , and 16) had four scars, and theremaining one (No. 8) two scars ; the average numberof scars being four and one half, and the average superficialarea three-quarters of a square inch.Of the three semi-confluent cases, No. I had fivescars, and this was the most severe ; and the remainingtwo (Nos. 3 and 13) had three scars each ; theaverage number of scars being three and two-thirds,and the average superficial area one square inch.Of the nine discrete cases, three (Nos. 5 , 10, and 12)had four scars, two (Nos. 9 and 14) three scars, two(Nos. 4 and 15) two scars, and the remaining two(Nos. 2 and 17) one scar each ; the average numberof scars being two and two-thirds, and the averagesuperficial area one half of a square inch. The followingtable gives a summary :-Average numberofscars.Average superficial areain square inches .5 confluent cases ...3 semi -confluent cases9 discrete cases ... ... 25533034324535..IMr. Davidson adds (p. 15)-" Comment on this issuperfluous, and I leave it to anyone caring to considerthe matter to judge for himself what he is toexpect from scars and superficial areas in this part ofthe country. If they teach anything, it is that themore you have of them, and the larger and deeperthey are, the more severe will be your small -pox. "THE SHEFFIELD EXPERIENCE . 211The best way to test the question is to compare theincidence of small-pox following vaccination by publicand private practitioners, for the public vaccinators arebound by their regulations to work up to a certainstandard. In the Sheffield epidemic ( 1887-88) it wasfound that 358, or 79.4 per cent. , of the 451 vaccinatedcases of small-pox under ten years of age hadbeen vaccinated by public vaccinators, who had onlyperformed 63 per cent. of the successful primary vaccinationsfor the ten-year period up to the epidemic ; ¹hence it follows that small-pox picked out the workof the public vaccinators , whose skilful and successfulperformances had qualified each operator for a Governmentgrant. Again, Sheffield Park, North Sheffield,and West Sheffield-the districts of the borough whichwere the most seriously afflicted with small-pox-hadthe largest percentage of their successful primary vaccinations,for the ten years previous to the epidemic,performed by public vaccinators ; whereas Ecclesall andUpper Hallam, with the smallest percentage, came offthe lightest of all the districts of Sheffield.The large proportion of three or four-mark cases ofsmall-pox in very efficiently vaccinated towns, as in thecase of Willenhall, strongly condemns the theory. Ofthe 681 vaccinated persons attacked in which thenumber of scars was known, 374, or 54.9 per cent. , hadfour marks , and 536, or 78.7 per cent. , had three or fourmarks, while the one-mark cases only amounted to 24,or 3.5 per cent. of the whole.1 Report on an Epidemic of Small- pox at Sheffield ( 1887-88 ) , pp. 185 ,187 ; Tables xcvii. , xcix .212THE MITIGATION THEORY.Before concluding the chapter, the opinion of Dr.George Gregory, the distinguished predecessor of Mr.Marson at the London Small-pox Hospital, is worthrecording. In the twenty-fourth volume of the " Medico-Chirurgical Transactions " ( 1841 , pp. 23, 24), after detailingseveral cases, he says :-" It follows, I think, fromthese cases, that the cicatrix cannot be relied on asaffording any certain test of the degree to which theconstitution has imbibed an anti-variolous influence. "Another authority (Dr. Fleetwood Churchill) observes:-" For some years I have only made one(puncture), on account of the severe inflammationwhich sometimes results from two or more, nor haveI had any reason to suppose that my object was notas completely attained. " ¹The more recent authorities also deprecate the " marktheory. " Thus, Dr. Birdwood observes that, in regardto primary vaccination, he advocates " the productionof one vaccine vesicle only ; " 2 and Dr. Ricketts writes-" Considering that scars vary in size and in appearancein the course of years , and that vaccinia must beregarded as a specific fever, it is not at first sightapparent what the characteristics of the inoculationcicatrices have to do with the amount of protectionafforded. But, after all, it is a question of fact, which,provided proper observations are made, ought to be,and can be settled in course of time by such statistics. "1 " The Diseases of Children," p. 821. ( Third edition. ) FleetwoodChurchill, M.D. Dublin. 1870.2 Sixth Report, Royal Commission on Vaccination. Q. 31,221 .3 Report of the Metropolitan Asylums Board for 1893 , p. 134.DR. COUPLAND'S FIGURES. 213Some observers, besides those already mentioned,obtained equivocal results. Dr. Dalton' gives thefollowing experiences :-Marks.I2345 or moreCases. Fatality per cent.126 24171 5'3177 2.8140 07932.2Also Dr. Coupland, who gives the following for theDewsbury epidemic :-Marks.I234 or moreCases. Deaths. Fatality per cent.3400175 10 5.7210 0042 I 2.4There is thus very slender evidence to show that theprotection depends upon the number or character ofmarks, and the little that exists is mainly affordedby the earlier statistics, such as Marson's, which it isobvious are inaccurately founded.From the foregoing facts it is evident that themitigation attributed to vaccination depends largelyupon the elimination of cases from the vaccinated lists,rather than to any real modification of the disease, andthis is borne out by the fact that the fatality of smallpoxin 1871-72, when a large proportion of the caseswere admittedly vaccinated, was as great as the averagefatality of the last century.1 " Small-pox in its Relation to Vaccination," p. 23. J. H. C. Dalton,M.A. , M.D. , B.C. ( Reprinted from the Medical Chronicle, October, 1893. )2 Final Report , Royal Commission on Vaccination, Appendix iii. , p. 115 .CHAPTER VII .RE -VACCINATION .THE admission that re-vaccination is necessary, is adeparture from the original position taken up by theprofession. It was not only Jenner who was so positiveabout the lifelong protection afforded by vaccination ,but his opinion has been endorsed by the highestauthorities at a later period. Sir John Simon says :-" On the conclusion of this artificial disorder (vaccination),neither renewed vaccination, nor inoculation withsmall-pox, nor the closest contact and cohabitation withsmall-pox patients, will occasion him (the vaccinatedperson) to betray any remnant of susceptibility toinfection. " "When this theory, upon which all vaccinationlegislation was initiated and justified, was discovereduntenable, that of re-vaccination was introduced.Instances of both mild and severe attacks of smallpoxtaking place at all periods after re-vaccinationare numerous. I propose to give a few of these. Mr.Badcock, the celebrated small-pox cow-pox vaccinator,relates his own personal experience : " Towards1 " Papers relating to the History and Practice of Vaccination, " p. xiv.1857.FAILURE OF TRIPLE VACCINATION . 215the end of the year 1836, I suffered severely from adangerous attack of small -pox, which happened buta few months after re- vaccination. " ¹ We also havethe experience of Mr. Justice Grantham :-" He impressedon the anti-vaccinators the peril they wereincurring to themselves and their neighbours by theiropposition to inoculation, and in support of his argumentsas to the effect of vaccination, stated that he,after having been twice inoculated, had an almostmiraculous recovery from an attack of small - pox ,which, in its incipient stages, was as bad as itcould be. " 2The following case shows the complete failure ofthree successful vaccinations to prevent a severe attackof small-pox. It is recorded by Dr. T. C. Wallace inthe American Medical Times of March 1 , 1862 (vol. iv. ,p. 122). The patient, Charles Nichols, aged thirty - fivehad an " extraordinarily severe " attack of confluentsmall-pox, and Dr. Wallace observed that he hadnever seen anyone so completely covered with pustules.The man had a large scar on the right arm,resulting, he informed Dr. Wallace, from vaccinationwhen a child, and a similar one on the left arm, dueto vaccination three years prior to attack. He wasagain vaccinated on the 24th of December, 1861 , thevesicle being " fully formed, large, and well filled," thevaccination being accompanied by some slight constitutionalsymptoms. He was attacked with small-pox1 " A Detail of Experiments confirming the power of Cow- pox, etc. ,"p. 11. John Badcock, chemist . Brighton. 1845 .2 Sussex Daily News, April 9, 1896 .216 RE - VACCINATION .on the 8th of January, 1862 , just fifteen days afterthe third vaccination .The British Medical Journal of December 7, 1872(vol. ii. , p. 643 ), reports a meeting of the Medical Societyof the College of Physicians in Ireland, when Dr. Darbyfurnished statistics of small-pox cases treated in theRathdown Union Hospital ; thirteen of the cases werere- vaccinated, with one death. At the same meeting,Dr. Grimshaw alluded to three re- vaccinated cases ofsmall-pox admitted to the Cork Street Hospital, oneof which was fatal .In a letter to the British MedicalJournal of December9, 1876 (vol. ii. , p. 774), Mr. R. G. Kellett wrote that,during an epidemic at Bilston, Staffordshire, in 1871-72 ,he re- vaccinated himself, his wife, and his two servants .Although the vaccination took well in all, each in turndeveloped small-pox, " certainly of a most abortive form ,not more than a dozen spots or so appearing on any ofus, but still it was small-poх."The same journal¹ also reports some cases of smallpox,which came under the observation of the HealthDepartment of Brooklyn, the statistics being furnishedto the Brooklyn Eagle, by Dr. J. H. Raymond, theHealth Commissioner. Among these is that of a child,aged three, who died of small - pox notwithstandingthat she had been well vaccinated in infancy and oncelater.In the Homerton Hospital Report for 1878 (pp. 23-25),Dr. Gayton gives six cases of small -pox after re-vaccination,with the following particulars :-1 British MedicalJournal, vol . i. , p. 749. ( May 20, 1882. )DR. GAYTON'S CASES. 2171. " Kate King, aged twenty, admitted February 18 ,1878 , three imperfect marks ; eruption very discrete;was placed on ' Full Diet ' February 22 , 1878 , and dischargedMarch 14, 1878. The re-vaccination wasstated to have been performed five years ago, withsuccess . The patient did not remember upon whicharm it was done, therefore the cicatrices observedmay have been due to either the primary or thesecondary operation, as no others were visible . "2. " John Wist, aged twenty - seven, two good marks ;admitted March 7, 1878, with discrete small -poxThe patient reported that he had been vaccinatedthree times in the course of his life; the first ininfancy, the operation succeeding ; the second at thetime of joining the Metropolitan Police, at twenty- twoyears of age, and that this took ' very slight ; ' thethird and last time, six months before becoming apatient, by a medical man in Whitechapel, but withouteffect. He was also positive that the two cicatricesseen upon the left arm were the result of the primaryoperation, as the sore left by the secondary one soonhealed up and left no marks. "3. " Samuel Fish, aged twenty-three, admitted March21 , 1878 , three imperfect marks ; eruption confluent,general symptoms very severe. Discharged cured June17, 1878. Was vaccinated in infancy, and again whenten years old. The certificate of re-vaccination in thiscase was produced, but it could not be satisfactorilydetermined to which operation the cicatrices were tobe attributed."4. " James Connelly, aged thirty-nine ; admittedMarch 30, 1878, with five marks, three good and two15218 RE - VACCINATION .imperfect, the eruption being discrete. He was puton ' Full Diet ' on April 1 , and transferred April 13 ,1878. The patient, an old soldier, stated that he wasre- vaccinated when in India about four years ago, andthat the operation was very successful. There werethree well foveated cicatrices close together, the extentof surface being about the size of a shilling. "5. " Ellen Clark, aged twenty- one, with one imperfectmark, admitted April 10, 1878, with small- pox of thehæmorrhagic form, and died April 12, 1878. Was saidto have been re- vaccinated, and arm to have beenslightly sore for three or four days, but no cicatrix,except the one referred to , could be traced. "6. " E. Williams, aged three years, admitted April 25 ,1878 ; eruption discrete. On April 27 had ordinary diet,and on May 18 discharged. Was stated by parents tohave been ' vaccinated when an infant,' one imperfectmark being now visible as the result. Six weeks ago ,in consequence of small-pox having occurred in thehouse, she was again vaccinated in four places, all ofwhich were attended , apparently, by some result. Themarks seen , reddish- brown in colour, were small in size,and not indented."In the Deptford Report for the period from April,1878 , to December, 1879, Dr. John MacCombie detailsthe following experience ( pp . 7, 8 ) :-I. " William W. , at. nineteen ; admitted May 13 ,1878. Three imperfect marks of primary vaccination ;re- vaccinated at. sixteen, two re-vaccination marks ;discrete attack ; discharged June 10."2. " Matilda B. , at. twenty ; admitted May 31 , 1878 .Two imperfect marks of primary vaccination ; reDR. MACCOMBIE'S CASES. 219vaccinated at. sixteen, three re-vaccination marks ;discrete attack ; discharged June 20. "3. " Caroline P., at. twenty-three ; admitted July 11 ,1878. Five imperfect marks of primary vaccination ;re -vaccinated at. ten and sixteen. She stated that shehad a ' sore arm ' on both occasions, but there wereno re-vaccination marks ; discrete attack ; dischargedAugust 22."4. " Emma S., at. twenty- one ; admitted July 25 ,1878. Two good marks of primary vaccination ; fourmarks of re-vaccination performed at the age of nineor ten ; discrete attack ; discharged August 31. "re-5. " Lucy H. , at. forty- two ; admitted August 5 , 1878 .Two imperfect marks of primary vaccination ;vaccinated at. twelve ; one re -vaccination mark ; discreteattack ; discharged August 22."6. " Sarah H. , at. thirty-six ; admitted August 13.1878. Three imperfect marks of primary vaccination ;three marks of re- vaccination performed at the ageof sixteen ; attack confluent ; discharged July 23 ,1879."7. " Fanny C. , at. thirty- three ; admitted March 11 ,1879. One imperfect mark of primary vaccination ;re - vaccinated at. twenty -one, on left arm in two places.There were no re-vaccination marks, but patient statedthat her arm was sore, and that the medical man towhom she showed it a week after the operation wasperformed said ' it was doing all right.' She died ofblack small -pox on March 14. "8. " Sarah P. , at. twenty- one ; admitted April 18, 1879 .Said to have been vaccinated in infancy, but therewere no marks. Has three marks of re- vaccination220 RE - VACCINATION .performed at the age of eighteen ; discrete attack ;discharged May 5. "9. " Fanny L. , at. thirty - six ; admitted October 13 ,1879. Three imperfect marks of primary vaccination ;two marks of re-vaccination performed at the age ofthirty- one ; discrete attack ; discharged November 8 ,1879."10. " James H. , at. twenty- seven ; admitted November8 , 1879. One good mark of primary vaccination ;re - vaccinated at. fifteen. Stated that he had a ' sorearm ' after re- vaccination. No marks ; discrete attack ;discharged December 12. "1Elsewhere Dr. John MacCombie says-" For myself,I am inclined to believe that small-pox after successfulre-vaccination is not infrequent. " Apparently anextended experience has not modified his views, forquite recently he says-" Some persons who havebeen successfully re-vaccinated do, however, contractsmall- pox. Of such cases observed by me the timeintervening between the re-vaccination and the attackof small -pox varied from one to twenty - five years ;the average being ten years." * And further on inthe same work he makes further admissions when hesays " it is impossible in all cases to promise immunityfrom attack or even from death after vaccination andre -vaccination. " "In the Homerton Hospital Report for 1881 (p . 11 ), Dr.Collie gives details of three cases after re -vaccination.1 " Transactions of the Epidemiological Society , " vol. iv . , part ii . , p. 193 .(Sessions 1877-78 and 1878-79. )Allbutt's " System of Medicine, " vol . ii . , p. 207. London. 1897.3 Ibid. , p. 222.DR . COLLIE'S CASES. 2211. " Henry P. , at. nineteen, admitted November, 11 .Primary vaccination in infancy ; re- vaccination sixyears ago ; three marks on right arm, two on left, butpatient cannot differentiate them ; all imperfect. Transferredto ' Atlas ' December 7. Mild discrete attack .(Admitted from City and sent in City ambulance. ) "2. " Emma P. (sister of above), at. twenty-two,admitted November 26. Primary vaccination in infancy; five imperfect marks ; re-vaccination six yearsago ; no marks, but said to have taken well ; againre - vaccinated on morning of November 5 ( firstsymptoms of small-pox on November 21 ) , seems tohave taken well. Transferred to ' Atlas ' December 7 .Mild discrete attack. ( Admitted from City and sent inCity ambulance. ) "3. " Ada J. , at. twelve, admitted December 12.Primary vaccination in infancy ; two imperfect anddoubtful marks ; re-vaccination six months ago ; patientsays it took well ; one imperfect and doubtful mark .Mild discrete attack. ( Sent by Hampstead in Hampsteadambulance . ) "These cases, together with those recorded by Dr.Gayton and Dr. MacCombie, have, through the courtesyof the Clerk, Mr. Duncombe Mann, been copiedverbatim from the reports of the Metropolitan AsylumsBoard. I wish to commend them to those who affirmthat compulsory re-vaccination would effectually extinguishsmall-pox.The following cases of small - pox, within shortperiods of re-vaccination, are given in the SheffieldReport.No. .NameAwgheena. ttackedVaccinationandr.-veaccinationi.innfancyEAH6l..5izabeth2912 Elizabeth J. 1872NShoerftfhield FW4.i5lliam2771 -SNhoerftfhield SG5a.rah12ΙΟΙSouth Sheffield 8FannyC.7PageofReport .District .1Ec3c9lesallPS8ha7erfkfieldΙΟΙSShoeuftfhield J3Wo.seph29VaccinatedovRafaencsdcuilntastionv.-reaccination-,cwTmiehaclrraletkreeidces-qtisuhnqarcurehatereers.airneas--,csvoORiiqannecxuceaetacthirrneiaxted,.1O8c8t7oberVaccinated.iinnfancy-vRaeccinated.,S1e8p8t7.Vaccinated.iinnfancy-vRaeccinated.i1n886Vaccinatedin infancy .v-Raeccinated1.i8n84Vaccinatedininfancy ..ianrceha,ccgTilohcaorastdsereicesa.isoornqvnecueeaharre,-cwmTieawclraoltkreidces-tsiohqnniucerahdre.area-lcwTmaiehar-lrrglekeeed,-chooaaannntleedrfices.iiasnnrqceuhaares.cTimwcaaoltlricescm-,wTieahclrraltekreeidces-iqtsnuhqcaruhreatereers.airneao-cssOiiqnncxueateathrreix.iainrnecah-fcwFmaieoaiclurrallr-kyed,-ttisorhnqniicuecrhaedrse.airnea.-cvsORiamneccaaecltilrniaxted.1i8n85Vaccinated.iinnfancyc-wTdmieheaclreralepkeeds,tqtruqhiarucreaeterseers.aiinrnceah.-cwvmRTieaaewclcraolctkireniadctesed.1i8n82C.-ospfmhoaaxlrlacterstAhuolaflvfeeegreedd-isfDpnmreoaocxlm-le;,1er8mu8bp7etrion:rtoohihnnagelnhytd.esanlpnosoyetwshereF,-iSpnemobaxrlularym,;av1ite8tlr8ady8ckf.,istdnlepeioleondtltsa-sopMtmfoitaxlaldclk1,;iN8no8v7ember.pniotttedmEaotifxtltadrcekmelyO,-ispnmcoatxlolber,;ipn1lio8ltt8t7ed.fdoauyrsteensaomVmtfieatlrladylc-kp,ia1nb8oo8xu8t,.pstnipwotoettnistnygsSoefmvaelrlepaotxtack1D;,in8e8c7ember.pbiatdtleydDR . DALTON'S CASES. 223In the Report of the Metropolitan Asylums Board for1890 (pp . 55-57), we learn that, during the year, twentysixpatients were admitted for small-pox, and two ofthese died. The first, aged twenty- six, had been unsuccessfullyvaccinated at nine months of age, andsuccessfully vaccinated when about ten years of age,and the scars were obscured by the eruption. Theother death was in a man aged forty-four, who hadbeen three times successfully vaccinated, once ininfancy, and again at seven and twenty-one years ofage. Five of the twenty- six patients were unvaccinated, and none of these died.Dr. Dalton, ¹ in his critical examination of 1,000 casesof small -pox, gives a list of sixty -one persons taking thedisease from one to forty years after re-vaccination. Ofthese, seven, or 11.5 per cent. , died, or a higher fatalitythan that for his 1,000 cases (8.5 per cent. ) .If any further evidence were required to demonstratethe futility of re- vaccination, it is furnished by theArmy and Navy Reports. Staff- Surgeon T. J. Prestoninformed the Royal Commission (Q. 3,270) that in 1883" three cases occurred in the ' Audacious,' which werecontracted at Shanghai. All three men had been successfullyre -vaccinated-one in 1880, one in 1881 , andthe third in 1882. The disease was of a very mildform , and the men were but slightly marked. "On p. 63 of the " Statistical Report of the Health ofthe Navy for the year 1881 , " dated 1882, there is areference to nine cases occurring on the " Eclipse," on1 " Small - pox in its Relation to Vaccination, " p. 25. J. H C. Dalton ,M.A. , M.D. , B.C. ( Reprinted from the Medical Chronicle, October, 1893. )224 RE - VACCINATION .the East Indies Station. " The first case, in the personof a leading seaman, aged thirty- one, was contracted atRangoon, where small-pox had been lately prevalent,and proved to be a severe case of the confluent form ofthe disease. The patient had been re-vaccinated twoyears before. He was taken ill on the 19th April ; therewas a copious confluent eruption, with high fever anddelirium. On the arrival of the ship at Trincomalee, hewas landed at a bungalow on Sober Island, where hedied on the next day, 28th April. On the 29th April,a second case appeared, in the person of an able seaman ,aged twenty-seven, who was at once landed in thetemporary hospital ; in his case the eruption was alsoconfluent, and he died on the eleventh day of thedisease. He is said to have been successfully re-vaccinatedfour years previously. " There were seven othercases, several of which were severe, and all of themvaccinated and re- vaccinated.¹With regard to the army, the tract before alluded toinforms us that the men are always re-vaccinated onentering the force, and it states (p. 7) that " officialexperience in England and abroad has shown thatsoldiers who have been re-vaccinated can live incities intensely affected by small-pox without themselvessuffering to any appreciable degree from thedisease."Brigade - Surgeon Nash, when examined before theRoyal Commission, also agreed ( Q. 3,559) that in the( Revised by the1Second Report , Royal Commission on Vaccination. Q. 3,284.2 Facts concerning Vaccination for Heads of Families.Local Government Board, and issued with their sanction. )RE - VACCINATION IN THE ARMY. 225army vaccination and re-vaccination was as perfect asendeavours could make it, and yet he handed in a listof 3,953 small -pox cases, with 391 deaths, for the years1860-88 . In 1889, among the troops in Egypt, therewere 42 cases of small-pox, with 6 deaths. These, onthe strength (3,431), give an attack - rate of 12,241 ,and a death-rate of 1,749 per million ; the attack-ratebeing six times that of Leicester, and five timesthat of Keighley, and the death - rate fifteen timesthat of Leicester and eight times that of Keighley inthe recent epidemics in these notoriously unvaccinatedtowns.The Army Medical Report for 1889 states (p. 190) :—" A detachment of the Ist Battalion Welsh Regiment wasstationed at Assouan during the latter part of 1888 andthe early part of 1889 ; during that time an outbreak ofsmall -pox occurred among the native population, andthe disease broke out among the troops ; two cases alsooccurred on the voyage from Assouan to Cairo. Notwithstandingall the precautions taken in Cairo, anddue regard having been paid to vaccination and revaccination,the disease kept on the increase, and in themonth of May presented signs of doing so still further.The Welsh regiment, which suffered most, was inKasr- el - Nil barracks, which are situated near a crowdedthoroughfare and on the banks of a navigable river. Itbeing more than probable that the disease was derivedfrom natives, the Welsh regiment, on the recommendationof the Principal Medical Officer, was removed toAbbassiyeh , where the situation is healthier and intercoursewith the natives could be prevented. Small-pox,the Principal Medical Officer, Deputy- Surgeon General226 RE -VACCINATION.Jameson, remarks, is always more or less prevalentamong the natives in Cairo, and, indeed throughoutEgypt, and as there exists no means of segregatingaffected cases, it is certain that patients in various stagesof the disease are permitted to walk about, and tofrequent bazaars and streets to the great danger ofthe public."If we take the figures over a long period, the resultsare the same.¹ Thus, in Egypt, in the fourteen years,1882-95 , there were 233 cases and 25 deaths fromsmall-pox among the troops, or an average annualattack- rate of 3,004, and a death- rate of 322 per million .The Indian army, during the same period, furnished691 cases and 68 deaths, the rates being 768 and 76 permillion respectively ; while in Leicester the rates wereonly 204 and 13 per million (446 cases and 29 deaths) .I may mention that the comparison is unfair to Leicester ,for the army consists of picked men living at a comparativelyinsusceptible period of life.The following cases extracted from a report bySurgeon I. Boulger, of the Army Medical Staff, relateto the small-pox which prevailed among the troops atCairo in 1885 :-" Private A. W-, 2nd East Surrey Regiment, agetwenty- three ; service, three years. Marks, three right(good). Re-vaccinated on enlistment ; modified. Admitted,4th December, 1884 ; discharged, 8th January, 1885-thirty-six days. This was a mild case ;See Appendix.2 " Report of a series of cases of smallpox which occurred amongst theBritish troops in Cairo from January to October, 1885. " Appendix to theArmy Medical Report for 1885, pp. 443-450.RE - VACCINATED SMALL- POX IN CAIRO. 227symptoms preceding eruption were well marked, suchas lumbar pain, vomiting, pyrexia ; but the eruptionwas scanty ; discrete throughout ; slight secondaryfever ; no pitting. "" Private F. A-, 2nd East Surrey, age twenty- three ;service, three and a quarter years . Marks , one right(good), three left (fair). Re-vaccinated on enlistment ;modified. Admitted, 2nd February, 1885 ; discharged,15th May, 1885-one hundred and three days. Patienthad been under treatment in hospital for a month withsecondary syphilis, when symptoms of small-pox appeared.The attack was most severe , of the confluenttype. Convalescence was delayed by large boils onlegs, and for a long time he was in a very anæmicstate. Skin much pitted. "" Private J. K-, 2nd East Surrey, age twenty- eight ;service, five and a half years. Marks, two right (good) ,one left ( faint). Re-vaccinated on enlistment ; modified.Admitted, 2nd February, 1885 ; discharged, 22ndMarch , 1885-forty-nine days. Was of the confluentvariety. Temperature before eruption appeared, 103 °Fahr. Patient very robust ; there was a large quantityof eruption, and it went on to maturation, though withoutmuch secondary fever. No complications ; throatwas sore ."Sapper J. H-, Royal Engineers, age twenty- five ;service, three years. Marks , two right (good). Revaccinatedon enlistment ; modified. Admitted, 2nd.February, 1885 ; discharged, 22nd February, 1885-twenty - one days. Very mild ; discrete ; eruptionscanty, but went on to maturation ; no complications ;no pitting ; desquamation rapidly completed. "228 RE -VACCINATION ." First -class Staff-Sergeant E. F-, Medical StaffCorps, age thirty-two ; service, fourteen years. Marks,two left (good), two right (fair). Re-vaccinated, 18thAugust, 1870 ; failed. Re-vaccinated, 2nd March,1876 ; perfect. Admitted, 2nd February, 1885 ; discharged,21st February, 1885-nineteen days. Verymild case ; very little eruption, and it never wentbeyond the vesicular stage ; had most severe initialsymptoms . The lumbar pain was intense, and twentyfourhours before eruption appeared, he had a wellmarkedattack of dry pleurisy on the left side ; thefriction sound was very marked, and the temperature,103 ° Fahr. "" Private F-, 2nd Royal Sussex, age twenty- two ;service, three years . Marks, two right and two left(faint). Re-vaccinated, 2nd February, 1882 ; perfect.Admitted, 22nd February, 1885 ; discharged, 13thMarch , 1885-eighty- two days. Very severe ; initialsymptoms, vomiting, lumbar pain, pyrexia very marked ;eruption preceded by a scarlatinous prodromal rashover pubes, and at flexures of joints. Eruption copious,confluent on face and forehead ; went on to suppuration,but there was not much secondary fever. Large,soft crusts formed on face when the pustules ruptured,and convalescence was long delayed owing to theadherence of these crusts."" Private P , 2nd Royal Sussex, age twenty-one ;service, two years. Marks, two left (fair). Revaccinated24th May, 1883 ; modified. Admitted 21stMarch , 1885 ; discharged, 4th May, 1885-forty - fivedays. Severe case. Eruption confluent, with markednervous symptoms ; eruption went on to pustulation ;RE -VACCINATED SMALL- POX IN CAIRO . 229secondary fever high ; extensive crusts formed on face ;desquamation was long delayed ; slight pitting. "" Private C-, 2nd Royal Sussex, age twenty-three ;service, four and a third years. Marks, two left (good ).Re-vaccinated, 2nd December, 1881 ; modified. Admitted24th March, 1885 ; discharged, 2nd May, 1885-forty days . Case of average severity ; semi-confluent.Eruption plentiful, and went on to pustulation. Nocomplications ; desquamation slow."" Lance - Corporal S-, 2nd Royal Sussex, agetwenty - three ; service, three and a quarter years .Marks, two right (good) , four left (fair). Re-vaccinated, 1881 ; modified. Admitted, 25th March, 1885 ;discharged, 21st April, 1885-twenty-eight days. Verymild case ; eruption scanty ; no secondary fever of anyconsequence ; pustules formed and soon dried up ;desquamation rapid. "" Private M-, Ist Yorkshire Regiment, age twenty ;service, two years . Marks, three right (good) . Revaccinatedon enlistment ; modified. Admitted, 16thApril, 1885 ; discharged, 16th May, 1885-thirty- onedays. Case of average severity. Eruption copious,but discrete ; went on to suppuration. No complications,except severe sore throat. "" Private O-, 2nd Royal Sussex, age twenty ; service,two years . Marks, three left (good). Re-vaccinated,25th August, 1883 ; modified. Admitted, 29th April,1885 ; discharged, 5th June, 1885-thirty-eight days .Case of average severity ; initial symptoms severe.Eruption copious, but discrete ; went on to pustulation ;not much secondary fever. No complications or pitting ;desquamation tedious. "230 RE - VACCINATION ." Private A-, 2nd Royal Sussex, age twenty ; service,two years. Marks, three right (good). Re-vaccinated,25th May, 1883 ; perfect. Admitted, 11th May, 1885 ;discharged, 22nd June, 1885-forty- three days. Case ofaverage severity. Eruption copious, but discrete ; wenton to formation of pustules ; very little secondary fever.No complications ; desquamation much prolonged. "" Private MacF-, Ist Gordon Highlanders, agetwenty- six ; service, five and two-thirds years . Marks,three left (very faint). Re- vaccinated, 10th October,1879 ; modified. Admitted, 20th May, 1885 ; died28th May, 1885-nine days. " ( Man contracted smallpoxwhile under treatment for syphilis at the hospital. )" Private J-, 2nd Duke of Cornwall's Light Infantry,age twenty- four ; service, four years. Marks, two left(good) . Re-vaccinated on enlistment ; modified . Admitted,24th June, 1885 ; discharged, 21st July, 1885-twenty - five days. Very mild case ; but the eruptionwent on to pustulation. Eruption scanty and discreteeverywhere ; no secondary fever ; desquamation rapid."" Private S-, Ist Royal West Kent, age twentytwo; service, three years. Marks, three left (good).Re- vaccinated , 1882 ; modified. Admitted, 27th June,1885 ; discharged, 12th August, 1885-forty - sevendays. " ( Muscular pains, followed by vomiting andrise of temperature. Copious discrete eruption all overbody, rapidly going on to pustulation ; desquamationtedious.)" Private F-, 2nd Oxford Light Infantry, age twenty ;service, two years . Marks, two left (good). Revaccinated, July, 1883 ; perfect. Admitted 15th July,1885 ; discharged, 12th August, 1885-twenty-nineRE - VACCINATED SMALL- POX IN BERLIN . 231days. Mild case; usual initial symptoms, and whichwere well marked. Eruption appeared on 17th ; wasscanty, and principally on forehead and face ; discreteeverywhere. Papular became vesicular on 19th,and then proceeded no further, but rapidly desiccated.No secondary fever. Case was complicated with slightsore throat ; desquamation rapid."" Lance - Corporal G-, Mounted Police, age twentysix; service, six years. Marks, four left (faint). Revaccinated,25th September, 1879 ; modified. Admitted30th July, 1885 ; died, 3rd August, 1885 - five days. "(Surgeon Boulger here gives details of the case, whichappeared to be of the hæmorrhagic variety. )In the 1870-72 epidemic at Berlin ' we have figureson a still larger scale. There were 1,036 re-vaccinatedcases of small- pox, and of these 162 are reported tohave died . This is a fatality of 15.6 per cent. , or verylittle less than the average fatality of small-pox duringthe last century in England, and over two and a halftimes that of unvaccinated Leicester in the recentepidemic.A statement which is always quoted as indisputableevidence of the special protective power of re-vaccination,is the alleged immunity of small-pox hospitalattendants.If re- vaccinated nurses do not take small -pox, asaffirmed, abundant evidence has been adduced to showthat this is not the case with re-vaccinated soldiers ;and hence it is clear that the nurses' immunity1 " Zeitschrift des Königlich Preussischen Statistischen Bureaux," p. 119.Berlin . 1873 .232 RE -VACCINATION.(such as it is) is rather a function of being nurses, thanof being re-vaccinated. Moreover, unre-vaccinatedattendants have had a like immunity, as shown bythe experience of M. Colin at the Bicêtre Hospitalanimmunity, it may be noted, which was not sharedto so marked a degree by the re -vaccinated. He foundthat out of nearly two hundred attendants on thehospital staff, almost all of whom had been re- vaccinatedunder his own eyes, fifteen were attacked with smallpox,with one death ; while among the forty doctors andchemists attached to the establishment, and among theforty nuns who took care of the patients night and day,and who lived in the centre of the hospital, none wereattacked, in spite of the fact that the greater numberof the staff, and a large number of the nuns neglected.to get themselves re-vaccinated. 'Examples of immunity, even when strongly exposedto small-pox, have also been observed in the unvaccinated; these have been alluded to in an earlierchapter. The following personal experience, detailedin a letter , dated March 10, 1897, from one of theManagers of the Metropolitan Asylums Board, is acase in point :-" In answer to yours of the 2nd inst. I was elected asManager to the Metropolitan Asylums Board in March,1892 , and placed on the Small-pox Hospital ShipsCommittee at once. This Committee meets at theShips every fortnight, except during holidays ; a surprisecommittee visits the ships in the intervalsbetween the Committee meetings. I generally visit1 La Variole, pp. 84, 114. Léon Colin. Paris. 1873 .IMMUNITY OF PLAGUE ATTENDANTS. 233the wards, speak to the patients, examine the bedcardsto ascertain the vaccinal state of the patients.The number of patients, according to the AnnualReports , admitted to the ships from 1802 to 1896inclusive is 4,952 ; and I have no doubt that I haveseen from 3,000 to 4,000 patients suffering from smallpox,and some of these cases twice or thrice. Mycase is stronger than you put it. I have not evenbeen vaccinated, or had small-pox to my knowledge ;the reason I was not vaccinated, I understand, beingthat I was too delicate in my young days to besubjected to the operation. "Apparently small-pox is not the only zymotic diseasein which an immunity of hospital attendants hasbeen observed, for Dr. James Cantlie, in his interestingreport on the recent outbreak of bubonic plague inHong Kong, specially alludes to the fact, that " nonurse, male or female, concerned in attendance at thehospitals devoted to plague, contracted the disease.""It is not quite manifest why persons frequentlyexposed to contagion should be immune. M. Colin,a strong advocate of vaccination, felt called upon togive some explanation of the cases coming under hisnotice, and he suggested that a certain tolerance wasacquired by repeated exposures. Of course, this mayor may not be true ; but whether the theory beaccepted or not, it is clear that some other explanationof the alleged immunity of the hospital attendants,than the one usually given, must be sought forto meet all the facts of the case.1 British Medical Journal, vol. ii. , p. 425. (August 25, 1894. )16234 RE - VACCINATION.Reference is often made to the German army. SirJoseph (now Lord) Lister, at the annual meeting ofthe British Association in 1896, is reported to have saidthat small-pox " is absolutely unknown in the hugeGerman army, in consequence of the rule that everysoldier is re-vaccinated on entering the service. " ¹In a letter to the Times of September 23, 1896, Mr.Trobridge pointed out that the ordinance enforcing revaccinationon all recruits, came into force on June 16,1834, and that it provided for at least ten insertionsbeing made in each arm ; and he quoted the evidenceof Dr. Arthur F. Hopkirk, who informed the RoyalCommission that he believed the law was alwaysobeyed ; and those men who refused were tied downand vaccinated by force ( Q. 6,799).The following are the figures for small-pox in theGerman army since 18252 :-Small-pox.Year. Cases . Deaths . Year.Small-pox.Cases. Deaths .1825 ? ... 12 1836 ... 130 91826 ? 16 ... 1837 ... 94 31827 ?23 1838 III ... 71828 ?... 35 1839 ... 89 21829 ?... 33 1840 ... 74 21830 ? 27 1841 ... 59 31831 ? 108 ... 1842 ... 99 21832 ?... 96 1843 ... 167 31833 ? 108 ... 1844 ... 69 31834 ... 619 38 1845 ... 30 I1835 ... 259 5 1846 ... 30 I1 The Times, September 17 , 1896 .2 " Beiträge zur Beurtheilung der Nutzens der Schutzpockenimpfung,"pp. 23 , 24. Berlin. 1888.SMALL- POX IN THE GERMAN ARMY.Small-pox.Cases. Deaths .235Small-pox .Cases. Deaths . Year. Year.1847 5Ο 186897 I1848 22 I 1869 108 ... I1849 62 I ... 18701 41 01850 ... 176 I 1870-712 ... 2,879 1641851 246 3 18713 828341852 87 I 1872 ... 389 121853 138 I 18734 26 2...1854 121 3 1873-745 22 1 ...1855 12 1874-75 26 0...1856 21 Ο 1875-76 20...1857 ... 35 I 1876-77 ... 19 Ο1858 64 Ο 1877-78 12 Ο...1859 58 2 1878-79 ... 15186044 3 1879-80 ... 701861 ... 56 4 1880-81 ... 230186225 I 1881-82 16 Ο...1863 90 Ο 1882-83 ... 9Ο1864 120 I..1883-84 ... 7 Ο1865 69 I 1884-85 ... 7 161866918 1885-86 6 Ο1867 188 2 1886-87 ... 7 ΟIt will thus be seen that since the year 1834, therehave been 7,505 cases and 291 deaths from small-pox inthe German army, and hence Lord Lister's statement isobviously inaccurate. On March 31 , 1897, at a meetingpresided over by the Duke of Westminster for theFrom January to June, 1870.2 From July , 1870, to June, 1871 .3 From July to December, 1871 .4 From January to March, 1873 .From April 1 , 1873 , to March 31 , 1874.The above death was of a man who was twice unsuccessfully revaccinatedwhen recruited.236 RE -VACCINATION.purpose of raising a fund for a national memorial toEdward Jenner, Lord Lister took occasion to modifyhis original statement. He excused his previous utteranceby saying that he had " quoted from memory afterreading an authority on the subject," and added that" if he had stated that ' fatal ' small-pox was absolutelyunknown in the German army he should have beenspeaking the literal truth. " With an exception in1884-85 , it is quite true that there have been no deathsfrom small -pox in the German army since 1874-75 ;but Lord Lister must be aware that " in consequenceis usually held to imply an effect following on a cause,and that it is scarcely clear, without further explanation,why we should wait for half a century for the allegedeffect of something which commenced to operate as analleged cause in 1824. In other words, Lord Listerin order to make good his case, even as amended,should account for the small - pox deaths in theGerman army since 1834, and more particularly the210 deaths in 1870-72, for whatever the vaccinalcondition for some years subsequent to the enactmentin 1834, all authorities agree that the Germanarmy was a thoroughly well re-vaccinated body in1870-72. The decline of small-pox and other zymoticdiseases in recent years in the German army is dueno doubt, as Mr. Trobridge has suggested, to the" great wave of sanitary reform which spread throughoutthe newly-formed German Empire in 1872, andwhich has reduced the general death- rate from 29 per1,000 living in that year to 24 per 1,000 in 1887. "1 The Times, April 1 , 1897 .SMALL - POX IN THE FRANCO-PRUSSIAN WAR. 237Another statement which is frequently appealed to is,that during the Franco- Prussian War, 23,469 died fromsmall-pox in the French army, whereas the Germanarmy only lost 263 from this disease, the differencebeing attributed to want of re-vaccination in theFrench army. In 1883 Dr. W. B. Carpenter refers tothe subject thus : " In Germany, vaccination is compulsoryin children under a year old ; and everyman on his entrance into the army is re-vaccinated.In France, on the other hand, vaccination is notcompulsory, and re-vaccination is not enforced onarmy- recruits. During the Franco-German War of1870-71 the total number of deaths from small-pox inthe German army was 263, while in the French army itwas 23,469, or very nearly ninety times as great. " ¹On June 19, 1883 , Sir Lyon, now Lord Playfair,triumphantly reproduced the statistic with greateffect in the House of Commons, in a speech whichis reputed to have influenced more votes than anyspeech ever made in Parliament. Mr. Ernest Hartgives us the authority for the statement. " Totaldeaths from small-pox in German army (where revaccinationwas rigorously enforced), 263 ; in theFrench army (where re-vaccination was neglected),23,469. Cf. Colin : La Variole."Now, there does not appear to be any authority forsaying that re-vaccination was not enforced in theFrench army, and exception must also be taken to1A letter to the Right Hon. Lyon Playfair, C. B. , M.P. , F.R.S. , p. 8.William B. Carpenter, C.B. , M.D. , F.R.S. London. 1883.* British Medical Journal, vol. i. , p. 1217 , foot-note. (June 23, 1883. )238 RE -VACCINATION.the 23,469 French soldiers reported to have died ofsmall -pox. Mr. Alexander Wheeler followed up thisstatement as soon as it was uttered, and he receivedassurances from the French War Office that there wereno official medical statistics taken out during the periodof the war in 1870-71 .According to the " Wiener Medizinische Wochenschrift,"¹ this figure (23,469) would appear to havebeen taken from a French source of information ; andDr. Hopkirk informed the Royal Commission that ithad been recently confirmed from Paris (Q. 1,543),that he believed the confirmation was official (Q. 1,654) ,and, moreover, an " absolute fact " (Q. 6,774) ; but whenhe was confronted with the French official records, inwhich it was stated that the medical statistics in 1871-72 were wanting (Q. 6,778-6,782), he was obliged toadmit that he was not aware of any figures on whichthe calculation was based ( Q. 6,787) .It appears that the statistic rests on certain figuresgiven by M. Colin for the garrison at Paris. Heestimated that there were about 1,600 small -pox deathson an effective strength of 170,000 men, indicating asmall-pox mortality of 94 per cent. The number23,469, it is said, was obtained by applying this ratioto the whole army of France .When Dr. Carpenter found that the statement he hadmade was incorrect, he most honourably retracted it1 " Wiener Medizinische Wochenschrift ," p. 896. (August 31 , 1872. )* See also " Rapport sur la Vaccine," p. 47. Proust. 1889.* La Variole, p. 58. Léon Colin. Paris. 1873 .* Letter from Dr. Jeunhomme to Dr. Collins. Sixth Report, RoyalCommission on Vaccination, Appendix, p. 727 , foot - note.SMALL- POX IN THE FRANCO - PRUSSIAN WAR. 239in the Daily News of August 7, 1883. He says, " Irequested Earl Granville to obtain what information hecould on this point ; and after considerable delay, I havereceived through Colonel Cameron (military attaché tothe Embassy in Paris) an explicit statement that thearmy medical returns of the Franco-German War areso incomplete as not to supply the total for whichI asked."Mr. Ernest Hart, whom I have also mentioned asgiving currency to the statement, has reproduced thediscredited statistic quite recently ( 1897). He refersto " the following utterances of M. de Freycinet whenMinister of War in 1890," and then quotes him asfollows :-" One now sees, not only in France, but inAlgeria, in Tunis, and in Tonquin, the army protectedby the strict application of compulsory vaccination.I cannot forget that, in 1870-71 , the Germanarmy, counting a million vaccinated and re-vaccinatedmen, only lost 459 men from small-pox in the twoyears, whereas our army, far less numerous, had, fromthe same cause, a loss of 23,400 men whom theprescient application of re - vaccination might havesaved for the service of France." This quotationfrom a report by M. de Freycinet, dated June 16,1882, is apparently taken from the sixth volume ofthe Royal Commission Evidence (Appendix, p. 727),which was published subsequently to Mr. Hart's article,and Mr. Hart has omitted to notice an asterisk at theend of the quotation ; this refers the reader to a footnotecontaining a letter from Dr. Jeunhomme to Dr.1Allbutt's " System of Medicine," vol. ii. , p. 662. London. 