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THE VACCINATION QUESTION IN THE LIGHT OF MODERN EXPERIENCE

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THE

VACCINATION QUESTION

IN THE LIGHT OF MODERN EXPERIENCE

AN APPEAL FOR RECONSIDERATION

BY

C. KILLICK MILLARD, M.D., D.Sc.

MEDICAL OFFICER OF HEALTH FOR LEICESTER MEDICAL SUPERINTENDENT OF THE ISOLATION AND SMALLPOX

HOSPITALS, LEICESTER FORMERLY MEDICAL OFFICER OF HEALTH FOR BURTON-ON-TRENT MEDICAL SUPERINTENDENT OF THE BIRMINGHAM CITY HOSPITALS

LONDON

LL K. LEWIS, 136 GOWER STREET, W.C.

1914

113 43

DeOicatcO

TO THE MEMORY OF

EDWIN CHADWICK,

A GREAT SANITARY REFORMER, WHOSE IDEALS, SO FAR AS THEY HAVE BEEN CARRIED OUT, HAVE LARGELY CONTRIBUTED TOWARDS ABOLISHING SMALLPOX FROM THESE ISLANDS.

PREFACE

It is now eighteen years since the Royal Commission on Vaccination issued its Final Report. Since then, little or no attempt has been made seriously to review the Vaccination Question in the light of the experience gained in recent years. Yet, without doubt, much has been learned and some things have been unlearned. Moreover, almost every writer, hitherto, has approached this question from the point of view of either the pro-vaccinist or the anti-vaccinist. The present writer has endeavoured to take up an entirely independent stand- point. He has not been concerned either to defend or to attack vaccination, and he has, therefore, felt quite at liberty to use any argument that appeared to him, after mature considera- tion, to be sound, irrespective of whether it told in favour of or against vaccination. At the same time he believes that the case he is presenting will be found logical and consistent and neither lacking in colour nor devoid of definite conclusions.

The Royal Commissioners issued their Report in 1896. In place of reaffirming the principle of uncompromising compul- sion— as many expected and hoped — the Report went a long way towards the abolition of compulsion by recommending the recognition of the " conscientious objector." At that time, the country had had comparatively little experience of those modern measures for dealing with smallpox — notification, isolation, supervision of contacts, etc. — which have since proved so effective, and the " Leicester Experiment " had been on its trial for only about twelve years. The Commissioners naturally felt considerable doubt as to how far these modern measures could be trusted to control smallpox in the absence of infantile vaccination. Nevertheless, a transference of only three votes

vii

viii

PREFACE

(in a Commission of thirteen) would have given a majority, even at that time, in favour of the entire abolition of compulsory vaccination.

If the Commissioners could have had laid before them the experience which is now available ; if they could have foreseen how efficacious these modern measures would prove in stamping out smallpox outbreaks ; if they could have been assured that the prophecies of disaster where vaccination was neglected would have been unfulfilled ; if the " Leicester Experiment " had been tried successfully for thirty years (as is now the case) instead of only twelve, it is highly probable — to say the least of it — that their verdict would have been against compulsion in any form.

For forty years, corresponding roughly with the advent of the " sanitary era," smallpox has gradually but steadily been leaving this country. For the past ten years the disease has ceased to have any appreciable effect upon our mortality statistics. For most of that period it has been entirely absent except for a few isolated outbreaks here and there. It is reason- able to believe that with the perfecting and more general adop- tion of modern methods of control and with improved sanitation (using the term in its widest sense) smallpox will be as completely banished from this country as has been the case with plague, cholera, or typhus fever.

Accompanying this decline in smallpox there has been a notable diminution during the past decade in the amount of infantile vaccination. This falling off in vaccination is steadily increasing and is becoming very widespread.

Meanwhile the agitation against vaccination continues, and it is likely to continue so long as the compulsory clauses of the Vaccination Acts remain unrepealed. To the anti-vaccinist vaccination is not merely useless and objectionable, it is posi- tively hateful, and he regards the compulsory clauses of the Vaccination Acts as a blot on the Statute Book. This attitude towards vaccination may be unreasonable, but it has to be reckoned with. After all it is hardly surprising that the anti- vaccinist is not satisfied with the " privilege " of being allowed to beg for " exemption " as a favour. Vaccination was originally made compulsory on the express grounds that such compulsion was necessary for the safety of the community and on the assump-

PREFACE

ix

tion that unvaccinated persons were a danger to their neighbours. It is becoming very doubtful, in the light of modern experience, whether this necessity any longer exists ; whilst it would appear that it is vaccinated persons whose vaccination has "worn out," rather than the un-vaccinated, who are the real danger to their neighbours.

The writer draws a broad distinction between the individual and the community as regards the effect of vaccination. So far as the effect upon the individual is concerned he differs little if at all from the orthodox pro-vaccinist position. He accepts the protective influence of vaccination upon the individual as absolutely proven, and starts with this proposition as axiomatic. On the other hand, he believes that there is still much room for further consideration as regards the effect upon the community.

Unfortunately, free and independent discussion on the question of vaccination has not, hitherto, received much encouragement. Indeed, it is no exaggeration to say that there has even been a tendency to stifle discussion. The writer can speak from personal experience. Two recent instances only need be quoted :

(1) A leading morning paper published some extreme pro- vaccinist statements prophesying that " red terror " would over- take this country if the neglect of infantile vaccination were persisted in. The writer sent a moderately-worded letter taking exception to these statements. The letter was returned with a polite note from the editor regretting that he could not find space for it and the controversy which it might evoke.

(2) The writer received a letter from the Honorary Secretary of the Section of State Medicine of a Health Congress requesting him, in the name of the President of the Section, to contribute a paper. A subject was suggested in which he thought the writer was interested, but, it was added, " the President will be glad to accept another subject if you prefer it." The writer replied that he would be pleased to contribute a paper, but as he was specially interested in the question of vaccination he proposed to take that as his subject. He mentioned that his views were not quite orthodox, and that the paper might there- fore lead to a good discussion. He received a reply thanking him for his letter, which had been laid before the President,

but saying : " Dr. asks me to say that he thinks it better

to decline your offer. He feels that Anti- Vaccinators, with

X

PREFACE

whose views you have nothing in common, might wilfully or unconsciously distort your statements. ..."

This book embodies the substance, in amplified form, of a course of lectures given in London early in the present year under the auspices of the Chad wick Trust. It is published in the hope that it may arouse fresh interest in a highly complex question, the last word on which has certainly not yet been said.

The writer owes an apology to his readers for the frequent use of the personal pronoun. The controversial nature of the subject, however, and the independent position taken up, have rendered it difficult to avoid this.

Cordial thanks are due to all those who have assisted the writer with information, including a large number of Medical Officers of Health and the Registrars-General of England, Scot- land, and Ireland. He desires specially to mention Dr. Arthur Drury, Honorary Secretary of the Association of Public Vacci- nators, and Miss L. Loat, Secretary of the National Anti- Vaccina- tion League. He is indebted to his colleague, Dr. Allan Warner, School Medical Officer for Leicester, and formerly Resident Medical Officer at the Leicester Smallpox Hospital, for two of the photographs of smallpox cases.

He is indebted to his wife for much help and assistance in the preparation of the book, including her careful revision of the proof sheets.

C. K. M.

Leicester, 1914.