1897.240 RE - VACCINATION .Collins, in which Dr. Jeunhomme states that no officialdocuments exist, and he proceeds to explain how thestatistics for the whole army have been arrived at bycalculation from the estimate given by M. Colin ofthe small -pox mortality of the army in Paris .Even if the 23,469 statistic were true, it would beabsurd to compare the small-pox mortality of thestrong, resolute Germans, conscious of victory, withthat of the cowed, worn, starved , and discomfitedFrench. As it happens, the figure is a pure assumption;but no statement has probably ever been quoted withmore telling effect, or done such service to the causeof compulsory vaccination .CHAPTER VIII .INFLUENCE OF SANITARY MEASURES ON THEINCIDENCE AND MORTALITY OF SMALL- POX .THE influence of sanitation as regulating the attackand death-incidence of small-pox has already beenalluded to in various parts of this work, more particularlyin the third chapter, dealing with the causesof the decline of the disease. Since that chapter waswritten, a resolution has been adopted by the JennerSociety, signed by a large number of medical officersof health, denying the sufficiency of sanitation as apreventive of small -pox, and affirming that " the onlytrustworthy protection at present known against smallpox,alike for the individual and the community, isefficient vaccination in infancy and subsequent re-vaccination,and that the only effective way of stampingout epidemics of this disease lies in the free use of theseagencies." It is necessary, therefore, to deal with thisimportant branch of the subject more fully.The views of the Royal Commission may be gatheredby the following quotations extracted from their FinalReport."The question how far the behaviour of small-pox in theeighteenth century and earlier was influenced by sanitary conditions,is one rendered difficult by the lack of exact information .We may distinguish between overcrowding as one insanitary242 INFLUENCE OF SANITARY MEASURES.condition and all other insanitary conditions, such as lack ofcleanliness and the like. A priori we should expect that a densepopulation, especially one of great internal movement, and onein continual interchange with surrounding populations, by offeringgreater facilities for the conveyance of contagion, would leadto a greater amount of small-pox. " ( Section 78. )" We might a priori expect the other acknowledged imperfectsanitary conditions of the eighteenth century to increase thefatality of, and so to a corresponding extent, the mortality fromsmall-pox; but there is no exact evidence to confirm this supposition." ( Section 78. )" In general both the incidence of, and mortality from, smallpoxseem to have been far less affected by sanitary conditionsthan might à priori have been expected." ( Section 78. )" Admitting à priori that crowded dwellings tend to increasethe liability to contagion, and so the prevalence of the disease,while other insanitary conditions tend in addition to increase thefatality among those attacked, so that insanitary conditions asa whole must tend to increase the mortality from small-pox ; noevidence is forthcoming which distinctly shows that the dependenceof the prevalence of, or the mortality from, small-pox, on thelack of sanitary conditions, was a feature of the history of smallpoxduring the eighteenth century. " ( Section 79. )" Whatever may have been the sanitary improvements duringthe first quarter of this century in England and some othercountries, there seems no ground for supposing that throughoutWestern Europe the period was marked by great changes in thedirection of improved sanitation. Indeed, in many countries downto a recent period, in some it may perhaps be said even to thepresent time, insanitary conditions have continued to prevail ."(Section 81. )" There is no proof that sanitary improvements were themain cause of the decline of small -pox under discussion. Andno adequate evidence is forthcoming to show to what extentsuch improvements may be considered as a subsidiary cause."(Section 82.)" We have already pointed out that small-pox tends at timesto become epidemic, i.e., to spread more readily than at otherVIEWS OF THE ROYAL COMMISSION. 243times. The occurrence of the conditions, whatever they may be,which cause the disease to be thus epidemic has of course norelation to the state of the population as regards vaccination,even conceding to the full that it has a protective effect. Theonly result of widespread vaccination, in a case where small-poxbecame epidemic, could be to render the extent of the epidemicmore limited, and its fatality less than it would otherwise be."(Section 144.)" It is beyond doubt that an infectious disease like small -poxis, other things being equal, more likely to spread in towns thanin country districts, and more likely to spread in crowded towndistricts than in others not so densely populated ; so that weshould expect a lessened proportion of overcrowded dwellings,by diminishing the opportunities for contagion, to check the prevalenceof the disease and consequently to render its mortalityless. " (Section 147.)" We have already pointed out that on à priori grounds it isreasonable to think that improved sanitary conditions would tendto diminish the fatality of, and so to a corresponding extent themortality from, small -pox. And there can be no doubt that theperiod with which we are dealing has been characterised by animprovement of this description. There has been better drainage,a supply of purer water, and in other respects more wholesomeconditions have prevailed. " ( Section 151. )" We do not mean to indicate an opinion that sanitary improvementshave been without an effect on small-pox mortality, but onlythat, when all the changes which have occurred are considered, itcannot be asserted that they afford an adequate explanation of thediminished mortality from small-pox. " (Section 153. )" We fully recognise that sanitary improvements have had aneffect in reducing the mortality from small-pox as from the otherdiseases to which we have just been referring." ( Section 166. )If these various quotations and fluctuating opinionsare summed up, they amount to this. The Commissionstate ( 144) that the occurrence of the conditionswhich cause small-pox to be epidemic has no relation244 INFLUENCE OF SANITARY MEASURES.to the state of the population as regards vaccination.They also imply (481¹) and admit (494¹ ) that someother reason than vaccination must be sought for toexplain the decline of small-pox. They allow thatovercrowding, which is distinctly an insanitary condition,accentuates the disease (78 , 79, 147). Theyalso admit that other insanitary conditions have someinfluence (78, 79, 151 , 153 , 166). They say that sanitaryimprovements act especially in the direction ofdiminishing fatality (79, 151), although there is noproof that they are the main cause (82), and thatthey cannot be asserted to form an adequate explanationof the diminished mortality from small -pox ( 153) .I am not at all sure that those who favour the viewthat sanitary measures are responsible for the diminutionof small-pox will be disposed to quarrel with theseconclusions ; my own reading of the Report is that theCommissioners, in their desire to state the case fairly,have been obliged, somewhat reluctantly, to admitsufficient to seriously discredit the point of view forwhich they are arguing. I do not know that it hasever been seriously maintained that the amelioration ofinsanitary conditions is the only cause of the decline ofsmall-pox, as others have been suggested, to which Ihave alluded in my third chapter, but that insanitaryconditions are among the principal causes of the prevalenceand mortality of this complaint must, I think,1 In section 481 the Commissioners refer to the experience of Leicester ;and in section 494 to the recent decline in small-pox in the Metropolis,and they add-" We think it is impossible to attribute this change tovaccination ."OPINION OF LORD SHAFTESBURY . 245be allowed. The purport of the present chapter is tosupply further evidence under this heading.A prominent feature of small-pox is that it has beenconfined almost exclusively to the lower stratas ofsociety, or among those who live in the least favourablesanitary conditions. In Austria, small-pox is calledthe " beggars' disease," and in this country it is largelyspread by tramps, who not only live under unhealthycircumstances, but are frequently deprived of thecommon necessaries of life .Mr. John Cross found that at Norwich, in 1819, thesmall-pox epidemic was " confined, almost exclusively,to the very lowest orders of the people. "'In the Provincial Medical and Surgical Journal forDecember 22 , 1852, in an article entitled, " Report onSmall-pox, as it occurred during three Epidemics inthe practice of the Canterbury Dispensary between theyears 1837 and 1848," Mr. Rigden says, concerning thethird epidemic (p. 682), that " The most severe cases,and the greatest number, existed, generally speaking, inthe districts most thickly populated by the lower orders,and most badly drained. "In the debate on the Compulsory Vaccination Bill of1853 , Lord Shaftesbury confessed that it was perfectlycorrect " that the small-pox was chiefly confined to thelowest class of the population, and he believed thatwith improved lodging- houses the disease might beall but exterminated. "1 " A History of the Variolous Epidemic which occurred in Norwich inthe year 1819, " p. 7. John Cross, M.R.C.S. London. 1820.Hansard's Parliamentary Debates, third series, vol. cxxv. , p. 1012 .(April 12 , 1853. )246 INFLUENCE OF SANITARY MEASURES.The Medical Times and Gazette of February 11 , 1871(vol. i. , p. 159), in referring to mistakes in diagnosis,indicates very plainly the class of people and themiserable environment of those who took small-poxin the 1871-72 epidemic, and observes :-" Medicalmen cannot be too cautious in such a matter ; butwhen it is considered that the diagnosis has often tobe made under most unfavourable circumstances, indark corners of ill- lighted rooms, amidst the discomfortsof squalid surroundings, chattering women, andsqualling children, often by candle-light, and uponindividuals where the dirt upon the skin is apt toobscure otherwise distinct signs, while the patientsare too stupid to reply clearly to questions, thedrift of which they are at a loss to comprehend ,one cannot altogether wonder at occasional occurrenceof error."Likewise at Birkenhead, in 1877, Mr. Francis Vacher ,the Medical Officer of Health, noted that " an overwhelmingmajority of the sufferers in this epidemic(consisting of 603 cases of small-pox) were derivedfrom the labouring class, and the remainder-six onlyexcepted-from the artizan class. " The six exceptionsalluded to were two professional men, two clerks ,an insurance agent, and a shipbroker.Dr. Savill, in his report on the Warrington epidemicfor the Royal Commission, has pointed out that all buteleven of the 455 infected houses were rated at lessthan £ 16 per annum, and 406 of them at £8 or lower ;1 " Notes on the Small -pox Epidemic at Birkenhead in 1877 , " p. 16 .2 Final Report, Royal Commission on Vaccination , Appendix v. , p. 87.RESULTS OF SANITARY IMPROVEMENT. 247and Dr. Coupland found that at Dewsbury the incidenceof the disease with but few exceptions fell uponmembers of the working class community.On the other hand, it has been observed that inindustrial dwellings, where the poor are aggregatedunder strict sanitary supervision, there has been amarked immunity from small-pox. Thus Dr. SouthwoodSmith observed that " There has been in theimproved dwellings complete exemption from typhus,cholera, and it may be added small-pox ; yet it mustbe admitted, that other forms of zymotic diseasescarletfever, measles, whooping-cough, and diarrhoeahaveoccurred, though rarely, and these maladies havein no instance spread." 2 Dr. Collins and Mr. Pictonalso report that they learn from the secretary ofthe Improved Industrial Dwellings Company that in1880-82 there were but 2 deaths from small - poxamong more than 15,000 tenants, while there were3,268 small -pox deaths in those years in London witha population of 3,800,000.3In the Fifth Annual Report of the Registrar- General ,dated 1843 , will be found replies from MetropolitanRegistrars relative to the sanitary state of their districts.A number of these testify to the occurrenceof small -pox and other zymotic diseases in the poorestand most filthy parts of their districts, from which Ihave taken the following :-1 Final Report, Royal Commission on Vaccination, Appendix iii. , p. 28.2 " Results of Sanitary Improvement," p. 17. Southwood Smith, M.D.London. 1854 .3Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 231 .248 INFLUENCE OF SANITARY MEASURES.The Registrar of the north-east district of Chelsearemarked that the crowded buildings in his districtare more fatal to the first four classes of cases (smallpox,measles , scarlatina, and whooping -cough) than toany of the others (p. 486).The Registrar of the Hanover Square district ofSt. George, Hanover Square, reports (pp. 487, 488) thatthe districts which suffered most from contagious andepidemic diseases were Oxford Buildings, Brown Street,Hart Street, Toms Court, George Street, GrosvenorMarket, Grosvenor Mews, and Thomas Street. " TomsCourt," he says , " contains eight houses ; inhabitantsin a wretched state in many cases, partly from wantof employ, partly intemperance. Small-pox and epidemicshave raged here. "The Registrar of the Rectory division of Marylebonestated (p. 498) that the greatest number of deaths fromsmall -pox , measles , and scarlet fever occurred in YorkCourt and Calmell Buildings. He further stated thatYork Court , Calmell Buildings, and Gray's Buildingsappeared to be the unhealthiest portions of the district.He added that the drainage of York Court was bad,that of Calmell Buildings " good ; or rather middling ; "the inhabitants complained of the inefficiency of thewater supply, and the districts were anything butcleanly. According to the previous year's census, theinhabitants of one house ranged from fifteen to seventy,the greatest number known to sleep in one room beingeleven . He remarked that Calmell Buildings, which wasprincipally inhabited by the Irish poor, was a narrowcourt about twenty- two feet in breadth, and the houses,three storeys high, were surrounded and overtopped byINSANITARY CONDITIONS. 249the adjacent buildings ; the drainage was carried on bya common sewer running down the centre of the court,and the lower apartments, especially the kitchens, whichwere underground, were damp and badly ventilated,light and air being admitted through a grating on alevel with the court. At all times, but especially inwarm weather, most offensive effluvia were perceptibleeverywhere. According to the previous year's censusthere were 944 inhabitants, and the number of personsin one house varied from two to seventy (p. 499).The Registrar of the St. Mary division of Marylebonestated (p. 501 ) that " the few cases of small -pox whichoccur in my district are invariably amongst the poor,"but that the other zymotic diseases named were notconfined disproportionally to any parts or class ofinhabitants.The Registrar of the Gray's Inn Lane division ofSt. Pancras remarked that the small-pox, measles, andwhooping-cough had been most prevalent in certaindistricts, which included Battle Bridge, comprisingBritannia, George, Charlotte, Field, and ParadiseStreets, with many small courts and places leadingtherefrom. He stated that in the Battle Bridgedistrict' the condition was extremely bad, the streetsbeing unpaved and impassable, occasioned by quantitiesof rubbish and filth thrown thereon. The watersupply was generally very good, but drainage verybad in many places, and great want of cleanlinessuniversally.1 The district known as Battle Bridge formerly occupied the site onwhich King's Cross Station now stands.17250 INFLUENCE OF SANITARY MEASURES.He forwarded the accompanying statement, whichbears upon the subject under consideration (p. 506)." I beg to state," he says, " that I adopted the plan ofsearching all the register books from November , 1837 ,to the present time. I made columns, headed by thenames of the several diseases, and as they appeared inthe books, placed the names of the streets in whichdeaths occurred ; this plan gave me at once the meansof ascertaining amongst what particular classes theseveral diseases most prevail. I found between 50 and60 cases of small -pox, the whole of which, with twoexceptions only, are confined to the occupants of thelowest habitations ; between 15 and 20 cases of typhus ,occurring only amongst the lower classes ; 60 or 70cases of measles, in the proportion of about two to oneamongst the lower classes ; of whooping- cough between80 and 90, occurring in about the same proportion asthe measles ; of scarlatina between 70 and 80, whichappeared to prevail without regard to circumstances orplace; very few cases of diarrhea, dysentery, cholera,and influenza, and those not confined to any particularpart. The population of my district is 22,149. "In the St. Anne division of the Strand the Registrarobserves ( p. 523)-" Of small-pox in 1838 there werethirty - one cases ; in 1839, none ; in 1840, two ; in 1841 ,five ; and in 1842, eight. Of those in 1838, three werein Falconberg Court, three in St. Anne's Court, andfour in Crown Street. These are poor places , anddensely peopled ; in Falconberg Court and CrownStreet there are some Irish. The remaining cases aredispersed over the parish. "The report of the Registrar of the Goswell StreetSALUTARY EFFECT OF OPEN SPACES . 251division of Clerkenwell is of interest as illustrating theeffect on small -pox and other zymotic diseases of agood system of drainage, combined with abundant openspaces. The Registrar found that there had been noepidemic prevalent in his district since the commencementof registration (July 1 , 1837). This is the moreremarkable as the opening years of registration wereoccupied with one of the most disastrous small -poxepidemics of the present century. " The whole district,"he remarks, " with the exception of about a hundredhouses, has been built on since the year 1806 ; it isbounded on the south and west by spacious streets ;on the north and east by two great roads, and throughits centre runs the high road to Islington. It containsthree large squares, with the vast area occupied by theNew River- head. The whole district belongs to fourgreat proprietors, namely, the Marquis of Northampton ,the New River Company, the Brewers' Company, andthe Skinners' Company, who secured by their buildingleases as perfect a system of drainage as can probablybe found in any part of the Metropolis " (p . 527) .The Registrar of the north-west division of the Cityof London observed that at " Christ's Hospital (occupiedby eight hundred Blue-coat boys) there are not morethan one or two deaths in a year, the diet and hoursbeing regular, and the wards lofty and cleanly " (p. 542).The Registrar of the St. Leonard's division of Shoreditch,reported (p. 547)-" The whole of my districthas been particularly healthy during the last twelvemonths , except in the winter of 1840 and 1841 , whensmall -pox prevailed with great fatality in New Courtand Old Court, Hackney Road. They were the only252 INFLUENCE OF SANITARY MEASURES.unhealthy parts of my district, the small-pox havingbeen introduced into the place by travelling gypsiesand other vagrants occupying the huts in these courts :since which time they have been well cleansed andpurified by the parish authorities , and have sincebeen in a very healthy state, and are well suppliedwith water. "In the Church division of Bethnal Green the Registrarstated that the greatest number of deaths in theunhealthy parts of his district took place from smallpox, measles, scarlatina , whooping - cough, diarrhea ,influenza, and typhus ; these places were entirely withoutdrainage ; there was a great want of cleanliness,and with regard to the water supply there was butone hand-cock to many houses. He observes that inmany cases six persons occupied a room of ten feetsquare by eight feet high (p. 551 ).The Registrar of the Borough Road division of St.George, Southwark, observed that there was scarcely astreet or court in his district which had not been visitedby small -pox, measles , or whooping-cough. The supplyof water was plentiful, but drainage very deficient ;cleanliness little attended to by a great number, andthere was extreme overcrowding ( p. 580) .The Registrar of the Kennington district of Lambethstated that small-pox was most rife in WandsworthRoad, Spring Place, and the poor streets of SouthLambeth. The water supply was good, but drainagebad and the district dirty, and in winter frequentlyinundated. The neighbourhood was also thickly populated,from three to five persons sleeping in a room.In Hamilton Street in the Wandsworth Road was aINSANITARY CONDITIONS. 253filthy open ditch called the Corporation CommonSewer, which the Registrar considered to be veryunhealthy (pp. 586, 587) .The Report of the Registrar-General on the state ofthe public health in different parts of England andWales, during the year 1856, shows how the minds ofotherwise sensible people may overlook facts and beunconsciously warped by the vaccination dogma. TheRegistrar of Bury South ascribes the entire absence ofsmall-pox " to the attention paid to vaccination, " andthe freedom from other zymotic diseases " to the greatimprovement which has taken place in the last tenyears in the sewering, paving, and cleansing the streets ,and to the regulations under the Improvement Bill forcommon lodging- houses. " ¹In the Twentieth Annual Report of the Registrar-General, it is stated (p. xxiv.) that " the deplorableneglect of sanitary measures, and the extent to whichthe lives of the poor people of Dudley are sacrificed,may be inferred from this one appalling fact : ' smallpoxwas fatal in fifty- one cases. " The Twenty-secondReport (p. xxiv.) states that " In the South- Westerndivision, Wilts, Dorset, and Devon suffered an unusuallyhigh rate of mortality; scarlatina, diphtheria,and small - pox have proved fatal in many cases.' Sanitary arrangements are far from good in manyhouses,' not only of Abbotsbury, where three deathsoccurred in one house over drains in the worst possiblecondition, but it is to be feared in many other parts ofthese great counties."1 Nineteenth Annual Report of the Registrar- General, p. xxxiv.254 INFLUENCE OF SANITARY MEASURES.In 1864 the Registrar of the St. Helen's sub-districtof Prescot writes to the Registrar-General thus :-" The deaths exceed the average considerably. Themortality has been greatest among children in consequenceof the prevalence of scarlatina and small-pox.One hundred and twenty deaths occurred from scarlatina,and twenty- four from small-pox. Small-pox ismost prevalent in that part of the town noted for itsdefective sanitary arrangements, and inhabited principallyby the Irish. In this portion of St. Helen's, theevils arising from want of sewers, unpaved streets, smalland unhealthy dwellings, are still further increased bythe crowding of several families in one house, and anentire absence, apparently, of all ideas of cleanliness. " ¹In 1855 , or about two years after vaccination wasmade compulsory, we have the following notable wordsfrom Dr. Southwood Smith :-“ Overcrowding, for example,we can prevent; the accumulation of filth intowns and houses we can prevent ; the supply of light,air, and water, together with the several other appliancesincluded in the all-comprehensive word Cleanliness, wecan secure. To the extent to which it is in our powerto do this, it is in our power to prevent epidemics.The human family have now lived together in communitiesmore than six thousand years, yet they havenot learnt to make their habitations clean. At last weare beginning to learn the lesson. When we shall havemastered it , we shall have conquered epidemics. " ?1 Twenty- seventh Annual Report of the Registrar-General, p. Ixiv.2 Two Lectures delivered at Edinburgh in November, 1855 , entitled,"Epidemics considered with relation to their common nature, and toclimate and civilisation ," p. 23.HOW SMALL- POX IS PROPAGATED . 255In 1871 , during the great small-pox epidemic, severalimportant testimonies crop up in favour of the viewthat small-pox is controllable by sanitary measures.Mr. Henry Carr, in a letter to the Times of February 9 ,1871 , under the heading, " How small- pox is propagated," writes-" I pray your insertion of the followingreport of one visit of inspection among the habitationsof the poor in Westminster :-St. James's Court, St.Ann's Street. This is a blind court, no thoroughfareand no through ventilation ; the entrance a narrowarchway, three feet wide ; the houses, two rooms each,opposite ; the space between the opposite houses notmore than five feet; at the end of the court a dead wall,dust-heap, etc. No back windows or doors . Only onecloset for the whole court, and that at times in mostfoul condition. At present in this court there aresixteen families-sixty- five persons." Then follows aminute description of insanitary horrors, coupled withabounding small -pox as the natural result. From alater issue of the Times (February 15, 1871 , ) it appearedthat the authorities inspected St. James's Court,and that the whole court was condemned as unfit forhuman habitation .In the Lancet of January 14, 1871 ( vol. i. , p. 63 ), underthe heading of " Small-pox in Belfast," is the following:-" From a circular lately issued by the Poor-lawCommissioners of Ireland relative to the spread ofsmall -pox in Belfast, we find that seventy-nine caseshave occurred there, resulting in nine deaths, sinceMarch, 1870. The Commissioners point out to theGuardians of the Belfast Union that, when the diseasehad been imported into other parts of Ireland, it has256 INFLUENCE OF SANITARY MEASURES .either not spread or quickly died out, and that itsbreaking out into an epidemic at Belfast is probablyowing to two causes-namely, the dangerous sanitarycondition of parts of the town, and the very defectivestate of the vaccination ."In the same volume, under the date March 18, isan article by Dr. Grieve, medical superintendent tothe Hampstead Small -pox Hospital. In some concludingremarks Dr. Grieve observes (p. 372)-" Badas this epidemic when upon us may appear to be, letus hope that it will bear fruits of good results. Alreadyunder its pressure our sanitary reformers are on themove ; and the report of the Sanitary Commission justcomes in time. It is to be hoped that this epidemicof small -pox will be the last of its kind ; that it willprove to be, as it were, the boundary-stone placed tomark the place where the old rule of complete localself-management was replaced by that of a propercentralisation under a competent head ; and that thereign of confusion, in which Boards of Guardians,Vestries , Local Boards, and other intractable bodieshave to be coaxed and wheedled into doing theirduty, is fast drawing to an end. We look forwardwith pleasurable anticipation to that time when, underthe firm rule of a Minister of Public Health, sanitarymeasures will be judiciously and vigorously enforced ,and zymotic diseases-small-pox among the numberwillbe driven out of our island as effectively as St.Patrick banished reptiles from Ireland."Even from the writings of so pronounced a vaccinepropagandist as Mr. Ernest Hart is the following admissionregarding an epidemic of small-pox at Douglas,DR. FARR'S TESTIMONY.1257Isle of Man, in 1877 :-" The disease spread veryrapidly, especially in the filthy purlieus of the old town,until, between July 8, 1877, and March 11 , 1878, no lessthan 257 cases occurred." It is true that Mr. ErnestHart observes that there was no system of compulsoryvaccination in the Isle of Man, and thus a number ofthe sufferers may well have been among the unvaccinated,which only shows from what class theunvaccinated are usually drawn, and how absolutelyunfair it is to compare their small-pox incidence andmortality with that of the better fed, better housed, andmore cleanly vaccinated population .One of the greatest sanitary reformers, Dr. WilliamFarr, has said that " healthy sanitary condition as tofood, drink, and cleanliness of person, house, and city,stands first in importance ; after it, but surbordinately,come quarantine, vaccination, and other preventives, asmeans of subduing mortality ; for the mere exclusion ofone out of many diseases appears to be taken advantageof by those other diseases, just as the extirpationof one weed makes way for other kinds of weeds in afoul garden. " 2Another eminent sanitarian, Sir Edwin Chadwick,mantained " that cases of small-pox, of typhus, and ofothers of the ordinary epidemics, occur in the greatestproportion, on common conditions of foul air, fromstagnant putrefaction, from bad house drainage, fromsewers of deposit, from excrement-sodden sites, fromfilthy street surfaces, from impure water, and from overBritish Medical Journal, vol. ii. , p. 78. (July 17, 1880. )2 Supplement to the Thirty- fifth Annual Report of the Registrar -Generalp. xli. ( 1875. )258 INFLUENCE OF SANITARY MEASURES.crowding in foul houses. That the entire removal ofsuch conditions by complete sanitation and by improveddwellings is the effectual preventive of diseasesof those species, and of ordinary as well as extraordinaryepidemic visitations . " 1The two following statements, printed within aboutsix months of each other, if taken together, almostentirely concede the case. The British Medical Journalstated that " all sanitarians are agreed that insanitaryconditions greatly favour the spread of small - pox , " andDr. W. B. Carpenter admitted " that in the generalmitigation of the type of this disease (small -pox), andin the enormous reduction in its mortality which havetaken place during the last hundred years, the improvedsanitary condition of our population (evinced by areduction in the general death-rate) has had a largeshare. " 3Another authority, Dr. August Hirsch, maintainedthat " small-pox, as well as typhus, takes up its abodemost readily in those places where the noxious influencesdue to neglected hygiene make themselvesmost felt . " 4With reference to sanitation in Europe generally,the reader who is interested in the subject may with1 Printed copy of addresses on " Prevention of Epidemics," pp. 22, 23.Delivered by Mr. Edwin Chadwick, C. B. , at Brighton Health Congress ,December 14 , 1881 .* British Medical Journal, vol. ii . , p. 801. ( October 21 , 1882. )The Nineteenth Century, p. 527. (April , 1882. )4 " Handbook of Geographical and Historical Pathology," vol . i . , p. 481 ,by Dr. August Hirsch. Translation by Dr. Charles Creighton. London.1883.BERLIN PREVIOUS TO 1872 . 259advantage consult a work by Dr. T. M. Legge on the" Public Health in European Capitals. " ¹It is claimed by Dr. Edwardes, Dr. Charles Drysdale,and Mr. Ernest Hart, with endless reiteration, that thenotable reduction of small-pox in Germany during thelast two decades is due to vaccination and compulsoryre-vaccination. On page 38 Dr. Legge observes that,prior to 1872, the drainage in Berlin was of the mostprimitive description ; privies were in nearly everyhouse ; open drains, badly built, and with insufficientfall, ran through many of the streets , and dischargedtheir contents into the Spree, the pollution of whichbecame well-nigh intolerable. On page 10 he informsus that between 1871 and 1892 the Corporation ofBerlin spent on buildings connected with publichealth, including waterworks, drainage, sewage farms ,hospitals, asylums, abattoirs, disinfecting stations, nightshelter, infirmary, and public baths, nearly £9,500,000,or, on an average, about £450,000 a-year. This largeoutlay appears to have been judiciously expended, foron page 41 Dr. Legge says that, since the introductionof the drainage works, the total mortality has declinedfrom 32.9 per 1,000 in 1875 to 20.2 in 1892, and he alsopoints out the enormous reduction in the mortality fromtyphoid fever during the period under review.From the foregoing it is evident that neglect of sanitarymeasures is very largely responsible for the prevalenceand mortality of small-pox as well as of otherzymotic diseases. As the late Sir B. W. Richardson1 " Public Health in European Capitals." Thomas Morison Legge,Μ.Α. , Μ.Ι) . ( Oxon. ) , D.P.H. London. 1896 .260 INFLUENCE OF SANITARY MEASURES.most aptly puts it-" If by some magic spell , Englandcould wake up to- morrow clean, she would wake up purealso in spirit and godly in the comprehensiveness ofgoodness. Cleanliness covers the whole field of sanitarylabour. It is the beginning and the end. Practised inits entirety it would banish all disease from the world."Another cause of the lessened fatality of small -pox isthat better methods of treatment are now in vogue thanthose which prevailed formerly. Anyone reading thepages of Sydenham cannot fail to have been struckwith the distressing results of the treatment practised inhis time. This was known as the hot regimen. Thepatient was put to bed, the blankets were piled up overhim, every breath of fresh air and all light was carefullyexcluded from his room, and he was plied withhot cordials.This distinguished medical reformer protests againstthis treatment, and says-" We must take especial care,lest the ebullition rise too high. This it may do underthe weight of blankets, under the over-heated state of theair in the apartment of the patient, or under the use ofheating medicines and cordials."" " From the use ofyourvaunted cordials, and from your hot treatment," he says ," the pustules may be crowded together and renderedconfluent. " 2 Again he observes-" Had they (pustules)been left to their own pace they would merely havebeen discrete, and the chances would have been better. " 3" Medical Observations. " The Works of Thomas Sydenham, M.D.Translation from the Latin edition of Dr. Greenhill, with a life of theauthor, by R. G. Lathom, M.D. , vol. i. , p. 134. Printed for the SydenhamSociety . 1848 .Ibid. , p. 135 . Ibid. , p. 139.SYDENHAM'S TREATMENT OF SMALL- POX. 261In speaking of his own more rational method oftreatment :-" This is the true and genuine methodof treating this sort of small-pox, and however muchit may be opposed by the great and unfounded prejudiceof the partisans of an opposite practice, it is themethod which will prevail when I am dead. I willnot deny that many have been treated on a differentprinciple, and that under such treatment they haverecovered . On the other hand, it must be confessedthat many have died under it. And this, when we considerthat the disease of the distinct sort is in no wisedangerous of itself, is a sad reflection . " ¹Sydenham must have felt saddened at the prevailingignorance when he wrote " Considering thepractices that obtain, both amongst learned andignorant physicians, it had been happy for mankind,that either the art of physic had never been exercised,or the notion of malignity never stumbled upon. " *Sydenham was greatly in advance of his age,and consequently was subjected to the unmeasuredopprobrium of his contemporaries.1 " Medical Observations ,” vol. i. , p. 142. Printed for the SydenhamSociety. 1848 .Letter to Mr. Robert Boyle, vol. i., p. lxxii .3 Sydenham's writings are full of appeals to his colleagues to trust moreto Nature in the cure of disease . " Frequently, however, it is less fromthe character of the morbific virus than from the effects of unskilful treatmentthat such severity has occurred. We often attend too little to theintentions of Nature in the cure of disease, and set up on insufficientgrounds some different method of cure. From this arises a perturbationof the whole bodily economy, and, this being upset, a melancholy stateof things , worse than that of the original disease, is induced. " ( Vol. i. ,p. 98. )In referring to the pleasant sensations produced among his patients by3262 INFLUENCE OF SANITARY MEASURES." To crown my misfortunes," he observes, " it hassometimes happened that, after the standers-by hadrejected my advice throughout the whole disease, Ihave still been held answerable for the loss of thepatient ; and this has happened after I have talkedmyself hoarse against the heating treatment of thefriends and nurses. For reasons like this, I have oftenthought that it would be better for me never to undertakea case of small-pox, than to oppose the insuperableprejudices of the οι πόλλοι.”In spite of the teachings of Sydenham, these barbarousmethods of treatment continued to prevail, forin the eighteenth century we find much the same statethe cool regimen, he observes-" This has often made me draw a differencebetween the deceptions of reason (so-called) and the realities of oursenses ; from whence I infer that-provided that they be not absolutelyunreasonable, and deadly-much more than is usually given should beallowed to the appetites and sensations of the patients themselves. Theseare better than the treacherous rules of art. E.g. , a fever-patient ardentlylongs for cooling drinks freely bestowed. Art denies them. Art hasa theory of its own. Art has an end and aim of its own. Art assumesthat cool liquors are adverse to its doctrines : and so starves an appetite,giving a cordial instead. The same patient loathes all food , unless accompaniedby diluent drinks. Art - the art of nurses and lookers - oncontends that he must eat . After a long languor, he probably asks forsomething absurd , or prejudicial , and asks earnestly. Art is again in theway, and threatens death in case of disobedience-unless, indeed, theartist be wise enough to remember Hippocrates :-more bad than good,whether food or drink, if palatable, is preferable to more good than bad,ifunpalatable. A man of moderate medical practice, but ofdiligent observation, will freely own, that many patients who have spurnedphysic and followed their own inventions, have been the better for doingso." (Vol . ii . , pp. 67 , 68. )1 Letter to Dr. Cole. The Works of Thomas Sydenham, vol. ii ,p. 66.A PARALLEL. 263of things recorded. Buchan,' in his " Domestic Medicine,"remarks on the practice of confining the patienttoo soon to bed and plying him with warm cordials andsudorific medicines, thereby increasing the number ofpustules and tending to make them become confluent." The good women," he says, " as soon as they see thesmall -pox begin to appear, commonly ply their tendercharge with cordials, saffron, and marigold-teas, wine,punch, and even brandy itself. All these are given witha view, as they term it, to throw out the eruption fromthe heart. " Buchan also comments on the practice ofcrowding patients together, which reminds us of thedisgraceful state of things which prevailed at theGloucester Hospital in the recent epidemic. He says-" Laying several children who have the small-pox inthe same bed, has many ill consequences. They ought,if possible, never to be in the same chamber, as theperspiration, the heat, the smell, etc. , all tend to augmentthe fever, and to heighten the disease. It is commonamong the poor to see two or three children lying inthe same bed, with such a load of pustules that eventheir skins stick together. One can hardly view a sceneof this kind without being sickened by the sight. Buthow must the effluvia affect the poor patients, many ofwhom perish by this usage ? "In a foot - note he remarks " This observation is likewiseapplicable to hospitals, workhouses, etc. , wherenumbers of children happen to have the small-pox atthe same time. I have seen about forty children cooped1 " Domestic Medicine," pp. 241-244 . William Buchan, M.D. ( Tenthedition. ) London. 1788 .264 INFLUENCE OF SANITARY MEASURES.up in one apartment all the while they had this disease,without any of them being admitted to breathe the freshair. No one can be at a loss to see the impropriety ofsuch conduct. It ought to be a rule, not only in hospitalsfor the small-pox, but likewise for other diseases,that no patient should be within sight or hearing ofanother. This is a matter to which too little regard ispaid. In most hospitals and infirmaries, the sick, thedying, and the dead are often to be seen in the sameapartment. " On the other hand, Buchan had seen poorwomen travelling in the depth of winter, and carryingtheir children afflicted with small-pox along with them,and had frequently observed others begging by thewayside, with infants in their arms covered with thepustules ; yet, he says, " I could never learn that one ofthese children died by this sort of treatment." He alsoobserves-" A very dirty custom prevails amongst thelower class of people, of allowing children in the smallpoxto keep on the same linen during the whole periodof that loathsome disease. This is done lest they shouldcatch cold; but it has many ill consequences. The linenbecomes hard by the moisture which it absorbs, andfrets the tender skin. It likewise occasions a bad smell,which is very pernicious both to the patient and thoseabout him ; besides, the filth and sordes which adhere tothe linen being resorbed, or taken up again into thebody, greatly augment the disease. "Writing in the early part of the present century, Mr.John Cross, in his history of the Norwich small-pox11 " A History of the Variolous Epidemic which occurred in Norwich inthe year 1819," pp. 11 , 12. London. 1820.THE EFFECTS OF FRESH AIR. 265epidemic, stated that the disease was often aggravatedand made to assume its worst characters by the mostinjudicious treatment. This was as follows :-" At thecommencement, to set the object before a large fire,and supply it plentifully with saffron and brandy tobring out the eruption ; during the whole of the nextstage, to keep it in bed covered with flannel, and even thebed-curtains pinned together to prevent a breath of air ;to allow no change of linen for ten or more days, untilthe eruption had turned ; and to regard the best symptomto be a costive state of the bowels during the wholecourse of the disease."The effect of fresh air-which the current practiceexcluded in the treatment of small -pox is illustratedby the following singular incident. In 1731 a fire tookplace in Blandford, in Dorset. This was so violent andrapid that few had time to save much, and many couldsave nothing. " The calamity," we are informed, " washeightened by the small-pox raging in about sixtyfamilies ; none of the sick perished in the flames, butwere removed under hedges in the fields, gardens , andunder the arches of the bridge, and but one died ;-astrong argument for the cool regimen ." ¹I should here like to quote the words of a lady whohas probably done as much for the mitigation of diseaseand human suffering as any person now living. I referto Miss Florence Nightingale, and the axiom I wishto impress is contained in the following notable words :-" The very first canon of nursing, the first and the last1 " The History and Antiquities of the County of Dorset," vol. i. , p. 76 .John Hutchins , M.A. London. 1774 .18266 INFLUENCE OF SANITARY MEASURES.thing upon which a nurse's attention must be fixed, thefirst essential to the patient, without which all the restyou can do for him is as nothing, with which I hadalmost said you may leave all the rest alone, is this : tokeep the air he breathes as pure as the external air, withoutchilling him."There cannot be the shadow of a doubt that the displacementof the obsolete and deadly methods describedby Sydenham and others, by the fresh air and judiciousnursing which accompany the modern treatment ofsmall-pox, and in which Miss Florence Nightingale wassuch a distinguished pioneer, has had a potent influenceon its mitigation in recent years, although for someoccult reason, vaccination (which, by the way, has beensensibly diminishing) has managed to obtain all thecredit.One word with reference to the blindness producedby small-pox. We have always been taught to believe,and statistics are ingeniously arranged to show, that thediminution has been brought about by vaccination.Apparently this is not so. One of the greatest authoritieson small -pox informs us-"As to corneal ulceration,this affection is probably not a part of small -pox, but isaccidentally associated with it. It occurs late in thedisease, both in the vaccinated and the unvaccinated, theprevention of permanent eye mischief resulting morefrom altered methods of treatment, improved nursing,and hospital hygiene than from vaccination. " 21 " Notes on Nursing," p. 8. Florence Nightingale. London. 1876.2 Dr. Birdwood's Evidence. Sixth Report, Royal Commission on Vaccination.Q. 31,146.CHAPTER IX.THE INJURIOUS RESULTS OF VACCINATION.VACCINATION has been advocated and its enforcementrecommended not only as an absolute protection againstsmall-pox, but as a safe and even benign operation, andattended with no more danger than " the scratch of apin," or, as a well - known authority would have usbelieve, " it is not more harmful than piercing the earsto place rings in them. " ¹In his petition to the House of Commons ( 1802),Jenner claimed that cow- pox " admits of being inoculatedon the human frame with the most perfect easeand safety, and is attended with the singularly beneficialeffect of rendering through life the persons so inoculatedperfectly secure from the infection of the small -pox. " 2In the Report of Small-pox and Vaccination 3 preparedby the Committee of the Epidemiological Society,the Report, it may be added, on which the first compulsoryAct of Parliament was based, it is stated(p. 4)-" We are ourselves satisfied, and it is the concurrentand unanimous testimony of nearly two thousand1 " A Manual of Animal Vaccination," p. 153. E. Worlomont. Translationby Dr. Harries. London. 1885 .2 Baron's " Life of Jenner," vol . i . , p. 490.* Parliamentary Paper 434. ( Ordered by the House of Commons to teprinted, 3rd May, 1853. )268INJURIOUS RESULTS OF VACCINATION .medical men, with whom, as we have already stated, wehave been in correspondence, that vaccination is aperfectly safe and efficient prophylactic against thisdisease."Sir John Simon has identified himself with thisposition when he says that against the " vast gain " byvaccination " there is no loss to count. Of the variousalleged drawbacks to such great advantages the presentstate of medical knowledge recognises no single trace. " 1Again, he says-" I must say that I believe it to beutterly impossible, except under circumstances of grossand punishable misconduct, for any other infection thanthat of cow-pox to be communicated in what pretendsto be the performance of vaccination . " 2 Elsewhere, SirJohn candidly gives it as his opinion that, " If Governmentcould not reasonably guarantee that it gave purevaccine lymph, it should not force the public to accept it." 3Now, if it can be shown that there is no such thingknown or obtainable as pure lymph, setting on one sidethe question of its supposed protective value, compulsoryvaccination is totally unjustifiable.Let us see what precautions the Government take tosecure the purity of lymph. Mr. Farn, of the NationalVaccine Establishment, when under examination beforethe Royal Commission, furnished some interestingdetails, as follows :-Q. 4,130. You are not a medical man, are you ?-No.1 " Papers relating to the History and Practice of Vaccination, " p. lxvii.1857.* Ibid. , p. Ixiii.* Report from the Select Committee on the Vaccination Act ( 1867) .Q. 3,458 . 1871 .SOME DAMAGING ADMISSIONS. 269Q. 4,133. Have you made any special study ofmicrobes ? No.Q.4,154. With such (microscopic) power as you are ableto employ would you be able to recogniseor distinguish any micro-organisms whichmight be present ?-No, I should not.Q. 4,155. Have any micro-organisms been identified ,or stated to have been identified, for sucha disease as erysipelas and so on ?-I amafraid you are going rather out of mydepth as a non-medical man.Q. 4,159. Is there any disease within your experiencewhose cause you can identify with suchmicroscopical power as you employ ?Not that I am aware of.Q. 4,173. Having regard to what you have told us, doyou think it would be possible, from themicroscopical examination you made, toguarantee that any lymph was pure ?-No ; I should not undertake to say whetherit would be a guarantee that the lymphwas pure. I do not know that you coulddo it.Q. 4,200. Are we to understand that, as a matter of fact,you have ever guaranteed lymph ?