CHAPTER I

THE VACCINATION CONTROVERSY AT THE PRESENT DAY

The Vaccination Controversy Unique — Pro-vaccinists and Anti-vaccinists — Extreme Attitude of the Two Sides — Bitterness of the Controversy - — Where the Truth Lies — The Writer's Credentials — Outline of the Writer's Position — Visit of Writer's Family to Leicester Smallpox

Hospital . . . . . . . pp. 1-8

CHAPTER II

THE VACCINATION QUESTION IN DETAIL

Distinction between Individual and Community — Vaccination a Pro- tection to Individual — An Error of Tactics — The Real Question at Issue — Effect on Community — Smallpox Leaving Great Britain Independently of Vaccination — Mortality during Past 1 50 Years — ■ Modern Methods of Dealing with Smallpox — Isolation, Notification, Surveillance of Contacts, etc. — Relative Risks of Vaccination and Smallpox — Vaccination not Ideal — Risk of Infants Contracting Smallpox Over-estimated — Infantile Vaccination alone Quite In- sufficient to Protect Community — Tendency of Vaccination to Spread Smallpox — Re-vaccination ...... pp. 9-26

CHAPTER III

THE ROYAL COMMISSION ON VACCINATION

A Remarkable Inquiry — The Terms of Reference — Findings of the Com- mission— Majority Report — Effect of Vaccination in Preventing Smallpox — Conclusions of Commissioners as to Protective Effect — ■ Means other than Vaccination for Preventing Smallpox — Value of Hospital Isolation — Opinion of Buchanan and Thorn — Experience of London — Means for Preventing ill-effects of Vaccination — Ques- tion of Compulsion — Minority Report . . . . pp 27-43

xi

xii

CONTENTS

CHAPTER IV

THE RELATIVE IMPORTANCE OF VACCINATION AND SANITATION

Meaning of the Word " Sanitation " : Includes Isolation, and Other Modern Measures — Definition of " Sanitation " given in Minority Report — Edwin Chadwick and Sanitation — The Experience of India — Experience of Japan — Experience of Great Britain — Examples of Good Vaccination but Bad Sanitation: (i) Middlesbrough; (2) Warrington ; (3 ) Sheffield — Why not Vaccination plus Sanitation ?

pp. 44-62

CHAPTER V

THE TENDENCY OF VACCINATION TO SPREAD SMALLPOX BY MASKING THE DISEASE

This Aspect of the Question Hitherto Overlooked — In Mitigating Small- pox Vaccination also Masks the Disease — Apparent " Mildness" of Smallpox Modified by Vaccination (being an Acquired Character) is not Transmitted — Authoritative Opinions as to the Role of the Unrecognised Case: J. Niven : A. K. Chalmers: G. F. McCleary : W. E. Armstrong: Ernest Hart — Frank Admissions — P. Boobbyer — J. H. C. Dalton — Unrecognised Cases in the Unvaccinated — Experience of Individual Towns — Leicester . . pp. 63-77

CHAPTER VI

THE TENDENCY OF VACCINATION TO SPREAD SMALLPOX

(Continued)

The Experience of Other Towns — London : Fatal Outbreak at Mile End Infirmary Caused by Vaccinated Child — Kirkcaldy : Fatal Outbreak Caused by Vaccinated Child — Ossett : School Outbreak of Very Mild Type Caused by Unvaccinated Child — Newhaven : Fatal Outbreak Caused by Sailor (presumably Vaccinated) — Halifax : Disastrous Effect of Unrecognised Cases in Vaccinated Persons — Coventry- Cardiff ......... pp. 78-100

CHAPTER VII

THE LEICESTER EXPERIMENT

(a) THE MOVEMENT AGAINST VACCINATION

McVail on " Leicester's Gigantic Experiment " — Misapprehensions as to the Experience of Leicester — Prof. Berry's " Incontrovertible " Facts — History of the Movement Against Vaccination — Prosecuting Campaign — Great Anti-vaccination Demonstration — Emphatic Warn- ings— Leicester and the R.C.V. — Leicester Guardians and the L.G.B. — Writ of Mandamus ...... pp. 101-118

CONTENTS

xiii

CHAPTER VIII

THE LEICESTER EXPERIMENT {Continued) (b) RESULTS

History of Smallpox in Leicester — The Great Epidemic of 1871-2 — -Why the Disease Spread — -Dawn of Sanitation in Leicester — Aid. Windley Appointed Chairman of Sanitary Committee — -Effect of Sanitation upon Smallpox — Statistics of Smallpox Epidemics in Leicester — The "Leicester Method" of Dealing with Smallpox: Surveillance of Contacts : Quarantine : Searching for Contacts — Vaccination and Compensation of Contacts — Chief Inspector Braley — The Epidemic of 1892-3 — Effect of Unrecognised Cases — Outbreak in the Fever Hospital — The Epidemic of 1902-3 — The April " Flare " — How the Situation was Saved — The Epidemic of 1903-4 — Fatality of Smallpox in Leicester Compared with Other Towns . pp. 119-141

CHAPTER IX

THE LEICESTER EXPERIMENT (continued)

(c) SOME OBSERVATIONS ON THE EXPERIENCE OF LEICESTER

Prophecies Unfulfilled : A Complete Justification of Policy Pursued— Experience of Leicester Quite Conclusive as to Value of Vaccination in Protecting Individual — The Smallpox Hospital Staff — Effect of Vaccination after Exposure to Infection — Vaccinal Condition of Invaded Houses — Low Case Mortality of Smallpox in Leicester — Small Part Played by the Children and Schools — Comparative Im- munity of Infants — Influence of General Vaccination — Cost of Dealing with Smallpox in Leicester ..... pp. 142-151

CHAPTER X

DEWSBURY AND GLOUCESTER : AN INSTRUCTIVE CHAPTER IN THE HISTORY OF SMALLPOX PREVENTION

I. THE CASE OF DEWSBURY

How not to Deal with Smallpox — Dr. Wheaton's Report on Condition of Dewsbury Hospital — Ravensthorpe : the Breakdown of Hospital Isolation — Spread of Infection from Hospital, and by LInrecognised Cases — Dr. Spencer Low's Report — The Failure of the L.G.B.

II. THE CASE OF GLOUCESTER

Dr. Coupland's Opinion — Gloucester's Tragic Experience — History of the Epidemic — Heavy Mortality amongst the Unvaccinated — Origin of Epidemic in Vaccinated Cases — School Outbreaks — Rapid Exten- sion— Breakdown of Hospital Isolation — Comparison with Leicester — Origin of School Outbreaks — What the Government Might have Done ......... pp. 152-166

xiv

CONTENTS

CHAPTER XI

INJURIES CAUSED BY VACCINATION

Difficulty of Appreciating Vaccinal Injuries at True Value — Anti-vaccin- ists Exaggerate, Pro-vaccinists Under-estimate Them — -Pecuniary Interest of Medical Profession — The Misterton Outbreak of Vaccinal Erysipelas — -Other Outbreaks — The R.C.V. and Injuries Caused by Vaccination — The Minority Report — Dr. T. D. Acland on Vaccinal Injuries : Eczema ; Impetigo ; Erysipelas ; Ulceration and Abscess ; Gangrene ; Septic Infection ; Vaccinal Syphilis — Concluding Remarks

pp. 167-184

CHAPTER XII

CONCLUSION

The Future Outlook — Emergency Vaccination — Practicability of Vaccinat- ing an Entire Community as a dernier ressort — How to Improve the Alternative Means of Defence — The Danger of Unrecognised Cases — Lack of Medical Skill in Diagnosis — The Remedy — Germany and Great Britain — Vaccination still necessary in Special Cases — Con- clusion ........ pp. 185-192

APPENDICES

I. Some Characteristics of Smallpox which Dis- tinguish IT FROM OTHER ZYMOTIC DISEASES . p. I95

II. Comparison between Vaccination and Smallpox

Inoculation ....... p. 197

III. Synopsis of Principal Events in the History

of Vaccination as a State Institution . p. 199

IV. Warnings by Medical Officers of Health as

to Danger of Neglecting Infantile Vaccina- tion ........ p. 201

V. Statistical Proof of the Effect of Vaccination

in Modifying Smallpox . . . p. 206

(i) Bristol. (2) Bradford. (3) Manchester.

CONTENTS XV

VI. (i) Particulars of Outbreaks of Smallpox

occurring in leicester in i902 . . p. 209 (2) Statistics of Smallpox in Leicester, 1903-

1904 p. 213

VII. Further Illustrations of the Danger of Un- recognised Cases of Smallpox modified by Vaccination ...... p. 223

(1) Bristol. (5) Nottingham. (9) Glasgow.

(2) Manchester. (6) Oldham. (10) South Shields.

(3) Salford. (7) Bootle. (11) Cambridge.

(4) Newcastle-on-Tyne. (8) Leeds.

LIST OF ILLUSTRATIONS

PLATES

I. Recently Vaccinated Persons need not fear

Smallpox ........ 8

1(a). Hands and Forearms of Patients seen in Pre- vious Plate ....... 8

II. Unmodified Smallpox ...... 64

III. Smallpox Modified by Vaccination ... 64

IV. Smallpox in an Unvaccinated Child ... 64 V. Smallpox in a Vaccinated Child .... 64

VI. Which is the Greater Danger to the Community 64

VII. The Value of Vaccination in Protecting Small- pox Nurses ....... 144

VIII. Fatal Smallpox in a Nurse .... 144

IX. The Foolish Father and the Wise Child . . 147

DIAGRAMS

I. Mortality from Smallpox and Other Zymotic

Diseases in London, 1760-1910 .... 14

II. Smallpox, Scarlet Fever, Enteric, and Vaccina- tion, England and Wales . . . .16

III. Smallpox, Scarlet Fever, and Vaccination,

Scotland . . . . . . . .17

IV. Smallpox, Scarlet Fever, and Vaccination,

Ireland . . . . . . . .18

\) xvii

Xviii LIST OF ILLUSTRATIONS

PAr.r.

V. Smallpox in Leicester, 1893, Effect of Unrecog- nised Cases ....... 73

VI. Smallpox in Leicester, 1903, Effect of Unrecog- nised Cases . . . . . . . 76.

VII. Smallpox in Newhaven, 191 3, Effect of Unrecog- nised Cases ....... 89

VIII. Smallpox in Halifax, 1903, Effect of Unrecog- nised Cases ....... 93

IX. Smallpox in Coventry, 1903, Effect of Unrecog- nised Cases ....... 96

X. Smallpox in Cardiff, 1903, Effect of Unrecognised

Cases ........ 98

XI. Leicester, Mortality from " Fevers," Smallpox

and Scarlet Fever, 1838-1912 .... 120

THE VACCINATION QUESTION

IN THE

LIGHT OF MODERN EXPERIENCE

CHAPTER I

THE VACCINATION CONTROVERSY AT THE PRESENT

DAY

The Vaccination Controversy Unique — Pro-vaccinists and Anti-vaccinists — Extreme Attitude of the Two Sides — Bitterness of the Controversy Where the Truth Lies — The Writer's Credentials — Outline of the Writer's Position — Visit of Writer's Family to Leicester Smallpox Hospital.

The Vaccination Question undoubtedly constitutes one of the most remarkable controversies of the age. In many ways it is unique. Beginning in the early days of last century when vaccination was first introduced, it only became a popular question when vaccination was made compulsory in 1853. It attained its most acute phase after the Vaccination Act of 1872, which, passed with the object of securing the more efficient enforcement of the Vaccination Laws by the appointment of Vaccination Officers, may be regarded as representing the high- water mark of compulsion. Since the Vaccination Act of 1898 with the noteworthy Conscience Clause, and still more since the Act of 1907 permitting the father to make a statutory declara- tion before a Justice of the Peace in place of having to go into Court, real compulsion has been very largely abolished, and popular feeling in connection with vaccination has naturally cooled down considerably ; but, at the same time, the opposition to vaccination is still strong and widespread, whilst the number of those who do not have their children vaccinated is steadily 1

2

THE VACCINATION QUESTION

increasing. The frequency with which the question of vac- cination crops up in Parliament, and the persistency with which the President of the L.G.B. is bombarded with interrogations at every opportunity and on any kind of pretext, is evidence of the strength and popular character of the feeling against vaccination. Without doubt the agitation against vaccination is the outcome of the compulsory law and would die a natural death if the compulsory clauses were repealed. At the present time active controversy is chiefly kept up, on the one side by certain medical men specially interested in the subject and who are backed up by the great majority of the medical pro- fession— these we shall refer to as the Pro-vaccinists — and on the other side by certain very active individuals of independent views and opinions, whom we shall refer to as the Anti-vaccinists, who have comparatively little, if any, respect for authority as such, and who frequently differ from orthodox teaching on other subjects besides vaccination.1 These Anti-vaccinists

1 The Official Society of the Anti-vaccinists is the National Anti- vaccination League, and their office is at 27, Southampton Street, Strand. The Secretary is Miss L. Loat. The official organ of the society is The Vaccination Inquirer, published monthly. The Society employs a lecturer and organiser (Mr. J. H. Bonner).

At the present time the principal pro-vaccinist organisation is the Association of Public Vaccinators of England and Wales, of which Dr. Arthur Drury is the energetic Hon. Secretary and moving spirit. The official organ of the Association is The Jennerian, a monthly supplement to The Medical Officer, Dr. Drury being the Editor. For many years the Jenner Society, founded by the late Dr. F. T. Bond, of Gloucester, was the principal pro-vaccinist society, and it carried on at one time an active propaganda by means of lectures, popular literature, and news- paper correspondence. The remains of this organisation have now been taken over by Dr. Drury.

Towards the end of his life Dr. Bond considerably modified some of his views, and became much less pro-vaccinist than when he first started the Jenner Society. The writer frequently corresponded with him and has reason for thinking that he had ceased to believe in the great importance or necessity for compulsory vaccination. Dr. Bond publicly advocated the extension of the age limit for primary vaccination to six years, on the ground that the vaccination of infants was not very necessary and open to some objection. At the same time he advocated compulsory re-vaccination.

About fifteen years ago another organisation — The Imperial Vaccina- tion League — came into existence and carried on an active campaign for a short period. The Hon. Secretary and moving spirit was Mrs. Garrett Anderson, M.D. This society appears now to have ceased to exist.

PRESENT -DAY CONTROVERSY

3

undoubtedly have a large number of sympathisers, chiefly, though by no means exclusively, amongst the democracy.

A regrettable feature of the controversy is the great bitterness which exists in connection with it, but this is hardly surprising in view of the penal clauses of the Vaccination Acts, which, prior to the passing of the Conscience Clause, were often enforced with much severity, not to say tyranny.

There is also the fact that some of the most bitter Anti-vac- cinists believe, possibly with good reason, that they themselves, or members of their families, have suffered serious injury to their health through vaccination. The thorough-going Anti- vaccinist is not merely opposed to vaccination, but hates it as the accursed thing.1 To resist the Vaccination Laws is with him a matter of duty, almost of religion. The Pro-vaccinist, on the other hand, convinced of the strength of the case for vaccination, has an outspoken contempt for the " ignorance " and " misguided folly " of the Anti-vaccinist, and many of the medical journals can scarcely speak of the Anti-vaccinists with patience or civility. This attitude of the Pro-vaccinist Press is certainly to be regretted, especially as there is serious reason to believe that the Anti-vaccinist is not wholly in error.