-No.It seems , therefore, that there is no such thing knownor obtainable as pure vaccine lymph, and it is verysignificant that as long ago as 1883 the Grocers'Company, by reason of the numerous disasters followingvaccination, offered a prize of £1,000 for the discoveryof any vaccine contagium cultivated apart from an270 INJURIOUS RESULTS OF VACCINATION .animal body, but up to the present time the award hasnot been made. The matter has, however, been settledbeyond all dispute by the Royal Commission itself. Theysay:-" It is established that lymph contains organisms ,and may contain those which under certain circumstanceswould be productive of erysipelas " (section 410).With regard to the dangers attending vaccination ,in the official tract, entitled, " Facts concerning Vaccinationfor Heads of Families," is the following (p. 3) :-"Asto the alleged injury from vaccination, all competentauthorities are agreed that, with due care in the performanceof the operation, no risk of any injurious effectsfrom it need be feared."That vaccination produces injurious results of adefinite kind can be shown from a very early periodin the history of vaccination. The disease cow -poxitself, as Dr. Edward Ballard has pointed out, is onethat is not to be " trifled " with. In describing thecomplaint in milkers, Jenner says :-" The systembecomes affected-the pulse is quickened ; and shiverings,with general lassitude and pains about the loinsand limbs, with vomiting, come on. The head ispainful, and the patient is now and then even affectedwith delirium. These symptoms, varying in theirdegrees of violence, generally continue from one day tothree or four, leaving ulcerated sores about the hands,which, from the sensibility of the parts, are very troublesome,and commonly heal slowly, frequently becomingphagedenic, like those from whence they sprung. " ¹ And,1 " An Inquiry into the Causes and Effects of the Variola Vaccina,"p. 5. London. 1798 .IMPLANTING THE SEEDS OF A DISEASE. 271in referring to the case of Sarah Wynne, he remarks :-" She caught the complaint from the cows, and wasaffected with it (cow-pox) in so violent a degree thatshe was incapable of doing any work for the spaceof ten days. " 1Again, in the case of Thomas Edinburgh, describedby Dr. Pearson :-" He was so lame from the eruptionon the palm of the hands as to leave his employ, inorder to be for some time in a public hospital.According to the patient's description, the disease wasuncommonly painful and of long continuance. " 2That vaccination is, indeed, a serious matter has beenfully recognised by the late Dr. Ballard, one of HerMajesty's Inspectors of Vaccination. " Medical menand parents alike should drive from their minds theidea so prevalent, that vaccination is but a trivialoperation at the most. They should keep inmind that in the act of vaccination they are not merelyimparting a protection, not merely performing a sort ofmagic rite, but that they are engaged, in very truth,in implanting the seeds of a disease." The resultshave been described by the Royal Commission asfollows :-" The introduction into the system of evena mild virus, however carefully performed, is necessarilyattended by the production of local inflammation and1 Taken from Jenner's original paper, which was forwarded to theCouncil of the Royal Society, and afterwards returned to him. SeeCrookshank's " History and Pathology of Vaccination," vol . i. , p. 275 .2 " An Inquiry concerning the History of the Cow- pox," p. 15. London.1798.3 " On Vaccination : Its Value and Alleged Dangers," p. 362. A PrizeEssay. London. 1868.272 INJURIOUS results OF VACCINATION.of febrile illness " (section 409) . Elsewhere in theReport the Commissioners affirm that " it is not opento doubt that there have been cases in which injury anddeath have resulted from vaccination " (section 399),and that the admission that some risk attaches to theoperation is one " which must without hesitation bemade " ( section 379).InSir James Paget wrote in 1863 :-" The progress of thevaccine or variolous infection of the blood shows usthat a permanent morbid condition of that fluid is establishedby the action of these specific poisons uponit. And although this condition may, so far at leastas it protects the individual from any further attackof the same disease, be regarded as exercising abeneficial influence upon the economy, yet it is notthe less to be looked upon as a morbid state.forming an estimate of the persistent changes producedin the blood by these and similar infectiousdiseases, we must not lose sight of the influencewhich the tissues, themselves altered by the inoculation,exercise upon the blood. They will necessarilyre-act upon it, so as to assist materially in preservinga permanent morbid, though beneficial condition. " 1It is not altogether clear how a permanent morbid conditionof this vital fluid can be beneficial to the animaleconomy, but it is worthy of notice that one of ourgreatest living English surgeons has put it on recordthat the principle of inoculation involves an unhealthyas distinguished from a healthy state of the system .1 " Lectures on Surgical Pathology," pp. 39, 40, foot-note. JamesPaget , F.R.S. London. 1863 .SYMPTOMS ACCOMPANYING VACCINATION . 273،،The general symptoms accompanying vaccinationhave been given in some detail by Dr. Acland in hisvaluable contribution on vaccinal injuries to Allbutt'sSystem of Medicine." Dr. Acland says :-" These arecommonly unimportant ; sometimes a slight rise oftemperature is noted about the third day after inoculation; this may be followed by remissions, and thepyrexia, if any occur, reaches its maximum generallybefore the eighth day. These slight disturbancesare often the only evidence of a general diffusionof the virus, although eruptions such as erythema,roseola, or urticaria, may accompany even the mildestand most favourable cases of vaccination. Theserashes, which may develop early in children who areunusually susceptible to the vaccine virus, may occurwithin four or five days of inoculation , or they maydevelop during the period of maturity and subsidenceof the pocks ; they have no special significance, and,as a rule, are not harmful except in SO far asthey produce irritation and consequent restlessness.Amongst the more usual complications which occur ator about the period of the full development of the pocksare those which are common in all the acute exanthems :they consist in headache (in adults and in elder children),lassitude, irritability, sleeplessness, disturbances of thedigestive system-such as anorexia, vomiting, catarrhaldiarrhoea; and possibly, during the onset of the vaccinalfever, rigors may occur in adults and in the re-vaccinated,and convulsions in children . In relation to these indicationsof a general infection, in some instances there willbe evidence of a corresponding disturbance of the circulatoryor respiratory apparatus, as shown by increased274 INJURIOUS results OF VACCINATION .rapidity of pulse and respiration, bronchial catarrh, orslight temporary albuminuria. " ¹I wish especially to draw attention to the possibilityof convulsions in children supervening on vaccination, towhich Dr. Acland has alluded; and though it is difficultto prove in all cases that this condition is the directresult of vaccination, the occurrence, and that not unfrequentlyafter vaccination, has led to a belief that theyare often in some way related to the operation. (Seefatal cases in Appendix ix. to Final Report of the RoyalCommission, more especially Nos. vi. , lv. , cii. , clviii. , clxx. ,45, 119, 123 , E.G. (p. 334), 216, and 223.)Another result of ordinary vaccination is enlargementof glands, sometimes giving rise to an abscess in thearmpit. According to Dr. Louis Frank, " Adenitis isquite a common complication of an otherwise normalcourse of vaccination, and needs but a passing mention."2 As this condition appears to be of such frequentoccurrence, one would like to feel a little more certainthat scrofulous affections do not sometimes arise in thisway, as they are admitted to do in connection withglandular enlargement associated with other diseases,such as measles.Although it appears to be thought by many that injuriousresults from vaccination are only of comparativelymodern occurrence, a study of the older writings on vaccinationproves that this is very far from being the case.In the year 1800 some cases of injury with oneAllbutt's " System of Medicine," vol. ii . , pp. 562, 563. London. 1897 .Journal of Cutaneous and Genito- Urinary Diseases, vol. xiii . , p. 144.(New York , April , 1895. )THE CLAPHAM CASES. 275death were reported as having taken place in ThunderboltAlley, Clapham.¹ According to the narrative, theparents of some of the children were " much prejudiced ,full of invective, and refused to converse reasonably."In a report signed by certain medical men, the symptomsproduced were extensive erysipelas rapidly spreadingfrom the inoculated parts, accompanied in manyinstances by considerable constitutional disturbance,and followed in most cases by an immediate ulcerativeprocess, and in some cases even a tendency to gangrene.Then, as now, vaccination had its apologists. On thisoccasion Dr. Lettsom , a leading London physician ,undertook the office. " The disease," he said , “ wasnot the cow-pock, but morbid ulceration, originatingfrom the purulent matter formed under the scab ordried pustule of the cow- pock. "Mr. B. Maddock, of Nottingham, in bringing forwardcases of injury, wrote that he would be sorry to exciteprejudices against the introduction of vaccinationas a substitute for small-pox inoculation, but hehad to lament that its advantages were somewhatoverrated when it was said, on respectable authority,that it was a disease free from danger. " It is a greatmisfortune," he said, " that proselytes to new systems donot always carefully examine into opinions handed downfrom high authority, but give them implicit credit ; andit is equally unfortunate, that, in the recommendation ofany new doctrine, the unfavourable symptoms are too1 London Medical Review and Magazine, vol . v. , pp. 276-289.(January, 1801. )* Medical and PhysicalJournal, vol . v. , p. 161. ( February, 1801. )276 INJURIOUS RESULTS OF VACCINATION.frequently placed in the background, and only the morepleasing ones exposed to public view. "In November, 1805, the editors of the Medical andChirurgical Review, in referring to the cases of injuryrecorded in the minutes of the Vaccine-pock Institution,observe :-" This case, with others to be found in thesereports , serves to show that constitutional affectionmakes an essential part of the vaccina as well as ofvariolous inoculation ; it proves also that the disorderis occasionally severe, contrary to what some haveasserted."Dr. Robert Willan, a supporter of vaccination, in anearly work on the subject, also noticed that the resultsof the new inoculation were occasionally severe. Hewrites :-" There may also be a few in which theinoculation excites a new mode of action, terminatingin erysipelas , phagedenic ulcer, or other morbid appearancesnot necessarily connected with the specific disease.Several of these anomalies or exceptions to the generalrule have occurred, but certainly not so often as wasexpected by those who considered the subject, from thefirst , dispassionately, nor have they been in sufficientnumber to form any serious objection to the practicefounded on Dr. Jenner's discovery." 2On December, 15 , 1806, the Royal College of Surgeons³Medical and Chirurgical Review, vol. xii . , p. lxxvii . , foot- note.2 " On Vaccine Inoculation," pp. 20, 21. Robert Willan, M.D.London. 1806 .3 Report of the Royal College of Physicians of London on Vaccination ,with an Appendix, containing the opinions of the Royal Colleges ofPhysicians of Edinburgh and Dublin, and of the Royal Colleges ofSurgeons of London, of Dublin , and of Edinburgh, pp. 10, 11. ( Orderedto be printed , 8th July, 1807. )THE COLLEGE OF SURGEONS' REPORT. 277addressed a letter to their members on the subject ofvaccination, among other questions asking them for thenumber of vaccinations they had performed, and forinformation about any injurious results in their practice.The replies, when summarised, showed that out of164,381 vaccinated there were 66 cases of skin eruptionsand 24 cases of inflammation of the arm, of which 3proved fatal. The College reported that in theMetropolis vaccination was on the decrease, and theyassigned the following reasons :-(1 ) Imperfect vaccination .(2) Instances of small- pox after vaccination.(3) Supposed bad consequences.(4) Publications against the practice.(5) Popular prejudices.Sir John Simon, in his classic " Papers relating to theHistory and Practice of Vaccination," while printingthe College of Physicians' report, which was stronglyfavourable to vaccination, omitted any reference to theappendix containing the report of the Royal College ofSurgeons.In 1808 Dr. Richard Reece wrote " Even if thecow -pox did afford a certain security against small -poxinfection, as Dr. Jenner has represented it, it wouldstill remain a question whether the human race wouldreally be benefited by its universal adoption, since thecutaneous eruptions that have followed have in manyinstances proved more fulsome than even small -poxitself. That those eruptions do occur after cow infectionmust be allowed by its most strenuous advocates ,being perfectly novel, of a nature unknown before the278 INJURIOUS RESULTS OF VACCINATION.introduction of vaccination, and peculiar to those whohave been vaccinated, and often so inveterate as morethan to counterbalance the trivial advantages that wewere first led to expect from its introduction. " Again,he says " It must be allowed that the local inflammationexcited by the inoculation with this matter, is ofa very unfavourable nature, and often ends in a deepsloughing, frequently producing such an adhesion of themuscles of the arm, as very much to confine its motions ;and some instances have occurred of the mortificationspreading, so as to destroy the life of the child ; aninstance of which happened in St. George's Fields.The child was inoculated at the Cow-pox Institution,Salisbury Square, Fleet Street ; the inflammation of thearm exceeded its usual boundary ; on the sixth daymortification ensued, which proved fatal to the child." ¹In the Medical Observer for September, 1810, Dr.Charles Maclean gives a list of sixty cases of vaccinalinjuries , with the names and addresses of ten medicalmen, including two professors of anatomy, whosefamilies had suffered from vaccination. In the LondonMedical Gazette for December 21 , 1833 , Mr. CharlesFluder reported that " five children were recentlyvaccinated from the arm of a healthy child, whichhad been vaccinated about a week previously. Eachof these children became the subject of much constitutionaldisturbance almost immediately ; their armswere enormously swollen and ædematous ; one childhad convulsions ; in two of them abscesses formed ;1 See Article on " Cow-pox," in " A Practical Dictionary of DomesticMedicine." Richard Reece, M.D. London. 1808.* Medical Observer, vol . viii . , pp. 195-197 ." THE LANCET " IN 1854. 279• and in all there was an alarming degree of febrileexcitement. " 1The Lancet for July 15, 1854 (vol. ii. , p. 35 ), remarksin a leading article :-" There is a belief-it may bedenounced as a prejudice, but it is not the less a deeplyrootedconviction, and one not confined to the poor or theignorant-that if the vaccine disease may be transmittedby inoculation, other diseases less beneficial may be propagatedin the same manner, and by the same operation .Many a parent of high and low degree dates constitutionaldisease in her offspring to vaccination with ' badmatter. ' Who shall say that this etiological conclusionis always false ? " In the number for October 28, 1854(vol. ii. , p, 360), it is stated :-" The poor are told thatthey must carry their children to be vaccinated bymedical men who may be strangers to them. Theyapprehend-and the apprehension is not altogetherunfounded, or unshared by the educated classes-thatthe vaccine matter employed may carry with it the seedsof other diseases not less loathsome than the one it isintended to prevent. " On November 11 , 1854 (vol. ii. ,p. 404), it says :-" So widely extended is the dread,that along with the prophylactic remedy somethingelse may be inoculated, lest the germ of future diseasesmay be planted, that few medical practitioners wouldcare to vaccinate their own children from a source ofthe purity of which they were not well assured. "In 1869 Dr. Felix von Niemeyer writes :-" It cannotbe denied that it (vaccination) sometimes endangers life ,and in other cases leaves permanent impairment of1 London Medical Gazette, vol. xiii. , pp. 440, 441 .280INJURIOUS RESULTS OF VACCINATION .health , especially cutaneous eruptions, and other scrofulousaffections . " 1In 1880 Dr. Benjamin Bell writes as follows :-" Everyman," he says, " who has seen much of the kind ofpersons who apply to dispensaries and vaccine institutionsmust have an impression, perhaps indefinite, butstill reasonable, that hereditary disease may be communicatedby the channel of vaccination. Children arebrought very properly to such institutions, manifestingdistinct indications of syphilitic and scrofulous disease.Are these indications always recognised ? And is lymphnever taken from the arms of such children ? My ownbelief is, that many mothers speak correctly when theytell us that their child was poisoned when it took thecow-pox. I have seen such cases, and their existencecannot be doubted since the publication of Mr. JonathanHutchinson's valuable series of cases. " ?In 1880 a Select Committee of the LegislativeAssembly of the Colony of Victoria was appointed toinquire into the subject of vaccination. After recordingthe " conflicting and contradictory " testimonies ofmedical men examined by them with regard to lengthof time vaccination protects, the requisite number ofmarks, etc. , the Committee came to the conclusion that" Greater unanimity prevailed on the question of thecommunication of extraneous diseases, such as syphilisand scrofula, by vaccination ; although some of the1 Dr. Felix von Niemeyer's " Text- Book of Practical Medicine," vol . ii. ,p. 557. Translation by George H. Humphreys, M.D. , and Charles E.Hackley, M.D. New York. 1869.2* Edinburgh Medical Journal, vol . xxv. , p. 976. (May, 1880. )VACCINATION OF YOUNG INFANTS. 281witnesses maintained that there would be no liability tosuch transmission unless blood were drawn during theoperation . Dr. Beaney and Dr. Sparling, however,mentioned instances that came under their observation ,of syphilis and erysipelas being communicated tochildren from purely colourless vaccine matter whichcontained no trace of blood. " 1That the disease-cow-pox in itself is sufficient tocause death to a weakly child, is shown by the fatalitydue to calf lymph recorded by Dr. Farrar, in the BritishMedical Journal of October 13, 1894 (vol. ii . , p. 807).After describing the case, Dr. Farrar says :-" I considerher death to have been due to a constitutional malaise,induced by vaccinia in a poorly nourished child. " Dr.Farrar very rightly publishes the case as a warning tovaccinators to avoid vaccinating weakly children ; and ifit be dangerous to vaccinate weakly children, it is surelyso in the case of the newly- born ; and yet this objectionablepractice is in vogue in workhouses, and moreover,it is encouraged by the Local Government Board ,as will be seen from the following letter." Local Government Board, Whitehall, S.W.," 27th January, 1881 ." Sir, I am directed by the Local Government Board to statethat their attention has been called, in connection with the stateof vaccination and the present prevalence of small-pox in theMetropolis, to the large proportion of children who, having beenborn in workhouses, are discharged with their mothers before1 Report from the Select Committee upon Vaccination Law, togetherwith the Proceedings of the Committee, Minutes of Evidence, and Appen.dices . ( Ordered by the Legislative Assembly to be printed, 24th March ,1881. )19282 INJURIOUS RESULTS OF VACCINATION.being vaccinated, and many of whom escape vaccination altogetherbecause the vaccination officer has no means of tracing them ." 1. The Board are desirous of being informed, as regards theseveral workhouses and poor law infirmaries in the Metropolis,how many children were born in each during the year 1880, andhow many of those so born were discharged before being vaccinatedor before the vaccination has been ascertained to be successful,and I am to request that you will have the goodness to furnishthe Board with this information as respects any such poor lawestablishments under the control of the Guardians ."2. I am at the same time to state that some Boards ofGuardians have passed a resolution requiring the medical officer,subject to the exercise of his judgment as to making exception inparticular cases, to secure the vaccination of all children born inthe workhouse as soon as possible after birth, and it has beenfound practicable as a rule to vaccinate the children when sixdays old, and to inspect the results on the thirteenth day, as themothers in such cases rarely leave the workhouse within a fortnightafter their confinement. The Board would be glad to learn whetherthe Guardians have directed the adoption ofthis practice." 3. The Board also request that they may be informed whethera specific fee is paid to the medical officer of each workhouse orinfirmary for every vaccination or re-vaccination successfully performedby him." I am, Sir,"Your obedient Servant,"JOHN LAMBERT, Secretary."The following is a case in point. At an inquestheld on December 8, 1882, on the body of Lilian AdaWilliams, born in St. Pancras Workhouse, and vaccinatedon the seventh day after birth, the jury found " thatthe death was caused by suppurating meningitis , followingulceration of vaccine vesicles on the arm, and theywere of opinion from the results of the post-mortemexamination that the vaccination of the child oughtto have been postponed."VACCINATION OF YOUNG INFANTS. 283mous.""Such instances are by no means rare, as disclosedin Appendix ix. to Final Report of the Royal Commission,one of the most flagrant cases there reportedbeing a fatal one of pyæmia in a puny and probablysyphilitic seven months child weighing 4lbs. 2ozs., andvaccinated when less than two days after birth. (No. cxxi. )With regard to the most suitable age for vaccination ,the profession does not appear to be altogether unani-The following from one of the leading authoritiesof the last century, with reference to the best age forinoculation , may possibly be of interest in guiding usat the present day. Dr. Percival, in citing argumentsagainst the inoculation of children in early infancy,remarked that " Nature, weak and feeble as she then is,can scarcely struggle with the diseases to which sheis ordinarily exposed ; it is therefore equally cruel andunjust, to add to the number with which she is alreadyoppressed. " 1 It is also interesting to notice that ina communication from the Government of Norwayappended to Sir John Simon's " Papers, " it is stated :-" Experience has taught us that in the great majorityof cases vaccination may be performed without dangerin the earliest infancy ; but the experience of theCommittee, as well as that of several other medicalmen, has also shown, on many occasions, that infants,after vaccination, do not unfrequently become sicklyin various ways. As it hardly ever happens that thefirst case of epidemic small- pox occurs in a child, the"Article on the Arguments against the Inoculation of Children inEarly Infancy," by Thomas Percival, M.D. , F. R. S. Gentleman'sMagazine, vol. xxxviii. , p. 162. (London, 1768. )284 INJURIOUS RESULTS OF VACCINATION.Committee (particularly on account of the difficultyof control), in their proposal for a new law on vaccination,have not hesitated to recommend deferring ituntil school-time begins . " 1The Vaccination Commissioners are not quite soaccommodating, but their recommendations are in thesame direction, and it is certainly rather significantthat after forty- two years with a compulsory age- limitof three months the Commission recommend extendingthe time to six months. The reasons they give areunassailable. " Looking at the circumstance that thetenure of life in children of a very early age is frail,and that where a disease supervenes upon vaccinationthe ability to battle against it may determine whetherthe result is fatal or not, or to what degree injurious ,we should à priori think that the chances of death orinjury from such a cause would be less, looking atthe matter as a whole, when the age of the child wasmore advanced. " (Section 438.) And they further thinkthat, provided the children coming within the range ofthe present compulsory law could be vaccinated on theoccasion of the introduction of small-pox into the district,the " age might be advantageously extended to oneyear from the date of birth, and that the number of casesin which death was, whether correctly or not, attributed tovaccination would then much diminish. " (Section 440.)Vaccine Généralisée.This name has been given to a widely- spread eruptionof vaccine vesicles on different parts of the body, the" Papers relating to the History and Practice of Vaccination,"Appendix, p. 187. 1857 .VACCINE GENERALISEE. 285lesions being identical in character with the typicalvesicle, and containing an inoculable fluid. Some ofthese are doubtless cases of auto- inoculation from theoriginal sore, but the remainder are examples of true,specific generalised cow-pox eruption. A case is relatedby Dr. Martin, of Boston, in the Medical Record¹ ofApril 15, 1882, where there were four hundred clearlydefined, perfectly circular, invariably umbilicatedvesicles. According to Dr. Prince A. Morrow, numerousexamples of generalised eruption have been recordedby experienced vaccinators, and we also have it on hisauthority that " French vaccination literature, especially,abounds in cases of this character." 2In this country, apparently, the complication is not socommon, but a few cases are given in Appendix ix. toFinal Report of the Royal Commission. (See Nos. li. ,clxii. , cxciv. , 109, 173, and 214.) Anyone wishing to seehow serious this disease may really be will do well toconsult the coloured drawings of the fatal case figured byDr. Acland in the " Transactions of the Clinical Society. "(No. 214 of Vaccination Commission Cases. )Skin Diseases.Of the various diseases alleged to be induced byvaccination, skin disease takes an important place.How common is the mother's remark that the childnever had a blemish until it was vaccinated ! And,1 Medical Record, vol . xxi . , p. 393. ( New York. )Journal of Cutaneous and Venereal Diseases, vol. i. , p. 173. (NewYork, March, 1883. )3 " Transactions of the Clinical Society," vol. xxvi. p. 114. London. 1893.286 INJURIOUS RESULTS OF VACCINATION.according to Dr. Robert Lee,¹ it appears that there issome foundation for the allegation. He found froman experience of three thousand cases of skin diseasetreated at Great Ormond Street Hospital, that in threehundred, or 10 per cent. , the mothers attributed therash to vaccination, and Dr. Lee thought that we werenot justified in pooh-poohing the notion ; and therecan be but very little doubt that Dr. Lee is correct in hissurmise, and for this reason, viz. , that a secondary rash,as in syphilis, is not unfrequently part and parcel of thedisease cow-pox. Mr. Robert Ceely, in describing thecasual disease in milkers, says :-" Papular, vesicular, andbulbous eruptions, are occasionally seen attendant oncasual cow -pox, especially in young persons of sanguinetemperament or florid complexion, at the height orafter the decline of the disease. They are generally ofthe same character as those known to attend the inoculateddisease. " 2 Again, in writing about the inoculateddisease when primary lymph is used " about thisstage of the areola, especially on children, small supernumeraryvaccine vesicles in miniature often appearwithin its limits, sometimes on the shoulder, and stillmore rarely on the face and body. The well-knownpapular, vesicular, and bulbous eruptions, occurring insuch subjects are frequently observed. "-With regard to cutaneous affections, the VaccinationCommissioners say (section 418)-" It is to be freelyadmitted that vaccinia, like varicella, does occasionally1 Sixth Report , Royal Commission on Vaccination, pp. 564, 565." Transactions of the Provincial Medical and Surgical Association,"vol . viii . , p. 337. 1840.Ibid. , p. 346.SKIN ERUPTIONS. 287cause an irritable condition of the skin, which may lastlong."The complication of skin disease, and that not unfrequently,was noticed very early in the history ofvaccination. Thus, Mr. Thomas Wainwright, in theMedical and Physical Journal for November, 1805 (vol.xiv. , p. 435), in reviewing a vaccination experience ofthree thousand cases, observes that " Various kinds ofobstinate cutaneous eruptions are not unfrequently consequentto the vaccination of young children ; but theyvery rarely take place in those who have the cow-pockat the age of ten years or at any later period. " Wealso have it on the authority of Dr. Robert Willan that" during the progress of the vesicle some disorder takesplace in the constitution, and there is frequently on thearms and back a papulous eruption resembling someforms of the lichen and strophulus. " 'Mr. Ross in a paper read before the Medical Societyof London, on February 7, 1857, drew the attention ofthe profession to the occurrence of secondary eruptionsfollowing vaccination. These generally appear afterthe eighth day. " No experience," Mr. Ross concludes,66on this matter can be worth much that is limited to anobservation of the pock on the eighth day, as is theordinary practice in public institutions. Hence I donot regard as of any weight the objections of thosegentlemen who, with such an experience, have denied" On Vaccine Inoculation," p. 10. Robert Willan, M.D. , London.1806.2 See also remarks by Dr. Hugh Thomson at the Birmingham meetingof the British Medical Association. British Medical Journal, vol. ii. ,p. 1231. (November 29, 1890. )288 INJURIOUS RESULTS OF VACCINATION .the existence of a special secondary eruption. BeingPublic Vaccinator for an extensive district, I vaccinatea considerable number of children every week, at thepresent time, yet from never watching the cases afterthe eighth day, I rarely hear of instances of secondaryeruption ; but I have not the slightest doubt that Ishould discover them, as frequently as heretofore, if Ifollowed the cases up as I did when I was conductingthese investigations. I think that I have now adducedevidence sufficient, if not to convince absolutely, at leastto induce a strong presumption in the mind of an unbiasedman, that vaccinia, under certain circumstances ,is followed by a secondary eruption, special in its nature,though various in forms, which observes fixed periodsof evolution, and is an integral part of the originalaffection." ¹A considerable discussion followed the paper , and, inreply, Mr. Ross observed that the " external character ofthe eruptions differed, but in their nature he believedthey were specific-in fact, sui generis ; that they weredirectly caused by the vaccination, and were evolved bythe actions going on in the economy, though it mightbe difficult to explain those actions. " 2 Dr. Louis Frankhas testified that " the skin diseases attributed to vaccinationare exceedingly numerous," and he adds, " therecan hardly be any doubt in the minds of those who havehad great experience in vaccination that there exists anintricate connection between vaccination and cutaneouseruptions as a sequel thereof. "3 Dr. William C. Cutler,Lancet, vol . i. , p. 166. ( February 14, 1857. )*Medical Circular, vol . x. , p. 68. ( February 11 , 1857. )Journal of Cutaneous and Genito- Urinary Diseases, vol . xiii. , p. 142.(April , 1895. )MR. HUTCHINSON'S OPINION . 289in discussing the various forms of injury incident tovaccination , remarks that " vaccine roseola or lichen isso often met with in the practice of all physicians thatit hardly needs to be mentioned in this connection. " 1Indeed, Mr. Jonathan Hutchinson has probably notoverstated the case, when he says that " the wonder isnot that vaccination should sometimes produce anexanthem, but that it should ever be without one. " 2Dr. P. A. Morrow, in alluding to the frequency ofvaccinal eruptions, quotes the experience of Behrend,who only observed them six times in three hundredsuccessive cases, and says-" From the unusually largenumber of cases reported in the various medicaljournals within the last few years, I should judge thatthe proportion was much greater. " 3 He remarks thatpreceding and accompanying erythematous eruptions,there may be slight febrile reaction, headache, malaise,and other evidences of constitutional disturbance. Dr.Acland has also testified that vaccinal eruptions are" often attended with much irritation, considerablegeneral disturbance, and some pyrexia. " 4 Now, if theseeruptions are an integral part of the vaccine disease,and often attended with constitutional disturbance andmuch irritation, even if they are usually characterisedby a temporary duration, as stated by Dr. Acland, I1 Annual Report of the Health Department of the City of Baltimore , forthe year 1883 , p. 62.2 " Lectures on Clinical Surgery, " vol . i. , p. 18. Jonathan Hutchinson,F.R.C.S. London. 1879.Journal of Cutaneous and Venereal Diseases, vol. i. , p. 176. (NewYork , March, 1883. )*Allbutt's " System of Medicine," vol. ii. , p. 564. London. 1897.290 INJURIOUS Results OF VACCINATION .cannot help thinking that all this offers a somewhatserious objection to the practice of vaccination.Occasionally these eruptive disorders may prove morevirulent. Thus, Professor Hardy, of Paris, at the InternationalMedical Congress held in London in 1881 ,related an unpleasant reminiscence of which he was thesubject in 1870. Three days after being re-vaccinatedhe was attacked by an intense urticaria, developed onthe skin and in the bronchial mucous membrane, in thelatter situation exciting attacks of suffocation so seriousas to put his life in danger. We have it on the highauthority of Drs. Colcott Fox and Louis Frank thatthis complication of vaccination (urticaria) is not at alluncommon.21With regard to eczema, there can be but little doubtthat quite a large number of cases are attributable tovaccination. In an article on " Vaccinal Skin Eruptions "Dr. George Thin says-" All practitioners of any experiencemust be able to recall cases in which obstinateeczema in infants has first shown itself after vaccination,and other ailments of a general character are probablysometimes produced by the effect of the vaccine viruson the system in delicate persons. During the lateepidemic of small-pox in London I had occasion to meetwith several cases in which patients attributed a temporarycondition of depressed health to re-vaccination.3The following gives the age-distribution of eczemacases during the first year of life coming under the care1 " Transactions of the Seventh Session of the International MedicalCongress, " vol. iii. , p. 158. London. 1881 .* British Medical Journal, vol. ii. , p. 1235 (November 29, 1890) ; andJournal of Cutaneous and Genito- Urinary Diseases, vol. xiii. , p. 145(April , 1895) .Edinburgh MedicalJournal, vol . xxvii. , pp. 523, 524. ( December, 1881. )EXPERIENCE OF DR. COLCOTT FOX. 291Cases.... 33of Dr. Colcott Fox ' at the Paddington Green Children'sHospital :-0-1 monthCases.6 7 months ... 10I 2 months 22 7- 8 months ... 42 3 months ... 258 9months 233 - 4 months ... 39 9 10 months I4 - 5 months ... 2310 II months I5 6 months ... 7 11 12 months 3The large proportion under three months of ageseems to afford ground for believing that vaccinationis not to be held responsible for the majority of casesof infantile eczema. At the same time, as Dr. Acland2says, it must be noted that there is definite increase inthe numbers in the fourth and in the ninth months, atperiods when the irritation of vaccination and teethingrespectively might be expected to come into play. Forcases recorded in Appendix ix. to the Commissioners'Final Report, see Nos. xcix., cxi. , 14, 15 , 25 , 95, 98, 101 ,B. S. and J. W. (p. 282), 120, 130, 140 (three cases ) , 192 ,B. R. ( p. 389), 225 , A. H. and A. G. (p. 444).Adisease of the skin which has been especially referredto by the Vaccination Commissioners is impetigo contagiosa.The frequent occurrence of this malady aftervaccination has been remarked on by the late Dr.Tilbury Fox³ and others. An extensive epidemic ofimpetigo contagiosa was occasioned by vaccination in theIsle of Rügen in 1885 ; 79 children were vaccinated on1 British MedicalJournal, vol. ii. , p. 1235. ( November 29, 1890. )* Allbutt's " System of Medicine," vol. ii . , p. 580. London. 1897 .British MedicalJournal, vol. i . , p. 553. ( May 21 , 1864. )Q. 9,797-9,834, Third Report , Royal Commission on Vaccination .292 INJURIOUS RESULTS OF VACCINATION .June II with humanised thymos-lymph obtained froma Government establishment at Stettin ; all, with threeexceptions, were attacked with impetigo contagiosa, and,by infection, the disease was spread to 320 out of apopulation of 5,000 inhabitants. A Commission ofInquiry was appointed by the German Government,who reported that they were unanimously of opinionthat the outbreak of the disease had been a directconsequence of vaccination.2Skin eruptions from vaccination are not unfrequentlycomplicated with intense irritation. A case of thisnature is recorded by Mr. Jonathan Hutchinson. Thepatient (aged 13) was vaccinated when nine months old,and the eruption began within a fortnight, and had beenincreasing ever since (twelve years). Mr. Hutchinsonwas told that the patient would sometimes lay awakemost of the night scratching herself. Weather andseasons made no difference, and " the eruption itchedintolerably and incessantly." Mr. Hutchinson addsthat the vaccine eruption and that of varicella appearto be alike in their proneness to evoke prurigo.year, " he says, " passes but brings before me freshexamples of the causation referred to. "" No1 Extensive outbreaks are also reported by Protze ( see " Viertelgahresschriftfür Dermatologie und Syphilis, " vol. xx. , pp. 478, 479, Vienna, 1888 ) ;by Melichar in Allgemeine Wiener Medizinische Zeitung, December 10 ,1889 , vol . xxxiv. , pp. 581 , 582 ; by Perron, Pourquier, and others. Seealso Nos. cx. , 9, 12 , 19, 20, 29, 82, 129, 180, М.С.В. (p. 368), 196, and 230in Appendix ix . to Final Report of the Royal Commission on Vaccination ,and cases at St. Pancras Workhouse in 1890-91 , reported in " Archives ofSurgery, " vol. iii. , pp. 206-215 , January , 1892 .2 " Archives of Surgery, " vol . i. , pp. 161 , 162 ( October, 1889) . JonathanHutchinson , LL.D. , F.R.S.M. RICORD ON VACCINATION .Syphilis.293With regard to the communication of syphilis byvaccination , Professor Ricord declared in a lecture atthe Hotel Dieu that " if it be true that vaccinationcan transmit syphilis, then vaccination is done for .For who, pray, will run the risk of being affected withthe great to escape the small pox." 1These ominous words from the greatest authorityon the subject of syphilis may well have occasioneddismay among the promoters of vaccination, and thuswe find that medical literature was, and up to quiterecent times has been, full of denials of the possibilityof such an occurrence . The official tract before referredto informs us (p. 4) that " The fear that a foul diseasemay be implanted by vaccination is an unfounded one.Such mischief could only happen through the mostgross and culpable carelessness on the part of thevaccinator. The alleged injury arising from vaccinationis, indeed, disproved by all medical experience." 2To illustrate the sceptical attitude of the medicalpress on this subject, the British Medical Journal ofDecember 21 , 1861 (vol. ii. , p. 666) , in referring to areport in an Italian medical journal of childrensyphilised by vaccination at Rivalta, heads thearticle " An Absurd Tale," and says in conclusion-" We need hardly add, that our main object in referringto this matter is not so much to warn the profession1 Lecture delivered at the Hotel Dieu. Translation by Dr. HeronWatson. Edinburgh Medical Journal, vol. vii . , p. 859. ( March, 1862. )2 " Facts concerning Vaccination for Heads of Families. " ( Revised bythe Local Government Board, and issued with their sanction. )294 INJURIOUS RESULTS OF VACCINATION.against such a tale, as to enable our brethren to give ananswer concerning it to those of the ignorant publicwho may be frightened by it. It is unfortunately truethat there are only too many strangely-minded peoplewho will be glad to make capital against vaccinationout of such a tale. "But, in spite of all denials in the past, the matter hasnow been placed beyond dispute by the leading authoritieson this subject.Mr. James G. Beaney, of Melbourne, in his work on" Constitutional Syphilis," says "And I at onceannounce at the outset my firm belief that syphilis isin very many instances communicated by means of' child's vaccine lymph.' This opinion I have deliberatelyformed, and as firmly defend. The evidences ofsuch being the case have, in my practice, been numerousand well -pronounced ; so distinct, indeed, that no doubtwhatever could exist as to the nature of the eruptions ,and the certainty of transmission . " 'M. Fournier, Professor of the Faculty of Medicine ofParis, in discussing the subject, remarks-" From thatwhich precedes, it results in the first instance, and quiteclearly, that in a general way a real and serious dangeris contained in vaccination. But that danger, surely, isquite of a nature to evoke our solicitude for a numberof reasons . For ( 1 ) every individual is destined toundergo, one or several times in his life, the vaccineinoculation. The danger then of vaccinal syphilis isencountered by all the world once or several times inthe course of existence ; ( 2 ) the excessive and ever-1 " Constitutional Syphilis," p. 373. James George Beaney, M.D. ,F.R.C.S. Melbourne. 1880.MR. BRUDENELL CARTER'S OPINION . 295increasing diffusion of syphilis in modern societies willonly increase numerically the risks of that danger ;(3 ) the syphilis which attacks subjects quite young(that is to say, which invades the organism at theusual age at which vaccination is practised) is particularlygrave, everyone knows it, and grave to the extentof terminating it in a fatal manner on many occasions. " ।Dr. Edward Ballard, in his " Prize Essay " (p. 344) ,informs us that " the thing has happened over and overagain in cases which may now be counted by hundreds ;so that this disposes for ever of the cry of ' impossible,' "and therefore Dr. Charles Drysdale was probably notvery wide of the mark when he said " I think there canbe no doubt in the minds of instructed and unprejudicedmedical men that syphilis has occasionally been ratherwidely propagated by means of vaccination. " 2One of the most serious charges which has ever,probably, been made against vaccination was made byMr. Brudenell Carter, the well-known oculist. Hesays-" I think that syphilitic contamination by vaccinelymph is by no means an unusual occurrence, and thatit is very generally overlooked, because people do notknow either when or where to look for it. I think thata large proportion of the cases of apparently inheritedsyphilis are in reality vaccinal ; and that the syphilis inthese cases does not show itself until the age of fromeight to ten years ; by which time the relation betweencause and effect is apt to be lost sight of." 31 " Leçons sur la Syphilis Vaccinale," pp. 17, 18. Alfred Fournier.Paris. 1889.2 Medical Press and Circular, vol. i . , p. 194. (March 8 , 1876. )3 Mr. Carter's statement was communicated to the North London MedicalSociety by Dr. Kesteven in a paper read on May 8 , 1877. MedicalExaminer, vol . ii. , p. 409. ( May 24, 1877. )296 INJURIOUS results OF VACCINATION .The following is a list of alleged cases of vaccinosyphiliswhich have been reported from time to time :-Year.Alleged Cases of Vaccino- Syphilis.Place. No.1814 Undine 301821 Cremona 401830 Frederiksborg 71841 CremonaSaône)641843 Quers (Haute- About1845 Constantine1849 Piedmont1849 Coblentz1852 Freienfels (Oberfranken)1852 Paris30321984I 1855 Lyons1855-7 Czomad ( near 34Pesth)1856 Lupara 341858 Cherbourg 2Authority and Reference .Marcolini . " Annali Universali diMedicini ," vol. xxix. , pp. 146-150,Milan , January, 1824 .Cerioli . See " Revue Médicale Françaiseet Etrangère," vol. iii. , pp.54, 55 , Paris , September , 1845 .Ewertzen . " Notizen aus dem Gebieteder Natur und Heilkunde" ( Froriep'sNotizen) , vol . xxxiv. , p. 303 , September,1832 .Cerioli . Ibid.Aliès. " La Revue Médicale Françaiseet Etrangère, " vol. i. , pp. 29-33, January 15, 1865.See Layet . Traité pratique , de la VaccinationAnimale, p. 70, Paris, 1889.Viani . " Gazette Médicale de Paris ,"3S . , vol . iv . , p. 874, November 10,1849.Wegeler. "Medicinische Zeitung," vol .xix. , pp. 69, 70 , Berlin, April 3 , 1850.Hübner's Cases . See " AerztlichesIntelligenz -Blatt," vol. i. , pp. 166-168 , Munich , May 27, 1854 ; also" Gazette Hebdomadaire de Médecineet de Chirurgie, " IS . , vol . ii . ,pp. 176-178 , Paris, March 9, 1855 .Auzias-Turenne. See " Bulletin del'Académie Impérialede Médecine,"IS. , vol. xxx. , p. 467, 1864-65.Rodet. See "Bulletin de l'AcadémieImpériale de Médicine, ” IS . ,vol . xxx. , pp. 466 , 467 , 1864-65.Glatter . See Bohn's " Handbuch derVaccination," p. 322, Leipzig , 1875 .Marone. See " Lancet," May 31 ,1862 , vol. i. , pp. 567 , 568 ; alsoLancereaux on " Syphilis,"p.641.Lecoq. " Gazette de Hôpitaux," vol .xi . , p. 598, Paris , December 24, 1859 .ALLEGED CASES OF VACCINO-SYPHILIS. 297Year. Place. No.1860 Rufina (nearFlorence)141861 Rivalta1861-2 Paris46I1862 Torre de' Busi51863 Paris I1863 Paris I1863 Paris1863IBéziers I1863 BergamoFranceAuthority and Reference.Galligo . " Gazette Hebdomadaire deMédecine et de Chirurgie, " IS. , vol .vii . , pp. 519 , 520 , August 10, 1860.Coggiola. See Cerise in " L'UnionMédicale, " 2S. , vol. xii . , pp. 259-264, Paris, November 9, 1861 ; also" Gazette Hebdomadaire de Médecineet de Chirurgie," IS. , vol. viii . ,pp. 779-782 , December 6, 1861 ;and " Lancet, " November 16, 1861 ,vol. ii . , pp. 485 , 486.Trousseau. See Depaul, “ Bulletinde l'Académie Impériale de Médecine, " IS. , vol . xxx. , pp. 144, 145 ,1864-65.Adelasio. " Gazzetta Medica ItalianiLombardia, " 5S. , vol . iv. , pp. 158-161 , Milan , May 1 , 1865 .Chassaignac. " Bulletin de la Sociétéde Chirurgie de Paris," 2S. , vol .iv. , p. 361 , 1864. For drawingof case by R. Druitt, see Trans.Obstet. Soc. Lond. for 1863, vol .v. , p. 196 , 197.Devergie. " Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxviii . , pp. 664-669, 1862-63.Hérard. Ibid. , pp. 1189, 1190.Sébastian. " Gazette des Hôpitaux,"vol . xvi . , p. 493, October 22 , 1864 ;also " Gazette Hebdomadaire deMédecine et de Chirurgie," 2S. ,vol. ii . , p. 41 , January 20, 1865.Adelasio . " Gazette des Hôpitaux,"vol. xvi . , p. 494, October 22, 1864.2 or 3 Auzias-Turenne. " Bulletin de l'AcadémieImpériale de Médecine ," IS . ,vol . xxx. , pp. 322, 323, 1864-65 .Laroyenne. Ibid. , pp. 470, 471 .2I12 or Depaul. Ibid. , vol . xxxii. , pp. 1048-moreParis1865 Paris1866 Argenta (Fer- 27rara)1866 Rosheim ΙΟ1056, 1866-67 .Gamberini. " Gazette des Hôpitaux, "vol . xxi . , p. 505, November, 1869.Schuh. See Depaul in " Bulletin del'Académie Impérialede Médecine, "IS . , vol . xxxii. , pp. 1058-1061 ,1866-67 .20298 INJURIOUS results OF VACCINATION.Year. Place. No.1866 Auray ( Morbihan)50 ormoreIII35Depaul.Authority and Reference ." Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxxii . , pp. 201-224 and 1033-1038.Fuqua. See Joseph Jones' " Medicaland Surgical Memoirs, " p. 472 ,New Orleans, 1890.Depaul. See " Bulletin de l'AcadémieIn périale de Médecine , " I S. ,vol . xxxii . , pp. 1039-1043 , 1866-67 .Verfasser. See Köbner in " Archivfür Dermatologie und Syphilis , "vol . iii . , p. 159, Prague , 1871 .Guérin . "Bulletin de l'AcadémieImpériale de Médecine," IS. , vol .xxxiv. , p. 512, 1869 .Zallonis. See Depaul, Ibid. , pp.1017, 1018 .Vicherat. Ibid. , pp. 1103-1106.Kocevar. " Allgemeine Wiener MedizinischeZeitung," vol. xv. , pp.266-268 , May 24, 1870.1866 Florida 521866 Cardeillac ( Lot ) 131869 Prussia1869 ParisSyra (Greece) 2Villemaréchal1869 Schleinitzand St.Veit ( Styria)1869and218701875 New YorkKöbner. " Archiv für Dermatologieund Syphilis," vol. iii. , p. 133 ,1871 .I Taylor . " Archives of Dermatology,"vol. ii. , pp. 203-209, New York,April , 1876 .1876 Lebus ( Prussia) 15 Appendix to Report of German VaccinationCommission , 1884. ( SeeQ. 9,961 , Third Report, RoyalCommission on Vaccination. )58 Journal D'Hygiène, vol . vi. , pp. 399,I400, Paris , August 25, 1881 .Moré. " Bulletin de l'Académie deMédecine, " 2S. , vol. xiii. , p. 1240,1884.Layet. Traité pratique de la VaccinationAnimale, p. 74, Paris, 1889 .Perrin . " Annales de Dermatologieet de Syphiligraphie," 3S. , vol. i. ,pp. 654-657 , Paris, 1890.Hervieux. " Bulletin de l'Académiede Médecine," 3S . , vol . xxii . , pp .116-125, 1889.Hervieux. Ibid. , pp. 230, 496 , 517 .Rosenthal . " Deutsche MedicinischeWochenschrift, " vol. xviii. , p. 121 ,Leipzig and Berlin, Feb. 11 , 1892.1880 AlgiersFrance I1885 Turin 351889 Marseilles I1889 Oise 51889 Motte- aux-Bois1891 Germany43DR. JAMES WHITEHEAD'S CASES. 299Thus we have a total of over 700, without includingEnglish cases to be mentioned hereafter.The cases which first attracted serious attention tothe subject in this country are those of Dr. JamesWhitehead. He made a systematic examination ofchildren brought to the Hospital, and 1,435 out of 1,717were found to have been vaccinated. In a considerablenumber of instances the mothers blamed vaccinationas the cause of the disease from which the childrensuffered, and in thirty-four cases Dr. Whiteheadthought that the evidence appeared to be sufficientlyconvincing to warrant the belief that a taint had beencommunicated ; in fourteen he considered the diseaseto be of true syphilitic character, as shown by thesymptoms and by the mode of its derivation ; and inthe remaining twenty, although the history was lessclear, the symptoms so precisely resembled constitutionalsyphilis that the treatment employed was that commonlyused in syphilitic disease, and was in most cases attendedwith satisfactory results. In the four following cases,described by Dr. Whitehead, the local vaccine vesiclesdeveloped into sores, and thus, in these instances atany rate, there can be but very little doubt thatthe syphilitic symptoms were actually produced byvaccination .Case 2. An infant, aged nine months, of a bad habitof body. Copper-coloured blotches appeared aftervaccination. When seen, there was a mixed eruptionon the face and scalp and extreme irritability of the1 Third Report of the Clinical Hospital , Manchester. James Whitehead,M.D. London. 1859.300 INJURIOUS RESULTS OF VACCINATION .whole surface; the vaccinated spots remained unhealedat the end of five months, presenting a well-formedrupia with excavation. The father and mother aredescribed as apparently healthy.Case 11. An infant, aged eleven weeks, of mediumhabit of body. When seen, there were two deep ulcerswith hardened bases where the vaccine vesicles wereformed three weeks previously ; copper-coloured roseolaon the nates and chin, sallow complexion, mucoustubercles round the anus, eruptions and intertrigobehind the ears, coryxa, atrophy, and dysentery. Thehistory of the case is that roseola appeared from twelveto fourteen days after the vaccination, at the age oftwo months ; the mucous tubercles nine weeks after,while under treatment, and atrophy four months after.Father said to be healthy ; mother feeble, but apparentlyfree from taint.Case 56. An infant, aged seven and a half months,of good habit of body. After the subsidence of thevaccination, the vesicles degenerated into ulcers ,surrounded by erythema. When seen, there wereerythematous blotches of a copper colour on the chestand neck, eczema auris, arthritis of the left elbowjoint, and syphilitic pallor. Father said to be healthy ;mother apparently healthy.Case 57. A child, aged three years and three months,of good habit of body. She was healthy up to thetime of vaccination, three months previously. The threevaccinated spots degenerated into three deep ulcerationswith hardened bases, which remained open for twomonths. When seen, there were all over the trunk andlimbs flat herpetic-like crusts, with large erythematousMR. HUTCHINSON'S CASES. 301areolæ of copper tint, most numerous on the thighs ; thecicatrices of the first-formed patches being of a deepcopper colour. The patient suffered from great prostration,inappetence, eneuresis, and dysuria, erythema ofthe vulva without discharge, chronic blepharitis, photophobia,and syphilitic pallor. The first symptoms wereulceration of the vaccinated spots with copper-colouredblotches. Father and mother apparently healthy.Mr. Jonathan Hutchinson, on April 25, 1871 , madehis first communication to the Royal Medical andChirurgical Society on the subject. Twelve persons(mostly young adults ) were successfully vaccinated withlymph from a healthy- looking infant. In all excepttwo, indurated chancres developed in the vaccinationscars .Shortly afterwards, Mr. Warren Tay, one of Mr.Hutchinson's colleagues, came across another series ofcases. Two children of the same family, aged fouryears and sixteen months respectively, had been vaccinatedseven weeks before they came to be treated forskin eruption ; the vaccination spots were unhealed andindurated at the base. By means of the vaccinationregister, twenty- four others vaccinated with the samelymph were traced. It was found that nine children ,counting the two previously mentioned, had unquestionablesymptoms of constitutional syphilis, and therewere suspicious symptoms in six others , a certainnumber entirely escaping. It is important to note thatnothing had occurred to excite the vaccinator's suspicions,none of the children having been taken back tohim on account of the unhealthy condition of the arm .Two of the patients, however, had been under medical302 INJURIOUS RESULTS OF VACCINATION .care, but in not a single instance had the real nature ofthe disease been suspected.Mr. Hutchinson's third series consisted of one caseonly. The patient, aged forty- six, came under his careat the Moorfields Eye Hospital for acute iritis. Hehad been vaccinated three months previously, and thevaccination spots were the seat of chancrous induration.Mr. Hutchinson called on the vaccinator, who said hehad never seen such sores as were displayed on thisman's arm , but had not, however, suspected the realnature of the disease. About twelve other personswere vaccinated at the same time, and from the samechild, and with the exception of a little trouble in thehealing of the sores in one or two of the patients, theyhad shown nothing peculiar.In the fourth series, the patient was a woman agedforty-six. Neither the patient nor the surgeon whovaccinated her had suspected she had been syphilised.The fifth series was brought under Mr. Hutchinson'snotice by Mr. Warren Tay in April, 1876. A motherand her two children, one an infant and the other achild of two, were found to be suffering from secondarysyphilis. The children were vaccinated in September,1875, and their vaccination sores had re- opened and fora long time remained unhealed. The mother had contracteda sore on her nipple from the younger child,and her symptoms were two months behind those ofthe children. The husband subsequently contractedsyphilis from his wife.Mr. Hutchinson also relates a case of vaccino - syphilishe had seen in a lady recently arrived from India. Thevaccination did not take, but a little spot like aMR. MAKUNA'S " INQUIRY.” 303mosquito - bite resulted ; this healed, and six weeksafterwards a sore formed. When seen by Mr. Hutchinsonshe had two indurated and dusky chancres on thearm, and was covered with a syphilitic eruption .When we consider that in a number of these casesthe nature of the complaint had been unsuspected (insome, even by the medical men) until they had comeunder the care of Mr. Hutchinson or Mr. Warren Tay, itseems more than probable that a large number of casesof vaccino - syphilis remain unrecognised as such, andnever come to light at all .In 1883 questions were addressed to medical men onthe subject of vaccination . Among others, it wasasked, " What diseases have you, in your experience,known to be conveyed or occasioned or intensified byvaccination ? " Three hundred and eighty- four replieswere received, and they are published in Mr. M. D.Makuna's " Transactions of the Vaccination Inquiry."The following testimonies have been extracted relativeto the occurrence of syphilis after vaccination :-5. " Syphilis once only."18. " I have only seen one case of syphilis which I attributed25.to vaccination from a syphilitic infant. "" A certain amount of syphilis, in rare instances. "40. " I have known syphilis in aggravated forms .... to followvery speedily the operation ."51. " I only remember one case in my practice in whom syphiliswas intensified."52. " I have seen one case of syphilis apparently conveyed. "64. " I have known syphilis occasioned by it ."93. " I have seen syphilis more than once."96. " Syphilis once with an incrustated rash."112. " Syphilis."304 INJURIOUS RESULTS OF VACCINATION .114. " Syphilis .... having previously been dormant."120. " I remember one case of syphilis" (intensified by vaccination).130. " Syphilis."139 and 140. " Syphilis in two cases."162. " Occasionally in rare instances it has appeared to conveyI cannot recall any syphilitic ...disease.such cases in my experience as absolutely proved,although I have had my suspicions aroused."164. " I cannot quite assent that I have seen syphilis conveyedby vaccination, but I firmly believe I have seen three orfour such cases ."175. " One case of death from syphilis in a boy about two yearsold, who was found afterwards to have been vaccinatedfrom a child born with symptoms of syphilis. "190. Had seen syphilis in other medical men's practice.192. Had seen syphilis "perhaps once."211. " Syphilis and death occasioned."231. "Three cases of syphilis." (Notes of cases lost.)238. " I have also on two occasions seen among children inLondon what I thought to be syphilitic eczema, whichyielded to mercury."262. " I have seen syphilis .... produced by vaccination."271. " Syphilis conveyed twice, once by primary, and once byre-vaccination."274. " Syphilis " (conveyed).277. "Only one case in which syphilis was suspected."281. " Very rarely syphilis conveyed by impure vaccination."282. " I have seen one child die of syphilis, I believe fromvaccination."288. "When a student I have seen syphilis conveyed, but havenot details of cases."291. Two cases, one of which doubtful. (Notes of cases given.)299. "One case at St. George's Hospital, when I was a pupiltwenty years ago, in a young woman, ofsyphilis."318. "Secondary or probably tertiary syphilitic symptoms."326. " I have known two cases where there were good groundsfor supposing syphilis was conveyed by vaccination."FURTHER CASES OF VACCINO- SYPHILIS.331. " Syphilis once."305340. " I remember a case of syphilitic sores on the arms of a boyfrom vaccination, five years ago. "353. " One case of syphilis . "383. " I have known lymph taken from a syphilitic or scrofulouschild communicating analogous disease to the childrenvaccinated with it ."384. " One case of syphilis ."Quite recently, and before the Royal Commission(Sixth Report, pp. 218, 219), Mr. E. Ward mentionedthree cases which had come to his knowledge, two inthe practice of Mr. Holmes, of Leeds, in 1871 , and thethird a very sad case in a young woman of twenty-two.She was vaccinated in 1888, and about four or fiveweeks afterwards the points of vaccination becameindurated. This was followed by the usual phenomenaof syphilis, and the case terminated two years afterwardsby death with cerebral symptoms.For further British cases, see next page :-306 INJURIOUS RESULTS OF VACCINATION.Alleged Cases of Vaccino- Syphilis.Year. Place. No.1839 I1843 Bodmin 2| 1863 Glasgow ILondon 31866 London I1866 London I1870 London I1872 Belfast I1873 London I1883 London IAuthority and Reference .Whitehead. " On the Transmissionfrom Parent to Offspring of someForms of Disease and of MorbidTaints and Tendencies, " pp. 174-176. 1851 .Haydon. Medical Times and Gazette,March 29, 1862, vol. i. , p. 316 .Buchanan. Glasgow MedicalJournal,April, 1865 , vol . xiii. , pp. 60-65.Nayler. " A Practical and TheoreticalTreatise on the Diseases of theSkin," pp. 279-281 . London, 1866 .Drysdale. British MedicalJournal,April 25 , 1868 , vol. i. , p. 396.Pollock. Lancet, April 21 , 1866, vol .i. , p. 424.Smith . " Transactions of the ClinicalSociety, " vol. iv. , pp. 53-59. 1871 .Scott. Medical Press and Circular,January 29, 1873 , vol . i. , pp. 84,85.Hulke. Medical Times and Gazette,February 8 , 1873 , vol. i. , p. 153 .Collins . 1 " Transactions of the VaccinationInquiry," p. 63. 1883 .For some time after the publication of Mr. Hutchinson'scases, although the communicability of syphilis byvaccination was admitted, it was stated that this couldonly take place if the blood of the vaccinifer was takenwith the lymph. In this connection it may be mentionedthat a committee consisting of Dr. Bristowe, ProfessorHumphry, Mr. Hutchinson, and Dr. Ballard, in reporting1 These cases are also alluded to in the list on pp. 303, 304, and areumbered 18 and 291 respectively.ALL LYMPH CONTAINS BLOOD CELLS. 307on a well -known case,¹ said-" It is conclusively provedthat it is possible for syphilis to be communicated in vaccinationfrom a vaccine vesicle on a syphilitic person,notwithstanding that the operation be performed withthe utmost care to avoid the admixture with blood . "All lymph, however, contains blood cells, and thisapparently was known as long ago as 1862. Dr. HeronWatson writes-" There is no vaccine matter, howevercarefully removed from the vesicle, which, on microscopicinvestigation, will not be found to contain bloodcorpuscles. " 2 This has been corroborated by Drs.Barthélemy³ and Husband, the latter's statement beforethe Royal Commission being accepted as final. Thusthe Commissioners say (section 430)-" The evidencegiven by Dr. Husband, of the Vaccine Institution ofEdinburgh , established the fact that all lymph, howeverpellucid, really does contain blood cells. "There is nothing necessarily in the appearance of thevaccine vesicle to lead one to suspect syphilis ; and Dr.Ballard informs us that " The perfect character of thevesicle is no guarantee that it will not furnish both vaccineand syphilitic virus." 5Again, a vaccinifer may exhibit no signs of the disease.1 See Supplement, containing the report of the Medical Officer , to theTwelfth Annual Report of the Local Government Board, pp. 46-51 ,1882-83 , and for subsequent history of case Allbutt's " System of Medicine,"vol. ii . , p. 608. London. 1897 .2 Edinburgh MedicalJournal, vol . vii. , p. 859, foot-note. (March, 1862. )3 See " Leçons sur la Syphilis Vaccinale," pp. 112-114 , foot-note. AlfredFournier. Paris. 1889.* Sixth Report , Royal Commission on Vaccination. Q. 27,327-9." On Vaccination : Its Value and Alleged Dangers." A Prize Essay.P. 345. London. 1868 .308 INJURIOUS RESULTS OF VACCINATION .Mr. Hutchinson, referring to a discussion on the subject,before the British Medical Association at Birmingham,in which he had taken part, observes " In reference tothe possibility of conveying syphilis from a vacciniferwho did not reveal the taint by any visible symptoms orany degree of cachexia , I felt bound in honesty to saythat I felt sure of it. No surgeon in his senses wouldever vaccinate from a child which showed obvioussymptoms. The fact is, however, that a certain numberof syphilitic infants look perfectly healthy whilst yet veryefficiently contagious. There is no use, and much danger,in denying this important clinical fact. " ¹He then mentions that the child from which the lymphwas taken to vaccinate his first series of cases, onlyrevealed a little sore ; this was seen by several medicalmen, including Sir John Simon, who questioned whetherit could be considered proof of taint. In the secondseries , the vaccinifer did not present a single visiblesymptom, and Mr. Hutchinson concludes that " It isabsurd to assert that inherited syphilis is always to bedetected, and it is a cruel injustice to imply that allaccidents have been the result of carelessness," indeed ina large number of cases, the vaccinifer has presented notrace of syphilitic disease. This brings us face to facewith the terrible thought that there may be some relationshipbetween the two diseases-cow-pox and syphilis.In the first chapter of this volume, I have alluded to themisleading name of variola vaccina or small -pox of thecow, given to the disease by Jenner. It is this misleading1 " Archives of Surgery," vol. ii. , p. 104 ( October, 1890) . JonathanHutchinson , LL.D. , F.R.S.:TRAMMELS OF JENNERIAN PATHOLOGY. 309name that has been, and is, even at the present time,largely responsible for the misunderstanding of the cardinalsymptoms of cow-pox, and this has been pointed outby none more forcibly than by the great Dr. Gregory :-" The more I reflect on the phenomena of small -pox aftervaccination, the more convinced I am that, so long asthe notion of the identity of cow-pox and small -pox thusobstinately prevails in our minds, so long will all justviews of vaccine pathology be embarrassed. " 1In a letter to Stewart, of Kelso, Dr. Gregory writes-" I have never yet addressed anyone in writing on thesubject, and I now write to you upon it, because I seethat you have considered it well-that you have thrownoff the trammels of Jennerian pathology, and think foryourself. Observe, I say, Jennerian pathology, notJennerian practice. I feel assured you do not viewvaccination as a kind of small -pox. The term variolavaccina was incorrect in pathology. Cow-pock is asomething that alters the human blood, and indisposesit to take small-pox. But it is not small-pox. A coatingof gold secures our salt spoons from the action ofchlorine ; but gold is not chlorine. Small -pox, aftervaccination, is not on a par with double small-pox. " 2The disease that cow-pox most resembles is notsmall -pox, but syphilis. This view of the analogyof cow- pox with syphilis was held by Auzias- Turenne,and in this country it has been advocated by Dr.Creighton. Auzias -Turenne says-" Between syphilis1 London Medical Gazette, vol. xxix. , p. 193. (October 29 , 1841. )2 " An Investigation of the Present Unsatisfactory and Defective State ofVaccination," p. 106 , 107. Thomas Brown, formerly medical practitionerin Musselburgh . Edinburgh. 1842 .310 INJURIOUS Results OF VACCINATION .and cow-pox the analogy may be a long way followedup. The inoculation of cow-pox-a malady with afixed virus sufficiently well-named pox of the cow(vérole de vache) may, for example, give rise to polymorphicvaccinides, and sometimes to disseminatedpathognomonic vesico-pustules, just as the contagion ofthe mucous patch, symptom of a malady with anequally fixed virus, gives rise to various secondaryeruptions, and sometimes to the appearance of disseminatedmucous patches. But, happily for the vaccinated,cow -pox passes through a rapid evolution, anddoes not leave virulent remains for so long a time or sofrequently as syphilis. " ¹The difficulty of distinguishing some cases of cowpoxfrom syphilis has been recognised by the bestauthorities. Mr. George Berry, ophthalmic surgeon tothe Royal Infirmary, Edinburgh, in a communicationon cow- pox of the eye-lids, says that the main interestin these cases " consists in the possibility of the inoculationtaking place at all, and in the differential diagnosisbetween vaccinia and a primary syphilitic sore. " 2Dr. Seaton has also alluded to this difficulty : " Amongthe sources of fallacy against which we have to be onour guard in cases in which syphilis has been said tohave been produced by vaccination, one is an erroneousdiagnosis. Persons talk very glibly about sores beingsyphilitic, and eruptions being syphilitic, as thoughthe characters of syphilitic sores and syphilitic eruptionswere so made out that there could never be any mistake1 " History and Pathology of Vaccination , " vol. ii . , p. 552. Edgar M.Crookshank , M.B. London. 1889.2 British MedicalJournal, vol. i. , pp. 1483, 1484. (June 28, 1890. )SYMPTOMS OF NATURAL COW- POX . 311about them. Yet such mistakes are daily being made bypractitioners in general, and are occasionally made by thevery highest authorities. About four years ago one ofthose amongst us most conversant with syphilis, Mr.Henry Lee, announced to the Medico - Chirurgical Societythat he had a case under his care in which a syphiliticchancre had been produced on the arm of a child byvaccination. The case was seen by many membersof the profession, some of whom agreed with Mr. Lee,while others saw nothing but a sore arm, the result of adegenerated vaccine vesicle. The subsequent progressof the case quite satisfied Mr. Lee that he had beenmistaken in his diagnosis, as he publicly acknowledged. " יThe accounts of cow- pox in milkers and in the earlyremoves from the cow describe it as consisting of corroding,hard, and painful sores with small disposition toheal, accompanied by enlargement of the neighbouringlymphatic glands. There appeared also considerableconstitutional disturbance and secondary eruptions. Acontagious disease presenting these characteristics cannotbe very far removed from syphilis, and there seemsnothing improbable in the suggestion that cases of socalledvaccinal syphilis are merely the reversion ofcow-pox to a former type. What is known as the Leedscase is an instance in point.Emily Maud Child was vaccinated on March 26, 1889,and died at the Leeds Infirmary on July I of the sameyear. At the inquest on July 10, four members of theinfirmary staff-Messrs. M'Gill, Ward, Littlewood, and1 " Handbook of Vaccination, " p. 322. Edward C. Seaton, M.D.London. 1868 .312 INJURIOUS results OF VACCINATION .Dr. Barrs-gave evidence that the child died from vaccino-syphilis , and the verdict of the jury was that she" died from syphilis acquired at or from vaccination."The case was shortly afterwards made the subject ofinquiry by Dr. Ballard, one of the medical inspectors ofthe Local Government Board, and his conclusions wereas stated in Parliament by the President of the LocalGovernment Board, Mr. Ritchie, who used the followingwords:-" An inquiry has been made by an Inspector ofthe Board with regard to the case. His conclusions arenot the same as those arrived at at the inquest. Hestates that the child in question was the only suffererfrom subsequent syphilis among all the children hereached and whom he saw that had been vaccinated withthe same or any other lymph in the whole course of thevaccinator's March vaccinations ; and further, that theentire family to which the alleged vaccinifer belongedwere, as far as he could discover by examination of them,free from any syphilitic taint or suspicion of such taint.The Report of the Inspector will be at the disposal ofthe Royal Commission on Vaccination. "¹This implies that the child died from hereditarysyphilis , and I would direct my readers' attention tothe following from Mr. E. Ward's evidence before theRoyal Commission :-Q. 23,688 . ( Dr. Collins.) Did you examine the twoelder children, the brother and sister ofEmily Maud C.?-Yes, on several occasions.1 Hansard's Parliamentary Debates, third series , vol. cccxli . , p. 1330,1331. ( February 27, 1890. )THE LEEDS CASE. 313Q. 23,689. Did you find them " stunted in growth " ?-No, they struck me, the girl particularly,as being remarkably fine children.Q. 23,690. Did you find the central upper permanentincisors of Eva, the eldest child, notchedin the characteristic syphilitic manner ?I do not think it was at all characteristicof syphilis ; and I do not think Mr.Hutchinson thinks so.Q. 23,691 . (Chairman.) Do you know what was referredto as the " notching " ?-Yes, perfectly.Q. 23,692. (Dr. Collins.) Did you get any history of" prolonged snuffles " in the second child,the boy ? No, that is nothing ; when Isaw the boy he was a little stuffy in thenostrils, but so many children are thatnothingthat I should attach any importanceto-it was long after any snufflesfound in the ordinary course even of congenitalsyphilis would have disappeared.Q. 23,701 . Would it be true to say that the familywas in any sense a " syphilitic family " ?-I should say certainly not.The words within quotation marks were presumablyquoted by the Chairman and by Dr. Collins from Dr.Ballard's report to the Local Government Board, andhence there can be no possible doubt of the nature ofthis report.The matter would probably have been left at thisstage were it not that a Royal Commission was then21314 INJURIOUS results OF VACCINATION .sitting. An independent inquiry was, therefore, madeby Dr. Barlow on behalf of this body, and he reportedthat there was no evidence of syphilis in either parentof the child, no evidence of inherited or acquiredsyphilis in either of the two elder children, nor did thehistory of the third (deceased) child suggest to himthat it was the subject of inherited syphilis. Mr.Hutchinson has also testified to the fact that there isno evidence of syphilis in any of the family. It maybe mentioned that Dr. Ballard's report containing thisaccusation was refused to the parents, but handedover to the Royal Commission, who, for some reasonor other, have omitted to publish it in their reports.The conclusion of the Commissioners on the case isthat it " may probably be classed with a few others asexamples of gangrene and blood poisoning, the directresult of vaccination, which are not to be explainedby supposing the introduction of any syphilitic orother poison . " (Section 427.) Considering that thecase was taken for syphilis by the four members ofthe infirmary staff, and also by Dr. Ballard, it appearsthat symptoms presenting all the characteristic phenomenaof syphilis can be produced by the vaccine diseaseitself.Mr. Hutchinson, in alluding to this and other similarcases , says, " Lastly, the question has to be entertainedwhether the cases are examples of syphilis in any form .To many I am aware it will seem undue scepticismto doubt this. When such symptoms as snuffles, thrush ,1 Hansard's Parliamentary Debates, third series, vol . cccliii . , p. 881 .(May 22, 1891. )RELATIONSHIP OF COW- POX TO SYPHILIS. 315the eruption on the genitals in infancy are mentioned,not a few will hold that the suspicion is rendered verystrong, if not actually proven. In the same way, nodeson the head, bubo in the armpit, phagedænic sores,abscesses and eruptions on the genitals occurring inconnection with a vaccination sore which has gonewrong, will be held by many as conclusive proofs thatsyphilis has been introduced. I cannot but freelyadmit that they bring with them much suspicion, andthat this suspicion is strengthened by the fact thatwell - experienced surgeons, who saw these varioussymptoms and examined them carefully, thought thatthey could be none other than syphilis. Further, thereis the fact that two of the infants were thought to havebeen much benefited by mercurial treatment. " ¹ Mr.Hutchinson also observed that if syphilis were conclusivelyproved in any one he would admit it in theothers.On the next page is a list of cases presenting featuressimilar to the Leeds case ; in some the symptomswere not so well marked as in others, but the casesmay all be said to come under the same category." Archives of Surgery," vol . i . , pp. 114 , 115. ( October , 1889. )316 INJURIOUS RESULTS OF VACCINATION .Authority. Number. Reference .Taylor and Fyson ILucas IHutchinson IHutchinson ( Dr. E.'s case) ISixth Report , R.C.V. , pp. 196-198.Guy's Hospital Reports , 3 S. ,vol. xxvii . , pp. 31-37 . 1884.Illustrations of Clinical Surgery ,vol. i. , p. 141 , plate xxv. , fig. 3 .London, 1878 .Archives of Surgery, vol . i. , pp.98-104. October, 1889.Hutchinson ( Dr. W.'s case) I Ibid. , pp 193, 194 Jan. , 1890.Hutchinson ( Dr. H.'scases ) Several Ibid. , pp. 194, 195.HutchinsonHutchinsonHutchinsonParsonsI Ibid. , pp. 197, 198 .I Ibid. , vol. ii , pp. 23, 24. July,1890.ILocal Government Board,Nos. xix. , xlii. , lix. ,lx. , xciv.Royal Commission on Vaccination, Nos. II , 21 ,35, 39, 113, 139, 141 , 162 ,167 , 169 , 175 , 177 , 183 ,199, 202, 204, 206, 207 ,208 , 241 , 258 , 326 , 416 .Ibid. , pp. 213-215. Jan. , 1891 .Several British Medical Journal, Nov.29, 1890, vol . ii. , p. 1233 .Appendix ix. to Final Report,R.C.V.523 ormoreAppendix ix. to Final Report,R.C.V.It might have been anticipated that some furtherlight would have been thrown on cases of this descriptionby Dr. Acland in his article in Allbutt's " Systemof Medicine, " but he contents himself by quoting theopinion of the Royal Commission that the relationshipof cow-pox to syphilis " is a point of speculative,almost it might be said of transcendental pathology,"and, although he admits that Nos. 109, 113 , 207, and416, in Appendix ix. to the Final Report of the RoyalCommission, are similar to the Leeds case and othersdescribed by Mr. Hutchinson, he apparently has nothingCALF LYMPH AND VACCINO -SYPHILIS. 317further to add, for he remarks that " it would not bepossible here to enter into these cases in detail. " 'If it be a fact, as maintained by Dr. Creighton , thatthe phenomena of vaccino -syphilis so-called, are due tothe inherent, though mostly dormant natural historycharacters of cow-pox itself, we should expect the sameappearances to take place occasionally in cases of calflymph ; and in this connection the experience recordedby Mr. Hutchinson in the " Archives " for January, 189T(pp. 213-215 ), is of interest. He particularises a case ofvaccination with calf lymph presenting certain symptomssimulating syphilis.The child was born of healthy parents in July, 1890 ;was perfectly healthy at birth ; was vaccinated at threemonths of age with Renner's calf lymph, at the sametime as several others who did well ; on the eighth day,only one place seemed to have taken, but later on allthree looked satisfactory ; at the end of three weeks, thearm was inflamed, and there were large black scabs withpus at their edges ; a week later a large slough comprisedall the vaccination sores and passed deeply almost tothe bone, and there was also a pustule on the nose, andthree nodes on the skull .Mr. Hutchinson compares this case with another hehad described in an earlier number of the " Archives "(October, 1889, p. 110). These two cases resembled oneanother, in that in both the infant was perfectly healthyup to the time of vaccination ; the lymph used was nottaken from the human subject, the skin around thevaccination sores passed into gangrene, with at the time1 Allbutt's " System of Medicine," vol . ii. , p. 604. London. 1897.318 INJURIOUS results OF VACCINATION.a large glandular swelling in the armpit. There werealso periosteal swellings of considerable size on the skullbones, suspicious sores on the skin ; and both patientsappeared to be much benefited by mercurial treatment.Mr. Hutchinson says-" It is obvious that these twocases give mutual support to the belief that no accidentalcontamination of the calf lymph by syphilitic secretionsoccurred. This was a suggestion which, although therewas not the slightest evidence in its support, it wasdifficult to wholly exclude in an isolated case. It is,however, improbable in the highest degree that such anaccident should occur in two cases, and in each shouldbe followed by precisely similar results ." There remains then the question : Were these infantsthe subjects of a latent inherited taint which vaccinationroused into activity ? In neither case was there theslightest evidence that either parent had suffered fromsyphilis, and in neither had the infant prior to vaccinationshown any symptoms. In one case the child wasa first- born , but in the other there was a healthy elderchild." The final supposition is that it is possible for vaccinationindependently of any syphilis, whether implantedor hereditary, to evoke symptoms which have hithertobeen regarded as peculiar to the latter malady, andwhich are apparently greatly benefited by specific treatment.On this point we must hold our minds open tothe reception of further evidence."A case perfectly parallel with the above-mentionedand the Leeds case was that described by Dr. FrederickTaylor and Mr. Edmund Fyson before the Royal Commission( Sixth Report, pp. 196-198). Every possibleDISASTERS IN THE AMERICAN CIVIL WAR. 319precaution appears to have been taken. The infant wasin good health. Dr. Renner's calf lymph had been used,and the needle with which the child was vaccinated hadnever been employed before. Gangrene of the pocksensued, and also gangrenous spots in other parts, andthe case terminated fatally.When it is said that vaccino-syphilis is rare, it mustbe remembered that these and other cases similar haveonly recently been published, and until further informationis forthcoming, it would be hazardous to assertthat a general introduction of calf lymph would rid usof the danger of vaccino-syphilis ; indeed, it remains tobe proved that by the repeated transmission throughthe bovine species, cow- pox will not again acquire muchof its old character. Before the Royal Commission, Dr.Cory gave his experience of 32,002 vaccinations performedat the calf lymph station ; 323 cases returnedfor complaint, 260 of which had sore arms , and Dr.Cory gave it as his impression that you got more sorearms after using calf lymph than from the humanisedvariety. This experience has been borne out by othercompetent observers .1Before concluding the evidence under the heading of" Syphilis, " I wish to allude to the disastrous consequencesof vaccination in the American Civil War( 1861-65 ), in which some hundreds of men were affectedwith a disease presenting all the characters of syphilis .The facts are related by Dr. Joseph Jones, andthe conditions described were truly frightful. The1 In this class of cases there was unwillingness of the sore to heal, andsome induration. Q. 4,377, 4,380.320 INJURIOUS RESULTS OF VACCINATION .symptoms included phagedenic ulcers, with induratedand everted edges, secondary skin affections, ulceratedthroats, loss of hair, and other phenomena distinctiveof syphilis. In some cases the gangrenous ulcerscaused extensive destruction of tissue, exposing arteries,nerves, and bones, in many cases necessitatingamputations.Dr. J. T. Gilmore, in a letter to Professor F. Eve,referring to three hundred cases in the Georgiabrigades , remarked-" The cases presented the appearancesthat are familiar to those of us who were connectedwith the Confederate army-large rupia- lookingsores, sometimes only one ; generally several on thearm in which the virus was inserted. In a number ofcases these sores extended, or rather appeared on theforearm, and in two cases that I saw, they appeared onthe lower extremities. The men suffered severely fromnocturnal rheumatism. Several cases had, to all appearances,syphilitic roseola. I saw enough of thetrouble to convince me thoroughly that the virus owedits impurity to a syphilitic contamination. " יDr. James Bolton testified that " on careful inspectionthe ulcers presented the various appearances of genuinechancre. In some instances there was the elevated,cartilaginous, well-cut edge surrounding the indolent,greenish ulcer ; in others there was a burrowing ulcer,with ragged edge ; in others there was the terribledestructive sloughing process devastating the integumentsof the arm. Many of the cases were so situated1 " Medical and Surgical Memoirs," vol. iii . , part 1 , p. 466. JosephJones, M.D. New Orleans.DISASTERS IN THE AMERICAN CIVIL WAR. 321that their history could be preserved, and in thesesecondary symptoms appeared, followed in due time bytertiary symptoms. The chancre was followed successivelyby axillary bubo, sore throat, and various formsof eruption ( syphilis dermata), while the system fell intoa state of cachexia. " ¹Dr. E. A. Flewellen testified that " while the armyof General Bragg was at Tullahoma, I was medicaldirector, and I know that very great complaint wasmade to me as to the character of the vaccinationpractised in the army. A large number of men wererepresented as unfit for duty. I think that one divisionrepresented nearly a thousand men as unfit forduty on account of spurious vaccination. I saw anumber of cases in the early progress of the vaccination,but they presented nothing abnormal that I coulddetect. But, as it advanced, the cases seemed to havethe appearance very nearly of syphilitic rupia. It diffuseditself more or less over the whole surface. A largenumber of surgeons regarded it as a complication ofvaccinia and syphilis. Finally, they settled into theopinion that it was not syphilitic. There never was, Imay say, any settled opinion among the surgeons of theConfederate army as to what was the true character ofthis impure virus . " 2Dr. George H. Hubbard relates that on November 30,1863 , he arrived at Fort Smith, Arkansas, having beenappointed Medical Director of the Army of the Fron1 " Medical and Surgical Memoirs," vol. iii. , part 1 , p. 467. JosephJones, M.D. New Orleans.* Ibid. , p. 480.322 INJURIOUS RESULTS OF VACCINATION.tier. His attention was immediately directed to severalhundred men disabled in consequence of " spuriousvaccination. " A Medical Board was appointed to investigatethese cases, and they reported : "At thetime we examined the patients, some had well- markedHunterian chancre ; some had large excavated ulcers,with edges everted above the raw and surrounding induration;the centres, when not recently cauterised, wereofa brownish hue-some,whose primary ulcers were abouthealed, had secondary symptoms, such as swelling andulcerations of the glands in different parts of the body;while others had pain and stiffening of the joints. Thedisease was brought to the First Arkansas Infantry bydeserters from the Confederate army, and in ouropinion is syphilis. " ¹Dr. William F. Fuqua, formerly surgeon of the 7thFlorida Regiment, reported fifty- two cases in Confederatesoldiers who presented abscesses in the axillary glands,pains in the limbs and joints, ulceration of the throat,buboes, coppery-coloured eruptions, loss of hair, andthese symptoms were only relieved by anti-syphilitictreatment. The cases were attributed to inoculationwith virus from the arm of a sailor who was labouringunder syphilis .Although the annals of vaccination disasters do notfurnish any other records of vaccino-syphilis on sovast a scale as that which occurred in the AmericanCivil War, other disasters have been recorded of1" Medical and Surgical Memoirs," vol. iii. , part 1 , p. 483. JosephJones, M.D. New Orleans .2 Ibid. , p. 471 ." SPURIOUS VACCINATION " AT GRANITEVILLE. 323sufficient importance to demand special reference .Among these may be mentioned the cases of " spuriousvaccination " at Graniteville, related by Dr. W. F.Percival , and included in Dr. Jones' work. Dr. Percivalsays-" About the last of April, 1866, I was requestedto take charge of some cases of spurious vaccinationat the manufacturing village of Graniteville. Onehundred and fifty cases were presented for examination,men, women, and children of all ages, from fiftyyears to twelve months. The larger proportion wereoperatives in the factory, the others engaged in outdoorwork . There was every variety of constitution, fromthe pale, attenuated girl, to the hardy and robustlabourer. Of the hundred and fifty cases, ninety - threehad been previously vaccinated. The appearance ofthe sore was identical in every case, viz. , an excavatedulcer, of circular form, with raised and hardenededges and base. They varied in size, from one halfto two inches in diameter, covered with grey or darksloughy matter, and secreting unhealthy pus. Therewas no appearance of granulation . In some casesulcers of a similar character appeared on the armsaffected ; in others on the opposite arm, and in a fewon the lower limbs. In some, abscesses formed onthe inside of the arm, and in nearly all the axillaryglands were inflamed, and many suppurated. A thickand unhealthy crust would form, to be soon separatedby the pus which accumulated beneath. In one case,there was a copper-coloured eruption on the body andlimbs ; in two or three the hair dropped off. Noneof these cases were in the primary stage. The diseasehad existed from three to eight weeks. Most of them324 Injurious results OF VACCINATION.pursued their ordinary avocations, as far as possible,and complained of no constitutional symptoms, or anyloss of appetite. The history of these cases, as givento me by the individuals first vaccinated, was thatthey had obtained the virus from a man whom theyafterwards discovered to have had primary syphilis.One was vaccinated from the other, and so it spread.None of the ulcers had evinced any tendency toheal." 1 Dr. Percival adds that the usual treatmentfor venereal ulcers effected a cure in from three to sixweeks.I may also allude to the disasters resulting fromvaccination at Algiers in 1880.On December 30 fifty-eight recruits of the 4th Regimentof Zouaves were vaccinated from a child whichlooked perfectly healthy. They were all infected withsyphilis, and about half are reported to have died, theremainder being dismissed the service. No blamewas attached to the operating surgeon. Anotherseries which created a painful impression on the publicat the time was that of fifteen young school -girls whowere syphilised by vaccination at Lebus (Prussia) in1876.Leprosy.2There is considerable evidence that leprosy has beeninvaccinated, and the question has been raised as towhether some part at least of the recent spread of the1 " Medical and Surgical Memoirs," vol. iii. , part 1 , p. 478. JosephJones , M.D. New Orleans.2 Third Report, Royal Commission on Vaccination . Q. 9,540, 9,736.DR. HAWTREY BENSON'S CASE .325disease in certain countries is not due to the practice ofarm -to-arm vaccination. This has been so fully discussedin a volume entitled " The Recrudescence ofLeprosy " ¹ that it might be thought unnecessary tore-open the subject, especially as the facts which it isproposed to lay before the reader must be largely arepetition of what has been so exhaustively treated inmy father's work. The matter, however, is admittedlyof such serious and far-reaching importance that noaccount of the century's experience of vaccinationwould be complete which did not deal with the mainpoints of this question .It is not proposed to discuss the etiology of leprosy,except in so far as to show that it is a communicabledisease, and may be communicated by inoculation orby vaccination .There are instances on record of Europeans contractingthe disease in leprous countries, as, for instance,the case of Father Damien in Molokai, Father Boglioliin New Orleans, a French Sister of Mercy in FrenchGuiana, and another in Tahiti ; but perhaps the mostimportant case is that related by Dr. Hawtrey Benson.2An Irish soldier returned home from India, where hehad resided for twenty-two years ; a few months afterwardssymptoms of leprosy developed. The patientwas under Dr. Benson's care at the City of DublinHospital , but ultimately went home, where he died ofthe disease. During this last period of his life his1 " The Recrudescence of Leprosy, and its Causation." William Tebb.London. 1893 .* Dublin Journal of Medical Science , vol. Ixiii. , pp. 562, 563. (June,1877. )326 INJURIOUS results OF VACCINATION .brother slept in the same bed, and wore the leper'sclothes. The brother had never been out of Ireland,except once, forty-six years previously, when he spentsome time in England. He developed leprosy, andDr. Benson exhibited the case before the MedicalSociety of the College of Physicians, Ireland, whenthe diagnosis was confirmed by those acquainted withthe malady. In making his concluding observationsbefore the Society, Dr. Benson pointed out thatone fragment of positive evidence on the subject wasworth a vast amount of negative evidence.This case must be regarded as affording absoluteproof of the communicability of leprosy from person toperson.¹An experiment made on the condemned criminal,Keanu, by Dr. Edward Arning, is interesting from the1 For further testimonies seeBakewell . Q. 3,656 , Report from the Select Committee on the VaccinationAct ( 1867) . 1871 .Tilbury Fox. " Skin Diseases," third edition, p. 322. London. 1873.Vandyke Carter. " On Leprosy and Elephantiasis," p. 187, foot- note.London. 1874 .Macnamara. " Leprosy a Communicable Disease." London. 1889 .Moore. Journal of the Leprosy Investigation Committee, No. 1 , p. 28 .August, 1890.Francis. Ibid. , p. 56.Cayley. Ibid. , p. 36 .Murray. Ibid. , p. 46.Hanson. Ibid. , No. 2 , p. 64. February, 1891 .Report of the Cape of Good Hope Leprosy Commissioners , 1895 , vol .iv. , p. 101 .Report of the International Leprosy Conference, vol. ii. , pp. 191 , 192.Berlin . 1897 .2 Journal of the Leprosy Investigation Committee, No. 2, pp. 132, 133 .February, 1891 .THE INOCULATION OF LEPROSY . 327point of view of the possibility of the invaccination ofleprosy. The Hawaiian , who, at the time of the operation,was carefully examined by several physicians andpronounced to be in perfect health and remarkablystrong, was inoculated with a portion of a leprousnodule on the left forearm. A month later the mansuffered from rheumatic pains in the joints of the leftarm, and a painful swelling of the ulnar and mediannerves . In the course of six months a small leprousnodule was formed on the keloid spot where the inoculationtook place, and leprosy bacilli were detected atthe seat of the keloid scar for a period of sixteenmonths after the operation. Distinct symptoms ofleprosy were observed three years after the inoculation,and in another year the disease was at its full height.It may be mentioned that the patient was isolated fromthe day of the operation for three years afterwards. Ithas subsequently transpired that a son, a nephew, and acousin of Keanu's, have shown symptoms of the disease,but Dr. Arning, urges that at the time of the operation,Keanu himself was perfectly free from leprosy, and thatdistinct signs appeared three years afterwards , and atpresent ( 1891 ) furnishes a typical case of generalleprosy.Mr. C. N. Macnamara, ¹ in referring to a report on thiscase by Dr. N. B. Emerson, President of the Board ofHealth, and Mr. J. H. Kimball, Government physician ,Honolulu, says-" This report establishes unequivocallythe fact that the inoculated man has become leprous ;1 " Leprosy a Communicable Disease," second edition, p. 45. C. N.Macnamara. 