Disparaging epithets are freely used by either side, though it must be admitted that the Anti-vaccinists easily have pride of place for the richest and most varied vocabulary ! Whilst the Pro-vaccinists like to refer to their opponents as " cranks," and " ignorant faddists," guilty of " criminal folly," etc., the Anti-vaccinists do not hesitate to describe the Pro-vaccinists as " medical impostors " and " blood-sucking tyrants." Whilst Pro-vaccinists rejoice in referring to vaccination as " one of the most beneficent agents for the health of the human race that has ever been given to man," the Anti-vaccinists ring the changes on such appellations as " filthy rite," " relic of bar- barism," " grotesque superstition," " monstrous imposition," and " legalised assassination " ! I think it was a well-known

1 The Vaccination Inquirer, March 1 9 14, wrote : " Many of us would prefer an attack of smallpox to vaccination, all of us would prefer the risk of smallpox to the certainty of vaccination. Smallpox is a natural disease running a known course. . . . Vaccination is a loathsome disease of uncertain origin, artificially transmitted through various beasts and capable of setting up a variety of repulsive, dangerous, and even fatal affections."

4

THE VACCINATION QUESTION

stalwart from Birmingham, a past-master in the use of this picturesque language, who recently referred to public vaccinators as " myrmidons of the rabid cult of official blood-poisoners " ! Whilst Jenner likened the typical vaccine vesicle to " a pearl upon a rose-petal," the Anti-vaccinist speaks of " corruption " and refers to vaccine lymph as " putrescent slime."

It may be added that the two sides in this controversy en- tirely distrust each other and refuse to accept as reliable the facts put forward by the other side when not convenient to refute them by argument. Indeed, each side regards the other as thoroughly unscrupulous and untrustworthy in its con- troversial methods. It is scarcely necessary to say that each side is quite convinced of the strength of its own case and of the unanswerableness of its arguments, and fails to comprehend how there can reasonably be two opinions about a question at once so simple and so capable of easy demonstration — or refutation — as that of vaccination. The Anti-vaccinists firmly believe that the entire medical profession, with a few honourable exceptions — who happen to be Anti-vaccinists, have entered into a conspiracy to deceive the public with the object of making money out of vaccination. The Pro-vaccinists, on the other hand, regard the Anti-vaccinists as noisy and misguided fanatics, unworthy of the serious consideration of intelligent men.

The moderate man may well exclaim, " A plague o' both your houses ! " As regards public debate and newspaper con- troversy, it may be mentioned that the expert Anti-vaccinist, who has often made a life-study of the subject and has all the facts at his fingers' ends as well as being an expert and skilful dialectician, is frequently more than a match for the average medical defender of vaccination, who is apt to rely too much on the stock arguments in favour of vaccination which he read in text-books as a medical student many years before. Latterly, indeed, there has been an increasing and judicious tendency on the part of medical men to avoid the public platform, and to leave open debate to those members of the profession who have made a special study of the subject.

Lastly, it is needless to say that both sides have suffered severely from the indiscretions of their friends. It would be easy to give numerous instances of the loose and inaccurate

PRESENT-DAY CONTROVERSY

5

statements which enthusiasts on either side have made, and, indeed, still frequently make whenever this subject is discussed.

Where the Truth Lies

I do not think the above sketch has been coloured too strongly. It is certainly the case that between the Pro-vaccinist and the Anti-vaccinist a great gulf is fixed, and hitherto no serious attempt has been made to bridge this over or to find out whether there be any common ground on which to reconcile the opposing parties. Consequently there has been no intermediate position open to the moderate man. He has had either to believe in vaccination or to disbelieve in it, and there was an end of it !

Now one object of this book is to show that the question of vaccination is not nearly so simple as its supporters and oppon- ents appear to think — that there is still room for legitimate discussion and inquiry, and to suggest that perhaps, after all, the whole truth does not lie in either one camp or the other, but will be found, rather, in an intermediate position lying somewhere between them.

The Writer's Credentials

Before essaying this task, however, I should like to say that the views I am about to put forward have not been lightly or hastily arrived at, or without a due sense of responsibility. They have been gradually forced upon me during a considerable period. For the past thirteen years I have held the position of Medical Officer of Health for the Borough of Leicester, a town which has played a unique part in connection with the vaccination question and which is recognised as being the most unvaccinated town in the country. Since I have been in Leicester, I have had to deal, in my official capacity, with two fairly extensive outbreaks of smallpox as well as with a number of minor outbreaks, and I have had, therefore, excep- tional opportunities for observing the behaviour of smallpox in the presence of what is largely an unvaccinated population. I have been led to study the question of vaccination from the point of view of those opposed to the practice, as well as from the orthodox medical point of view. Moreover, I was

6

THE VACCINATION QUESTION

specially interested in the subject of smallpox and vaccination before I came to Leicester.1

I first enunciated my present views nearly twelve years ago in a paper contributed to the Public Health Congress at Exeter in 1902, and subsequently, with more confidence, in a paper read before the Society of Medical Officers of Health in 1904. 2 Since that time, with increased experience and further con- sideration, the views then put forward tentatively and with much diffidence have been further developed and have ripened into convictions.

Outline of the Writer's Position

It will be well, in order to prevent misapprehension, to outline my position with reference to the two contending parties in this controversy.

(1) In the first place, then, I believe absolutely in vaccination, though with certain important reservations, and I differ in toto from the Anti-vaccinist when he asserts that vaccination is a " myth " and a " delusion."

I agree entirely with the Pro-vaccinist that recent vaccination confers on the individual protection against smallpox which, for practical purposes, is complete though unfortunately only temporary.

(2) I regard vaccination, repeated as often as necessary, as invaluable for protecting individuals who for any reason are specially exposed to the infection of smallpox, e.g. smallpox doctors and nurses.

(3) Vaccination is also of very great value for protecting individuals after actual exposure to infection, i.e. smallpox " contacts." Incidentally, I would point out that for these purposes the question of duration of the protection conferred by vaccination is immaterial. It would be almost equally valuable even if it only lasted for a few months.

1 The writer was for a time Resident Medical Officer at the Birmingham Smallpox Hospital during the 1892-3 epidemic in that city, and he chose the subject of smallpox for his thesis (commended) for the M.D. degree. In his early days he once filled the role, in a very small way, of popular lecturer on vaccination and newspaper controversialist on strictly orthodox lines.

2 " The Leicester Method of Dealing with Smallpox," Public Health, July 1904.

PRESENT-DAY CONTROVERSY

7

(4) I agree entirely with the Pro-vaccinist that vaccination has a remarkable power of modifying and mitigating smallpox for many years after its power to protect against attack has worn out. Moreover, the protection conferred by vaccination can be renewed by revaccination.

(5) On the other hand, I agree with the Anti-vaccinist in doubting the value to the community, under modern conditions in this country, of infantile' vaccination as provided by law. I think that an altogether exaggerated view has been taken as to the effect of such vaccination in preventing the spread of smallpox, which is the real problem before us at the present day.

(6) I agree with the Anti-vaccinist that " sanitation " — includ- ing in this term notification, isolation, surveillance of contacts, and other modern measures which are now becoming generally adopted — has played a much more important part in the aboli- tion of smallpox from this country during the past thirty or forty years than has infantile vaccination.

(7) I think the Anti-vaccinist is right when he contends that the drawbacks to infantile vaccination and the injuries to health caused by it are not sufficiently recognised by the medical profession, who in their anxiety to defend vaccination have been inclined to minimise these drawbacks.

(8) On the other hand, I quite admit that the Anti-vaccinist in his hostility to vaccination has frequently run into the opposite extreme and greatly exaggerated these drawbacks whilst endeavouring to prejudice the question of vaccination by making wild assertions about the nature and origin of vaccine lymph and its deleterious effect upon human beings.

(9) There is definite evidence that smallpox is leaving this country, in spite of the increasing neglect of vaccination ; and I think it probable that this neglect of vaccination will continue until the majority of the population has become un vaccinated. I am inclined to believe that, should this happen, the problem of smallpox prevention will very possibly be simplified and made more easy rather than more difficult. I feel justified, there- fore, in regarding the outlook with comparative equanimity, instead of with the serious alarm which appears to prevail with so many of my colleagues in the Public Health Service.

(10) The great difficulty in controlling the spread of smallpox at the present day in this country is the occurrence of unrecognised

8

THE VACCINATION QUESTION

or " missed " cases of the disease, which spread infection broad- cast before any precautions can be taken. Most medical officers of health who have had experience in dealing with smallpox outbreaks in recent times agree as to this, but an important fact, the significance of which does not yet appear to be suffici- ently realised, is that these unrecognised cases which do so much mischief, and which go so far to thwart our efforts to control the disease, occur chiefly amongst persons vaccinated in infancy and because they were so vaccinated.

In other words, it would seem that infantile vaccination has a distinct tendency to encourage the spread of smallpox, which goes far to neutralise any benefit which the community might otherwise derive from the fact that such vaccination largely protects the child population against the disease. I propose in a later chapter to enter more fully into this aspect of the case, which hitherto has been but little considered.

Visit of the Writer's Family to the Smallpox Hospital

I gave a very practical demonstration of my belief in the power of recent vaccination to confer complete immunity on the individual during the course of the 1903 epidemic of smallpox in Leicester. I took my wife and two children, the latter aged six months and two years respectively, all recently vaccinated, to the Leicester Smallpox Hospital, and there, in a ward full of patients, I photographed them sitting by the bed- side of a confluent case of the disease. I then took the elder child and visited each of the wards, stopping to introduce him to the patients.

It is scarcely necessary to add that neither my wife nor the children were the least bit the worse for their little adventure.

Of course, I do not suggest that the visit of my children to the smallpox hospital constituted in itself . any actual proof of the efficacy of vaccination. It was merely a proof of the genuineness of my belief, and that of my wife, in its efficacy. At the same time, I may say that in endeavouring to persuade "contacts" to get vaccinated I have found the photograph which I obtained on the occasion in question of very great assistance in bringing home the value of vaccination, and I believe it was- more efficacious in overcoming scepticism than any other argument at my disposal.

Plate I (a)

The hands and forearms of the smallpox patient seen in Plate I. The case was of the confluent type.

8]

CHAPTER II

THE VACCINATION QUESTION IN DETAIL

Distinction between Individual and Community — Vaccination a Pro- tection to Individual — An Error of Tactics — The Real Question at Issue — Effect on Community — Smallpox Leaving Great Britain Independently of Vaccination — Mortality during Past 150 Years — Modern Methods of Dealing with Smallpox — Isolation, Notification, Surveillance of Contacts, etc. — Relative Risks of Vaccination and Smallpox — Vaccination not Ideal — Risk of Infants Contracting Smallpox Over-estimated — Infantile Vaccination Alone Quite In- sufficient to Protect Community — Tendency of Vaccination to Spread Smallpox — Revaccination.

In this chapter I shall consider in rather more detail the position outlined in the previous chapter.

The Distinction between the Individual and the Community

It is necessary at the outset to insist upon the importance of making a clear distinction between the effect of vaccination upon the individual and the community. Neglect to recognise this distinction has been the cause of much confusion and futile controversy and largely explains why each side arrives at such opposite conclusions as to the so-called effect of vaccination in preventing smallpox.1

1 The A nalogous Case of Inoculation. — It is sometimes urged, as a logical sequence, that the effect of vaccination upon the community must be the same as its effect upon the individual, since the community is com- posed of individuals. In order to show the fallacy of this deduction, we may cite the analogous case of inoculation. Undoubtedly, inocu- lation had a beneficial effect upon the individual, conferring protection upon him against the natural disease which, at the period when inocu- lation was introduced, was a very serious danger. But it was afterwards discovered that although inoculation protected the individual it certainly did not protect the community . Indeed, it was found to have the very opposite effect and to tend to spread the disease. It will be instructive

9

10

THE VACCINATION QUESTION

i. Vaccination has, Beyond all Doubt, so far as the In- dividual is Concerned, a Protective Influence against Smallpox

I regard this proposition as axiomatic. Practically the whole of my case is based upon it, and I may say at once that I do not propose to adduce any evidence in support of it or to attempt to prove it. My justification for taking this course must be that I think it a pity to spend time in proving a proposition which has already been proved over and over again.1 Far too much time and energy have been spent and, as I consider, wasted in the course of this controversy over this one salient point. Both sides appear to have regarded it as the key to the whole question at issue, and in almost every controversial battle over vaccination the fight has raged hottest and most furiously round

to pause to consider why inoculation failed so conspicuously to protect the community. If smallpox infection had been almost universal — if it had been the case that every individual who was susceptible to it was bound to contract the disease at some period of his life — then inoculation, by substituting a comparatively trifling illness for a serious, loathsome, and possibly fatal one, would have been a great blessing to the com- munity. Or had it been the case that inoculation was so universally practised that every one was protected by it, it would at least have done no harm in the way of spreading the disease to others. But as a matter of fact neither of these conditions obtained. On the one hand, only a certain proportion of the population — chiefly the upper classes, with whom the cost would not be a deterrent — availed themselves of inoculation ; whilst, on the other hand, smallpox infection was not ubiquitous. Remote districts often escaped visitations of smallpox for long periods, and many susceptible persons went through life without contracting the disease. To persons who were not inoculated inoculation, in other persons, became a real source of danger by introducing the infection of smallpox into localities which otherwise might have remained free from it. I suggest that the effect of vaccination will be found in some respects to be quite analogous to that of inoculation.

1 I feel the more justification for adopting this course and dismissing this part of the vaccination question thus summarily, as I am conscious of having given close and sympathetic attention to the case for anti- vaccination for many years.

As to the nature and extent of the protective influence of vaccination upon the individual, I accept the finding of the Royal Commission on Vaccination, as stated in Section 377 of the Final Report, my only reserva- tion being that the period of "highest protective potency " is certainly not as much as ten years, as suggested by the Commissioners. I agree with other observers that five years is probably nearer the mark.

IN DETAIL

II

this particular position. Now if this position — viz. the pro- tective influence of vaccination upon the individual — really be the key to the whole question, then I regard the anti-vaccinist as hopelessly defeated without the shadow of a chance of success, for I am absolutely certain that this position is quite impregnable. I am sorry to seem dogmatic, but I am anxious to prevent mis- apprehension as to where I stand. It is the only point on which I shall venture to insist with the same emphasis. Even the most brilliant scientific champions of the anti-vaccinists fail to support them in denying this protective influence of vaccina- tion upon the individual. Thus, Professor E. M. Crookshank, in his evidence before the Royal Commission on Vaccination,1 admitted that there was a " temporary antagonism " between cowpox (vaccinia) and smallpox, which lasted for two or three years, and which explained why inoculation with smallpox would not " take " in a person who had been previously vaccin- ated ; and the Dissentient Commissioners, in what is known as " The Minority Report " of the Royal Commission, practically admit the same thing. They say (Sect. 125) : "It would appear from the foregoing facts that while shortly after vaccina- tion there may be a certain amount of immunity or antagonism to the influence of renewed vaccination or inoculation with smallpox, and therefore, it may be argued, to the natural disease, this soon wears off, perhaps more rapidly in some than in others." If it will make the proposition more acceptable to anti-vaccinists I will willingly substitute the phrase " temporary antagonism " for " protective influence," for it will suit my argument equally well. Moreover, the exact duration of this " temporary an- tagonism " is immaterial, though it is only right to observe that, as admitted by Professor Crookshank, it lasts for a period of years.