1889.328 INJURIOUS Results OF VACCINATION .and as he had been inoculated three years previously,there is every reason to believe that the disease is theresult of the inoculation."Keanu has since succumbed to the leprous disease.The inoculability of leprosy once established, itscommunicability by arm-to-arm vaccination must beaccepted, and in order to throw some light on thesubject, Dr. Edward Arning vaccinated a number oflepers. He says-" These experiments lead to theresult I anticipated. In cases of extensive cutaneousleprosy, in which skin apparently healthy containsbacilli , these were likewise to be detected in thelymph ; but there were no bacilli to be found in thelymph taken from cases of pure Lepra nervorum, inwhich no trace of the bacillus is to be found in theskin. " ¹Other experiments have been recorded by Drs.Beaven Rake and G. A. Buckmaster. Most of thesewere negative, but we read that " Suspicious lookingrods taking fuchsin were seen in one case in vesiclesraised over tuberculated ears, and in another case invesicles over anæsthetic patches." Even if these resultshad all been entirely negative, it would hardly detractfrom the value of Dr. Arning's careful investigations .Further evidence of the communicability of leprosy byvaccination is furnished by cases which have beenrecorded from time to time.1Journal of the Leprosy Investigation Committee, No. 2, p. 131 .February, 1891 .2 Ibid. , No. 4, p. 34. December , 1891 .SIR WILLIAM GAIRDNER'S CASES. 329The instances which have probably attracted the mostattention are those related by Sir William Gairdner inthe British Medical Journal of June 11 , 1887 (vol. i. ,pp. 1269, 1270), in an article entitled " A RemarkableExperience concerning Leprosy; involving certain Factsand Statements bearing on the Question-Is Leprosycommunicable through Vaccination ? " The case asstated by Sir William Gairdner is as follows :-" The time seems to have arrived when, without injury or offenceto anyone concerned, it is possible to bring under the notice of mymedical brethren some facts, and some inferences arising more orless directly out of the facts, in a case which occurred to me someyears ago, but which I have found it necessary hitherto to dealwith as involving matters of professional confidence not suitablefor publication. Even now I shall deem it expedient to frame thismere narrative in such terms as shall not point to any definitelocality, or to any recognisable person, among those chiefly concerned; although, by a formal certificate granted only the otherday, I feel, as it were, absolved from the last tie that bound me, evenunder the most fastidious sense of professional duty, to reticence." Six or seven years ago the parents of a young boy, fairlyhealthy in appearance, but with a peculiar eruption on the skinbrought him to me, and along with him a letter from a medicalgentleman whom I had entirely, or almost entirely, forgotten, butwho stated himself to have been a pupil of mine in Edinburghconsiderably over twenty years before. It is unnecessary toenlarge on the particulars of this case further than to state thatafter more than one most careful examination, in which I hadthe assistance of my colleague, Professor M'Call Anderson, wecame to the conclusion which we announced to the parents,that the boy was suffering from incipient, but still quite wellmarked,leprosy in its exanthematous form ; a diagnosis afterwardsamply confirmed. What struck me at the time as most peculiarwas, that this case, coming from a well-known endemic seat ofleprosy (an island within the tropics) and with a letter involvingmedical details by a medical practitioner of many years' local22330 INJURIOUS results OF VACCINATION.experience ; sent to me, moreover, for medical opinion andguidance, should not have been more frankly dealt with by adiagnosis announced even to the parents, before they left theisland. The father of the child was a sea-captain constantlyengaged in long voyages for the most part between this countryand the island alluded to. Both father and mother were Scotch,and there were several other children, all reported as quitehealthy, as also were both the parents. Under these circumstancesI wrote to the medical man-who in the sequel may becalled, for brevity, Dr. X.-simply stating the diagnosis arrivedat, and indicating the line of treatment proposed. The parentswere informed that it would be best for the child to live in thiscountry, and his mother agreed to remain with him accordingly.And, as they appeared anxious to have every available suggestionand advice, I mentioned the name of Dr. Robert Liveing ashaving given much attention to the subject, and offered to writeto him if they would take the boy to London, as they appeareddesirous of doing. Although I wrote to Dr. Liveing, circumstancesunknown to me led to a change in their plans, and, instead ofgoing to London, they went to Manchester, where I believesome physician was consulted, but I do not remember who hewas. Ultimately, the mother determined for a while to settlein Greenock, and I placed her accordingly in communicationwith Dr. Wilson of that town, who for some time thereafterremained in medical charge of the case ." Meanwhile, the course of post brought me in a few monthsa reply from Dr. X., not only entirely assenting to our diagnosisas communicated to him, but stating that he had been perfectlywell aware from the first of the case being one of leprosy, buthad deliberately chosen not to affirm the fact or even to alludeto it in any way, either in his communications with the parentsor in his letter to me. No reason was assigned for this (as itappeared to me) very remarkable reticence ; but, as I did notwish to have the credit of having discovered for the first timewhat a gentleman so much more familiar with the disease mighthave been supposed to have overlooked, I took means to informthe parents of Dr. X.'s reply, and of his having been all alongof the same opinion with regard to the disease as we were.SIR WILLIAM GAIRDNER'S CASES. 331"After this the matter passed out of my mind, and for severalyears I neither saw nor heard of this child except accidentally,and in a way entirely to confirm first impressions. About threeyears ago, however, while engaged in lecturing on specific diseases,and among others, briefly, on leprosy, I made an effort to find outsomething more about this patient. The mother had removedfrom Greenock, and had brought over the whole family to Helensburgh,where, as I learned, they were visited by Drs. Reid andSewell, and from the latter I now learned that the poor boy hadgone steadily to the worse, and was extremely feeble, coveredwith sores, and in a most deplorable condition physically, but stillreceiving every attention and care that constant medical treatment,with the most faithful and loving maternal nursing, couldafford to lighten his sufferings. I accordingly proposed, withinthe next few days, a visit to my old patient as a matter of satisfactionto myself. Unhappily there was no other apparent object,either as regards diagnosis or treatment, for a visit which was,nevertheless , very gratefully accepted." The case was now in the most advanced stage of leprosy,proceeding to mutilation of the extremities, and accompanied notonly by external sores, but presumably by internal lesions, whichhad reduced the patient to the last stage of emaciation. It wason this visit that the curious particulars now to be related werefirst brought to my knowledge by Dr. Sewell, and afterwards confirmedby the statement of the mother, showing very clearly,though, of course, upon second-hand information to a certainextent, that Dr. X. had a very special reason for his extraordinaryreticence in the first instance. Her husband, who in his frequentvoyages had opportunities of coming into communication withDr. X., had remarked to him how very strange it was that, evenin writing to a medical man about the case, he had given no hintof his opinion about it. The doctor's reply to this was, in theend, to the effect that he had kept silence because he did not wishto compromise a boy of his own, whom he ( Dr. X. ) believed to bea leper, and from whom he believed at the time that the boy hehad sent to this country had become infected with the disease.He further explained that he had vaccinated his own boy withvirus derived from a native child in a leprous family, and, as I332 INJURIOUS RESULTS OF VACCINATION.understood(though perhaps not definitely so stated), that leprosyhaddeclared itself in the native child after the vaccination ; and,further, that (using his own child as a vaccinifer) he had vaccinatedour patient directly from him. Before sending the lastnamedpatient away with his parents, he had satisfied his ownmind not only that his own boy was leprous, but that he had inthis way become the source of the disease to another; but thedisease in his own child being in a very mild form, he was anxiousnot to disclose its existence. Meanwhile Dr. X. had died ; hisestate had passed into the hands of trustees ; and I was informedthat this reputed leper-boy had been, under the instructions of hisfather and his guardian, placed and retained at a public schoolwell known to me in this country, and that the boy was pursuingthe usual course of a public school education, in entire unconsciousnessof the disease with which he was supposed to be affected." This information, so communicated, placed me in rather adifficult dilemma, namely was I justified in taking steps toascertain the truth of the story as regards Dr. X.'s boy, either bypersonal investigation or, at least, by inquiries conducted so as toresult in a well-grounded and scientifically exact opinion as to thefacts ? And, further, supposing that such opinion should turn outto be that Dr. X.'s boy was a leper, was it a matter of duty onaccount of others to formally disclose the fact, be the consequencesto the boy what they might ? It was hardly probable that a boygenerally known to be a leper would be retained permanently inany public school in this country, even had it been unquestionablya matter of medical doctrine that such a proceeding was quitesafe. On the other hand, the boy was receiving the benefits of anEnglish education at the express wish and on the responsibility ofhis father and guardian, and without (so far as appeared) anymisgivings on the part of anyone. He was an orphan, and inwhat was to him a foreign land ; his remaining under instructionmight be, and probably was, a matter of the greatest possibleimportance to him. To bring him, therefore, even by an indiscreetinquiry, under the ban which in many or most countries stillattaches to leprosy was certainly no part of the business of an outsider,and could only be justified at all by an overwhelming senseof duty to others .SIR WILLIAM GAIRDNER'S CASES. 333" Under these circumstances I thought it well to consult,privately, one or two of those friends in London whom I believedto know most about leprosy, and among others Dr. Liveing, whomI was able to remind, at this stage, of my previous letter. Thesefriends concurred in assuring me that, in the rather improbableevent of their being personally consulted as to the retention of aleper in a public school ( it being presumed, of course, that he wasphysically fit otherwise), they would have no hesitation at all inaffirming that the other boys would not be endangered by suchproceeding. As I happened to be very well acquainted with oneof the medical officers (though not the ordinary medical officer) ofthe school in question, I communicated these opinions to him, andstated to him at the same time the extraordinary circumstanceswhich had begotten, for me, such a lively interest in the son ofDr. X. In the course of a few days I was informed that an inquiryhad been held by the medical staff ; that the boy had been sent forand privately examined (though not ostensibly ill in any sense) ;and that it was, beyond all doubt, considered to be a case ofleprosy. The medical authorities decided, however, that underthe circumstances it was not their duty to sound the alarm, or inany way to disturb the boy's education ." From this time onwards (except the death of the first patientsoon afterwards) I heard nothing more of these matters till a fewweeks ago, when I was asked to see Dr. X.'s son professionallyon behalf of the school authorities ; and, if so advised, to requestDr. Anderson also to give an opinion as to the present state ofhealth of this young man, who happened at the time to be visitingsome friends in Glasgow. It was represented to me that he hadmaintained, on the whole, fairly good health since I last heardof him through my medical friend, and had not been incapacitatedfrom school work except on account of a contagious eczemawhich had been prevailing, and with which he had been affectedin common with other boys. Apparently, however, the opinionhad arisen that his general health was not quite so good, andthat in view of a cutaneous affection of this kind, apparentlycommunicable, existing, it was no longer expedient that he shouldremain at the school. Indeed, I could not but come to theconclusion that his removal, on public grounds, had been practi334INJURIOUS results OF VACCINATION .cally settled ; and, with every desire to soften the blow as muchas possible to the poor boy, it was felt to be necessary that hisguardian, at least, should receive unequivocal and unbiasedtestimony as to the actual state of the facts and circumstancesunder which the decision was arrived at . Under these circumstancesI saw and examined this boy, and made a report, alongwith Dr. Anderson, to the effect that the disease was evidentlyleprosy, though of a remarkably mild type, as shown by discolourationsand cicatrices, and also by large anesthetic areason the back of one limb. All breaches of surface, however, andall discharge had ceased at the time of our report, and Dr.Anderson felt still in a position to affirm that no danger to otherscould occur from the boy's remaining at school. On this lastpoint I did not feel able to give an unqualified assent to mycolleague's opinion ; but as regards the matters of fact andobservation there was no doubt whatever, and our report accordinglyon these was substantially as above. "In a subsequent communication, Sir William Gairdnersays-" Dr. X. confessedly vaccinated his own child froma leprous family, though probably not from an actual orapparent leper, and then vaccinated the ' sea -captain'sboy ' from his own. " ¹Mr. C. N. Macnamara, in alluding to these and othercases of a similar kind, remarks that they " seem torender it probable that leprosy may be conveyed froman affected to a healthy person in vaccine lymph ; andin localities where leprosy is endemic, we should becareful as to the source from which vaccine lymph isobtained . " ?One of the earlier references to the subject was bySir Ranald Martin, who says, " The dangers to Euro-British MedicalJournal, vol. ii . , pp. 799, 800. ( October 8, 1887. )* Art . on Leprosy in Davidson's " Hygiene and Diseases of WarmClimates, " p. 445. London. 1893 .SIR RANALD MARTIN'S CASE . 335peans arise chiefly from vaccination, and from wetnursing.I felt that very early in my career in India,and I took the precautions which are here recorded.I saw an English lady last year in a horrible condition(she said), from having been vaccinated from a leprousnative child. " יDr. Hall Bakewell, who has occupied the position ofVaccinator-General and Medical Superintendent of theLeper Hospital at Trinidad, also alluded to cases beforethe Select Committee of the House of Commons in1871 ( Q. 3,564). " I have seen several cases in whichit (vaccination) seemed to be the only explanation. Ihave a case now under treatment of the son of a gentlemanfrom India who has contracted leprosy, both theparents being of English origin. I saw the case of achild last year who, though a creole of the Island ofTrinidad, is born of English parents, and is a leper,and there is no other cause to which it is attributable."Mr. John D. Hillis gives the following cases, in whichhe says there could be no doubt the disease was producedby vaccination." Joseph Francis C-, a fair Portuguese, born inDemerara, now aged twenty years. His parents arealive and healthy. He has been suffering for the lastten years from tuberculated lepra. He has a sister,aged eighteen years, at present (1879) an inmate ofthe Asylum, suffering from the same form of leprosy.They were both admitted on July 30, 1877, from MurrayStreet, Georgetown. They have three sisters and one1 Report on Leprosy by the Royal College of Physicians , Appendix,p. 227. London. 1867 .336 INJURIOUS RESULTS OF VACCINATION.a reddishbrother,who are alive and well. Our patient, J. F. C-,and his sister were vaccinated with lymph obtainedfrom a member of a Portuguese family' in whomleprosy was afterwards found to exist. They werethe only members of the C- family vaccinatedwith this lymph. Within eighteen months of theperformance of the operation by Dr.brown spot appeared on the inner side of the rightthigh, preceded, it is stated, by some constitutionaldisturbance ; this spot was raised and tender, accompaniedby profuse sweating all over the body, andremained for some time. Subsequently other spotsmade their appearance on the right buttock (whichdisappeared shortly after), between the shoulders, andon each cheek. They were all ushered in by moreor less well-marked febrile symptoms. A red patchnext appeared on the forehead, and epistaxis set in,periodically occurring to this day. Tubercles thenmade their appearance on the face, the other patchescontinuing to increase in thickness and roughness, andforming tubercular infiltration. The latter was removedby gurjun oil, under which treatment many ofthe symptoms were ameliorated."" State and Condition on November 30, 1879.-He hasa light -brown irregular patch on the front of his chest ;this has been larger, thicker, and mahogany-coloured,and has evidently undergone partial absorption. Thereis a patch of tubercular filtration on the back of thearms, and at the bend of the elbows. The fingers areMr. Hillis says, " It is within the knowledge of Dr. Manget, Surgeon-General, and the author, that this family are at present afflicted withtuberculated lepra. "MR. HILLIS' CASES. 337swollen, shining, and dark-looking, a solitary tubercleforming on the back of the hand. The swollen conditionof the fingers and hands is very characteristic.There are two tubercles on each cheek, the size of largemarbles ; the lobes of the ears are thickened , and atubercle is forming on the upper tip. There is noappearance of hair growing on the face. There arereddish- brown discolourations on the front and back ofthe legs. There are a few small scattered tubercles onthe dorsum of the feet, and the lower part of the legsare swollen and hard to the touch . There are tubercleson the scrotum, an ulcer on the leg where a tuberclehas ulcerated, and the larger tubercles are slightlyanæsthetic. This young man is one of the carpentersof the institution ; he is in hopes the treatment nowbeing adopted may yet arrest the disease which is,however, making slow but sure progress. "Mr. Hillis quotes the following case from a work byDr. Piffard, of New York :-" William T-, aged twenty- five years, was admittedinto Bell Hospital in May, 1864. He was of Englishparentage, but was born and passed his early life inBritish Guiana. After a vaccination performed whenyoung, his arm became greatly swollen and inflamed,and large sloughs separated. Investigation revealedthe fact that the vaccine virus had been taken from anegro whose mother was a leper. At the age of sevenyears some brownish spots appeared upon his back andarms ; and at the age of eleven a blister formed on the1 " Leprosy in British Guiana," p. 30, 31. London. 1881 .* Ibid. , p. 208 .338 INJURIOUS RESULTS OF VACCINATION .palm of the right hand, followed by permanent contractionof the flexor tendons. A few months later hefelt a tingling sensation around the nail of the rightindex finger, followed by a line of suppuration and lossof the nail. The finger soon healed, but the samemorbid process separated itself in the other fingers ofthe same hand. After a few months, according to hisstatement, the skin of the distal phalanges split, andthe flesh shrank away from the bones, leaving themexposed. The bones separated at the joints and thestumps healed. These various processes occupiedeighteen months or two years . The disease thenaffected the distal phalanges of the left hand in thesame manner. After this it attacked the right foot,and a slough formed over the lower part of theinstep. The great toe then became swollen, the skinsplit, and its distal bone separated, then, withoutmuch regularity, the remaining phalangeal bones offingers and toes necrosed and came away. "Sir Erasmus Wilson relates a case in the 1867 Reportof the Royal College of Physicians ( Appendix, p. 235 ).Elephantiasis tuberculosa ; duration of latent period, twoyears ; total duration, five years ; no pains ; febrileattack simulating rubeola ; vaccinatedfrom a nativechild." A young gentleman, aged sixteen, with fair hairand complexion, and somewhat more youthful in appearancethan might be expected of his age, has beenafflicted with the tubercular form of leprosy about fiveyears. He was born in Ceylon, is the son of Europeanparents, and one of six children, all of whom areOPINION OF THE COLLEGE OF PHYSICIANS. 339healthy. His father and mother have always enjoyedgood health, the father having resided in Ceylon fortwenty years, the mother since her marriage. He wasnursed by his mother, but vaccinated with lymph takenfrom a native child." ( For detailed description ofsymptoms, see Physicians' Report. )The College of Physicians, in their Report (p. lxxiv. ,foot -note) , refer to the evidence of Sir Erasmus Wilsonand Sir Ranald Martin thus : " The question alluded toin the communications from Mr. Erasmus Wilson andSir R. Martin (vide Appendix) as to the transmissionof leprous disease by vaccination and wet-nursing, isone of special interest to Europeans resident in Indiaand other tropical countries, and calls for a searchingexamination."The following case of Elephantiasis anæsthetica isalso recorded by Sir Erasmus Wilson.¹" A lady, aged twenty- six, the wife of an officer of theIndian army, became affected with elephantiasis in 1861 .She was born in Calcutta of European parents, andbrought to England when two years old ; she returnedto India in 1853 ; was married in 1855 ; has been eightyears married, and has now ( 1863 ) revisited Englandfor medical treatment, the length of her residence inIndia being ten years. In 1861 , being then in Oude,she was vaccinated from a native child, and shortlyafter the vaccination ' a slight spot came on her cheek,and increased in size to the diameter of a shilling.' Itwas hard to the touch, a little raised above the level of1 " Diseases of the Skin," sixth edition, pp. 620-622. Erasmus Wilson,F.R.S. London. 1867 .340 INJURIOUS Results OF VACCINATION .the surrounding skin, and of a dull red colour, withoutpain or tenderness. The swelling was painted withiodine, and afterwards blistered several times, and theblister kept open ; but although somewhat reduced insize, the prominence was not removed. About sixmonths later, dull red flat spots appeared, dispersedover the greater part of her body. Her hands and feetbecame swollen, and she had pains of some severity inher joints and feet. "The following cases were published in an article byDr. Daubler in " Monatshefte für praktische Dermatologie," February 1 , 1889, vol. viii ., pp. 123-129.Case 1. Mrs. H-, from W-, thirty-six years ofage, married , and the mother of a healthy child oftwelve. The closest inquiries established beyond doubtthat her family was quite free from leprosy. Severalyears previously, in consequence of an epidemic ofsmall-pox, she was re-vaccinated. During the twomonths immediately following re-vaccination she experiencedattacks of shivering three to five timesweekly, was thirsty, but passed less urine than usual ;at the same time the vaccine wounds swelled andbecame brown, and the patient experienced greatlassitude. The patient had been vaccinated in threeplaces on each arm over the insertion of the deltoid,and when she saw the medical man two and a halfmonths after vaccination the vaccine wounds wereswollen. The swelling had been noticed on the thirdday after vaccination, and reached its greatest heighteight days afterwards. At this time the parts becameyellowish, and fourteen days after vaccination aroundeach of the vaccine cuts there was a raised yellowishDR.DAUBLER'S CASES. 341brown discolouration of the skin of the size of a twoshillingpiece. These patches gradually became flatterafter about five weeks from the date of vaccination, butincreased in area, and when seen by her doctor tenweeks after vaccination the skin of the arms and ofthe upper third of the forearms was brown in colourand wrinkled. The brown spots extended still further ,and after three more weeks, during which time she wasfeverish and ill, the patches became smaller and smaller,but the skin never regained its normal colour. In thefourteenth week after vaccination she had a severerigor, which was twice repeated during the followingweek ; subsequently the attacks of fever were lessfrequent and violent. At and shortly after the timeof the most severe rigors brownish spots appearedon the forehead and cheeks . Eighteen weeks aftervaccination tubercles developed on the brow andshortly afterwards on the cheeks. Two years laterthe woman was sent to the leper asylum at RobbenIsland, where she was seen and photographed byDr. Daubler, tubercular leprosy having fully developed.Dr. Daubler here gives a minute description of thesymptoms, and with regard to vaccination he says thatthe old vaccination scars were visible, but there werenone from the re-vaccination which took place threeand a half years previously, as there were then nopustules formed, but only swelling and discolourationof the skin occurred .Case 2. R. du Toit, a half-caste girl, aged fifteen,also from W-, and in whose family no cases of leprosyever occurred. The patient stated that she had always342 INJURIOUS RESULTS OF VACCINATION .been healthy till vaccination, which was performed bythe same doctor, and at the same time as Mrs. Н—.At first the same local appearances were noticed on thearms as in the case of Mrs. H-, but after two months,prominent dark patches appeared on the forehead andcheeks, and after three months more leprosy was fullydeveloped on the forehead. When seen and photographedby Dr. Daubler, the disease had lasted threeand a half years. Inquiries made in W- (the domicileof the two patients), and also from the doctor who performedthe vaccinations, showed that the person fromwhom the lymph was taken to vaccinate these twopatients had died a short time previously from tubercularleprosy, other members of the family being leprous ,facts of which the doctor was , however, ignorant.Concerning the question as to whether vaccinationis responsible to any extent for the spread of leprosyin certain countries, the following from Dr. EdwardArning is not without interest : -" Another point which requires our notice regardingthe Hawaiian leprosy epidemic, and which was speciallyraised by the late Dr. Hillebrand ' Has leprosy beenspread in that island by means of universal vaccination ? '" There can be no doubt as regards the synchronousnessof the diffusion of leprosy and the introduction ofvaccination into the Hawaiian Isles ; but it still remainsan open question whether it is possible to form a positivecausative connection between the two. I find that thefirst authentic record of leprosy cases dates from theyear 1830, though the terrible diffusion of the diseaseover the whole group of islands occurred twenty- fiveyears later, at a time when a severe small -pox epidemicDOES VACCINATION SPREAD LEPROSY ? 343was raging. This occasioned universal vaccination,which, however, was performed in a careless way, andprincipally by laymen. And it is this fact that Hillebrandand others consider the foundation for theirargument regarding the diffusion of the disease bymeans of vaccination . We do not desire to overlookthis fact of simultaneousness, but we are able to giveit a different explanation. When we consider thatcases of well-defined leprosy existed in 1830, we mustnecessarily date the importation of the disease somefew years earlier. During the subsequent few yearswe perceive that the disease gradually expanded aroundthe centre of origin. The explanation of the apparentsudden diffusion of the disease at the beginning of 1850,must lie in the fact that leprosy is essentially a familydisease, though possibly neither congenital nor hereditary.A sufficiently long time had elapsed from thetime of the importation of the disease down to theperiod in question, to enable a new generation to springup; and this new generation formed new families, andfrom each of these individual centres leprosy was againdiffused . Moreover, we must bear in mind the immenseinfluence which from 1830-1850 the introduction ofcivilisation , and the influx of a great Mongolian andCaucasian population must necessarily have had uponthe natives. There is another observation bearing uponthe connection between leprosy and vaccination, whichI consider of still greater importance. This dates froma later period in which no concomitant factors, as in theabove, come into play." I am able to state-having excellent authority forso doing, though unfortunately no statistics-that a344 INJURIOUS RESULTS OF VACCINATION .very remarkable local accumulation of fresh leprosycases took place in 1871-72, in a place called Lahaina,on the Island of Mani. This happened about one yearafter a universal arm-to-arm vaccination, which had beenmost carefully performed. About fifty to sixty casesoccurred suddenly in this locality, which up to that timehad been comparatively free from the disease." 1Dr. Arning emphatically condemns arm-to-arm vaccinationin leprous countries. He says-" When in Hawaii I attended a German boy, agedtwelve, who suffered from leprosy, from whom when hewas seven years old several white families had beenvaccinated. I am not able to assert that leprosy wasspecially diffused on account of this, but still I considersuch a fact to indicate that an arm-to-arm vaccinationshould be prohibited in countries in which leprosyabounds." 2In a recent essay by Dr. James Cantlie, we havefurther corroboration that in the Sandwich Islands andelsewhere, the spread of leprosy has to a certain extentbeen caused by vaccination. A series of questions weresent out to a number of authorities in China, Indo-China, Malaya, the Archipelago, and Oceania, andamong them it was asked , " Has leprosy increased withthe use of vaccination ? "Among the replies are the following importanttestimonies :-Dr. Macdonald, of Fatshan, near Canton, says, " Ithink leprosy is on the increase with the increasing1Journal of the Leprosy Investigation Committee, No. 2, pp. 130, 131 .February, 1891 .2Ibid. , pp. 131 , 132.DOES VACCINATION SPREAD LEPROSY ? 345population of the country, and that vaccination is aslight factor in the increase. Lack of efficient segregation,however, accounts for most of it." ¹With regard to Swatow, Dr. Anna Scott reports(p. 308)-" I answer a most emphatic ' yes ' to thisquestion. The increase of leprosy among children isfrequently remarked upon by our (mission) people, andI have been forced to the conclusion that vaccinationfrom arm to arm, practised by a class of Chinese(quack) doctors, has caused this very marked increase."Dr. Albricht, of Sourabaya, Java, writes (p. 358)-" I cannot bring decisive proof that there is a connectionbetween vaccination and leprosy, but the tendency ofbelief is in that direction. "With regard to Hawaii, Dr. C. B. Wood writes (pp. 375,376)-" A number of years ago, when arm-to-arm vaccinationwas practised, it undoubtedly helped to spreadleprosy. All vaccine now used is imported, hermeticallysealed. " And Mr. Richard Oliver reports to the sameeffect (p. 376)-" In years gone by vaccination undoubtedlycaused increase of leprosy, owing to thelymph being obtained indiscriminately and carelessly."With these important testimonies from responsibleofficials, it is difficult to resist the conclusion that vaccinationhas acted as a factor in the spread of leprosy.Erysipelas.Erysipelas and allied septic conditions are perhapsthe most frequent of the more serious complications of1 " Prize Essay on Leprosy," p. 305. Thompson and Cantlie. NewSydenham Society. London. 1897.23346 INJURIOUS RESULTS OF VACCINATION .vaccination. The recorded deaths from " erysipelas aftervaccination " in England and Wales for the years 1859-80are as follows. Since 1880 the deaths from " erysipelasafter vaccination" have been merged into the generalheading of " Cow-pox and other Effects of Vaccination. "Deathsfromerysipelas aftervaccination.Year.Deathsfromerysipelas aftervaccination .Year.18591860... ... 5 1870 20... ... 3 1871 ... 241861 2 ... 1872 16...1862... ... 3 1873 ... ... 191863 ... ... II 1874 ... ... 291864 ... 13 1875 ... 371865 10 ...... 1876 21......1866... 10 ... 1877 ... ... 291867 ... ... 4 1878 ... ... 351868 ... ... 9 1879 ... ... 321869 ... 191880 39Itmust not be assumed that these deaths are all thathave occurred from "erysipelas after vaccination "during the period named. This matter will be furtherdiscussed in a subsequent part of the present chapter.The early descriptions of cow-pox seem to show thata certain amount of inflammation is a part of the diseaseitself. Jenner, in his account of the vaccination of hisfirst case, Phipps, describes an efflorescence spreadinground the incisions, which had more of an erysipelatouslook than was commonly seen when small-pox was inoculated.Again, he says :-" In calling the inflammation,that is excited by the cow-pox virus, erysipelatous,perhaps I may not be critically exact, but it certainlyapproaches near to it. " ¹1 " Further Observations on the Variola Vaccina, or Cow -pox ," p. 61 .Edward Jenner , M.D. , F.R.S. London. 1799.COW- POX AND ERYSIPELAS. 347Jenner records an instance in which an extensiveinflammation of the erysipelatous kind appeared withoutany apparent cause upon the upper part of the thigh ofa sucking colt." The disease was communicated to aherd of cows, and thence to milkers ; and produced inthem true cow-pox. Jenner's writings, however, do notappear to inspire that confidence which we might haveanticipated, and thus it may be thought advisable tosupplement his evidence. One of the leading Germanauthorities, Bohn, concluded that " the lymph of a trueJennerian vesicle, pure and clear, is therefore endowedwith a power of engendering erysipelas." 2 I may alsomention that Unna, in his work on the pathology ofthe skin, in describing a normal vaccination with animallymph, talks of the contents of the pock on the ninth ortenth day as " seated on a deeply- reddened, erysipelaslike,swollen base."The following are a few of the cases of vaccinal erysipelaswhich have been described from time to time : —In the American Journal of the Medical Sciences forOctober, 1850, Mr. W. Morland, the Secretary of theBoston Society for Medical Improvement, gives extractsfrom the records of the society, relating to erysipelasfollowing vaccination, and reported on by medical men.Eleven cases were given, three being fatal ; of the eight1" An Inquiry into the Causes and Effects of the Variola Vaccina,"p. 72. Edward Jenner , M.D. , F.R.S. London. 1798 ." Handbuch der Vaccination," p. 174. Leipzig. 1875-" The Histopathology of the Diseases of the Skin," p. 449. By Dr.P. G. Unna. Translation from the German by Norman Walker, M.D. ,F.R.C.P. , Ed. Edinburgh and New York. 1896.* American Journal of the Medical Sciences, N.S. , vol . xx. , pp. 318-321 .348 INJURIOUS RESULTS OF VACCINATION .non-fatal ones, four were very severe, of which threewere attended with extensive sloughing.In the Dublin Medical Press¹ of April 25, 1860, Dr. J.Smith Chartres related that in the previous October hehad under his care four cases of severe phlegmonousinflammation of the upper extremity occurring aftervaccination ; in one instance the destruction of thetissues was so extensive as to necessitate amputation.Mr. J. W. Wells, in the Lancet of May 30, 1863 (vol. i. ,pp. 618, 619), relates the case of a lady, aged 55 years ,who underwent re-vaccination ; symptoms of phlegmonouserysipelas developed on the following day, andshe died four days after the operation .In 1876 there was an official Inquiry at Gainsboroughby Mr. Netten Radcliffe, of the Local Government Board,into cases of erysipelas following vaccination, of whichsix died ; a searching investigation failed to dissociatethe operation from the fatal erysipelas .In 1882 another Local Government Board Inquirywas held by Mr. Henley and Dr. Airy at Norwich intocertain deaths alleged to have been caused by vaccination.It was shown that eight children suffered fromerysipelas " due to some abnormal peculiarity or contaminationof the lymph' ; " 2 of these, four died .3On the 25th May, 1883, sixty-eight recruits werevaccinated at Dortrecht, Holland. Of these seven were1 Dublin Medical Press, 2 S. , vol . i . , pp. 323 , 324.Copy of " Report to the President of the Local Government Boardby the Inspectors Appointed to Inquire into certain Deaths and Injuriesalleged to have been caused by Vaccination at Norwich," p. 9. ( Orderedby the House of Commons to be printed, 24th October, 1882. )Q. 9,465-9,468 . Third Report, Royal Commission on Vaccination.DR. VACHELL'S CASES. 349attacked with erysipelas, and three died. In consequenceof these cases, the Minister of War, Mr. Weitzel ,issued a circular notifying recruits that hereafter revaccinationwas not obligatory in the Netherlands army.Before the South Wales and Monmouthshire Branchof the British Medical Association, on November 15,1883 , Dr. C. T. Vachell, of Cardiff, related a series of caseswhere erysipelas followed vaccination. On November 1 ,a child, aged three months, and an adult were vaccinatedwith lymph obtained from London. On theeighth day the arm of the adult was much swollen andred. On the same day the child presented every appearanceof having been successfully vaccinated, and fivetubes were charged from it. On November 10 fivechildren were vaccinated from these tubes. On the 11thand 12th all these cases were attacked with erysipelas ofthe arm vaccinated, and , on inquiry, it was found thatthe child from whom the vaccine lymph had been takenwas attacked with erysipelas on November 9.The Lancet of November 24, 1883 (vol. ii., pp. 919, 920),relates on the authority of the Suffolk and Essex FreePress that two children named Elliston and Griggs werevaccinated on October 16. They remained well until theirvisit to the vaccination station on October 23, when oneof them supplied lymph for the vaccination of two otherchildren, and was noticed by the mother to have aswollen face at the time of leaving the station. Subsequentlythe vaccinifer and one of the vaccinees diedfrom erysipelas, as well as the other child vaccinated onthe 16th October.1 British Medical Journal, vol . ii . , p. 1213. ( December 15 , 1883. )350 INJURIOUS RESULTS OF VACCINATION.Dr. P. S. Fentem, in the Lancet of December 8, 1883(vol. ii., p. 1010), reports the following:-On October 2he vaccinated seven children from the same tube oflymph. Three of them developed symptoms of erysipelasabout the 'vaccination marks on the twelfth,thirteenth, and fourteenth days afterwards, and oneterminated fatally. He noted that the sanitary surroundingsin two of the cases were unsatisfactory, butattributed the erysipelas to a certain kind of soap usedto wash the clothes of the three children.Examples of acute septic poisoning occurred in thecourse of some vaccinations at Asprières (Aveyron) inthe month of March, 1885. An official report wasissued, from which it appeared that forty-two infantswere attacked, six of whom died. The symptoms ofthose who died comprised repeated vomiting, diarrhea ,great agitation, and, in two cases, convulsions. 'Among the older records of the Local GovernmentBoard are the following :-(1 ) A series of nineteen cases of erysipelas from vaccinationat Warrington, with five deaths, in 1871 .(2) A case of serious erysipelas from vaccinationwith National Vaccine Establishment lymph at StokeNewington in 1871 , in which inquiry elicited thatviolent inflammation had occurred in others vaccinatedwith lymph from the saine vaccinifer ; the vacciniferhaving an inflamed arm on the thirteenth day and asmall abscess in the axilla.1 Third Report, Royal Commission on Vaccination, Appendix, pp. 210-213." Royal Commission on Vaccination, Dissentient Commissioners' Statement,section 192 .VACCINAL ERYSIPELAS. 351(3) Six cases of serious inflammation and threedeaths in a series vaccinated with ninth-day lymphfrom one vaccinifer at Appleby, in 1873.(4) Several cases of erysipelas and inflammation, withfive deaths, in a series of vaccinations at Chelsea, in 1875 .(5) Twelve cases of excessive inflammation, six oferysipelas, with three deaths, two cases of axillaryabscess, and one large ulcer, in a series of vaccinationsat Plomesgate, in 1878.(6) Ten cases of erysipelas or abscesses, with fourdeaths, and several cases of eczema in a series of vaccinationsat Clerkenwell, in 1879, in which " it is clearthat the erysipelatous contagion was imparted at thetime of vaccination . "(7) Three cases of extensive erysipelas from vaccinationat Blandford, in 1883 .(8) Three fatal cases of erysipelas from vaccinationat Sudbury, in 1883 .Between the Ist of November, 1888, and the 30th ofNovember, 1891 , one hundred and thirty-two cases ofinflammatory or septic disease (mostly erysipelas)following vaccination and terminating fatally, were thesubject of inquiry by the Local Government Board.Numerous cases have also been investigated by theRoyal Commission on Vaccination, and are cited inAppendix ix. to their Final Report.Cases of erysipelas following vaccination are notinfrequently objected to on the ground that the diseasemust have been acquired subsequently to the act ofvaccination, and therefore, it is said, preventable.Doubtless many cases may be attributed to the carelesstreatment of arms, insanitary surroundings of the352 INJURIOUS RESULTS OF VACCINATION.patient, and other conditions not directly related to theoperation ; but the State which compels vaccination willhardly escape responsibility for these accidents ; and,from the conditions under which a number of our poorstill live, it may be doubted whether there would notalways arise cases of the description under consideration.Attempts have been made to distinguish these casesfrom those in which the lymph itself is at fault. It hasbeen suggested that the incubation period will afford ameans of settling the difficulty. In certain experimentsmade by Fehleisen' it was found that the incubationperiod varied from fifteen to sixty-one hours ; but itmust be remembered, as Dr. Acland has pointed out,that clinical observation gives " much wider limits ." 2The length of the incubation period of erysipelas mayvary " in a remarkable degree," 3 as has been shown bycertain series of cases reported on by medical men onbehalf of the Vaccination Commission, where severalof the children vaccinated at or about the same timehave been affected, and thus pointing to a contaminationof the lymph.Thus, in a series of cases in some villages nearNorwich (No. 23), Dr. Barlow found from his briefprovisional investigation that " some septic materialhad been introduced at the time of the insertion ofthe vaccine lymph. " 4 The inflammation commencedat intervals from the first to the tenth day." Bacteria in Relation to Disease," p. 283. Edited by W. WatsonCheyne, M.B. , F.R.C.S. New Sydenham Society. 1886."Appendix ix. , Final Report, Royal Commission on Vaccination, p. 246,foot-note.Ibid., p. 294. * Ibid. , p. 232.VACCINAL ERYSIPELAS . 353In a series investigated by Dr. Acland ( No. 115 ) therewas a still greater range ; that is to say, the erysipelasappeared at intervals of six hours, sixteen hours, fivedays, and nineteen days in four cases where it wasalmost " a certainty that the infection of the erysipelaswas derived from the vaccinifer."Dr. Acland also records another series (No. 181 ) ofsix children attacked in whom " it can hardly be doubtedthat the abnormal results were due to the quality of thelymph. " The period varied from two or three days tomore than two weeks. ( For further testimonies regardingthe variability of the incubation period of erysipelassee Tillmanns in Deutsche Chirurgie, vol. v. , pp. 96,120, 121. Stuttgart. 1880.)It is also argued that if only one or two childrensuffer out of a certain number vaccinated, that thiswould exclude the lymph ; but it may be pointed outthat in cases of syphilis it is unusual for all thosevaccinated with the same lymph to be attacked. ThusTrousseau records an instance where only one out offive children vaccinated from the same vaccinifer contractedsyphilis ; and in the Paris case recorded byGuérin one out of forty infants vaccinated was attacked.Mr. Jonathan Hutchinson 5 remarks that in his firstseries of cases two out of twelve successfully vaccinated1Appendix ix. , Final Report , Royal Commission on Vaccination, p. 294.2 Ibid. , p. 369.3 " Bulletin de l'Académie Impériale de Médecine," I S. , vol . xxx. , pp.144, 145. 1864-65 .* Ibid. , I S. , vol . xxxiv. , p. 512. 1869.5 " Illustrations of Clinical Surgery," vol. i. , pp. 129, 130. London.1878 .354 INJURIOUS RESULTS OF VACCINATION .wholly escaped, in his second series of about twenty-sixcases more than one-half escaped, and in the thirdseries only one out of twelve is known to have beenattacked, while in the fourth series only one sufferedand probably six or eight escaped.These facts point to the conclusion that the lymphcannot be exonerated by any such criteria as have beensuggested.Tubercle.In the case of consumption, tubercle, and scrofula,there is not the same amount of unimpeachable evidenceof their connection with vaccination as in the diseasesbefore considered. Dr. Acland says-" Althoughvaccination may be in no way the cause of the disease,it may and must always be difficult in such cases rightlyto apportion the precise effect of inheritance, circumstances,and vaccination; especially if, owing to feeblehealth , degenerate tissues, and bad surroundings, vaccinationhas been followed by ulceration, glandularabscesses , or some other complication likely to excitefebrile disturbance." The Vaccination Commissionersallow (section 417) that " It may, indeed, easily be thefact that vaccination, in common with chicken-pox,measles, small-pox, and other specific fevers, doesoccasionally serve as an inciting cause of a scrofulousoutbreak. " In this connection some suggestive figuresare given by two French writers, Rilliet and Barthez ,who found that in 208 vaccinated children 138 diedtubercular and 70 non- tubercular, whereas in 95children who died unvaccinated 30 were tubercular1 Allbutt's " System of Medicine, " vol. ii. , p. 623. London. 1897.VACCINATION AND TUBERCLE. 355and 65 not so.1 Dr. James Copland, who quotes thesefigures, remarks that " it cannot be doubted that vaccinationfavours the prevalence of the several formsof scrofula." 2 Again , he says-" Notwithstanding thelaudation bestowed upon vaccination, I believe that, asthe lapse of time allows the fact to be more fullydemonstrated, it will be found to be a not unfruitfulsource of scrofula and tubercles . " 2Dr. Felix von Niemeyer writes :-" The injurious influencewhich diseases have on the constitution, andthereby on the tendency to consumption, manifestsitself most frequently and in the most lasting manner inearliest infancy. It is fortunate if children escape disease,particularly in the first years of their life, during whichby far the most rapid development of the body takesplace, and when by favourable or unfavourable externalcircumstances the foundation is laid, in a great measure ,for a strong and robust, or a weak and delicate health.Even vaccination may, by the febrile disturbance precedingthe eruption, as well as by that accompanyingthe suppuration, both of which are never absent, andaccording to my numerous thermometrical observationssometimes reach a very high degree, considerablyweaken, more especially those children who are notvery strong, and may leave behind it the germs of adisposition to consumption. " 31 " Traité Clinique et Pratique des Maladies des Enfants," vol . iii. ,p. 116, foot-note. Paris. 