An Error of Tactics

Now it seems to me a very serious error of tactics, to say the least of it, on the part of the anti-vaccinists to ignore this evidence of Prof. Crookshank, and to continue to deny, or to try to explain away, this temporary antagonism between vaccinia and smallpox as so many of them do. Obviously, if

1 Fourth Report R.C.V., p. 93.

12

THE VACCINATION QUESTION

there be this temporary antagonism which is sufficient to prevent taking smallpox even though the disease be actually inoculated (the severest of all tests), and which lasts for some years, it is a fact of great significance and importance and entirely refutes the anti-vaccinist assertion that vaccination is a "myth" or a " grotesque superstition." It may be " magnificent " to hurl oneself heroically against an impregnable position, but it is " not war," and I have no doubt that this fatal error accounts very largely for the little real progress which is being made by the anti-vaccinist movement in the way of converting scientific opinion.

The Real Question at Issue

But I wish to suggest that this particular point, viz. the pro- tective influence of vaccination upon the individual — important though it undoubtedly is — is not the key to the whole vaccination question. The real issue, as I submit, is the effect of vaccina- tion upon the community ; and though the anti-vaccinists are certainly in error on the first point it by no means follows that they are beaten all along the line. I think I can show that there is a flanking movement open to them by which the impreg- nable position of the pro-vaccinist can be " turned," so to speak, and ultimate victory be achieved, so far at least as the abolition of compulsion is concerned.

(2) The Effect of Vaccination upon the Community is a Variable Quantity

My next proposition is that the effect of vaccination upon the community, as distinct from its effect upon the individual, is a variable quantity and depends largely upon circumstances. In the first place it is important to define what we mean by " vaccination." Do we mean a system of incomplete infantile vaccination such as exists in this country ; or do we mean a more or less complete system of vaccination and re- vaccination such as exists in Germany ? I think I shall be able to show that the effect of only partially protecting a community — which is all that even the most efficient system of infantile vaccination can ever accomplish — may possibly be productive, under certain circumstances, of more harm than good. Certainly, it must

IN DETAIL

13

be admitted that such a system alone is quite ineffective so far as preventing widespread and fatal epidemics of smallpox is concerned, as witness the experience of Middlesbrough and other well-vaccinated towns.

Secondly, the effect of vaccination upon a community depends upon the position of that community in regard to smallpox prevalence and smallpox prevention independently of vaccina- tion. Thus, at the beginning of last century, the effect of vaccination in the town of Leicester, where smallpox, as in the rest of the country, was a terrible scourge and was allowed to spread quite unchecked, would be totally different from what it would be now, when the prevalence of smallpox has been so enormously reduced and " sanitation " so greatly improved.

Similarly, the effect of vaccination, even at the present day, in such countries as India or China, where the disease is endemic, will be totally different from what it is in this country. It is quite logical to suggest that it may be almost useless or even detrimental here, although an incalculable boon there.

Again, the effect of vaccination would be different in towns such as Warrington or Gloucester, which were more or less in- sanitary and admittedly unprepared to deal with smallpox by means other than vaccination, from what it would be in a sanitary and comparatively well-equipped town, such, may I say, as Leicester ?

It is, of course, no new idea that an institution may be bene- ficial in one age, and yet become out-of-date, obsolete, and even positively harmful at a later age.

(3) Smallpox is Disappearing from Great Britain Inde- pendently of the Practice of Infantile Vaccination

It will be necessary to consider this, my third proposition, in some detail, as it is evidently a fundamental one. If it can be established, it must materially affect our whole outlook as to the necessity for vaccination as a State institution.

The two crucial and outstanding facts which I wish to lay stress upon, are :

(a) The unexpected and remarkable experience of the town of Leicester, which for thirty years has abandoned infantile

14

THE VACCINATION QUESTION

vaccination and yet has shown an enormous decline in smallpox mortality.

(b) The fact that although infantile vaccination is falling more and more into disuse throughout the whole country, yet smallpox, contrary to all pro-vaccinist expectation and pro- phecy, continues to decline and has now almost disappeared. The disease is repeatedly being introduced into this country from abroad, there is an increasing number of un vaccinated persons to contract it, yet it is showing an unmistakable dis- inclination to establish itself in this country in serious epidemic form. It is useless for us to shut our eyes to these facts much longer. I submit that any one who takes a calm and unpre- judiced survey of the whole history of smallpox in this country will be forced to the conclusion that this disease is following a number of other zymotics — e.g. leprosy, cholera, plague, typhus — which at one time were a scourge and a terror in these islands, but have now practically disappeared.1

In saying this I do not wish to suggest that we have seen the last of smallpox epidemics. There are still many weak places in our national armour, and our weapons of defence against the disease are very far indeed from being perfect. But we are gaining experience with every fresh visitation. There has not been a single widespread epidemic of smallpox during recent years but has taught some useful lesson and left the affected district better prepared to deal with the disease in future.

I think it may reasonably be claimed that we now know better how to deal with smallpox (apart from the question of infantile vaccination) than with any other zymotic disease.

Smallpox Mortality in the British Isles during the Past

150 Years

Let us now take a general bird's-eye view of smallpox mor- tality in this country during the past 150 years (Diagram I). Death registration only began with the year 1838, so that prior to that date it is usual to take the London Bills of Mortality as the best available index of the ravages of smallpox during

1 Enteric fever also appears to be going, whilst scarlet fever has ceased to be a serious cause of death.

DIAGRAM I.

MORTALITY FROM SMALLPOX AND OTHER ZYMOTIC DISEASES IN LONDON, 1760 TO 1910.

500

400

300

200

100

The Other Zymotic Diseases include Measles, Scarlet Fever, Diph

500

400

300

200

100

heria, Whooping Cough and " Fevers.

The first half of the diagram is after A. R. Wallace. The latter half has been constructed from the figures given by the Registrar General.

IN DETAIL

15

the eighteenth and the beginning of the nineteenth century. Although the London Bills only refer to burials within the City of London, where smallpox certainly caused a much higher average mortality than throughout the country generally, yet for the purpose of studying the progress of the disease from year to year they are quite sufficient. The first half of Diagram I is based on the figures for smallpox given in the London Bills,1 and is after A. R. Wallace.2 It shows graphically the number of deaths from smallpox in London in each of the years 1764-1834. For comparison, the deaths from other zymotic diseases (measles, scarlet fever, diphtheria, whooping cough, and " fevers ") are also shown.

It is clear that the mortality from both causes fell very remarkably, and that in the case of smallpox as well as in the case of " other zymotics " the decline had set in before the end of the eighteenth century — in other words before the beginning of the vaccination era.

Jenner's discovery, it will be recalled, was published in 1798, and the practice of vaccination hardly became general until several years after that date.