1843 ." Copland's " Dictionary of Medicine," vol. iii . , pp. 740, 741. London.1858.3 " Clinical Lectures on Pulmonary Consumption, " p. 22.from the second German edition by C. Baeumler, M.D.Sydenham Society. London. 1870.TranslationThe New356 INJURIOUS RESULTS OF VACCINATION .This eminent authority adds, " I must protest againstunconditional compulsory vaccination, particularly duringthe first two years of life. "Other writers have endorsed Dr. Niemeyer's opinion.Thus, Dr. Rühle, in an article on " Pulmonary Consumptionand Acute Miliary Tuberculosis," remarks that" Scrofula also often appears for the first time afterrecovery from certain diseases, such as the acuteexanthemata, and especially measles. Vaccination hasalso been regarded as a cause, and probably correctly.It does not, however, seem to produce scrofula directlyby the inoculation of a ' scrofulous poison,' but byinducing the manifestation of the hitherto latent scrofuloussymptoms, through an abnormal course of thevaccine pustule and the active fever accompanying it,in the same way as other febrile diseases of childrenact."Dr. Birch- Hirschfeld, in the same work, observes :-" Frequent experience shows that vaccination also maynot infrequently be followed by a breaking out ofscrofulous symptoms " 2-although he remarks that itis to be supposed that in the majority of these casesvaccination only excites the dormant disease.Apparently the German Government were fullyalive to the danger, for their statute prohibited thetaking of lymph from a scrofulous child ; but, as Dr.Birch - Hirschfeld says, " This caution, however, becomesillusory, in the majority of cases, so far as first vaccina-1 Ziessen's " Cyclopedia of the Practice of Medicine ," Englishedition, vol . v. , p. 485. 1875 ." Ibid. , vol. xvi . , p. 773 .ANIMAL LYMPH AND TUBERCULOSIS. 357tions are concerned, because scrofulosis generally doesnot show itself during the first years of life, and prooffor the possible existence of a scrofulous constitutioncan be found only by an examination of the physicalcondition of the parents, brothers, and sisters of thechild." 1It is generally held that tubercle is due to a specificorganism, and hence the possibility of its communicabilityby vaccination must be admitted. The experimentswhich have a practical bearing on this subject arethose of M. Toussaint. He vaccinated a tuberculouscow on the vulva with lymph from a well - formedvaccine vesicle raised on a healthy child of strongparentage. With lymph from the pocks on the cow hevaccinated four rabbits and a pig. Two rabbits killedtwo months afterwards were found to be suffering fromtuberculosis at the point of inoculation, in the glands,and also in the lungs. The pig developed signs oftuberculosis both local and general .The Medical Times and Gazette, in referring toToussaint's experiments, says, " The significance of theseexperiments can scarcely be overrated ; for, though ajudicious vaccinator would not use lymph taken froma child who exhibited already evidence of the disease,the chances of cows in whom spontaneous vaccinia mayappear, and whose lymph would at the present time be1 Ziemssen's " Cyclopædia of the Practice of Medicine ," Englishedition, vol. xvi . , p. 774.2" Comptes Rendus Hebdomadaires des Séances de l'Académie desSciences," vol . xciii. , pp. 322-324. 1881 .358 INJURIOUS RESULTS OF VACCINATION.eagerly sought after, being, like so many of their species,tuberculous, are great ; and it would seem, in consequence,that the dangers of animal vaccination maybe greater than those of human, which are supposed tobe avoided by having recourse to the cow." 1"Although Sir Richard Thorne, in his recent report tothe Local Government Board, refers to this danger asvery remote," it is evidently one which is apprehendedby the Medical Department of the Local GovernmentBoard ; for, with a view of reassuring the public, hestates that the tubercle bacillus, when experimentallyadded to a mixture of lymph and an aqueous solutionof glycerine, rapidly loses its vitality. Considering thatthe researches of Dr. Arthur Ransome and others haveindicated that small quantities of glycerine favour thegrowth of tubercle in culture media, it may be anticipatedthat Sir Richard Thorne's statement will be receivedwith a certain amount of scepticism .Lupus has occasionally been found growing in the siteof vaccination. Mr. Hutchinson has figured a case ina child eight years of age. The disease occurred inand around a vaccination scar, and commenced a fewmonths after the operation. Cases of a like natureMedical Times and Gazette, vol . ii . , p. 291. ( September 3 , 1881. )2 " Proceedings of the Royal Society for 1897 ," vol. lxii . , pp. 187-200.See also Nocard and Roux in " Annales de l'Institut Pasteur for 1887 ,"vol . i. , pp. 19-29 ; Crookshank in " Transactions of the Pathological Societyof London for 1890-91 ," vol. xlii. , pp. 333-336 ; and Beevor, ibid. , pp.344,345.3 " Illustrations of Clinical Surgery," vol . i . , p. 141 , plate xxv. , fig. 1 .London. 1878 .TETANUS AFTER VACCINATION . 359have been described by Besnier¹ and Lennander. Dr.Colcott Fox mentions three instances of lupus invaccination scars. In one case the lupus was leftbehind when the vaccination lesions healed. A patientwas also examined by Dr. Acland on behalf of theRoyal Commission on Vaccination (see No. 26, Appendixix.; also Mr. David Daker's evidence pp. 141 , 142 ,Sixth Report).Tetanus.It will have been observed that most of the disastersalleged to be induced by vaccination come under theheading of inoculable diseases ; tetanus, or lock -jaw, isno exception to this rule. The following cases have beenreported from time to time, and it must not be assumedthat they represent the total number of cases of tetanusattributable to vaccination .Reported by(1 ) Dr. Joseph B. Cottman. New Orleans Medical andSurgical Journal, 1854-55, vol. xi. , p. 783. Negressaffected with tetanus following vaccination ; period oftime not stated. Recovery in two weeks by use of largedoses of opium.(2) Dr. George Ross. The Southern Clinic, 1878-79,vol. i. , p. 468. Boy, three and a half years old whenvaccinated. Tetanus supervened three weeks afterwardswith death on the third day. No other lesion beyondvaccination.1 " Annales de Dermatologie et de Syphiligraphie, " vol. x. , pp. 576 , 577 .Paris. 1889.2 " Upsala Läkareförenings Förhandlingar," vol . xxv. , pp. 65-70.Upsala. 1889-90.The Practitioner, vol . lvi . , p. 500. ( May, 1896. )360 INJURIOUS RESULTS OF VACCINATION .(3) Dr. Theodore Dimon. St. Louis Courier ofMedicine,1882, vol. vii. , pp. 310-312. Boy, nine years old ; vaccinatedJanuary 6, 1882, with bovine lymph. Tetanussupervened on January 27 ; no cause discovered exceptvaccination, which was followed by an irregular shapedulcer. Boy died on the tenth day.(4) Dr. H. J. Berkeley. Maryland Medical Journal,1882-83 , vol. ix., pp. 241-245 . Healthy man, forty yearsold; vaccinated in the middle of January, 1882. Tetanussupervened on February 7 ; death on February 13. Nolesion discovered except at the point of vaccination,which was occupied by a deep ulcer, with an inflamedand indurated border.(5 ) Dr. W. T. C. Bates. “ Transactions of the SouthCarolina Medical Association," 1882, vol. xxxii. , p. 105 .Mulatto boy, aged five years ; vaccinated February 9,1882, with humanised lymph. Tetanic symptoms supervenedon March 8. No other cause but vaccinationdiscovered. Boy lived fifteen days .(6) Dr. R. Garcia Rijo. " Cronica Médico - Quirurgicade la Habana, " 1886, vol. xii. , p. 388. White child, twoyears old ; vaccinated in April, 1886. Characteristictetanus appeared in latter part of May. No lesionbeyond vaccination discovered. Death followed on thefourth day.(7) Dr. Zahiroodeen Ahmed. Indian Medical Gazette,March , 1889, vol . xxiv. , p. 90. Adult, aged twenty- one.The symptoms appeared fourteen days after primaryvaccination .( 8) Local Government Board, Case x. , Appendix ix. ,Final Report, Royal Commission on Vaccination.Female, aged two months ; vaccinated on SeptemberTETANUS AFTER VACCINATION . 36110, 1889. Symptoms of tetanus first appeared onOctober 2 , and patient died on the 5th of October.Female(9) Dr. S. W. S. Toms. Medical News (Philadelphia),February 24, 1894, vol. lxiv., pp. 209-212.white child, five years five months old. VaccinatedNovember 6, 1893, with bovine lymph on ivory point.Characteristic trismus on November 30, with death onDecember 5 .For two recent cases of tetanus following vaccinationsee Medical Record, New York, January 22, 1898, vol.liii. , p. 129, and Indian Lancet, Calcutta, January 1 , 1898 ,vol . xi . , p. 42 .Dr. Acland mentions that the case included in theVaccination Commission Reports (No. x.) is the onlyone he is acquainted with in more than five millionvaccinations in this country. This would tend to showthat in England tetanus after vaccination is very rare,as we should expect it to be. It would be more interestingif we had the figures for Calcutta and other parts ofIndia. In an address to the Medical Society of Calcutta,on January 5, 1892, Sir Spencer Wells 2 stated that theinfant mortality from tetanus in that city during theyears 1881-90 almost equalled that for all other infantilediseases added together. Of course, I do not wish toimply that this large mortality is in any way attributableto vaccination ; but before deciding the question of thefrequency or otherwise of tetanus after vaccination weshould have before us the statistics from countrieswhere tetanus is prevalent.¹ Allbutt's " System of Medicine," vol. ii. , p. 598. London. 1897 .* Report on Sanitary Measures in India in 1891-92, p. 108.24362 INJURIOUS RESULTS OF VACCINATION .The Amount of Vaccinal Injury.It is impossible to form any accurate estimate of thetotal amount of serious and fatal injury produced byvaccination ; the following table only gives the deathsrecorded by the Registrar-General :-England and Wales. Deaths from cow-pox and other effectsof vaccination, from 1881 to 1896.1881 ... ... 58 1889 ... 581882 ... 65 1890 ... ... 431883 ... 55 1891 ...... 431884 ... 53 1892 ... ... 581885 ... ... 52 1893 ...... 591886 ... ... 45 1894 ... ... 501887 ... 45 1895 ... 561888 ... 45 1896 ... 42This shows that in England and Wales, according tomedical death-certificates, one child on an average diesevery week from the effects of vaccination. This fatalrecord , however, does not by any means represent thedamage done by the operation, as for every death theremust be a very large number of children who are injured,but survive for years with enfeebled constitutions.It has been noticed in the earlier part of the presentchapter that in all probability cases of vaccino-syphilisremain unrecognised, and there also seems reason tobelieve that, even if recognised, a certain number areunreported. In support of this, I may quote from ProfessorAlfred Fournier's work on vaccino-syphilis. Hesays-" There are certainly many more cases of vaccinalsyphilis on the cards or in the memories of practitionersthan in the columns of our journals. For myself, had IDR. PRINCE MORROW'S OPINION . 363up to this day published a single one of the numerouscases of this kind which I have observed, whether in myprivate practice or in hospital ? But how many of mycolleagues might say as much ? There is more. Thesame reticence must have sometimes concealed importantcases. For myself alone, I had knowledge oftwo actual epidemics of vaccinal syphilis, which havebeen kept secret, and upon which I have been able toobtain only incomplete information, the affair havingbeen hushed up."1The Royal Commission also remark (section 426)that " it is not to be forgotten that a natural reluctanceto register deaths as due to syphilis may have preventedsome cases where recently vaccinated persons have diedfrom that disease from being made public."Dr. P. A. Morrow, in referring to eruptions incidentto vaccination, observes " It must be confessed that theprofession has manifested a most decided unwillingnessto recognise their direct dependence upon vaccination. " 2Again, in the Local Government Board Inquiries onerysipelas, held by Mr. Netten Radcliffe at Gainsborough,and by Mr. Henley and Dr. Airy at Norwich, beforereferred to, there were in all ten deaths, and in only oneof these was vaccination mentioned on the certificate ofdeath . Also, in an Inquiry, on behalf of the RoyalCommission, on a series of injuries from vaccination atsome villages in Norfolk, in 1890, Dr. Barlow found ,from the brief provisional investigation he was able to1 " Leçons sur la Syphilis Vaccinale, " p. 53, foot-note. Alfred Fournier.Paris. 1889.2Journal of Cutaneous and Venereal Diseases, vol. i. , p. 176. (NewYork. March, 1883. )364 INJURIOUS RESULTS OF VACCINATION.make, that some septic material had been introduced atthe time ofthe insertion ofthe vaccine lymph, and thatthis was mainly responsible for the untoward resultsobtained. There were three deaths, and in none ofthese was the word " vaccination " mentioned on thedeath-certificate.Inthis connection Professor Schaefer, of the Women'sMedical College, Kansas City, remarks-" The pathologyof vaccination is a subject upon which very littlehas been written by writers on vaccination. There isno doubt that every experienced physician has seen oneor more cases of severe localised sepsis following theoperation of vaccination. It will be found, on surveyingthe field, that such accidents are by no means rare,contrary to the statements of the books, as we havebeen made to believe. " IDr. Bridges, formerly Inspector of the Local GovernmentBoard, gives the following explanation-" Medicalstatistics cannot be quite trustworthy on this point fromthe nature of the case. A doctor vaccinating a childwill obviously be unwilling to say that vaccination didharm, unless he is a man above the ordinary standardof courage and conscientiousness statisticsfounded on such uncertain facts-facts dependent notmerely on the skill but on the moral courage of thedoctor, can have no possible value. " 2 It is interestingto notice that history apparently has repeated itself; forSir Richard Blackmore, writing in 1723 about the pre-Journal of Cutaneous and Genito- Urinary Diseases, vol. xiv. , p. 399.(New York. October, 1896. )* Positivist Review, vol. iv. , p. 225. (November, 1896. )PREVARICATIONS OF THE INOCULATORS. 365varications of the inoculators, says-" It is in vain togive this matter another more favourable turn for theoperators, by saying, the patient was of a weakly constitution,and full of ill humours, or that he was of afroward and perverse temper, and died by a fit of peevishness,or that he was carried off by terrible convulsions,and not by the small -pox ; for inen of the least sagacitymust see through these ridiculous evasions invented tocover true history and defeat our inquiry into matter offact, and to buttress up the reputation of the inoculators. " 1On the following page he observes " To say that thesmall-pox, which the convulsions attended, was not thecause of the patient's death, but the convulsions, is thesame thing as to affirm that the axe that cuts off atraitor's head , is by no means the cause of his death, butthe effusion of blood and trembling motions of the body,that followed the separation."The Royal Commission (section 379), while admitting,as they were bound to do, that some risk attaches tovaccination, have attempted to minimise the dangers ofthe operation by comparing the risk to that of railwaytravelling ; in this they were promptly taken up byDr. Collins and Mr. Picton in their Statement ofDissent (section 184), who show from the Board ofTrade returns that the proportion returned as killed(from causes beyond their own control) to the numbercarried by railway was I in about 35,000,000, while therisk of dying from vaccination to the number vaccinated,according to the death-certificates of medical men, wasI in 14,159. Of course, these latter figures give no idea" Treatise upon the Small - pox," p. 93. Sir Richard Blackmore, MD. ,F.R.C.P. London. 1723.366 INJURIOUS RESULTS OF VACCINATION.of the total risk of vaccination, but they serve to showthe bias of the majority of the Vaccination Commissionersin their treatment of this subject.Animal Lymph.This new departure, recommended by the Royal VaccinationCommission, amounts to a virtual condemnationof the arm-to-arm system which has been enforced uponthe people for half a century. It is therefore importantto inquire whether a general introduction of calf lymph,as proposed, would be attended with any diminution inthe danger which appears to be inseparable from thepractice of vaccination. In the case of syphilis, facts andconsiderations have been presented to the reader forbelieving that this disease, or symptoms indistinguishabletherefrom, would not necessarily be excluded by the employmentof calf lymph ; as the Lancet observed incriticising an article by Dr. Henry A. Martin-" Thenotion that animal lymph would be free from chances ofsyphilitic contamination is so fallacious that we are surprisedto see Dr. Martin reproduce it, and so contributeto the perpetuation of the fanciful ideas which too commonlyobtain on the origin of vaccino-syphilis. " 'The remaining diseases which concern us in thiscountry are tubercle, to which I have already alludedin this connection, erysipelas, and other inflammatorycomplications, and skin diseases ; and, with regard tothese last, there is every reason to believe that theintroduction of animal lymph would be a disadvantageas compared with the present system .The Lancet, vol . i. , p. 909. (June 22, 1878. )MR . ROBERT CEELY ON ANIMAL LYMPH . 367In the American Medical Times for March 8, 1862 ,Dr. Henry M. Lyman observes-" It is certain that thedisturbances, produced by the use of a virus which hasbeen newly derived from the cow, are generally muchmore marked than the effects which follow the use ofa more perfectly humanised lymph. " 1With reference to the irritating effect of animal viruson the skin, we learn, on the high authority of Mr. RobertCeely, that " those who believe their children will escapecutaneous eruptions when vaccinated direct from thecow, will be greatly mistaken . Many children haveskins-all children more or less-prone to throw outeruptions, papular, vesicular, pustular, or exanthematic,upon the excitement of the least increased vascularaction. Hence ordinary vaccination will cause whatmost other febrile and cutaneous irritations produce.Hence more irritating lymph, as it is when direct fromthe cow, will be more effective in the production of theabove results. But there is a special vesicular vaccineeruption attending the acme and decline of the vaccinedisease. The Germans have called it ' Nachpocken. ' Ihave often, nay almost always, seen it as a secondaryeruption on the teats and udders of the cows immediatelybefore and after the decline of the disease in them.The same I have repeatedly seen in children, especiallyin the early removes from the cow; and still continueat times to witness it, to the great temporary disfigurementand annoyance of the patient, and the chagrinand vexation of the parent. It is essentially a genuinevaccine secondary eruption . I have witnessed it in1American Medical Times, vol . iv. , p. 135.368 INJURIOUS RESULTS OF VACCINATION .vaccinating the dog. I have coloured illustrations ofthis secondary eruption in man and animals, and haveseen some severe and a few dangerous cases in childrenwhere the skin and visible mucous membranes werecopiously occupied with it." 123It may also be noticed that Professor Depaul, of theParis Faculty of Medicine, expressed the opinion thatcalf lymph is more frequently followed by secondaryvaccinal eruptions. Ever since Ceely's day numerousauthorities have pointed out the greater potency of calflymph: thus Dr. Henry Blanc, a prominent advocate ofthis vaccine, in a treatise on " Compulsory Vaccination,"remarks on its " greater activity; " and the editor ofthe Practitioner, in reviewing the pamphlet, pertinentlyobserved that " the very argument which Dr. Blanc urgesin favour of the superior value of heifer vaccination is adistinct and serious objection to it. " 4By far the most damaging reports on animal lymph,however, come from those who have had the greatestexperience of its effects, viz. , the vaccinating surgeonsin the United States; for this method of inoculationwas adopted in the States much earlier and with muchgreater fervour than it ever has been in this country,and for the reason that humanised virus was found tobe attended with such serious consequences.In the Sixth Annual Report of the Board of HealthBritish Medical Journal, vol. i. , p. 19. (January 7, 1865. )* Ibid. , vol. ii . , p. 22. (July 3, 1880. )3 " Compulsory Vaccination : An Inquiry into the Present UnsatisfactoryCondition of Vaccine Lymph," pp. 16, 24. Henry Blanc, M.D. , F.R.G.S.London. 1869.* The Practitioner, vol. iii . , p. 236. ( October, 1869. )ANIMAL LYMPH IN THE UNITED STATES. 369of the State of New Jersey, Dr. Thomas F. Wood, inanswer to certain queries relative to vaccination, says :-" Vaccination with bovine lymph has brought to light aseries of phenomenal symptoms, except to those medicalmen who have kept fresh in their minds the descriptionsof Jenner and the early writers. Jenner described thedisease caused by early removes from the cow, and heconsequently gave a picture of only the intensest formsof it, in his ' Inquiry ' and ' Further Observations .' Aglance at the coloured engravings in Jenner's greatwork, in Woodville's, Pearson's, Bryce's, Willan's, andall others, shows that the vesicle was larger and theareola more intensely red than in the cases familiarto us up to the time of the introduction of the Beaugencylymph. The reader of the early vaccinographers canhardly believe there was not some exaggeration in theirdescriptions of the serious constitutional symptoms, andthe bad ulcers which sometimes succeeded vaccination ;ulcers so bad, indeed, that they had to be treated withsolution of white vitriol . " 1Continuing, he observes that " the degree of sicknessis generally greater following bovine vaccination. " 2Dr. Ezra M. Hunt, Secretary of the New Jersey StateBoard of Health, observes that " the degree of sicknessis, as a rule, greater in a genuine bovine than in ahumanised vaccination, and quite corresponds to Jenner'sstatement, made as to his own cases. " 3 With regard toeruptions-" Like the original cow lymph, as used byJenner, it is more active in its effects, and therefore is1 Sixth Annual Report of the Board of Health of the State of NewJersey, pp. 37, 38 .Ibid. , p. 39.( 1882. )Ibid. , p. 51 .370 INJURIOUS RESULTS OF VACCINATION .more likely to excite local irritation, and to be the occasionfor the appearance of some eruptive disorders, towhich the person may be inclined. " 1Dr. E. L. Griffin, President of the Wisconsin Board ofHealth, says-" The constitutional symptoms followingthe use of pure bovine lymph , and those induced bylymph humanised by a few removes from the heifer, aregenerally of a like character and degree. In the case ofboth, these symptoms are sometimes quite severe. Thecause is quite often found in the condition of the patienthimself. It must be admitted that during the past yearan unusual amount of severe constitutional symptomsand local complications have followed the use of bovinelymph. " ? About skin diseases he observes " Thefrequency of vaccinal erythema following the use ofbovine lymph is a noticeable phenomenon. This constitutionalmanifestation of the vaccinal disease isseldom observed in the use of humanised lymph ofdistant removes from the heifer. " 3 Dr. Griffin thoughtthe eruption to be of small account, and that it onlyindicated a thorough saturation of the system with thevaccinal disease.In the Report of the Oxford Local Board to the NewJersey Board of Health, Dr. L. B. Hoagland, in referringto an epidemic of small - pox, says-" About fifteenhundred persons were vaccinated during its prevalence,one - third of them with humanised virus, and theremainder with non-humanised bovine virus, the constitutionaleffect being much the more marked when theSixth Annual Report of the Board of Health of the State of NewJersey, p. 54. ( 1882. )Ibid. , p. 65 . 3 Ibid.ANIMAL LYMPH IN THE UNITED STATES. 371latter was used. One child, of five years, lost its life bytaking cold in her arm ; gangrene set in, and she diedfrom septicæmia. Some of the sores were three or fourmonths in healing. " ।Dr. William M. Hartpence, in the report of theWashington Local Board , remarks that " Bovine viruswas generally used, and our observations lead us toconclude that the constitutional effects were greater in alarger number of cases than we had observed in yearspast when using humanised virus ; and, also, our experiencemakes us believe that the resulting sores werelonger in healing (speaking in general) than with thehumanised virus." "Dr. E. J. Marsh, President of the Patterson Board ofHealth, said that although he had tried both varieties oflymph, " In my use of bovine lymph it was observedthat the vaccine vesicle resulting was much larger, theareola and inflammatory induration were more extensive,the crust large, flat and thin, generally ruptured, andcame away before the sore was cicatrised. In twoinstances the inflammatory action was so high that thevesicle sloughed out en masse, leaving a deep ulcer ." *The second Annual Report of the State Board ofHealth of Indiana, for the year ending October 31 , 1883 ,furnishes a list of reports on small-pox and vaccinationfrom the Health Officers throughout the State. Thefollowing relate to the effects of animal virus.Dr. Henry Gers, of Washington, reported that, three1 Sixth Annual Report of the Board of Health of the State of NewJersey, p. 180, 181 .* Ibid. , p. 182 .( 1882. )* Ibid. , p. 70.372 INJURIOUS results OF VACCINATION.years previously, unpleasant effects were noticed fromsupposed bovine virus. (P. 185.)Dr. D. W. Butler, of Connersville, said that bovinevirus was used entirely, and some cases of vaccinationwere unusually ill, with an eruption over the entirebody. (P. 186.)Dr. J. M. Gray, of Noblesville, remarked that in 1872erythema, as a result of vaccination, was quite common.In his experience bad results were more frequently seenafter bovine virus. ( P. 186.)Dr. N. S. Shipman, of Seymour, observed thatnothing but bovine virus was used, and " In a fewinstances we had ulcerous-looking sores, lasting sometimesfor six months." P. 187.)Dr. J. T. Jones, of Franklin, reported on a greatnumber of bad arms as the result of vaccination withbovine virus. ( P. 188.)Dr. Horace E. Jones, of Anderson, stated that " phlegmonousabscesses and sloughing ulcers frequentlyoccurred " as the result of bovine virus . ( P. 190.)Dr. S. H. Pearse, of Mount Vernon, reported thatbovine virus only was used, and that he saw no differencebetween the bovine and human. He observed thata year previously " extensive inflammation " followedthe use of bovine in two cases, and he remarks that inconsequence of a case of small-pox fourteen peoplein one house were vaccinated , all of whom had sorearms. (P. 190.)Dr. George B. Walker, of Evansville, ascertained thatthe bovine lymph was " more violent and caused troublesomeulceration, and sometimes eruption over the body ."(P. 191. )ERUPTIONS FROM ANIMAL LYMPΗ. 373Dr. C. E. Lining, of Evansville, reported some verybad arms, more following the use of bovine virus.And, lastly, Dr. J. R. Crapo, of Terre Haute, notedsevere dermatatis, and an eruption over the whole body,resembling lichen or eczema, as the result of the use ofanimal lymph.In the Journal of Cutaneous and Venereal Diseases Dr.Morrow bears out the almost universal opinion ofmedical men in the United States when he says-" Theexperience of the profession in this country with bovinelymph shows that it is slower in its development, moreintensely irritant in its local and constitutional effects ,and more prolonged in its active continuance. " ¹Dr. Alexander Napier, Assistant to the Professorof Materia Medica, Glasgow University, and Physicianto the Skin Department, Anderson's College Dispensary,calls attention to a certain remarkable group ofskin eruptions, which he finds reported in the Americanjournals, and with scarcely an exception they related tocases where animal lymph was used. He first refers toinstances reported by Dr. Rice in the Chicago MedicalJournal and Examiner for February, 1882 , in which thatgentleman states that " about one in ten of all vaccinatedhave bad arms, with a high grade of fever, anderuption resembling somewhat that of rötheln or Germanmeasles ."Further cases are given in the Boston Medical andSurgical Journal for 1882. In the number for MarchJournal of Cutaneous and Venereal Diseases, vol. i. , p. 167. (March,1883. )* Glasgow Medical Journal, new series, vol. xix. , pp. 424-432. (June,1883. )374 INJURIOUS RESULTS OF VACCINATION.23 , 1882, Dr. Alfred H. Holt¹ records eruptions in fivesuccessful primary vaccinations with bovine lymph .The rash resembling German measles appeared aboutnine days after vaccination, was attended with considerablefever, and, when it faded, a brownish stainwas left on the skin. Dr. Holt thought it was areasonable presumption that the eruption was due tovaccination , and remarks (p. 272)-" If such is the case,and this result is going to occasionally follow vaccinationwith animal virus, it is highly important that the factbe known."In the Journal for April 13, 1882 (p. 356), Mr. VincentBowditch recorded three similar cases ; the eruptionappeared on the ninth day, and was succeeded by brownstaining of the skin as in Dr. Holt's cases. In one of thepatients there was considerable constitutional disturbance,fever, headache, and malaise, and he remarks thatother physicians in the town had similar cases.Dr. A. I. Lawbaugh, in the issue for April 20, 1882(p. 384), says that in eight hundred of his own successfulprimary vaccinations with bovine lymph, sixty- eightwere attacked with a similar eruption, which was duskyred, covering nearly the whole surface of the body. Theeruption somewhat resembled measles ; and there wasintense itching, and a brown stain was left which disappearedin a few days. n thirteen successful primaryvaccinations with humanised lymph, one remove fromheifer , three had eruptions; but there were no eruptionsin two hundred successful re-vaccinations. He remarksthat his brother practitioners have noticed similar experiences.Boston Medical and Surgical Journal, vol. cvi. , pp. 271 , 272.(March 23, 1882. )DR. NAPIER'S CASES. 375Dr. Morton Prince, in the number for April 27 (p . 394) ,observed that, as city vaccinator, since the beginning ofthe year he had performed seven thousand vaccinations,and that skin eruptions accompanying successful vaccinationwere so frequently observed that he ceased toregard them as either unusual or accidental. He describespapular and erythematous eruptions, the formerbeing so common as to " cease to attract notice. " Dr.Prince furnishes notes of two cases of urticaria withsevere constitutional symptoms accompanying vaccination,and one of very marked and widespread erythema.He adds (p. 395)-" Judging from the number of timesI have been questioned by anxious parents on themeaning of these eruptions, I believe with Dr. Holtthat the fact of their liability to follow vaccinationshould be widely known."Dr. Napier's own cases are as follows :-¹I. A healthy child vaccinated with calf lymph.Normal course till tenth day, when a plentiful crop ofpapules appeared on the lower limbs, lower part oftrunk, and arms. The eruption disappeared in threedays.2. A child vaccinated with lymph taken from apatient who had been vaccinated with calf lymph eightdays previously. Normal course till the eleventh day,when large rings of erythema exudativum appeared onarms and thighs ; on the following day the eruptionspread, and changed from a purplish to a yellowish red ;it faded on the third, and completely disappeared on the1 See Glasgow Medical Journal, new series , vol. xix. , pp. 426-428 .(June, 1883. )376 INJURIOUS RESULTS OF VACCINATION .fourth day. The right hand and arm and left foot andankle were much swollen and deformed. No pain norirritation ; fever slight. Two other children vaccinatedwith the same lymph presented nothing abnormal .3. A sister of the preceding. In this case calf lymphused. Normal course till the tenth day, when a vividred, papular, measly eruption appeared over the wholebody, face, and head. Faded greatly in twenty- fourhours, and completely in two days .4. Calf lymph vaccination. Normal course till theninth day, when eruption precisely resembling the lastcase appeared. It faded by the evening of the next day.5. A doubtful case, which Dr. Napier hesitated toplace in the same category, as the interval before eruptionappeared was very long. Child was vaccinated withhuman lymph. On the twenty-eighth day eruptionexactly resembling that of measles appeared on thescalp and face, and to a lesser extent on the neck, chest,and upper arms ; it disappeared in five days. Therewas no catarrh, and no other member of the familywas affected .In summing up these experiences, Dr. Napier remarked(p. 430)-" In nearly every instance I havementioned in which spontaneous generalised eruptionsfollowed vaccination, the lymph used was animal lymph,not humanised lymph . What does this indicate ? That,as Dr. Cameron, M.P. , once argued before this Society,the nearer the virus to its original source in the daysof Jenner, the stronger it is, and the more efficientthe protection it affords ? Without venturing to giveany opinion as to the greater efficacy of calf lymphvaccination as a prophylactic against small-pox-aOPINION OF DRS. ACLAND AND BARLOW. 377matter which can only be settled on the basis of awide statistical inquiry-it seems very clear that inanimal lymph we have a more powerful material, onewhich more deeply and obviously affects the systemthan our ordinary humanised lymph, if the degree ofconstitutional disturbance is to be taken as an indexof the effectual working of the virus. " 1More recently we find in an article on " Small -poxin San Francisco, " by Dr. S. S. Herrick, the followingremarks :-" Besides the uncertainty of the bovine virus,there are other features of common occurrence, whichare not pleasant and which are not found in the humanproduct. The sores are apt to be quite serious incharacter ; a considerable eruption on the body is liableto take place ; and the points of vaccination frequentlydevelop a raspberry-like excrescence (sometimes a trueecchymosis) which may remain for weeks, and is oftenmistaken by the inexperienced for the normal result ofvaccination." 2Apparently the experience of the profession in thiscountry, as far as it goes, is much the same as has beenreported from America. Thus Drs. Acland and Barlow,who investigated cases of vaccinal injury for the RoyalCommission, " are of opinion that a certain proportionof children will always suffer after vaccination fromvarious forms of cutaneous eruption. These seem to bemore frequent after vaccination with calf lymph, and1 Glasgow Medical Journal, new series , vol . xix. , p. 430.2 Tenth Biennial Report of the State Board of Health of California,p. 139. ( 1888. )3Royal Commission on Vaccination, Dissentient Commissioners' Statement, section 186 .25378 INJURIOUS results OF VACCINATION.are for the most part free from danger, though oftengiving rise to considerable distress. " They also thinkthat " calf lymph as now usually employed tends toproduce more severe inflammatory reaction than thatwhich has been humanised ."Lastly, the Commissioners, although insisting thatparents should have the option of calf lymph for theirchildren (section 437), apparently do not recommendit with any degree of confidence ; for, a little above, onthe same page, they inform us that some of the bestqualified witnesses have expressed a deliberate preferencefor arm-to-arm vaccination, believing that theadvantages of calf lymph are more imaginary than real.A diminution, therefore, in the mortality and in theamount of suffering can hardly be expected from thisnew departure in the Jennerian cultus.Glycerinated Lymph.It has been frequently suggested that some of themost serious of the unfortunate results arising fromthe use of animal vaccine might be prevented, or at allevents mitigated, by improvements in existing modesof its collection and preservation ; but, up to the presenttime, in no country, though much ingenuity has beenexercised, has a really safe variety been discovered.A method, which has recently found favour in officialquarters, and seems likely to be adopted as far as publicvaccination is concerned, consists in the addition ofglycerine to the lymph ; it is hardly necessary to observethat this would be an entirely new departure from thepresent system of public vaccination, which is designed,as far as possible, to secure vaccination with fresh lymphGLYCERINATED CALF VACCINE LYMPH. 379from arm to arm. The alleged advantages of theadmixture with glycerine are, that all micro-organisms,with the exception of the vaccine germ, are therebyrendered inert and innocuous. Now, if it be true thatglycerine has this very extraordinary action, we mayinfer that lymph which has not been glycerinated containselements of danger. The promoters of glycerinatedlymph , viz. , the Local Government Board, are to becongratulated on this somewhat tardy admission of adanger which they have for years strenuously denied.¹This method of preservation appears to have beensuggested in or about the year 1849,2 and it has beenused extensively at one time or another, not only onthe continent of Europe, India, and Japan, but also inEngland .Dr. Renner, the well-known purveyor of calf lymph,writes to the British Medical Journal of October 30,1897 (vol . ii . , p. 1298)—“ I have myself prepared andsupplied none but glycerinated calf vaccine ever sincethe year 1883 at my establishment, except on ' points,'which, however, I have discontinued long ago, and Ihave frequently demonstrated my procedure in alldetails privately and in public ; " and hence we haveabundant means of testing whether glycerinated lymphis so very innocuous after all .In this connection the experience of the late SirGeorge Buchanan, Principal Medical Officer to theLocal Government Board, is of interest. It will be1 See " Facts concerning Vaccination for Heads of Families." ( Revisedby the Local Government Board, and issued with their sanction . )See Medical Times, vol. xxi . , pp. 227, 248. ( March 23 and 30, 1850. )380 INJURIOUS RESULTS OF VACCINATION.remembered that I have adverted to certain vaccinationsin the Isle of Rügen in 1885 , where of seventyninechildren vaccinated, all but three were attackedwith impetigo contagiosa, and by infection the diseasewas spread to three hundred and twenty out of a populationof five thousand inhabitants. The Rügen lymphwas mixed with glycerine (glycerinum purissimum), andit has been suggested by the late Sir George Buchanan¹that this was the cause of the untoward occurrences.He handed round to the members of the EpidemiologicalSociety a plan showing the component parts ofthe " stuff " used by Dr. Ebert in his Rügen vaccinations(p. 115) . Sir George had " heard of dilutions of lymphwith glycerine, always from people complaining of thelymph " (p. 117). And he concluded his remarks byobserving-" It will, I trust, be long before such preposterousadulterations of vaccine give the opportunity ofinvestigating their results in English practice " (p. 118) .It may be mentioned that the Chairman of the RoyalCommission, Lord Herschell, when this subject wasunder discussion, clearly indicated by his questions tomy father, when under examination, his opinion withregard to the danger of adulterating lymph withglycerine. This will be seen by the following :-Q. 9,804. ( Chairman. ) If there is a practice ofmixing the vaccine lymph with foreign" Transactions of the Epidemiological Society," 1885-86, new series ,vol. v. , pp. 114-118.* The Royal Commission say ( section 448)-" It was at one time suggestedthat the introduction of glycerine was likely to be mischievous.The question is one a further investigation of which is obviously desirable."LORD HERSCHELL ON GLYCERINATED LYMPH. 381matters, those foreign matters, if one ofthem is glycerine, may well be subject topollution ?-The intention is to improvethe quality of the lymph-to render itmore innocuous.Q. 9,805 . But you may have the best of intentionsin that direction, and you may carrythem out ; but unless the individual whogets the lymph from the Institution usesthat lymph just as he gets it, mixingnothing with it, the best of arrangementsin the Central Institution will not preventthings going wrong ?-That is so.Q. 9,810. ... but, it is surely a point of importancewhether it was a result arising from theuse of vaccine matter procured from awell- constituted establishment, or whetherit arose from the mixture of the vaccinematter with something else by the practitionerwho used it. You would admitthat, I suppose ?-I see that clearly.Dr. Lürman, of Bremen, gives an account of anepidemic of catarrhal jaundice in 1883-84 in a largeshipbuilding and machine-making establishment in thattown, which is of interest from the fact that the patientshad been re-vaccinated with glycerinated lymph. Onehundred and ninety- one persons were attacked. Thedisease began with symptoms of gastric and intestinalcatarrh , which persisted a week or more, until jaundice1 Berliner Klinische Wochenschrift, vol. xxii . , pp. 20-23 . ( January 121885. )382 INJURIOUS RESULTS OF VACCINATION .appeared. The symptoms comprised epigastric oppression,anorexia, vomiting, faintness, and there was usuallyconstipation . Yellow vision occurred in a few instances.In one case the patient suffered from general dropsywith cerebral symptoms, but none of the cases werefatal . Eighty-seven persons in the establishment, whowere re- vaccinated by other surgeons and other lymph,remained unaffected. Dr. Edwardes , who relates thesecases in the London Medical Record of April 15, 1885(vol. xiii. , p. 142), remarks that the epidemic wascausally connected with the re-vaccination, in someway or other. "66A feature of glycerinated lymph appears to be that,when it takes, great intensity of action is observed,both local and general. Thus Dr. James Cantlie¹ refersto " much constitutional disturbance " produced byJapanese lymph. I may also allude to an article byDr. Robert J. Carter. " He details the results of 319re-vaccinations with glycerinated calf lymph . Heobserves that in 106 of the patients the axillary glandswere " large, hard, and tender, and in some instances exquisitelypainful ; " in 3 of the cases the glands abovethe collar-bone were also affected. In 9 cases lymphangitiswas present, the lymphatic vessels being felt as hard,swollen, tender cords along the course of the axillaryvessels. In 98 of the patients there was ædema andinduration of the arm, and these manifestations were ofa " curiously persistent character. " Dr. Carter remarkedthat they were apparently dependent on the intensity ofthe local inflammation at the site of the vaccination .British Medical Journal, vol . ii. , p. 762. ( October 5, 1889. )The Lancet, vol. i. , pp. 1611 , 1612. (June 12, 1897. )GLYCERINATED LYMPH IN INDIA. 383Abundant evidence of the danger of glycerinatedlymph is adduced in Appendix ix. to the Final Reportof the Royal Commission. The cases are, of course,mostly erysipelas or of a septic nature ; and, withoutincluding those of a less severe character, they number84, and of these no less than 24 were fatal.¹In India glycerinated lymph has been a failure in everyway. In the first place, the success per centum has beenvery low, as will be seen from the following figures forMadras Presidency in 1894-95 :-Animal lymph .Number Successvaccinated. per cent.Direct from calf 378,955 97.4Preserved in glass tubes or plates 142,899 94 1Preserved with glycerine 642,296 89.2In 1895-96 the results are much the same :-3Animal lymph .Direct from calf ...Preserved in tubesPreserved with glycerinePreserved with lanolineNumber Successvaccinated. per cent.300,518 97.898,703 95.1... 641,181 89.523,193 94.5This low percentage of successful results is naturallyregarded as a very serious objection. In the Memorandumby the Army Sanitary Commission on theReport of the Sanitary Commissioner of Madras for 1894,it is stated :-" In the Madras Presidency, preservedlymph is largely used . No fewer than 642,296 personswere vaccinated with lymph preserved with glycerine.It is, we think, no matter of surprise that of these only1 See Nos. liii. , lxxxii. , xcix. , cviii. , cxii . , cxxvii . , cxxviii. , cxxxiv. ,cxliv. , cxlviii . , cl . , clxxxi. , clxxxix. , 21 , 81 , 122, 168 , 207, 208, 218 , 221 ,236, 237, 244, 249, 251 , 258, 312 .*Report on Sanitary Measures in India in 1894-95 , p. 113.3 Ibid. 1895-96 , p. 102 .384 INJURIOUS RESULTS OF VACCINATION .89.2 per cent. proved successful cases of vaccinationThis messing with vaccine lymph mixed with glycerineis evidently not only an expensive procedure, but disappointingin its results. Altogether, vaccination in theMadras Presidency seems to us to be capable of improvement."It appears that the results have been so unsatisfactorygenerally, that the preparation of glycerinated lymph,after a fair trial, has been entirely discontinued in theCalcutta and Darjeeling Depôts, the principal reasonassigned by the Sanitary Commissioner for Bengal beingthat " Glycerine is a nutritive medium for the growthof putrefactive and other germs, and, being fluid, thegerms soon pervade it throughout ; and, as a fact,this preparation (glycerinated lymph) in India soon becomesputrid and septically dangerous." 2 And whenwe consider that glycerine in small doses stimulates thegrowth of the tubercle bacillus, and even when undilutedwill not destroy the streptococcus of erysipelas, it seemsdoubtful whether the addition of the aqueous solutionof glycerine to the lymph as recommended by theGovernment will have any effect in lessening thedanger and amount of suffering attending the practiceof vaccination; and when the alleged prophylaxy ofvaccination is allowed to be so ephemeral by some ofits ablest defenders, the State may surely, as in the caseof other medical prescriptions, leave the matter to theparent, who, after all, is the most concerned, to saywhether his child shall be vaccinated or not.1 Report on Sanitary Measures in India in 1894-95, p. 217 .2 Indian Lancet, vol. ix. , p. 221. ( March 1 , 1897. )* Local Government Board, Report of the Medical Officer for 1896-97 ,p. 271 .CHAPTER X.SUMMARY AND CONCLUSIONS.BEFORE summing up my conclusions, a few words concerningthe enforcement of vaccination may not be outofplace, and my task has been simplified by the Reportof the Royal Commission. Four of the Commissionershave recommended that compulsion should be altogetherabolished, and the remaining nine, that honestobjectors should not be subject to fine or imprisonmentfor refusal to allow the vaccination of those for whomthey are responsible. Those who have studied theevidence given before this important tribunal, andespecially the Blue Book ' of 453 folio pages containingthe records of vaccinal disasters, will concur in accordingto the Commissioners their appreciation of these wiseand humane recommendations.The following are the points emphasised in mychapter on this serious aspect of the question:-1. That the principle and practice of vaccinationinvolves the introduction of a specific disease at leasttwice, and, according to numerous authorities, many1 " Papers relating to cases in which death or non-fatal injury wasalleged or suggested to have been caused by, or otherwise connected with ,vaccination. " Appendix ix. to the Final Report of the Royal Commissionon Vaccination .386 SUMMARY AND CONCLUSIONStimes into the human organism; that this specificdisease causes an undeniable impairment of healthand vitality, it being adistinctly morbid process.2. That the operation ofvaccination may occasion adefinite risk to life, one death on an average beingofficially registered from this cause every week inEngland and Wales.3. That there is good reason to believe that thisrecord greatly underestimates the fatalities and injuriesdirectly resulting from the operation.4. That no lymph, whether human or animal, oradulterated with other substances, can be guaranteed asfree from danger.5. That there is unimpeachable evidence proving thata variety of inoculable and some incurable diseases areinduced by vaccination.6. That there is no guarantee that syphilis, orsymptoms undistinguishable from this malady, may notbe induced by the inoculation of either human or animalvirus. One of the greatest of our physicians, the lateSir Thomas Watson, in referring to the risk of vaccinosyphilis, says :-" I can readily sympathise with, andeven applaud, a father who, with the presumed dreador misgiving in his mind, is willing to submit to multipliedjudicial penalties rather than expose his child tothe risk of an infection so ghastly." 1This outspoken deliverance was written twenty yearsago, when very few medical men had ventured to questionthe justice of compulsion, and is the more valuable,1 The Nineteenth Century, vol. iii. , p. 1006. (June, 1878. )COMPULSORY VACCINATION . 387inasmuch as Sir Thomas Watson was a firm believer inthe efficacy of vaccination .Once admitted that the risk is real, and one whichno amount of care can guard against (even if vaccinationwere a preventive of small-pox), all ground forcompulsion vanishes ; for it then becomes a question ofparental or individual responsibility, as in the case ofany other operation or treatment involving risk to lifeand health. No surgeon would dream of administeringchloroform or of performing the most trivial operationwithout first obtaining the patient's consent; and, therefore,no authority, whether medical or State, has theright to attempt to override a parent's or patient'sscruples. The matter should thus be left to the optionand good sense of the individual, as in the case of othermedical prescriptions. Compulsory vaccination is noweven by medical men beginning to be recognised as agrievous and mischievous mistake, and I have not theslightest doubt that the profession would willingly relinquishit to-morrow, if their credit and prestige were notso deeply involved. It seems, therefore, that theagitation for the repeal of the Vaccination Acts mustof necessity come, as it always has done, from thepeople themselves. Parliament, confessing its ownincompetence, and relying on medical promises whichhave been falsified all along the line of a century'sexperience, has decreed that vaccination shouldbe obligatory. Parliament must, therefore, be persuadedto undo the evil it has unwittingly committed.Unfortunately, the dead cannot be recalled to life, norcan the parents of those who have been injured bythe operation be compensated; nor will the scandalous388 SUMMARY AND CONCLUSIONS .and unrelenting persecution of upright and otherwiselaw-abiding citizens, whose only offence has been adetermination to preserve their children's bodies fromthe risk of inoculated disease, be easily condoned.The cruel hardship of qualified persons deprived ofemployment in the public service by reason of theirrefusal to submit to vaccination and re-vaccination callsfor prompt redress. This injustice is acutely felt in thecase of pupil teachers in the public elementary schools ;and the penalty for non-compliance is immeasurablygreater than the payment of a fine and costs. As the Commissioners,after seven years' inquiry, have recommendedthat all parents who conscientiously object to vaccinationshall no longer be subject to penalty, it is manifest thatthe refusal of employment in the public service to theseconscientious nonconformists cannot be logically orfairly defended.Pending the repeal of the Vaccination Acts, ourlegislators are in the responsible position of being aparty to the enforcement of a surgical operation, provedby the Royal Commission to be attended with danger,on every child born in this kingdom ; a compulsion,it may be added, about the expediency of which thepeople of this country have never had an opportunityof passing an opinion. In the meantime death-certificatesof children killed by vaccination are accumulatingat Somerset House, and most of these are doubtlessa direct consequence of this law.The more hotly-disputed question of the value ofvaccination itself has been considered in the foregoingpages at some length, and it only remains to brieflysummarise the various points.THE VARIOLOUS TEST. 389In the early days of vaccination, before it could beput to the test of experience, it appears to have beenfelt that the inoculation test would furnish absoluteproof of the protection afforded by the practice againstsmall-pox. In the first chapter of this volume it hasbeen shown that the lymph which convinced the professionof the efficacy of vaccination was Woodville's“hospital matter, " which was unquestionably contaminatedwith small-pox-hence the immunity whichit is claimed resulted from its use may have been animmunity produced by small-pox, which thereforeproved nothing in favour of vaccination. The fewvariolous tests which were performed by Jenner himselfhave been shown to be inconclusive ; and it issignificant that Jenner very early discarded the test infavour of that of re-vaccination .From the earliest days of vaccination numbers ofcases have been recorded of every description of smallpoxfollowing vaccination, from the mildest to the mostsevere and fatal, and within the shortest periods of theoperation. In the absence of any reliable method ofestimating the proportion of the population vaccinated,it is impossible to compare the relative attack- incidenceof small-pox in the two classes; but it is important tonote that the proportion of vaccinated cases in wellvaccinateddistricts has ranged as high as 95, 98, oreven 100 per cent. A method of comparison free fromobjection is the attack-incidence of small-pox indifferent towns. Gloucester in 1895-96 had an attackrateof 48 per 1,000, or about the same as that for thewell - vaccinated town of Willenhall in 1894, and the390 SUMMARY AND CONCLUSIONS.unvaccinated towns of Keighley and Leicester in therecent epidemics had only rates of 2.2 and 19 per 1,000respectively.With regard to the death-incidence, we may comparethe death- rates of small-pox at different periods in thehistory of vaccination, or in different towns ; or wemay split up the cases of small-pox into two classes,vaccinated and unvaccinated, and compare the casemortalityin each class. In the chapter on mitigation, Ihave dwelt at some length on the objections to thelatter method of procedure; and in my judgment theyare so vital that the evidence under this heading, inattempting to arrive at a decision as to the value ofvaccination, must be set on one side.There remains to consider the death-rates from smallpoxat different times and places, and, as the protectionis admittedly only of a temporary nature, to take intoaccount the proportion of the mortality borne bychildren. I have shown that the small-pox mortalitybegan to decline about 1781 , long before the introductionof vaccination ; and it was accompanied by adecline in fever and in deaths from all causes, and wasdue to the development of sanitary improvements. Thedecline continued after the introduction of vaccination,and it is almost certain that part of this reduction wasdue to the cessation of small-pox inoculation.¹Since the commencement of registration, the factslaid before the reader show that small-pox has paid no• The inoculation of out -patients at the London Small-pox Hospital wasdiscontinued in 1808. Baron's " Life of Jenner, " vol. ii. , p. 238.THE DECLINE IN SMALL- POX . 391heed to vaccination at all, one of the worst epidemics ofthe century taking place after seventeen years of compulsion; and quite recently, especially in London, as appearsby the figures cited , we have a remarkable declineof small -pox coincident with diminishing vaccination.Neither does vaccination seem to have had any effecton the severity of the disease ; the case-mortality beingas high in 1871-72, with a large percentage of thecases of small-pox vaccinated, as it was in the lastcentury, before Jenner's discovery. Hence, up to thetime of this epidemic the diminution of pock-markedfaces, as far as any diminution had been observed,cannot have been due to any diminished severity of thedisease, but must be attributed rather to a decline inthe prevalence of small-pox itself. Since 1871-72 , however,there has been a great decline in the severity ofthe disease, which has, doubtless, resulted from improvedhygiene and altered methods of treatment. It may alsobe noted that since the last century typhus, which isspread in much the same manner, has shown a greaterreduction than small-pox, and is now an almost extinctdisease.The death - incidence of small-pox in different townsis another method of comparison not open to objection .Gloucester heads the list of recent epidemics, with adeath- rate of over ten thousand per million ; but it hasbeen shown that in a list of twenty-four well-vaccinatedtowns the death- rates have varied from six thousand tonearly ten thousand per million, and hence the figurefor Gloucester is deprived of much of its significance.That unvaccinated towns can be kept comparatively392 SUMMARY AND CONCLUSIONS.free from small-pox is conclusively proved by the experienceof Keighley and Leicester, which had only ratesof two hundred and eighteen and one hundred and fourteenper million respectively, in the recent epidemics ;and that the most complete vaccination of a districtpossible will not prevent a serious epidemic, is shown inthe case of Mold, which, in spite of the vaccination ofevery child born and remaining in the district foreighteen years previous to the epidemic, had a small-poxdeath - rate of 3,614 per million, in 1871-72 .The last argument urged in the defence of vaccinationis the change in age-incidence. That this is not broughtabout entirely, or even principally, by vaccination, isclear, from the fact that a similar change has occurredin the unvaccinated, and therefore independently ofvaccination.Another important matter to which attention hasbeen directed is that, since the commencement of registration,the greatest decline in the infantile share ofsmall -pox deaths took place about 1871-72, and was notassociated with a very large increase in the amountof public infantile vaccination ; whereas the greatestincrease in public infantile vaccination was in the yearsfollowing the compulsory Act of 1853, and this wasaccompanied by quite a trifling reduction in the infantileproportion of the small -pox mortality.The Commissioners appear to attach considerableimportance to a comparison they make of the children'sshare of small-pox deaths in certain vaccinated andunvaccinated towns. Thus they show for recent epidemicsthat at Leicester and Gloucester the proportionMR. ALEXANDER PAUL ON AGE- INCIDENCE. 393of children's deaths from small-pox under ten years ofage was much larger than in the well-vaccinated townsof Sheffield and Warrington. In my second chapterI ventured to criticise these figures on the ground thatthe experience was not sufficiently extensive, and Ishowed that England and Wales in 1871-72, with only5 per cent. vaccination default, had almost as largea proportion of small - pox deaths under ten yearsof age as there were at Dewsbury in 1891-92 witha default of 37 per cent. , and I also pointedout that Mold and Willenhall, both extremely wellvaccinatedtowns at the time of their respectiveepidemics, had a large percentage of their small-poxdeaths under five years of age, and I instanced theepidemic in the unvaccinated town of Keighley, withseven small -pox deaths all over five years of age.Since writing my second chapter I have had theadvantage of consulting an important contribution tothe age - incidence controversy by Mr. Alexander Paul.¹He points out from the Commissioners' own figures thatthe children's percentages of small-pox deaths in thetowns specified only show similar variations to theirpercentages of small-pox illness ; whereas, according tothe theories of the Commissioners, the variations shouldbe far greater, for they think that the power of vaccinationto modify the character of small-pox is greatestduring the years immediately succeeding the operation.1" A Royal Commission's Arithmetic : A Criticism of VaccinationStatistics, and a Plea for Fresh Figures and Fair Inferences." AlexanderPaul . London. 1897 .26394 SUMMARY AND CONCLUSIONS.The following are the figures¹ for the attacks and deathsplaced side by side :-Children, aged 0-10.Percentage borne Percentage bornebythem oftotal small -poxdeaths.Epidemics.bythemoftotal small -poxillness.Warrington, 1892-93 ... 9.83 22.58Sheffield, 1887-88 12:42 25.60London, 1892-93 15.21 36.82Dewsbury, 1891-92 ... 21.64 51.82Gloucester, 1895-96 ... 35.67 64.52Leicester, 1892-93 ... 30°53 71.43 (or 66.60)、Of course the question will be raised, that, granted thedeaths only follow in the same proportion as the attacks,that is to say, that no extra penalty must be paid in theshape of death for neglecting vaccination, this will notaccount for the varying proportions of the children'sshare of small-pox illness in the different towns, whichranged from 9.83 per cent. at Warrington to 35.67 percent. at Gloucester.Mr. Paul explains this and I think the explanationis a reasonable one-by the varying incidence of smallpoxattack on adults and children in the several towns.Thus, at Warrington, small-pox was mainly spread inthe forges near the hospital ; at Gloucester an importantfactor was the introduction of the disease into the publicelementary schools ; and at Leicester the proximity ofthe scarlet fever wards to the hospital where small -poxThe figures for the deaths are those given by the Commissioners, thosefor small -pox illness being calculated from the Final Report of the RoyalCommission by Mr. Paul.AGE - INCIidence oF VACCINATED SMALL- POX . 395cases were treated undoubtedly raised the children'sshare of small -pox illness.The vaccination hypothesis I believe to be untenable,both for reasons given by Mr. Paul and also becauseit does not fit in with the experience of the earlyobservers on the relation of small-pox to vaccination.If there is anything at all in the theory that ina vaccinated population the children's share of smallpoxillness will be low, and vice versâ, it will be admittedthat in an extreme case-i.e. , where all the patientssuffering from small-pox have been vaccinated-thechildren's share of illness should be very low, indeedlower than the 9.83 per cent. at Warrington ; this isentirely at variance with the experience of vaccinatedsmall-pox in the early days, before the age- incidenceof small-pox had commenced to change. Indeed, thelarge proportion of young or recently-vaccinated casesled Mr. Edward Greenhow and others to suspectthat cow - pox was wholly, or in part, losing itsvirtue ; for he found that the numbers attacked werein the inverse ratio to the number of years which hadelapsed since they were vaccinated. One of Dr.Thomson's correspondents, Mr. William Gibson, givesfigures for the epidemic at New Lanark (see p. 152),where of 251 vaccinated cases of small-pox, 191 or 76·1per cent. took the disease at intervals, up to ten yearsafter vaccination. This high percentage is what weshould naturally expect at a period before the ageincidenceof small-pox had commenced to change. Theonly escape I can see for the supporters of vaccination,is to say that all the early operations were ineffectual,396 SUMMARY AND CONCLUSIONS.which is a dangerous argument for those who urge thatthe decline of small-pox was due to this prophylactic.This matter of the varying age-incidence of smallpoxin the different towns has been dwelt on so fullybecause much has been made of it by the Commissioners,but there are other points connected with thesubject which have been carefully worked out by Mr.Milnes, and tend to show that the only other diseasesat all comparable with small-pox have shown a similarchange in their age- incidence, and that it is sanitationto a large extent which must be held accountable,although, for reasons given in my third chapter, anothercause has doubtless been at work that is to say, ashifting of the small-pox mortality on to other diseases,such as measles and whooping-cough, which would thusexplain the insignificant reduction which has taken placein the mortality from these complaints .It may be asked at this juncture, how it is, with thesame set of facts before me, I have arrived at a differentconclusion to the Commissioners. My readers mayperhaps be able to judge for themselves if I putbefore them the facts which influenced this body totheir somewhat halting opinions. The essence of thecase which convinced the Commissioners of the efficacyof vaccination was given by their Chairman, Lord Herschell, at a meeting held on March 31, 1897, for thepurpose of raising a fund for a national memorial toEdward Jenner. '1 For full report of speech see British Medical Journal, vol. i. , pp.1247 , 1248. ( May 15 , 1897. )LORD HERSCHELL ON VACCINATION . 397After a few preliminary remarks on the terrors ofsmall-pox in the last century, and its decline after theintroduction of vaccination, Lord Herschell introducesthe statistical case for vaccination, and he deals withthree points-the first being the varying age-incidenceof small-pox in the six towns, the second the fatality ofthe vaccinated and of the unvaccinated in these towns,and the third point being an examination into thebehaviour of small-pox before and since vaccinationwas made compulsory. The first two matters havebeen dealt with so fully in this volume that I think itis hardly necessary to say anything further. Withregard to the third point, I will state the case in LordHerschell's own words. " I am going to invite yourattention," he says, " to the figures with reference to theeffects of the introduction of compulsory vaccination intothis country. It is undoubtedly recognised now that theprotection of vaccination is not permanent. It operatesmost effectually during the earlier years rather than thelater after the operation has been performed, and it isprobably during the first nine or ten years after vaccinationthat its operation is most efficient. Bearing that inmind, let me invite your attention to this, that in theyears from 1848 to 1854-that is, before the introductionof compulsory vaccination -the deaths of children underfive years of age were 1,514 to every million personsliving, and that from 1885 to 1894 they were 50 to everymillion persons living. Now take the other end of thescale-45 years and upwards. Of course, those of thatage would be no more affected by compulsory vaccinationbetween 1885 and 1894-the law having been passedin 1853-than children would be in the year prior to its398 SUMMARY AND CONCLUSIONS.introduction. In that class the deaths only fell from 24permillion to 19. "These figures have been taken from page 48 of theFinal Report of the Royal Commission, and the followingtable also gives the figures for the intervening yearperiods :-Deaths from small -poxpermillion living.Years. Under5. 45 and upwards.1848-54 1,514 2401855-64 788-8 36.21865-74 ... ... 782.5 87.51875-84 127.8 33.91885-94 .. 50°2 190I do not gather that Lord Herschell wishes to foundany argument from the latter part of his statement withreference to the reduction in the adult mortality from24 to 19 per million ; but it may be noted that prior tothe decline there was a large increase in the adult mortality,which has led Dr. Bridges to doubt if vaccinationever would have been made compulsory if these resultshad been anticipated. The point, no doubt, to whichLord Herschell wishes to draw attention is the declinein the children's mortality from 1,514 to 502 permillion. It will be observed that Lord Herschell omitsto state that there has also been a large decline in feverduring the period under review, nor does he hint thatthere may be a cause other than vaccination whichwould act more powerfully in children than in adultsviz., sanitation-to account for the reduction in themortality from small-pox.Let us now examine the facts Lord Herschell haspresented. In the first place, exception must be takenLORD HERSCHELL ON VACCINATION .399to the statement that the years from 1848 to 1854 arebefore the introduction of compulsory vaccination, forduring the year 1854 the public vaccinations in thiscountry reached a higher figure than they have evertouched in any year before or since, owing to the Actof 1853 ; secondly, it is unfair to put forward the period1885-1894 as if it were a period during which the vaccinationof children had been completely carried out, for,as I have shown, there has been a large reduction inthe infantile vaccinations as compared with the period1875-84, and Lord Herschell's own figures show thatcoincident with this reduction there has been a declineof 61 per cent. in the children's small-pox mortality.This decline he has placed to the credit of the prophylactiche is defending, and then he says he is" surprised " at the force of the evidence adduced infavour of vaccination .Although there does not appear to be trustworthyevidence to show that vaccination possesses any influenceover the prevalence or mortality of small-pox, it isunfortunate that a too implicit belief in its efficacy hasgiven rise to the pernicious doctrine that sanitarymeasures are of no avail in preventing this disease.We can quite understand that the owners of filthyrookeries and other insanitary premises are only tooready in their own interests to welcome such a theory,but for a great profession to have become wedded tothe doctrine has, I believe, greatly impeded the progressof sanitary reform; for while outbreaks of other diseases ,such as typhus, typhoid, cholera, and scarlet fever, haveproved valuable object lessons for municipal sanitaryamelioration, each epidemic of small-pox appears to400 SUMMARY AND CONCLUSIONS .have taught the profession little or nothing but thenecessity of repeated vaccinations.It is true that there have been occasional gleams oflight from the more independent thinkers in the medicaland lay press, but these have been unequal to directpublic authorities towards the only remedial and scientificpreventive-personal and municipal sanitation.Those who have followed the facts presented in thisvolume concerning the insanitary condition of Londonin previous centuries can have come to no other conclusionthan that this was the chief cause of the largesmall -pox and typhus death -rates. What else could beexpected with the narrow streets, courts, and alleys ;the imperfectly-constructed houses with little or nocurtilage ; the almost total absence of external ventilation; the exclusion of light and air by the operation ofthe window- tax ; the dense overcrowding ; the almostconstant inhaling of putrid excrement ; the loathsomeeffluvia from the intramural burial-grounds ; the limitedwater supply-these, added to the filthy personal anddomestic hygiene, cannot have failed to have influencedthe spread and mortality from these diseases. Neitheris it to be wondered at that the insanitary state of theprisons, as described by Howard, favoured the spread ofsmall-pox and typhus to the " destruction of multitudes."Much the same state of things prevails in partsof Egypt, China, and India of to-day, and it is thesedistricts where insanitary conditions are rife whichdemonstrate the utter futility of vaccination to copewith epidemic small -pox.In the Report on Sanitary Measures in India in1879-1880, p. 142, it is stated :-" The vaccinationSMALL- POX AND SANITATION. 401returns throughout India show the same fact, that thenumber of vaccinations does not necessarily bear aratio to the small-pox deaths. Small-pox in Indiais related to season, and also to epidemic prevalence ;it is not a disease, therefore, that can be controlled byvaccination, in the sense that vaccination is a specificagainst it. As an endemic and epidemic disease, itmust be dealt with by sanitary measures, and if theseare neglected small-pox is certain to increase duringepidemic times."Again, in the Memorandum of the Army SanitaryCommission on the Report of the Sanitary Commissionerfor the Punjab, for 1879, we read that " Vaccination inthe Punjab, as elsewhere in India, has no power apparentlyover the course of an epidemic. It may modifyit and diminish the number of fatal cases, but the wholeIndian experience points in one direction, and this isthat the severity of a small-pox epidemic is moreclosely connected with sanitary defects, which intensifythe activity of other epidemic diseases, than is usuallyimagined, and that to the general sanitary improvementof towns and villages must we look for the mitigation ofsmall -pox as of cholera and fever. " 1Thus it is on sanitation that we must henceforwardrely for the prevention and extermination of epidemicdiseases. The most necessary measures for the preventionof small -pox must therefore include-( 1 ) Demolition of dwellings unfit for human habitation.(2) Construction of houses to secure adequate externalReport on Sanitary Measures in India in 1879-80, p. 186.402 SUMMARY AND CONCLUSIONS.and internal ventilation, and the prompt removal of allfilth accumulations from the premises.(3) Adequate water supply and efficient seweragesystems.(4) Provision of open spaces in towns.Another wise method of prevention has been revivedin recent years, and this is the separation of the sickfrom the healthy. This system is mentioned in thewritings of Rast, Haygarth, and Faust, in the lastcentury, and was tried experimentally at Chester ; butthe advent of vaccination, with the confident promisesmade on its behalf, put a stop to further developmentof isolation at that time. Attention was again drawn tothe subject in 1868, by Sir James Simpson, in a paperentitled " Proposal to Stamp out Small-pox and otherContagious Diseases ; " and it was shortly afterwardsput to a practical test. Where it has been tried, coupledwith sanitation, as at Leicester and in the county ofLondon, it has been pre-eminently successful in reducingthe small -pox mortality. At the present time, compulsoryvaccination, by paralysing efforts in other directions,blocks the way towards sanitary reform. When the lawsare abrogated vaccination must, like all other medicalprescriptions and surgical operations, rest upon its ownmerits, or, in other words, on its inherent persuasiveness,unaided by the arm of the law. The practice will then,in my opinion, in the not very distant future be surelyabandoned.This will prepare the way for a new era of improvedhealth and human happiness, the result of scientificsanitary amelioration in all departments of our social,domestic, and municipal life.TRADITION OF THE DAIRYMAIDS. 403In due course of time the tradition of the dairymaidsof Gloucestershire will take its proper place among thelegends and folk-lore of the past ; and, if allowed toprophesy, I cannot help thinking that another generationwill look back with amazement and incredulity that fora hundred years the people of these islands should haveworshipped at the shrine of a strange, unreasonable, andmischievous superstition .
130012001100100090080070060050040030020010023561838718408918502SuccessSmall-f1850
APPENDIX.ENGLAND AND WALES .Successful Public Vaccinations under one year of age from1845-97.Years endingSeptember 29.Number ofunions andBirths.Successful public Percentage ofvaccinations under vaccinations.parishesone year of age . to births.returned.1845 580 486,632 147,958 30°41846 539 483,480 132,548 27.41847 621 523,682 141,487 2701848 627 532,046 169,611 31.91849 635 558,102 160,448 28.71850 637 559,721 168,703 3011851 639 592,347 181,351 30.61852 639 601,839 194,089 32.21853 638 601,223 195,700 32.61854 649 623,699 395,658 63.41855 653 623,181 343,029 5501856 653 640,840 341,231 53.21857 654 649,963 329,275 50.71858 656 654,914 333,579 50.91859 657 669,834 328,988 49.11860 657 689,060 349,142 50.71861 660 685,646 325,098 4741862 662 702,181 336,885 4801863 664 720,660 385,515 53.51864 665 739,236 363,885 49.21865 665 742,680 355,892 47.9665 743,859 338,664 1866 45.5406APPENDIX.Number ofYears endingSeptember 29.unions andBirths.parishesSuccessful public Percentage ofvaccinations under vaccinationsone year of age. tobirths.returned.1867 663 766,635 353,308 4611868 658 771,905 385,635 5001869 653 779,039 406,246 5211870 647 785,775 392,869 5001871 . 647 792,663 455,416 57.51872 647 810,291 462,321 57.11873 647 832,255 469,538 56.41874 647 845,286 470,256 55.61875 648 853,049 475,539 55.71876 650 881,518 486,031 5511877 649 881,897 498,577 56.51878 649 892,823 494,028 55.31879 649 884,995 500,646 56.61880 649 889,893 494,942 55.61881 647 874,474 501,125 57.31882 647 888,026 495,374 55.81883 647 892,524 495,056 55.51884 647 896,179 483,742 5401885 647 899,776 489,815 54.41886 647 906,819 480,306 5301887 647 885,860 457,301 51.61888 647 880,329 450,069 5111889 647 885,005 427,422 48.31890 648 883,647 412,388 46.71891 648 898,573 388,285 43.21892 648 901,459 375,634 4171893 648 912,325 369,627 40.51894 648 884,174 355,788 40° 21895 648 929,091 326,053 3511896 648 898,114 313,581 34.91897 649 930,707 295,727 31:8APPENDIX . 407ENGLAND AND WALES .For Small-pox, the death-rate per million living, from1838-42, and 1847-97.Small -poxdeath-rateper million living.Small-poxdeath-rateper million living.Years. Years.1838 ... ...1839 ... ...1,0645891868931869 701840661... ... 1870 1161841 400 1871 ...1842 168 1872 ......1,0158241843 ? .. 1873 ... ΙΟΙ1844 ? 1874 ... 911845? 1875 401846 ? 1876 ... 1031847 ...... 246 1877 1781848 ... 397 1878 ... 791849 ... 264 1879...... 251850262 1880... ...... 291851 ... 389 1881 ... 1241852 401 1882 ... 541853 ... 171 1883 ... 391854 151 1884 871855 ... 134 1885 ... 1071856 ... 1191886 131857 ... ... 204 1887 21...1858 3321888 ... 411859 195 1889 41860 138 1890 ... 41861 66 1891 51862 80 1892 ... 191863 ... 289 1893 ... 531864 367 1894 ... 311865 303 1895 ... ... 101866 ... 141 1896 ... 22 ...1867 116 1897 11 Except for the year 1897, small- pox includes chicken- pox .,-.'1FOSP7AFMO2T1AX-AL3L0LITYLocalityoftheepidemic.Period.Authority .Cases.Deaths .Poefrcentagef.atalitiesHalifaxRochdaleLeedst,pBHaorarawlidaisfrfhodarsxd-a,ppHaanarroltitishfhearxBradfordW-akefieldA--uLnsydhneteronMacclesfieldStockportWinter of 1721 to,A1(p7r2i2lT..PNhreitaltnlseton...,xv5pxo1xlii276 43 15.9Winter of 1721 toApril ,1722 Ibid. 177 3821'41otW7foi2n1terApril ,1722 Ibid. 792189 23.81722Ibid .,p.221 297 59 19.91722Ibid .,p.221 268 2810.41722 Ibid .,p.221129 36 27.91722 Ibid .,p.221 41857 13.61722 Ibid .,p.221279 562001722 Ibid .,p.221 302 37 12'21722 Ibid .,p.221 287 73 25.4Hatherfield1722 Ibid .,p.221 18020 11'1Chichester 1722 (to Oct. 15 ) Whitaker.Ibid.,p.223994168 16.9Haverfordwest1722Perrot Williams .Ibid .227 52 22.9.,BSaRaonirrdpsbptyoanndden,fppHoaoaafrurlirtisfhax1722mtftihroleowemns{" .JNuertitnl'eston,f"1A"o7cr2c3ount 230 38 16.5p.7Bolton 1)(?723{Jurin's f"A"ocrcount1723 ,p.8}406 89 21.6-Ware 1)(?723 .Ibid 61272 117Salisbury1723 (?) Ibid.1,244 165 13.2Rumsey,Hants1723 (?) Ibid. 913 143 15.6Havant1723 (?) Ibid.264 61 23.1BedfordShaftesbury,CnDoeeladcrhheasmterPlymouth-,nBAeayannrbhuory--SoAtnvroatnford,,12D75e2c5ember,t1N2o7o92v6.,12D75e2c5ember)(?1723Jurin's "Accountودfor7861.,p8723 147 18.41)(?724 I.,.f11pob27ri2d4 660100 15.11)(?724 .Ibid339106 3131)(?724 .Ibid 188 32 17.21S,,277e2p3tember R.,rMWeeracv.st.sore1,tD2o7e92c4. .,.fI15pob75ri2d5 133 25 18.81S,,27e72p3temberDr. Letherland .Ibid . 56289to Dec. 29 ,1724 15.8,,12S77e2p3tember..IDDbrii.cdkson,tD12oe79c2.4,12S77e2p3tember,t1D2o7e92c4.341 64 18.8S..ISHiblariondasne 105 20 190,,1S27e92p5tember,CoDLafryn.ntcehrb,JiuA"nurcri-yn's.,.f1c1"po7o7ru2n6t}503 6112'IIbid . 36233 9.1D,..iJIBnruber.iaidrnd73 15 20.5M-lBeoolotrosnCobhamDoverDeal,nWKeoearmrcpessteeyrUxbridgeHastingst,N12oo79v2.61727,1275261729-30,iDSTnrch.hoeruoclhdzf""Aeocrrc'sount11a77n22d78..,PDTFhrrri.aelnwsenv..,x1pox0lx8vii140 51 36.4705 97 13.713,192 2,26417.25..,.,.i,1"5Biov"HCE1pAi1fnroi1rp8p9ilse8i9.ttid4aogeirhmnytiocns27410 APPENDIX.EGYPT .Theaverage annual strength of the British army in Egypt, withthe number of admissions and deaths from small-pox for thefourteenyears 1882-95 :-Small-pox.1882 ... ... ...Strength.6,198Admissions . Deaths.301883 ... ... 7,897 8 31884 ... ... ... 6,468 25 I1885 ... ... ... 9,593 52 41886 11,062 51 31887 ... ... ... 5,272 26 41888 ... ... ... 3,346 14 41889 ... ... ... 3,431 4261890 ... ... ... 3,209 Ο Ο1891 ... ... ... 3,172 I1892 ... ... ... 3,102 2 Ο1893 ... ... 5,073 4 Ο1894 ... .. ... 5,226 0 Ο1895 ... ... ... 4,504 50INDIA .Theaverage annual strength ofthe number of admissions and deaths from small-pox for thefourteenyears, 1882-95.the British army in India, withSmall-pox.Strength. Admissions . Deaths.188257,344 44 41883 ... ... ... 56,190 105 91884 ... ... ... 55,252 7781885 ... 57,165 12 Ο1886... ... ... 61,757 22 I1887 ...... ... 63,942 40 21888 ... ... 68,795 106 101889 ... ... ... 68,545 152 171890 ... ... ... 67,456 36 41891 ... ... ... 66,178 14 I1892 ... ... ... 68,045 18 31893 ... 69,865 33 41894 ... ... ... 70,983 13 31895 ... 68,331 19 2APPENDIX . 411LEICESTER.Thepopulation of Leicester with attacks and deathsfrom smallpoxforthefourteen years 1882-95 :-Small-pox.Population. Attacks. Deaths .1882 126,275 29 (25) 51883 ... ... 129,483 12 (9) 31884 ... ... 132,773 6(3)1885 ...... 136,147 8 Ο1886 139,606 I Ο1887 ... 143,153 10 (9) 01888 146,790 22 (21) 01889 ... .. 150,520 Ο Ο1890 ... 154,344 Ο 01891 ... ... ... 177,353 Ο 01892 ... ... ... 180,066 38 61893 ... 184,547 308 151894 189,136 8 Ο1895 193,839 41Up to the year 1889 the figures have been taken from Diagram Dfacing p. 435, Fourth Report, Royal Commission on Vaccination.several instances the number of attacks is in excess of those given by theMedical Officer of Health in his report on the Leicester small -poxInepidemic, 1892-93. Dr. Priestley's figures, where they differ, are givenin brackets.VACCINATION ACT, 1898 .(61 AND 62 VICTORIA, CAP. 49.)BE it enacted by the Queen's most Excellent Majesty,by and with the advice and consent of the LordsSpiritual and Temporal, and Commons, in this presentParliament assembled, and by the authority of thesame, as follows :-1.-( 1 . ) The period within which the parent or other personhaving the custody of a child shall cause the child to be vaccinatedshall be six months from the birth of the child, instead ofthe period of three months mentioned in section sixteen of theVaccination Act of 1867, and so much of that section as requiresthe child to be taken to a public vaccinator to be vaccinated shallbe repealed.(2.) The public vaccinator of the district shall, if the parent orother person having the custody of a child so requires, visit thehome of the child for the purpose of vaccinating the child.(3.) If a child is not vaccinated within four months after itsbirth, the public vaccinator of the district, after at least twentyfourhours' notice to the parent, shall visit the home of the child,and shall offer to vaccinate the child with glycerinated calf lymph,or such other lymph as may be issued by the Local GovernmentBoard.(4. ) The public vaccinator shall not vaccinate a child, if, in hisopinion, the condition of the house in which it resides is such,APPENDIX . 413or there is or has been such a recent prevalence of infectiousdisease in the district, that it cannot be safely vaccinated, and inthat case shall give a certificate under section eighteen of theVaccination Act of 1867 of postponement of vaccination, andshall forthwith give notice of any such certificate to the medicalofficer of health for the district .(5. ) Notwithstanding any regulation of any lying -in hospital orinfirmary, or other similar institution, the parent of any child bornin any institution shall not be compelled under such regulation orotherwise to cause or permit the child to be vaccinated at anytime earlier than the expiration of six months from its birth.2.-( 1 . ) No parent or other person shall be liable to anypenalty under section twenty-nine or section thirty-one of theVaccination Act of 1867, if within four months from the birth ofthe child he satisfies two justices, or a stipendiary or metropolitanpolice magistrate, in petty sessions, that he conscientiouslybelieves that vaccination would be prejudicial to the health of thechild, and within seven days thereafter delivers to the vaccinationofficer for the district a certificate by such justices or magistrate ofsuch conscientious objection .(2.) This section shall come into operation on the passing ofthis Act, but in its application to a child born before the passingofthis Act there shall be substituted for the period of four monthsfrom the birth of the child the period of four months from thepassing of this Act.3. An order under section thirty-one of the Vaccination Act of1867 , directing that a child be vaccinated, shall not be made onany person who has previously been convicted of non-compliancewith a similar order relating to the same child.4.-No proceedings under section thirty-one of the VaccinationAct of 1867 shall be taken against any parent or person who hasbeen convicted under section twenty-nine of the said Act onaccount of the same child, until it has reached the age of fouryears.5.-Persons committed to prison on account of non-compliancewith any order or non - payment of fines or costs under theVaccination Acts shall be treated in the same way as first -classmisdemeanants.414 APPENDIX.6.-The Local Government Board maymake rules and regulationswith respect to the duties and remuneration of publicvaccinators, whether under contracts made before or after thepassingofthis Act.7.-The Local Government Board may by order, if in theiropinion it is expedient by reason of serious risk of outbreak ofsmall-pox or of other exceptional circumstances, require theguardians of any poor law union to provide vaccination stationsfor the vaccination of children with glycerinated calf lymph orsuch other lymph as may be issued by the Local GovernmentBoard, and modify as respects the area to which the order applies,and during the period for which it is in force, the provisions ofthisAct requiring the public vaccinator to visit the home of thechildotherwise than on request of the parent.8. The clerk of any sanitary authority which shall maintainahospital for the treatment of small-pox patients shall keep a listofthe names, addresses, ages, and condition as to vaccination ofall small-pox patients treated in the hospital, such entries to bemade on admission, and shall at all reasonable times allowsearches to be made therein, and upon demand give a copy underhis hand or under that of his deputy of every entry in the same onpayment of a fee of sixpence for each search, and threepence foreach copy.9. The enactments mentioned in the schedule to this Act arehereby repealed, during the continuance of this Act, to the extentspecified in the third column of that schedule.10.-( 1 . ) This Act shall not extend to Scotland or Ireland.(2.) This Act shall, except as by this Act specially provided,come into operation on the first day of January one thousand eighthundred and ninety-nine, and shall remain in force until the firstday of January one thousand nine hundred and four.(3.) This Act may be cited as the Vaccination Act, 1898, andthe Vaccination Act of 1867, the Vaccination Act, 1871 , the VaccinationAct, 1874, and this Act shall be construed together as oneAct, and may be cited collectively as the Vaccination Acts, 1867to 1898.APPENDIX . 415SCHEDULE .Session and Chapter.REPEALS.Short Title.30 and 31 Vict. The Vaccinationc. 84. Act of 1867.34 and 35 Vict. The Vaccinationc.98. Act, 1871 .Extent of Repeal .Section six .Section seven from " and shall"provide all stations" to theend of the section.So much of section eight as fixesthe amount of payment thereunder.Section twelve.Insection fifteen, from" according"to the provisions" to " per-" forming the operation."Section sixteen, the words " with-"in three months after the"birth of such child," and from"within three months after" receiving" to " period as" aforesaid ," and from " and" the public vaccinator" to theend of the section .Section seventeen, to " vaccina-" tions and," and in the samesection the words " if the" vaccinator so direct," andthe words " and inspected as" on the previous occasion."Section nineteen.In section twenty, the words"brought to him for vaccina-In section twenty-nine the words"to take such child or," thewords " to be taken," and thewords " according to the pro-" visions of this Act."In section thirty- seven the word"of."Section ten.In section eleven the words" take or " and the words " to"be taken."