During the earlier part of the nineteenth century, the drop in smallpox mortality was certainly very marked, and, person- ally, I am quite satisfied that the introduction of vaccination contributed largely to this drop. If we accept the proposition that vaccination confers upon the individual for a few years complete immunity to the disease, and subsequently modifies the severity of the- attack, then, at a time when smallpox over- ran the country, it almost necessarily follows that a reduction in mortality must have ensued. But it by no means follows that the whole of the reduction was due to the introduction of vaccination. Assuming, as I think we must, that a decline in smallpox mortality had already begun before the introduction of vaccination, it is quite reasonable to suggest that, whilst vaccination hastened the fall, the decline would have continued even without vaccination and would ultimately have reached the same point, though not so soon. Moreover, it will be noticed that the drop in the mortality from "other zymotics" was

1 Second Report R.C.V.

2 See Diagram I in Vaccination a Delusion, by A. R. Wallace, LL.D., D.C.L., F.R.S., etc.

16

IN DETAIL

17

almost as striking. So much is this the case, that, without being informed, it is difficult to tell which line represents small- pox, and which " other zymotics." Obviously, causes other than vaccination must have been at work to have produced this fall in " other zymotics," and we cannot say that the same cause did not also influence the mortality from smallpox.

o

1—1

	a Ui >		<	/		/		\ % \ \ % 1 1
	ALLPOX.		5 U					/I
CD	5 5 co co		z 0 l-					/ \ >
O CD	-s > i =		ACCINA					n s — 1
ao	Solid Dotted		>		L		\	\ \
O								> — <
CO
— * t 0
GO		✓			=aA
O ID				■\
			4			/

It will next be noticed that as the century advanced, in spite of the increasing use of vaccination, the decline in smallpox mortality became much less marked. This is easily accounted for by the fact that after the lapse of years all those persons vaccinated in the earlier part of the century were gradually 2

i8

THE VACCINATION QUESTION

losing their protection and again becoming susceptible to fatal smallpox.

The London Bills of Mortality only take us up to about the year 1834, but in 1838 systematic registration of deaths was instituted, so that from that time onwards we have the returns of the Registrar-General to guide us. The second half

O

0	EVER.		>	f		\ \
19 IALLPOX	u_ t- u _J ee -s		n			1 > / 1 \
t/) 0 " 1 0			CCINA1			1 1 1 1
19 Curve	0 Curve		■a. >			v — I / ✓ ✓ <
90 Solid	UJ >- 1- 0 a					I 1
00						— 7L- < >
0 CD					✓
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^SrV o 5 K

o ft o ^ o t3

rC ■ 1>

O in

2£ ft IS 3

. MH CD

E Si

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8 « ■»

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of Diagram I has been constructed from the Registrar-General's figures,1 and shows graphically the mortality from smallpox and other zymotics per 100,000 population. It will be observed that the mortality from smallpox continued to fall, though not very rapidly and with considerable fluctuations, until the year

1 Taken from the Final Report of the Royal Commission on Vaccina- tion, pp. 32, 43.

IN DETAIL

19

1871. It was then that this country, and indeed the whole of Europe, had such a rude awakening as to the total inadequacy of infantile vaccination, as then being practised, to protect the country from a terrible visitation of smallpox. The great extent to which London suffered is seen in the diagram.

Diagrams II, III, and IV show the smallpox mortality curves for England and Wales, Scotland, and Ireland, together with curves showing the mortality from scarlet fever. In each diagram the great leap in the smallpox mortality in the years 1871-3 is at once apparent. We notice in the scarlet-fever curve also remarkable exacerbations, very little less remarkable than those in the case of smallpox.

All of the three last diagrams being drawn to the same scale, it will be seen that there is a marked difference in the extent to which each of the three divisions of the United Kingdom has suffered ; England and Wales having suffered most, then Scotland, and Ireland least of all. Ireland has also suffered less from scarlet fever than either of the two other countries. Now it can hardly be contended that this difference in smallpox mortality has had anything to do with vaccination. As a matter of fact it would appear that in the past Ireland was less effici- ently vaccinated than either Scotland or England and Wales. There can be little doubt that the real explanation is to be found in the difference in density of population in the three countries ; Ireland, of course, being the least populous, Scotland coming next, and then England and Wales. The same explanation accounts for the fact that smallpox mortality in London (and in other great towns) was worse than in the country as a whole.

But density of population must be included in the term "sanitary condition," using that term in its broadest sense; so it would seem that " sanitary condition " may have more to do with the incidence of smallpox mortality than the mere question of the efficiency or otherwise of infantile vaccination.

We now come to the period from 1873 down to the present time. This may rightly be called the " Sanitary Era," as it is only during this period that the science of modern sanitation has come into existence. The great Public Health Act — passed in 1875 — may well be taken as marking the beginning of this era. True, this was not the first Act relating to the Public Health, nor the first attempt that had been made to improve

20

THE VACCINATION QUESTION

the wretched state of things existing. The dawn of sanitation had already appeared. But if any particular date is to be taken as marking the effective beginning of the "Sanitary Era/' the year 1875 may well be selected.

Modern Methods of Dealing with Smallpox

It is only since this date that those modern measures 1 for dealing with smallpox, which are now almost universally carried out in this country, with more or less efficiency, came into operation. It will be well to refer to the more important of these separately.

(a) Hospital Isolation. — It is only about forty years since the practice of isolating smallpox in special hospitals was begun. This marked a new era in the campaign against the disease, and we shall refer to it in more detail later. At first, however, smallpox hospitals, placed, as they usually were, in the midst of populous localities, overcrowded with patients and indifferently administered, were undoubtedly often a great source of danger to the surrounding population. It was many years before this was fully recognised, and it is only since smallpox hospitals have been moved outside the towns that the full advantage of hospital isolation has been obtained. A striking illustration of this is seen in the case of London. A very marked drop in smallpox mortality followed the removal of the smallpox hospitals outside the Metropolitan area in 1885.

(b) Notification. — Again, hospital isolation could only be really effective when supplemented by compulsory notification of the disease. When it is considered how much importance nowadays is attached to the early notification of smallpox if modern measures of prevention are to be of any use, it is astonishing to think that it was as recently as 1901 that the notification of infectious disease was made compulsory for the whole country, although most large towns had obtained com- pulsory powers by local Acts earlier than this. Leicester was one of the pioneers in this respect and obtained a compulsory Notification Act (in the face of considerable opposition from

1 An excellent account of the modern methods of dealing with smallpox is given in a little book, recently published, by Dr. W. McC. Wanklin, The Administrative Control of Smallpox.

IN DETAIL

21

the medical profession) as early as 1878, A great city like Sheffield, on the other hand, was without these powers as late as 1887, and depended upon a voluntary system, with the result that when smallpox visited the city in that year only one-fourth of the thirty-two cases known to have occurred during the first three months of the outbreak were notified. It is scarcely surprising that the disease spread and that a serious epidemic resulted.

(c) Surveillance of Contacts. — Still more recently the method has been adopted of carefully searching out all individuals who have been in contact with cases of smallpox and keeping them under strict supervision until the end of the incubation period, so that in the event of symptoms of the disease appearing, they can at once be removed to hospital before infecting others. This method is undoubtedly of the very first importance. In Leicester and some other towns "compensation" is paid to contacts for staying away from work. Further reference will be made to this part of our subject in Chapter VIII, when dealing with the "Leicester Method."

(d) Disinfection of Houses and Clothing. — Little need be said about this. It is now almost universally practised after small- pox, and when clothing cannot be efficiently disinfected it is generally destroyed.

(e) Visitation of Lodging-houses. — It has also now become the general practice in large towns for inspectors to systematic- ally visit common lodging-houses when smallpox is about, and many cases of the disease in tramps, which otherwise might have caused outbreaks, have thereby been discovered.