INDEX .ABERGAVENNY. PAGESmall - pox in 1871-72Acland, Dr. T. D.64Age- incidence.Ofsmall-pox (see Small-pox).Symptoms accompanying vaccinationConvulsions supervening on vaccinationVaccinaleruptionsVaccine généraliséeAge-distribution of eczema caseselationship of cow-pox to syphilisIncubation period of erysipelasVaccination and scrofulaCase oflupusfollowing vaccinationTetanus following vaccinationCalf lymphAdenitis complicating vaccinationAdmiralty.Vaccination failures on H.M.S. " Phaeton "Of fever (typhus, typhoid, and simple and ill - defined fevers ) 46 , 47 , 396273, 274273, 274289, 290285291316, 317352 , 353354359361377,378111 , 274, 351 , 354, 382149Of typhus fever 48, 49, 396Oftyphoid fever 49, 396Ofinfluenza 49,50And sanitation 75, 76 , 396 , 398, 399Ahmed, Dr. Z.Case of tetanus following vaccination 360Air-spaces in towns.Salutary effect ofAiry, Dr.Norwich cases of vaccinal erysipelas ( 1882 )Albricht, Dr.On the spreading of leprosy by vaccinationAlgiers.Vaccino-syphilis ( 1880)61-65, 251348, 363345324418INDEX.American Civil War.Vaccino - syphilisAnimal Lymph .And vaccino-syphilisAnd tubercleSkin diseases and inflammatory complications fromMr. Robert Ceely onDr. Cory's experienceDr. Prince Morrow onDrs . Acland and BarlowVaccination CommissionersAppleby.Serious and fatal vaccinal injuries ( 1873 )Army.Small - pox after re - vaccinationArning , Dr. Edward.Experiment on condemned criminal, KeanuResults of vaccination of lepersOn the spreading of leprosy by vaccinationAsprières.Cases of septic poisoning after vaccination at ( 1885 )Atthill, Dr." Good " and " bad " marksAuckland.Small -pox in 1871-72Auzias -Turenne, Dr.Relationship of cow- pox to syphilisAynho.Small - pox in 1723-24BADCOCK , Mr. John.Personal experience of small- pox after re- vaccinationPAGE319-322316-319, 366, 386357,358366-378367, 368319373377, 378366 , 378351224-231 , 410326, 327328342-34435020364, 94, 95309, 31043. 44, 181 , 409214, 215Bakewell, Dr. Hall.Communicability of leprosy 326Leprosy and vaccination 335Ballard , Dr Edward.Vaccination not a " trivial " operation 270Vaccino - syphilis 295Perfect vaccine vesicle may furnish syphilitic virus 307Report on Leeds caseBarker, Mr. J.Fever epidemic ( 1741 )Barlow , Dr.Report on Leeds caseVaccinal injuries in some Norfolk villages ( 1890)312-31438314Calf lymph352, 363, 364377, 378INDEX . 419Baron , Dr. John.Eruptions from Woodville's lymphOn Jenner's evasionsJenner's persistency::Jenner and his medical confrèresReports of vaccination failures begin to multiply ( 1804)PAGE2125, 2627, 28106113, 114Opposition to vaccination ( 1808 ) 124, 125Clamour about prevalence of small- pox after vaccination 143Hesitation of respectable persons concerning vaccination ( 1818) 143Barry , Dr. F. W.Small-pox at Sheffield, 1887-88 (see Small- pox) .Immunity to small-pox in the unvaccinated 170, 171Small-pox after recent vaccination at Sheffield ( 1887-88) 171-173Sheffield " census "Barthez , Dr.Small-pox after re-vaccination at Sheffield ( 1887-88)Barthélemy, Dr.On blood being omnipresent in vaccine lymphVaccination and tubercle221 , 222176 , 177307354, 355Bates , Dr. W. T. C.Case of tetanus following vaccination 360Bavaria.Small-pox after vaccination ( 1871 ) 175, 176Baylies , Dr. William .Immunity to small - pox in the unvaccinated 166, 167Beale , Dr. Lionel.Immunity to small-pox in the unvaccinated 169Beaney, Dr. James G.Injurious results of vaccination 281Vaccino-syphilis 281, 294Beddoes , Dr. Thomas.Criticises Jenner's theories 16Bedwellty.Small -pox in 1871-72 64, 94, 95Bell , Dr. Benjamin .Injurious results of vaccination 280Bellows, Mr. John.Experiences in the Franco - Prussian War 83Benson , Dr. Hawtrey.Case proving communicability of leprosy 325, 326Berkeley, Dr. H. J.Case of tetanus following vaccination 360420 INDEX .Berlin.PAGEInsanitary condition prior to 1872 259Small -pox in 1870-72 175, 198, 231Sanitary works at, with decline in mortality 259Berlin Leprosy Conference ( 1897) .Communicability of leprosy 326Berry, Mr. George.Diagnosis between a vaccine sore and syphilis 310Besnier, Dr.Case of lupus following vaccination 359Bideford.Small-pox in 1871-72 95Biggs, Mr. J. Т.Small-pox at Leicester 88, 411Bigsby, Dr. J. J.Scar theory at Newark ( 1839) - 203Birch -Hirschfeld, Dr.On vaccination and scrofula 356, 357Birdwood, Dr. R. A.Vaccination absolute protection up to no age whatever 164, 165On the obscuring of vaccination scars by eruptionFallacy of classifying small -pox cases by vaccination marksAdvocates " the production of one vaccine vesicle only "Causes of blindness associated with small-pox -194194, 195212266Birkenhead.Small -pox in 1877 - 246Birmingham.Park-space and death - rates from zymotic diseases ( 1870-79 ) 62Small -pox in 1891-94 92, 175 , 178 , 185Blackmore, Sir R.Blindness.Mild small -pox in the eighteenth centuryPrevarications of the inoculatorsBlair, Mr.Case of small-pox after vaccinationBlank, Dr. Henry.Animal vaccinationBlandford.Fire and small-pox ( 1731 )Vaccinal erysipelas ( 1883 )From small -pox, causes ofBlood.Omnipresent in vaccine lymphBoddington, Mr. (surgeon) .Letter of remonstrance to Jenner188364, 36511636826535126630725INDEX. 421Bristol.Bohn, Dr. H.Cow-pox and erysipelasBolton, Dr. James.Vaccino-syphilis in the American Civil WarBorington, Lord.Brings in bill to check small- pox inoculation ( 1813 )Boulger, Surgeon I.Re-vaccinated small-pox in the army at Cairo ( 1885 )Bowditch , Mr. Vincent .Results of animal lymphBradford.Bremen.Park- space and death - rates from zymotic diseases ( 1870-79)Epidemic of jaundice from glycerinated lymph ( 1883-84) -Bridges , Dr. J. H.Advocates alteration of vaccination lawsThe unvaccinated not a danger to their neighboursValue of returns of vaccinal injuriesBrighton.Park - space and death- rates from zymotic diseases ( 1870-79)Park - space and death - rates from zymotic diseases ( 1870-79)PAGE347320, 321132226-23137462381 , 382451783646262British Annals of Medicine.Deprecates silencing of inquiry into vaccination question - 152British MedicalJournal.Insanitary surroundings of the unvaccinatedInfluence of sanitary measures on snıall- pox197258Vaccino- syphilis 293, 294Bromley.Small -pox after vaccination ( 1881 ) 175Brooke, Dr. F. B.Report on Gloucester Hospitals ( 1896)Brown , Mr. Thomas (a critic of vaccination).- 99-102Cases of small-pox after vaccinationAcknowledges his former partiality -Opinion that vaccination must be surrenderedHis treatment by Jenner127127127128Browning, Dr. B.Experience with " good " marks 203Buchan , Dr. William .Effects of insanitary surroundings 75Intramural burial-grounds (eighteenth century).Treatment of small- pox (eighteenth century )77263, 264Buchanan, Sir George.Refers to glycerine as " preposterous " adulteration of vaccine 380422 INDEX .Buckmaster , Dr. J. A.Results of vaccination of lepersPAGE328Burial -grounds ( intramural) .Influence on mortality 76, 77, 400Burnett , Dr. W.Small -pox after vaccination on H.M.S. “ Phaeton " 149Butler, Dr. D. W.Animal lymph 372CAIRO.Re- vaccinated small-pox in the army ( 1885 ) 226-231Caistor.Small -pox in 1871-72 94,95Calcutta.Glycerinated lymph tried at, and given up 384Calf lymph ( see Animal Lymph) .Cambridge.Small -pox after vaccination ( 1808) 124Canning, Mr. George.Opinion on compulsory vaccination 162Cantlie, Dr. James.Immunity of plague attendants 233Recent Essay on leprosy referred to 344Constitutional disturbance from Japanese (glycerinated) lymph - 382Cape of Good Hope Leprosy Conınmissioners.Communicability of leprosy 326Carlisle .Small-pox in 1779-87Carpenter , Dr. W. B.43Vaccination at Montreal prior to small-pox epidemic ( 1885 )Statistics of small-pox in the Franco- Prussian WarInfluence of sanitary measures on small -pox mortalityCarr, Mr. Henry.How small - pox is propagated -102, 103237-239258255Carter, Mr. Brudenell.On vaccino- syphilis 295Carter, Dr. Robert J.Vaccinal injuries from glycerinated calf lymph 382Carter, Dr. Vandyke.Communicability of leprosy 326Cayley, Dr.Communicability of leprosy 326Ceely, Mr. Robert.On vaccination cicatrices wearing out 193Animal vaccination and skin eruptions 286, 367 , 368INDEX . 423Chadwick , Sir Edwin .Influence of sanitary measures on small - pox and typhusChartres , Dr. J. Smith .PAGE257, 258Cases ofphlegmonous inflammation of the arm after vaccination 348Chelsea.Fatal vaccinal injuries ( 1875 )Chester.Small -pox in 1774 -System of small -pox prevention (eighteenth century)Chester- le- Street ,Small -pox in 1871-72Chicken-pox.Deaths , Registrar-General on" Confluent " cases" Malignant ""casesChrist's Hospital.Immunity from zymotic diseasesChurchill , Dr. Fleetwood.On the requisite number of vaccination marks -Clapham.Cases of vaccinal injury ( 1800)Clerkenwell.Vaccinal injuries ( 1879)Colin, Dr.Immunity of the unre- vaccinated35143, 97, 182, 18340264, 95, 9645159, 160160251Estimates small -pox mortality of garrison at Paris ( 1871-72 )Collie, Dr.Cases of small - pox after re-vaccinationCollins Dr. W. J. (see Royal Vaccination Commissioners).212274, 275351232238220, 221Cologne.Small - pox after vaccination ( 1871-73) 175Compulsory vaccination 162-164 , 178 , 356 , 384, 386-388 , 402Convulsions supervening on vaccination - 274Cooke, Mr. Charles .Case of small-pox after natural cow- pox 110Copland, Dr. James.Thinks vaccination could never altogether banish small-pox" Transcendental laudation " of vaccination" Reverberated encomiums from well- paid vaccination boards "Vaccination and scrofulaCory, Dr. Robert.Experience of calf lymphCottman, Dr. J. B.Case of tetanus after vaccination165165165355319359424INDEX .Coupland, Dr. PAGEGloucester small-pox epidemic-causes of extension : 97-99Immunity to small-pox in the unvaccinated 171Scar statistics, Dewsbury ( 1891-92) - 213Small- pox at Dewsbury ( 1891-92) confined to working classes 247Cow-pox.JennerJenner first interested in 9Symptoms 16, 109-111 , 270-274, 276, 311Deaths, England and Wales ( 1881-96 ) 362"Spurious" 26-29, 108 , 109, 111 , 114And erysipelas 346, 347Identity with small - pox repudiated -Relationship to syphilisCrapo, Dr. J. R.Animal vaccinationCreighton, Dr. Charles.Small-pox in the seventeenth centuryExtent of ( small -pox ) inoculation practised from 1721-28 -Window- tax30, 309309-319373425966, 6767, 68180, 408, 409309, 317Insanitary condition of London in 17th and 18th centuriesSmall -pox fatality in 18th centuryRelationship of cow-pox to syphilisCrookshank , Prof. Edgar.Woodville's casesCross, Mr. John.Norwich small -pox epidemic ( 1819) confined to lower classesTreatment of small-pox ( 1819)Cutler , Dr. William C.Skin diseases attending vaccinationDAIRYMAIDS.The tradition of theDalton , Dr. J. Н. С.Scar statistics22245264, 265288, 289- 9,403213Cases of small -pox after re - vaccination 223Darby, Dr.Cases of small- pox after re- vaccination 216Darjeeling .Glycerinated lymph tried at, and given up 384Darlington.Small -pox in 1871-72 64Daubler, Dr.Cases of leprosy after vaccination 340-342Davidson, Mr. P. M.Scar statistics 207-210INDEX . 425Davies, Dr. PAGESmall-pox fatality in vaccinated and unvaccinated 184Decanteleu .Varieties of vaccination cicatrices 201Dennett , Mr. C.Immunity to small - pox in the unvaccinated168Depaul, Prof.Animal vaccination 368Dewsbury.Small -pox in 1891-92Small-pox epidemic ( 1891-92) confined to working classesDimon , Dr. Theodore.Case of tetanus following vaccinationDimsdale , Dr. Thomas ( inoculator)Dortrecht.Vaccinal erysipelas among recruits ( 1883 )Dover.Small -pox in 1871-72Drew , Mr. Walter .Case of small -pox after vaccination -- 52, 213 , 151 , 247, 393247360- 11 , 12348, 34994, 95118Drysdale , Dr. Charles .Vaccino- syphilisDudley.Small-pox in 1871-72Dunning, Mr. Richard.29564, 94, 95Sceptical about merits of vaccinationReassured by Jenner114114, 115Cases of small - pox after vaccination 117Durham.Small-pox in 1871-72 64, 94, 95EASINGTON.Small -pox in 1871-72 64, 94, 95Eczema after vaccination 290, 291 , 351Edinburgh Medical and SurgicalJournal.Pays amende honorable to Mr. Thomas Brown128Edinburgh Review.Criticism on vaccination - 148Edwardes, Dr.On jaundice epidemic at Bremen ( 1883-84)382Egypt.Re- vaccinated small-pox in the army 225-231 , 410Ellenborough, Lord.On vaccination 13428426 INDEX .Epidemiological Society.Enteric Fever ( see Typhoid Fever) .Promote the first Compulsory Vaccination Bill ( 1853 )Opinion that the unvaccinated are a danger to societyOn vaccination scars wearing outAssertion respecting safety of vaccinationErasmus .On practice of strewing floors with rushesErysipelas.VaccinalAnd cow-poxIncubation period variableEvelyn, John.Small -pox in his familyFARN, MR. (of National Vaccine Establishment) .Cannot guarantee purity of vaccine lymphFarr, Dr. William .Small-pox and fever death - rates ( 1629-1835)Zymotic diseases replace each otherInfluence of sanitary measuresPAGE163, 164164193267, 26870281 , 345-354346, 347352, 35342268, 26957,5885257281Farrar , Dr. Reginald.Fatality from calf lymphFehleisen , Dr.Incubation period of erysipelas 352Fentem , Dr. P. S.Cases of erysipelas after vaccination 350Fever (typhus , typhoid, and simple and ill-defined fevers) .Death- rates (1629-1835) - 57Death- rates ( 1838-95) 40Registrar -General on cause of decline 41, 42Age- incidence 46, 47Flewellen , Dr. E. A." Spurious " vaccination in the American Civil War 321Fluder, Mr. Charles.Vaccinal injuries ( 1833 ) - 278, 279Forbes, Mr. William .Case of small -pox after vaccination - 115Fosbrooke, Rev. T. D.“Spurious " cow-pox 110, IIIFournier, Professor.Vaccino-syphilis " a real and serious danger " 294Vaccino- syphilis cases more numerous than recorded 362, 363INDEX . 427Fox . Dr. Colcott .Urticaria complicating vaccinationAge-distribution of eczema casesThree cases of lupus following vaccinationFox, Dr. Tilbury.Impetigo contagiosa following vaccinationCommunicability of leprosyPAGE290291359291326Francis , Dr.Communicability of leprosy 326Franco- Prussian War.And small - pox mortality 80-83, 237-240Frank, Dr. Louis .Adenitis complicating vaccination 274Vaccination and skin diseases 288Urticaria complicating vaccination 290Freycinet, M. de.Statistics of small-pox in the Franco- Prussian War 239Fuqua, Dr. William F.Vaccino-syphilis in the American Civil War 322GAINSBOROUGH .Erysipelas after vaccination (1876)Gairdner, Sir William .Cases of leprosy following vaccinationGaitskell , Mr. William.Malignant small -pox after vaccinationGarceau, Dr.Causes of Montreal small-pox epidemic ( 1885 )Gardner, Mr. Edward.28 On vaccination falling into disrepute at Frampton ( 1817 ) -Gateshead.Small -pox in 1871-72Gatti ( French inoculator)Gayton , Dr. William.348, 363329-33414410314264. 95, 96IIPrimary vaccination " a very fleeting protection indeed "Mild small- pox in the unvaccinated164190Fatality of malignant small pox in vaccinated and unvaccinated 190His method of classifying cases of small -pox 194 , 202Causes of high small-pox fatality in the unvaccinated197Cases of small-pox after re-vaccination 216-218German army.Small-pox in 234-236428INDEX.German Laws. PAGEProhibit taking lymph from a scrofulcus child - 356Gers, Dr. Henry.Animal lymph 371 , 372Gibson, Mr. William .Age-incidence of vaccinated small -pox 152, 395Gilmore, Dr. J. T.Vaccino- syphilis in the American Civil War 320Glasgow.Mortality from small- pox, measles, whooping- cough ( 1783-1812) 84Gloucester.Small -pox in 1895-96 51-53, 96-102 , 185 , 263 , 389 , 391-395Gloucester Hospital ( 1896 ).Sanitary administration “ shockingly neglected "Treatment of patients compared with that of last centuryGlover, Dr. J. G.Leicester system of small-pox preventionGlycerine.Action of, on the growth of the tubercle bacillusAlleged advantages of its addition to vaccine lynophGlycerinated lymph.Suggested in 1849Used extensively in Europe, India, and Japan10026390, 91358379376379Promoted by the Local Government BoardCondemned by Sir George BuchananLord Herschell's opinion ofThe Royal Commission onEpidemic of jaundice " causally connected " with379379, 380380, 381380381, 382Injuries from . detailed by Dr. Robert CarterInjuries and fatalities from (Royal Commission cases )Given up at Calcutta and Darjeeling382383384In India soon becomes " putrid " and " septically dangerous " . 384And tubercle - 358, 384And erysipelas 384Goldson , Mr. William .Cases of small- pox after vaccination ( 1804) 114Pleads for further investigation of vaccination question 114Graniteville .Cases of " spurious ” vaccination at 323Grantham , Mr. Justice.Personal experience of small- pox after re- vaccination 215Gray, Dr. J. M.Animal lymph 372Greenhow, Mr. Edward.On small - pox after vaccination ( 1833 ) 151Age- incidence of vaccinated small-pox 151 , 395INDEX . 429Gregory, Dr. George.On Jenner's first publicationJenner's" presumption "PAGE17154Onthe " sanguine pathologists " of 1800 153Repudiates identity ofcow-pox with small -pox 30, 309Onthe "trammels of Jennerian pathology 309Fatal small -pox after vaccination ( 1825) 149, 150On " acknowledged frequency " of small -pox after vaccination - 153Onthe mitigating power of vaccination 179, 180Onthe obscuring of vaccination scars by eruption 192On vaccination scars wearing out 192, 193Vaccination cicatrix as a measure of protection 212Grieve, Dr.Class of patients who take malignant small - pox 191Influence of sanitary measures on small-pox 256Griffin, Dr. F. L.Results of animal lymph- 370Grocers' Company.Offer prize of £1,000 for a pure vaccine lymph ( 1883 ) 269, 270Guy, Dr.Grosvenor , Mr. John.Cases of small - pox after vaccination ( 1801 )War as a cause of disease11379, 80HACKNEY.Small - pox in 1871-72Hadwen, Dr. Walter.Small -pox fatality at Gloucester Hospital ( 1895-96) -Hall, Mr. R." Confluent " chicken -poxHanson , Dr.Communicability of leprosyHarding, Mr. T. M.Cases of small- pox after vaccinationHardy, Mr. Thomas .Attributes a case of small- pox to chicken-poxAfterwards " reluctantly " alters his opinionHardy, Prof.Unpleasant reminiscence of re - vaccinationHarris , Dr. Walter.Small -pox in the seventeenth centuryHarrison, Mr. E.Case of small -pox after vaccination -Harrison , Mr. Thomas.Cases of small- pox after vaccination94,959715932617415916029042, 43112141430 INDEX.Hart, Mr. Ernest .On pre-Jennerian small - poxLeicester system of small -pox preventionOn immunity of vaccinated childrenSmall -pox fatality in vaccinated and unvaccinatedStatistics of small -pox in the Franco- Prussian WarSmall-pox at Douglas ( 1877-78 )Hartlepool.Small -pox in 1871-72Hartpence, Dr. W. M.Results of animal lymph-Haygarth, Dr.System of small -pox prevention at Chester ( 18th century )Judicious counsels respecting vaccinationHeron, Dr.Cases of " malignant " chicken- poxHerrick, Dr. S. S.Kesults of animal lymph-Herschell, Lord .His opinion of glycerinated lymphOn vaccinationPAGE57,58- 88, 89173, 174184237, 239, 240256, 25764371402106, 107160377380, 381396-399Hillis , Mr. John D.Cases of leprosy following vaccination 335-337Hirsch, Dr. August.Habitat of small-pox 258Hoagland, Dr. L. B.Animal lymph 370, 371Holland , Sir Henry .Holmes, Mr.Holt, Dr. Alfred H.Non- realisation of earlier anticipations about vaccination -Cases of vaccino - syphilisResults of animal lymphHooper, Dr. R.Fatal case of small-pox after natural cow-poxHopkirk , Dr. Arthur F.Re- vaccination Law in the German army ( 1834)Statistics of small-pox in the Franco- Prussian WarHoughton-le- Spring .Small -pox in 1871-72House of Commons.Comınittee ( 1802) .Accepts Jenner's " spurious cow-pox " theoryEndorses Jenner's opinion respecting value of vaccination15230537411023423864,9529105House of Commons.Committee ( 1871 ) .INDEX . 431PAGEChairmancompares mortality of small-pox with that of the plagueOn Vaccination Act ( 1867 )3133Howard, John.Insanitary condition of prisons ( 18th century ) 73-75On window-tax in prisons74Hubbard, Dr. George H." Spurious " vaccination in the American Civil War 321 , 322Hugo, Mr. Thomas.Small -pox after vaccination at Crediton ( 1814) 134, 135Hull.Park -space and death -rates from zymotic diseases ( 1870-79 )62Hunt , Dr. Ezra M.Animal lymph369, 370Husband, Dr.Hutchinson , Mr. Jonathan.On blood being omnipresent in vaccine lymphVaccination and skin diseasesVaccination prurigoVaccinal impetigo at St. Pancras WorkhouseCases of vaccino- syphilisOn syphilitic infants sometimes looking perfectly healthy307289292292301-303308Leeds case 314Cases similar to Leeds case 316Diagnosis between the Leeds case and syphilis 314, 315Calf lymph and vaccino-syphilis 317 , 318Escape of co- vaccinees in vaccino- syphilis cases 353,354Case of lupus following vaccination 358Ofplague attendantsImpetigo Contagiosa.IMMUNITY.To small-pox in the unvaccinatedOf small -pox hospital nursesTo zymotic diseases in improved dwellingsAnd vaccinationIndia.Small -pox and vaccinationRe-vaccinated small-pox in the armyGlycerinated lymph a failureIndian Lancet.Case of tetanus following vaccinationInfluenza.Age- incidenceIngenhousz, Dr.Cautions Jenner166-171 , 232 , 233231-233233247291 , 292401226, 410383, 38436149, 50108432 INDEX .Inoculation (small-pox) . PAGEPopular in Turkey - 10Dr. Timoni's letter on 10Introduced into England by Lady Mary Wortley Montagu ( 1721 ) 10Condemned criminals experimented upon IISecures royal patronage ( 1722 ) IIProgress impeded by severity of results IIPractice almost ceased ( 1728 ) - IIRevived ( 1740)11,59Made gratuitous ( 1746) 59Sanctioned by Royal College of Physicians ( 1754 ) IIReformed by Gatti, Sutton, and Dimsdale (1763 ) 11 , 12Diffused small-pox 58-60Prohibition in Paris ( 1763) - 58, 59Effect of its displacement by vaccination - 58-61 , 86, 390Inoculation Test (see Variolous Test) .JACOBS, MR.Personal experience of cow- pox 108 , 109Jaundice.Epidemic at Bremen, from glycerinated lymph ( 1883-84) 381, 382Jenner, Dr. Edward.First interested in cow -pox 9On the " Tradition of the Dairymaids " 9On the symptoms of cow-pox in milkers 270, 271On the immunity of cow-poxed milkers to small -pox 10First vaccination ( 1796) -14Method of applying variolous test 13, 14Variolous test failures15Cautioned by Royal Society 106Theories criticised by Dr. Beddoes - 16His " presumption," Dr. George Gregory on154And his medical confrères 106Has no lymph (end of 1798) 16Uses Woodville's lymph 21On Woodville's lymph finally assuming the nature of vaccine 61Abandons variolous test ( 1804) 26, 389Coins term " spurious cow- pox"26Assertions respecting permanent value of vaccination 105 , 164 , 214 , 267Assertion respecting safety of vaccination 267Disregards Dr. Haygarth's counsels 107Cautioned by Dr. Ingenhousz 108In 1804 advised to come forward and vindicate his doctrines114Reassures his friend Dunning , who had become sceptical 114, 115Conference with Lord Henry Petty 122Rewarded by Parliament 123Jenner and vaccination " again to be put upon their trial " ( 1809 ) 125Accuses Brown of " fraud and artifice" 128On Grosvenor case130Brings forward new doctrine to repel failures 130, 131INDEX . 433Jenner, Dr. Edward. PAGEAnnoyed by the anti-vacks 132Also by Lord Ellenborough's remarks on vaccination ( 1813 ) 132 , 134Disparaging remarks on his discovery by Dr. Thomson ( 1822 ) - 147Disconcerted by criticism in the Edinburgh Review 148On the requisite number of vaccination marks- 204Onmild small -pox in the eighteenth century 189On cow-pox and erysipelas 346, 347Jenner Society.Small -pox and sanitation 241Jeunhomme, Dr.Statistics of small-pox in the Franco- Prussian War 238-240Jones, Dr. Horace E.Results of animal lymph- 372Jones, Dr. J. T.Results of animal lymph- 372Jones, Dr. Joseph .Vaccino- syphilis in the American Civil War 319 , 320Jones, Mr. William.Experiences in the Franco- Prussian War 82, 83Jurin's statistics.Of small - pox fatality in the eighteenth century 180-183 , 408 , 409Criticised by Dr. M'Vail 181The Royal Commission on 183KEIGHLEY .Small - pox in 1893 -Kellett , Mr. R. G.53 , 91 , 97 , 225 , 390, 392 , 393Cases of small - pox after re - vaccination in his familyKilmarnock.216Small-pox in 1728-63 43LAMBETH .Small -pox in 1871-72 95, 96Lancet.Vaccination failures " numerous and discouraging " ( 1853 ) 155Fatality of small -pox ( 1871 ) 184Pock-marked faces ( 1872) 56On the propagation of inoculable diseases by vaccination-Cases of erysipelas after vaccination279349Calf lymph and vaccino-syphilis 366Langworthy and Arscott, Messrs .Experiments, referred to 23, 24Lawbaugh, Dr. A. I.Results of animal lymph- 374434 INDEX .Lebus.Cases of vaccino - syphilis at ( 1876 )Lee, Dr. Robert .Skin diseases attending vaccination -PAGE324286Leeds .Park- space and death-rates from zymotic diseases ( 1870-79)Case of " vaccino- syphilis "62311-319Legge, Dr. T. М.Sanitary works at Berlin, with reduction in mortality259Leicester .Park- space and death- rates from zymotic diseases (1870-79)62Small-pox epidemic, 1892-94 (see Small -pox).System of small - pox prevention 88-91Vaccination returns ( 1885-95) - 87Lennander, Dr.Leprosy.Case of lupus following vaccination -Communicability ofInoculation ofIn-vaccination of ( cases ) -Whether spread by vaccination359325, 326326, 327329-342342-345Lettsom , Dr.Vaccinal injuries at Clapham ( 1800 ) 275Lining, Dr. C. Е.Animal lymph 373Lister, Lord.Small -pox in the Germany army 234-236Little, Dr.Cases of " confluent " chicken-pox 160, 161Liverpool.Typhus in 1839 48Park - space and death-rates from zymotic diseases ( 1870-79 ) 62Llanelly.Small - pox in 1871-72 95, 96Local Government Board .Powers under Vaccination Acts34On pre-Jennerian small -pox 186On the re-vaccination of the army 224Assertion respecting immunity of re - vaccinated soldiers 224On the safety of vaccination 270Encourage practice of vaccinating newly-born infants 281 , 282Assertion respecting vaccino - syphilis 293And the Leeds case312, 314INDEX . 435Local Government Board.Cases similar to Leeds caseInquiry into 132 fatal cases ( erysipelas, etc. ) after vaccinationPromote glycerinated lymphLondon.Population previous to present centurySmall -pox epidemics ( see Small-pox) .Small-pox and fever death - rates ( 1629-1835 )Typhus in 1685-86 , 1741 , 1837-38, 1847, and since 1871PAGE316351379325737-39, 48Insanitary condition in early times 67-73,400Park- space and death - rates from zymotic diseases ( 1870-79 )Squares , dates of construction of6265London Gazette.Pock -marked faces ( 17th and 18th centuries ) 55London Medical Repository.Case of small - pox after vaccination - 135On alarming number of vaccination failures ( 1817 ) 142London Sınall - pox Hospital.Vaccination failures ( 1825 , 1826-65, 1867 , 1871 )Lucas, Mr. Clement.Case similar to Leeds caseLürman , Dr.Jaundice epidemic at Bremen from glycerinated lymphLupus.Following vaccinationLyman, Dr. Henry M.35, 149 , 150, 175316381 , 382358, 359Animal lymph 367Lymph ( Vaccine) .No guarantee of purity ( Mr. Farn) 268, 269Lyttelton , Lord.Introduced Compulsory Vaccination Bill ( 1853 ) 163Promised certainty of vaccination as a preventive of small-pox - 163MACAULAY, Lord.Window-tax 66MacCombie, Dr. John.Small-pox fatality in vaccinated children 173" Good " Onmalignant small-pox- 190marks203, 204Cases of small-pox after re - vaccination 218-220Opinion respecting protective value of re -vaccination 220Macdonald, Dr.On the spreading of leprosy by vaccination 344, 345436INDEX.M'Ghie.Woodville's variolous testsMaclean, Dr. Charles.Vaccinal injuriesMacleod, Dr.Cases of small -pox after vaccinationMacnamara , Mr. C. N.Communicability of leprosyInoculation of leprosyIn-vaccination of leprosyM'Vail , Dr. John C.Age- incidence of small-poxCriticises Jurin's statisticsMaddock, Mr. B.Injurious results of vaccinationMaitland, Mr. Charles (early inoculator)Makuna, Dr.On classification of small-pox cases by vaccination marksCases of vaccino- syphillis reported in his " Inquiry "Malthus, T. R.Vicarious mortalityManchester .Typhus in 1839Small -pox in 1769-74Park - space and death - rates from zymotic diseases ( 1870-79 )Marsh, Dr. E. J.Animal lymphMarson, Mr. J. F.Mild small -pox in the unvaccinatedFatality of corymbose sinall-poxHis method of classifying small -pox casesHis scar statisticsMartin, Dr. Henry A.Case of vaccine généraliséeMartin , Sir Ranald.Leprosy and vaccinationMassey, Isaac.Mild small -pox in the eighteenth centuryMeasles.In Glasgow, takes the place of small-pox ( 1783-1812 )PAGE18278144-146326327, 32833449181275, 27610, 11202, 203303-30583,84434862371189191193, 194204, 205285334,335188-84, 85Medical and Chirurgical Review.INDEX.Cases of post - vaccinal small - pox, with remarks by editors -Case of small- pox attributed to chicken- poxOn Mr. John Ring's prevarications -Injurious results of vaccinationMedical and PhysicalJournal.Review on Mr. Goldson's objectionsMedical Observer.Fatal cases of small -pox after natural cow-pox113 cases with 16 deaths of small- pox after vaccinationSmall-pox mortality after vaccination at Witford ( 1810)Medical Record ( New York).Case of tetanus following vaccinationMedical Times and Gazette.Squalid surroundings of small-pox sufferers ( 1871 )On the transmission of tubercle by animal lymphMelichar, Dr.Epidemic of impetigo contagiosa following vaccinationMerthyr.Small-pox in 1871-72Metropolitan Asylums Board.437PAGE118-122157, 158158276114111125-127128, 129361246357,35829264, 95, 96Small -pox statistics in the Hospitals ( see Small -pox ) .Small-pox immunity in one of the Managers (unvaccinated) 232, 233Cases of small-pox after re - vaccinationMichaels , Mr.216-221 , 223Causes of Montreal small-pox epidemic ( 1885 ) 103Milnes , Mr. Alfred.Age- incidence of typhus and typhoid fevers 49Age- incidence of influenza 49, 50Age- incidence and sanitation 76, 396Mold.Small - pox in 1871-72 53, 93 , 94, 104. 392Montagu , Lady Mary Wortley.Introduces snmall - pox inoculation into England ( 1721 ) 10Montreal .Small - pox epidemic ( 1885) 102 , 103Moore, Mr. James.Moore , Sir William .Woodville's lymph -Effects of small-pox inoculationCommunicability of leprosy21 , 2259326Morland, Mr. W.Cases of erysipelas after vaccination 347,348438INDEX.Morrow, Dr. P. A.Vaccine généraliséeSkin diseases attending vaccinationReluctance of profession to recognise vaccinal injuryAnimal lymphMorton, Dr. Richard.Small-pox in the seventeenth centuryMoseley, Dr. Benjamin.Publication on vaccination failuresMudge, Mr. John.Messrs. Langworthy and Arscott's experimentsMild small-pox in the eighteenth centuryMudie, Dr. P.Acknowledges his prejudice in favour of vaccinationMurchison, Dr. Charles .Typhus fever epidemics ( 1685-86 , 1741 )Murray, Dr.PAGE2852893633734212223, 24188, 18916137326 Communicability of leprosyNAPIER, DR. ALEXANDER.Eruptions from calf lymph 373-377Nash , Brigade-Surgeon.Vaccination and re- vaccination in the army 224, 225Small -pox cases and deaths in the army ( 1860-88) 225National Vaccine Establishment.Founded ( 1807 ) 123Principal function 123Report on the Grosvenor caseCases of small- pox after vaccinationPock-marked faces ( 1821 , 1825)130143-145.14755,56223, 224IINavy.Small -pox after re - vaccinationNettleton, Mr. Thomas ( early inoculator)Neuss.Small-pox after vaccination at ( 1865-73) - 175Newcastle-on-Tyne.Park-space and death- rates from zymotic diseases ( 1870-79) 62Small-pox in 1871-72 64, 95, 96Niemeyer, Dr. Felix von .Dangers ofvaccination 279, 280On vaccination and tubercle355Opinion on compulsory vaccination356Nightingale, Miss Florence.Onthe first canon of nursing 265, 266INDEX.Northampton .Small-pox in 1871-72Norway.The Government of, on the vaccination of young childrenNorwich.Small-pox in 1819 confined to lower classesSmall -pox in 1871-72Park- space and death - rates from zymotic diseases ( 1870-79)Vaccinal erysipelas ( 1882)Nottingham.Fatal case of small-pox after vaccination ( 1809)Park - space and death-rates from zymotic diseases ( 1870-79 )Nurses.Immunity to small -pox and plagueNursing.Influence on small-pox fatalityOGLE, DR. WILLIAM.On age- incidence of zymotic diseasesOldham .Park- space and death- rates from zymotic diseases ( 1870-79 )Oliver , Mr. Richard.On the spreading of leprosy by vaccinationOpen Spaces in Towns.Salutary effect ofPAGET, SIR JAMES.Onthe effects of vaccinationParliament , Acts of.Relating to vaccinationPublic Health Act ( 1875 )Paul, Mr. Alexander.Small-pox age - incidence in recent local epidemicsPearse, Dr. S. H.Animal lymphPearson, Dr. George.439PAGE94, 95283, 2842459562348, 36312962231-233256, 266466234562, 63, 25127233-35 , 412-41554393-395372271120, 132, 13330132162Symptoms of cow-poxCases of small-pox after vaccinationRepudiates identity of cow-pox with small -poxHis " insinuations that vaccination is good for nothing "Peel, Sir Robert.Opinion on compulsory vaccination (reported by Mr. Duncombe)440 INDEX .Percival , Dr. Thomas .On the inoculation of infantsPercival , Dr. W. F." Spurious " vaccination at GranitevillePerron, Dr.Epidemic of impetigo contagiosa following vaccinationPhipps, James.Jenner's first vaccinationPicton, Mr. J. A. (see Royal Vaccination Commissioners) .Piffard, Dr.Case of leprosy following vaccinationPAGE28332329214337, 338Pitt, William .Condition of the poor in 1796 78Plague.Compared with small - pox 31 , 32Immunity of attendants 233Playfair , Lord.Statistics of small -pox in the Franco- Prussian War 237Plomesgate.Vaccinal injuries ( 1878 ) 351Plymouth.Park- space and death - rates from zymotic diseases ( 1870-79 ) 62Pock -marked faces.Pontypridd.Portsmouth .Prevalence in seventeenth and eighteenth centuriesDisappearance avowed by Vaccine Board ( 1821 , 1825 )Frequency deplored by Lancet ( 1872 )Cause of diminished prevalence since 1872Small- pox in 1871-72Park - space and death - rates from zymotic diseases ( 1870-79 )Pourquier , Dr.Epidemic of impetigo contagiosa following vaccinationPractitioner, The.Heifer vaccinationPreston.Severe and fatal small -pox after vaccinationPreston , Staff- Surgeon T. J.Small-pox after re -vaccination on H.M.S. " Audacious "Prince , Dr. M.Results of animal lymphPrisons.Insanitary condition , eighteenth centuryProtze, Dr.Fpidemic of impetigo contagiosa following vaccination5555,565639164, 94, 9562292368123, 12422337573-75292INDEX .Provincial Medical and Surgical Association .Vaccination failures ( 1840)Prurigo following vaccinationPublic Health Act ( 1875 ) , referred toRADCLIFFE, MR. NETTEN.Erysipelas after vaccination at Gainsborough ( 1876)Railway Travelling.Risk compared with that of vaccinationRake, Dr. Beavan.Results of vaccination of lepersRansome, Dr. Arthur.Action ofglycerine on the growth of the tubercle bacillusRaymond, Dr. J. H.Fatal case of small-pox after re-vaccination441PAGE154, 15529254348, 363365328358216136-141277, 278Redhead, Mr. M.Cases of small - pox after vaccinationReece , Dr. Richard .Injurious results of vaccinationRegistrar-General.Classifies small - pox deaths(Vaccinated) 199(Unvaccinated ) 199(No statement) 199Investigates " no statement" deaths from small -pox ( 1871-72) 199, 200Small - pox at Mold ( 1871-72) 93Most of the chicken -pox deaths are very probably " small -pox6645Influence of sanitary measures on small-pox 253Effect of sanitary reform on child mortality 75Causes of decline of fever 41, 42Deaths from vaccination, England and Wales ( 1859-96)Registrars (Metropolitan) .Influence of sanitary measures on small - pox ( 1843 )Re -vaccination.Personal experiences of failureExperience of the Metropolitan Asylums BoardIn the navyIn the armyFatal small -pox after, at Berlin ( 1870-72 )In the German armyRhazes.On varieties of small -poxRice, Dr.Results of animal lymph346, 362247-254214, 215216-221 , 223223, 224224-231231234-236186373Richardson, Sir B. W.On sanitation 259, 26029442 INDEX .Ricketts , Dr.On the obscuring of vaccination scars by eruptionOn vaccination scars wearing outFallacy of classifying small- pox cases by marksPAGE195, 196195195Ricord, Prof.On vaccino - syphilis 293Rigden, Mr.On small -pox being confined to the lower classes245Rijo, Dr. R. G.Case of tetanus after vaccination360Rilliet , Dr.Vaccination and tubercle354,355Ring, Mr. John.Cases of small - pox after vaccination 115-118His prevarications 158Case of " confluent " chicken- pox 159Robinson , Dr.Severe and fatal small -pox after vaccination at Preston123, 124Ross, Mr.Skin eruptions attending vaccination 287 , 288Ross, Dr. George.Case of tetanus after vaccination359Royal College of Physicians .Sanction small -pox inoculation IICondemn " spurious cow-pox " theoryReport favourably on vaccination ( 1807 ) -29123On vaccination and leprosy ( 1867 ) -339Royal College of Surgeons .On vaccinal injuries ( 1807 ) 276, 277Royal Commission on Vaccination. (Cases reported in Appendix ix. )Cases of convulsions after vaccination274Disgraceful case of vaccination of newly-born premature infant 283Cases of vaccine généralisée285Cases of eczema following vaccination 291Cases of impetigo contagiosa following vaccination 292Cases similar to Leeds case316Cases of vaccinal erysipelas351Case of lupus following vaccination359Case of tetanus after vaccinationInjuries and fatalities from glycerinated lymphRoyal Society.CautionJennerRoyal Vaccination Commissioners (Majority of).360, 361383106On Woodville's casesCriticise variolous test18:24INDEX . 443Royal Vaccination Commissioners ( Majority of) .On age- incidence of small -poxJurin's statisticsSmall -pox and sanitationRecent decline of small-pox in the MetropolisOn vaccine lymph containing organismsInjurious results of vaccinationVaccination of infantsSkin affections following vaccinationOn blood being omnipresent in vaccine lymphLeeds caseRelationship of cow-pox to syphilis -PAGE50-53, 392-396183241-244244270271 , 272284286, 287307314316Vaccination and scrofula 354Vaccino-syphilis cases more numerous than recordedCompare risk of vaccination with that of railway travellingCalf lymph363365366, 378Glycerinated lymph 380Recommendations with regard to conscientious nonconformists 385Royal Vaccination Commissioners ( Dr. Collins and Mr. Picton) .Pedigree of Woodville's lymph 19Reject Woodville's cases " as furnishing false evidence, andvalueless as a scientific experiment " 22Age- incidence of small-pox in the unvaccinated 46Small -pox age- incidence, Scotland ( 1871 ) 76Gloucester small-pox epidemic-causes of extension 97-99Small -pox fatality, Metropolitan Asylums Board ( 1870-94) 183On methods of classifying small- pox cases by vaccination marks 202Immunity to small-pox in improved dwellings - 247Vaccinal erysipelas (cases and deaths ) 350, 351Statistics of risk of vaccination, and of railway travelling 365Rühle, Dr.Vaccination and scrofula 356Rügen, Isle of.Epidemic of vaccinal impetigo ( 1885 ) 291 , 292 , 380Russell , Dr. James B.192197On the obscuring of vaccination scars by eruptionSmall -pox fatality at Glasgow ( 1871-72 )SALFORD .Park - space and death -rates from zymotic diseases ( 1870-79 )Sanitation .Influences small -pox ( see Small -pox) .Neglect of, in 17th, 18th , and early in 19th centuriesInfluences age- incidence of disease6267-75, 400Savill, Dr.On vaccination scars wearing out75, 76 , 396 , 398 , 399193Texture of vaccination scars 201 , 202444 INDEX.Savill, Dr.On the obscuring of vaccination scars by eruptionWarrington small -pox ( 1892-93) limited to smaller housesScarlet fever .Decline since 1861-65Schaefer , Prof.On vaccinal injury being greater than recordedScotland .Small-pox age - incidence ( 1871 )Scott, Dr. Anna.On the spreading of leprosy by vaccinationScrofula.And vaccinationSeaton, Dr. E. C.PAGE200246, 24740, 4136476345280, 305, 354-358Vaccination at Mold prior to 1871-72 small-pox epidemicVaccination at Swansea prior to 1871-72 small-pox epidemicSimilarity of vaccination sore to syphilis -Shaftesbury, Lord.9394310, 311On small -pox being chiefly confined to the lowest classImproved lodging-houses might exterminate small -pox245245Sheffield.Park- space and death- rates from zymotic diseases ( 1870-79 ) 62Small- pox in 1887-88 (see Small- pox) .Small-pox after recent vaccination ( 1887-88) 171-173Small -pox after re-vaccination ( 1887-88 ) - 221 , 222"Census" 176, 177Shipman , Dr. N. S.Animal lymph 372Shorter, Mr. John .Effect of inoculation after vaccination 14, 15Short Heath.Small - pox in 1894 92Simon, Sir John.Oncomplete immunity of the vaccinated to small - pox 164, 214Assertions respecting safety of vaccination 268If lymph be not guaranteed pure, vaccination should be optional 268Sims , Dr. John.Case of small- pox after natural cow-pox 108, 109Remarks on the " loathsomeness " of cow- pox 109Skin diseases.And vaccination 285-292And calf lymph 366-370, 372-378INDEX . 445Small-pox ( Variola) .Adisease of the poorAdisease of towns -Blindness fromDisfigurement fromDisplacement of (by measles, etc. )Identity with cow- pox repudiatedInoculation (see Inoculation).In the Franco- Prussian WarPAGE245-247 , 249, 250, 2576126655, 56, 39184, 85, 39630, 30980-83 , 237-240In the German army 234-236Treatment of - 186, 187 , 260-266, 391Age- incidence.In seventeenth century 42,54In eighteenth century 43,54Since 1837-38 44In local epidemics 51-53, 392-396Compared with that of other diseasesCauses of extension .InsanitationAnd vaccination 45, 46, 50-54, 125-129, 151 , 152 , 154, 155 , 392-396Influence of sanitary measures onInoculation (small -pox )Density of population on area and in dwellingsConımercial depression and high prices of wheat46-50, 39676, 396, 39858-61 , 86 , 39065-77, 241-260, 399-40161-65, 248-250, 25277-79War 79-8357, 58, 60, 390Decline.Prior to introduction of vaccinationFrom thence to the 1871-72 epidemicDuring recent yearsEpidemics.Aynho ( 1723-24)Bavaria ( 1871 )Berlin ( 1870-72 )Birkenhead ( 1877 ) -Birmingham ( 1891-94)Bromley ( 1881 )Cairo(1885)35 , 40, 41 , 5335, 36, 40, 41 , 54 , 244, 39143, 44, 181 , 409175, 176175, 198 , 23124692, 175, 178, 185175226-231Cairo ( 1888-89)Chester ( 1774)Cologne ( 1871-73 ) -Dewsbury ( 1891-92)England and Wales ( 1817-19)England and Wales ( 1837-38) -225, 22643, 97, 182 , 18317552, 213, 247,39379, 161 , 17938, 44, 61 , 79, 151 , 152England and Wales ( 1870-72 )31, 32, 34, 35, 41, 52, 54, 63, 83, 94-96, 199, 213, 246, 391-393England and Wales ( 1892-95): :Glasgow ( 1871-72) -199, 201197446INDEX.Small -pox ( Variola).Epidemics.Gloucester ( 1895-96)Keighley ( 1893 ):PAGE51-53, 96-102, 185, 263, 389, 391-39553, 91 , 97 , 225, 390, 392, 393Leicester ( 1892-94) 51-53, 88, 90, 91 , 94, 97-99, 171, 225, 226,London ( 1634 , 1685, 1710, 1714 , 1719 , 1757, 1796 )231 , 244, 390-395, 402, 41132, 77, 78London ( 1817-19) 79, 142-145London ( 1837-38 ) 38, 247-253London ( 1870-72 ) 32, 35, 36, 174, 185, 199 , 255 , 256London ( 1892-93) 36 , 52, 196 , 197 , 394Mold ( 1871-72) 53 , 93 , 94 , 104, 392Montreal ( 1885 ) 102, 103Norwich ( 1819) 245, 264, 265Scotland ( 1871 ) 76Sheffield ( 1887-88) - 52 , 92 , 171-173 , 175-177 , 185 , 206 , 207 , 211 ,221 , 222, 393,394Short Heath ( 1894) 92Sunderland ( 1884) -175Swansea ( 1871-72 ) - - 64,94Warrington ( 1773) - 43Warrington ( 1892-93) 52 , 92 , 175,394,395Willenhall ( 1894)53, 92, 93, 175 , 211 , 389, 393Witford, Hertfordshire ( 1810) - 128, 129Fatality.Pre-Jennerian 180-183, 186-189, 391, 408, 409Post-Jennerian 183, 184Statistics of, in the unvaccinated 185 , 197, 198 , 204, 205In the vaccinated 128 , 129, 173 , 174 , 179 , 180, 196-198, 203-205In the re- vaccinated231Influence of sanitation and treatment on 97-102 , 241-266, 391Immunity.Not in proportion to proximity of vaccination 141 , 151 , 152 , 154, 155In the unvaccinated 166-171 , 232 , 233Of hospital attendants 231-233In improved dwellings 247Prevention.By separation of the sick from the healthy 402Sanitary in provements 245, 247 , 251 , 254 , 256-260, 401 , 402Provision of open spaces in towns 61-65, 251, 402Sir Edwin Chadwick on -257, 258Dr. Southwood Smith on254At Berlin since 1872259Leicester's system 88-91Varieties .DiscreteConfluentMalignantCorymbose186-190, 260-262191-197, 260-262190, 191191INDEX. 447PAGESmall-pox after natural cow-pox - 27, 106-111Small - pox after re-vaccination 214-231Small - pox after vaccination (see Vaccination ).Small-pox by inoculation after vaccination 112 , 121 , 141Smith, Dr. Southwood.Immunity to small - pox in improved dwellings 247Prevention of epidemics - 254Southampton.Small -pox in 1871-72 95, 96South Shields.64, 94, 95281Small -pox in 1871-72Sparling, Dr.Injurious results of vaccinationSpurious cow-poxStevenson , Mr. John .Cases of small-pox by inoculation after vaccinationStockton.Small-pox in 1871-72Stoke Newington.Vaccinal injuries ( 1871 )Sudbury.Fatal vaccinal erysipelas ( 1883 )26-29, 108-111 , 11411264350351Sunderland.Small -pox in 1871-7264, 94, 95Small -pox in 1884 - 175Park- space and death- rates from zymotic diseases ( 1870-79 )62Sutton, Daniel ( inoculator) IISwansea .Small -pox in 1871-7264,94Sweeting , Dr.Hismethod of classifying small -pox cases by vaccination marks202Sydenham, Dr. Thomas.Fever epidemic ( 1685-86) 37Varieties and treatment of small -pox 186, 187 , 260-262Syphilis.And vaccinationNot always easy to detect in vacciniferAnalogy with cow- pox293-324307, 308309-319TAYLOR, DR. FREDERICK .Case similar to Leeds case 318, 319Tebb, Mr. William ." The Recrudescence of Leprosy," referred to 325448 INDEX.Tetanus.And vaccinationInfantile mortality at Calcutta ( 1881-90) -PAGE359-361361Thin, Dr. George.Eczema after vaccination290Thomson, Dr. John.Vaccination failures ( 1817-19) - 147Disparaging remarks on Jenner's discovery 147Thorne, Sir Richard.On calf lymph and tuberculosis 358Thornton, Mr.Variolous test failures 15, 16Thursfield , Dr. W. N.Immunity to small- pox in the unvaccinated 169, 170Tillmanns, Dr.Incubation period of erysipelas 353Timoni , Dr.Letter on inoculation 10Toms, Dr. S. W. S.Case of tetanus following vaccinationToussaint.His experiments , referred toTradition of the dairymaidsTriple vaccination.Failure to protect from small-poxTrobridge, Mr. Arthur.Small-pox in the German armyTubercle.And vaccinationGrowth in culture media favoured by glycerine3613579,403215, 216, 223234, 236354-359358, 384Turkey.Small -pox inoculation 10Typhoid fever.Age- incidence 49Typhus fever.Decline of37-41 , 53,391Causes of decline 40-42, 257 , 258, 400Epidemics ( 1685-86, 1741 , 1837-38, 1847 ) 37-39Epidemics and high prices of wheat 77-79Age-incidence 47-49Immunity in improved dwellings 247UNDERWOOD, DR. MICHAEL.Immunity to small -pox in the unvaccinated 167, 168INDEX. 449Unna , Dr. P. G. PAGECow-pox and erysipelas - 347Unvaccinated.Whether a danger to the community 164, 178Immunity to small-pox 166-171 , 232 , 233Alleged high fatality among 185Drawn from the lower strata of society 197, 25 7Urticaria .Complicating vaccinationVACCINAL ERYSIPELAS.Cases of290, 375And cow-poxVaccination.Jenner first interested in -346-351346, 3479Early experiences of 15, 16Critical position at end of 1798 16Rescued from oblivion by Woodville 17Accepted by profession 18Jenner's assertions respecting permanent value of 105, 164, 214, 267Opinion of some of Jenner's contemporaries 106-109Reports of failures begin to multiply ( 1804) 113Mr. Goldson on ( 1804) 114Investigation demanded by Medical and Chirurgical Review 118 , 119Failures become numerous ( 1806) 122Report of Royal College of Physicians ( 1807) 123Before Parliament 122, 123Established and endowed ( 1807 ) 123Almost abandoned at Preston on account of failures - 123, 124Failures at Cambridge reported by Sir Isaac Pennington ( 1808) 124Opposed by men of education and influence ( 1808) 124, 125Vaccination and Jenner " again to be put upon their trial " ( 1809) 125Criticised by Mr. Thomas Brown ( 1809) - 127, 128Failures at Witford ( 1810) 128, 129Insinuations by Dr. George Pearson ( 1812) 132Criticised by Lord Ellenborough ( 1813 ) 132, 133Failures reported by Mr. M. Redhead ( 1817 ) 135-141Mr. Thomas Harrison's confidence somewhat shaken 141Falls into disrepute at Frampton ( 1817) 142Medical Repository on " alarming " number of failures ( 1817 ) 142Clamour about failures ( 1818 ) 143Hesitation of respectable persons ( 1818) 143Reluctant admissions of National Vaccine Establishment 143-145 , 147Dr. Macleod loses faith ( 1820) 144, 145"Mortifying fallibility of medical opinions " 145Prejudices " not altogether unreasonable"Extensive failures ( 1817-19)147Pretensions " rather too unreservedly " admitted 147147450 INDEX.Vaccination . PAGEDisparaging remarks by Dr. John Thomson ( 1822) - 147Criticised by Edinburgh Review ( 1822) 148Failures on H.M.S. " Phaeton " ( 1825) 149At London Small -pox Hospital(1825) 149, 150Mr. Edward Greenhow on ( 1833 ) 151Reviewer in British Annals ofMedicine ( 1837)(1037)152Earlier anticipations not realised( Sir Henry Holland, 1839 ) 152Dr. George Gregory on ( 1823-52 ) 152-154Lancet on " numerous and discouraging " failures ( 1853 ) 155Made compulsory ( 1853) 162, 163Lord Lyttelton on 163, 164Criticised by Dr. James Copland ( 1858) 165, 166" A very fleeting protection, indeed " ( Dr. William Gayton) 164Lord Herschell on - 396-399Failures in various towns, etc. , since 1852 175Assertions respecting safety 267 , 268 , 270Ofinfants 281-284Risk compared with that of railway travelling 365, 366Injurious results from 267-384Injury greater than recorded 362-366Vaccination Acts 33, 34, 412-415Vaccination Registers 201Vaccination scars .Wear out 192, 193 , 195Obscured by eruption in confluent small -pox 192 , 194-196, 200201201 , 202VarietiesTexture -" Good " and " bad "As a measure of protectionVaccine lymph.Always contains bloodVaccine Pock Institution .Cases of small - pox after vaccinationVaccino- syphilisTables of alleged casesVachell , Dr. C. T.Cases of vaccinal erysipelas ( 1883 )Vacher , Mr. Francis .Method of classifying cases of small -pox202-205201-213307113 , 119 , 120293-324296-298, 306349193On small-pox being confined to the labouring and artisan classes 246Variola ( see Small-pox).Variola Vaccina .Misleading appellation of cow- poxVariolation ( see Inoculation ).30, 308, 309INDEX 451Variolous Test.Applied by Jenner -AppliedbyWoodvilleCriticised by Royal CommissionPAGE13-1517-2524,25Victoria, Select Committee of Legislative AssemblyOnvaccination 280, 281WAGSTAFFE, DR. WILLIAM.Effects ofsmall-pox inoculation58Varieties of small-pox 187, 188Wainwright, Mr. Thomas.Skindiseases attending vaccination 287Walker, Dr. George B.Animal lymph 372Wallace, Dr. T. C.Case of small-pox after triple vaccination 215Walsall .Small-pox-in 1871-72 95War.Effect on small- pox mortality 79-83Ward, Mr. E.Case of vaccino -syphilis 305Warlomont, Dr.Assertion respecting safety of vaccination 267Warrington.Small -pox in 1773 - 43Small-pox in 1892-93Small-pox epidemic ( 1892-93) limited to the smaller housesVaccinal erysipelas ( 1871 )Watson, Dr. Heron.On blood being omnipresent in vaccine lymphWatson, Dr. R. S.Experiences in the Franco- Prussian WarWatson, Sir Thomas.Fever epidemic ( 1838)Oncases of small-pox being ascribed to chicken-poxVaccino-syphilisWatt, Dr. Robert.Decline of small-pox-it's place taken by measles ( 1783-1812 ) - 84, 85Watts, Dr. Giles (inoculator ) - 1252, 92, 175, 394,39524635030780-8239155386, 387Wells, Mr. J. W.Fatal case of erysipelas after vaccination -Wells, Sir Spencer.Infantile mortality from tetanus at Calcutta ( 1881-90)348361Wheat.High prices and small -pox mortality 77-79452 INDEX.Wheeler, Mr. Alexander .Effects of war on small -pox mortalityFatality of malignant small- pox in vaccinated and unvaccinatedOn statistics of small -pox in the Franco- Prussian WarWhite, Dr. Andrew.Small -pox and vaccination at Montreal ( 1885 )Whitehaven.Small -pox in 1871-72Whitehead, Dr. James.Cases of vaccino-syphilisWillan, Dr. Robert .Insanitary condition of London ( 1800)Effects of window - taxInjurious results of vaccinationWillenhall.Small- pox in 1894Willis , Dr. Thomas.Small -pox in the seventeenth centuryWilson , Sir Erasmus .Cases of leprosy following vaccinationWindley, Alderman.On Leicester system of small - pox preventionWindow- tax -Winterbottom, Mr. T. M.PAGE80190238102- 95, 96299-30170-7371276, 287, 36953, 92, 93, 175, 211 , 389, 39342338, 3398965-67 , 71 , 74, 400116, 11762345369Confluent and fatal small-pox after vaccination ( 1805 )Wolverhampton.Park - space and death- rates from zymotic diseases ( 1870-79 )Wood, Dr. C. В.On the spreading of leprosy by vaccinationWood, Dr. Thomas F.Animal lymphWoodforde, Dr. James.Case of small -pox after natural cow- pox IIIWoodville, Dr. William .Receives news of cow- pox outbreak, Gray's Inn Lane ( 1799)Experiments at London Small-pox Hospital1717Three-fifths of " vaccinated " cases had variolous pustules on body 18Dr. Collins' and Mr. Picton's pedigree of his lymph 19His lymph contaminated with small -pox - 21, 389His lymph away from the Small -pox Hospital - 21, 22His variolous tests on the " vaccinated" convince profession - 18, 22Dr. Collins and Mr. Picton on the value of his experiments 22His lymph ultimately assumes the nature of vaccine61World's vaccine , i.e. , Woodville's lymph 22wwwThis book is a preservation photocopy.It is made in compliance with copyright lawand produced on acid- free archival60# book weight paperwhich meets the requirements ofANSI/NISO Z39.48-1992 (permanence ofpaper)Preservation photocopying and bindingbyAcme BookbindingCharlestown, Massachusetts2001
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