(f) Interchange between Different Sanitary Districts of Informa- tion regarding Smallpox Cases and Contacts. — It is difficult to over-estimate the importance of this modern measure. Port Sanitary Authorities now systematically forward to the districts concerned the names and addresses of any contacts landing from abroad.1

Other important though minor measures for dealing effec- tively with smallpox have been introduced and perfected during

1 An instance of the value of this occurred recently in Leicester. In- formation was sent by the M.O.H. for Liverpool of the arrival of a small- pox contact in Leicester, from Brazil. The contact developed smallpox, but, being under observation, no spread of infection occurred.

22

THE VACCINATION QUESTION

this " Sanitary Era," and, in addition, the general sanitary condition — including especially in this term overcrowding and standard of living — of almost every town has been very greatly improved, as evidenced by the reduced death-rate and infantile rate, and the reduced mortality from other zymotic diseases, It seems reasonable to contend that all this has contributed very largely to the remarkable reduction in smallpox mortality which has taken place during the period we are now considering. I do not suggest that the whole of the decline has necessarily been due to " sanitation," because it is quite possible that other and more subtle causes — causes which we cannot analyse, but which may be referred to as " epidemic influences " — have been at work. It is well known that some diseases tend to disappear just as others tend to increase (e.g., cerebro-spinal meningitis, and acute polimyelitis) without any assignable cause. But, whatever the cause, there seems to me to be no satisfactory reason for thinking that infantile vaccination has played any great part in the reduction in smallpox mortality. The striking facts that in Leicester, without infantile vaccination, the decline has been greater than in most places, and that throughout the country smallpox has continued to decrease in spite of the falling off in vaccination, should surely be sufficient grounds for legitimate doubt.

The Relative Risks of Vaccination and Smallpox

It cannot be denied that vaccination causes, in the aggregate, very considerable injury to health, most of it only temporary, but some permanent. It is true that the deaths certified as due to vaccination are less numerous now than they used to be, but some deaths still occur every year. In the twelve years ending 1910 (i.e., since the substitution of calf lymph for human lymph) there were 251 of these deaths in England and Wales. But in addition to the deaths certified as directly due to vaccina- tion there are certainly others indirectly due to it which are not so certified. In any case we have no official statistics as to the number of children whose health has been temporarily or permanently injured short of a fatal result. I have certainly no wish to exaggerate the injuries caused by vaccination. Com- pared with an average attack of unmodified smallpox an attack

IN DETAIL

23

of cowpox is usually a trifling matter. Whenever there is a grave risk of contracting the more serious disease, as in the case of persons who have been exposed, or are likely to be exposed, to the infection of smallpox (e.g. smallpox contacts and small- pox nurses) it is infinitely better to accept the lesser evil in order to escape the greater. At the same time we must never forget that vaccination is an evil. Vaccinia is just as much a disease as smallpox, though a less serious one, and all disease must be regarded as evil and to be avoided if possible. There is not the slightest evidence that vaccination, apart from its effect in preventing smallpox, is of the least value or anything but detrimental to the human race.

But now that the risk of being exposed to the infection of smallpox, or at least of contracting the disease, has become very remote, owing to the enormously reduced prevalence of the disease, it becomes an open question whether the risk incurred by vaccination is not too heavy a premium to pay for the sake of being ensured against the risk of smallpox. If only the im- munity conferred by vaccination really lasted for a lifetime, as Jenner hoped and at first asserted, the price to be paid for the insurance would be a matter of less importance. But it is quite certain that vaccination, to be reasonably effective through life, must be repeated.

During the last decade the deaths from vaccinia have several times outnumbered those from smallpox, whilst if we have regard to the amount of ill-health caused by the two diseases (and putting aside for the moment the question of the alleged effect of vaccination in lessening smallpox) it looks as if vaccinia were becoming, so far as the community is concerned, the more serious disease of the two.

The Principle of Vaccination not Ideal

Twelve years ago I wrote1: " It must never be forgotten that vaccinia is, after all, a disease, and those of us whose pro- fession it is to prevent disease should be ready to abandon it at the earliest possible moment consistent with the public safety. The control of disease by the substitution of one disease for another, whilst it may be expedient, can never be regarded as

1 In a paper read at the Public Health Congress at Exeter, in 1902.

24

THE VACCINATION QUESTION

an ideal method ; and, whilst I fully recognise the immense and lasting utility of vaccination under certain circumstances (e.g. after exposure to infection), I venture to suggest that universal compulsory vaccination need only be regarded as a temporary expedient."

At that time, with my limited experience, I was not prepared to go nearly so far in recommending the abolition of compulsory vaccination as I am to-day, but the assertion that the principle of preventing disease by the substitution of one disease for another was not ideal was as definite then as it is now, and I have nothing to add to it.

The Risk of Infants Contracting Smallpox

Before leaving this aspect of the subject I would mention that I believe the risk of infants contracting smallpox, in places where infantile vaccination is neglected, has been very much over-estimated. Even during times of epidemic in Leicester it is surprising how few infants have contracted the disease. During the epidemic of smallpox in Leicester in 1892-3, out of 365 cases which occurred, the number of unvaccinated infants attacked was only 6, 1 of whom died. .Again, in the 1903 epidemic, out of 394 cases there were 4 infants, 2 of whom died ; whilst in the epidemic of 1904, out of 321 cases, 6 were infants, 2 of whom died. Moreover, several of these were below the vaccination age, so would not necessarily have been protected, even if infantile vaccination had been in force in Leicester.

I recognise, of course, that during the epidemics in question the number of infants vaccinated was greater than usual, but this was not the result of compulsion, but rather in spite of it, and is certainly no argument for compelling all infants to be vaccinated whether smallpox is prevalent or not.

The late Dr. F. T. Bond of Gloucester, Founder and Hon. Sec. of the Jenner Society, became so satisfied that the danger of infants contracting smallpox, even though unvaccinated, was not very serious, that he, in conjunction with Mrs. Garrett Anderson, M.D., the Hon. Sec. of the Imperial Vaccination League, actually advocated the extension of the age limit for vaccination to six years.

IN DETAIL

25

Infantile Vaccination Alone, however Efficiently Enforced, can Never be Depended upon to Protect the Community

I do not think that any one who has studied the subject will deny that infantile vaccination alone is quite insufficient to protect a community from smallpox, no matter how efficiently it be carried out. If any doubt exists we have only to point to the experience of well-vaccinated towns such as Sheffield, Warrington, Liverpool, or Middlesbrough, before modern pre- ventive measures were efficiently practised, and when infantile vaccination alone was chiefly depended upon. We shall con- sider the case of these towns in Chapter IV. It will suffice to say here that, although infantile vaccination had been carried out with exemplary thoroughness, very severe epidemics of smallpox occurred and caused heavy loss of life.1

Infantile Vaccination has One Serious Drawback ; Whilst Mitigating Smallpox it also Disguises it, and in this way Tends to Spread the Disease.

I regard this proposition of so much importance, and it has hitherto received so little attention, that I propose to devote a separate chapter to its consideration.

Re-vaccination

As we are taking it as proven that vaccination confers com- plete immunity against smallpox for a time, and that such immunity can be renewed as often as desired by re-vaccination, it follows as a logical sequence that if all the individuals in a community were vaccinated and re- vaccinated often enough, smallpox could not exist. This is exactly what happens in the case of the staff of a smallpox hospital. In practice two re- vaccinations, making three vaccinations altogether in a life- time, would no doubt be sufficient. In Germany there is universal re-vaccination at school-age, followed by a third vaccination of all males on entering the army. Smallpox

1 I quite admit, of course, that had these towns been less well vac- cinated the mortality caused by these epidemics would almost certainly have been higher. All I am contending for here is that infantile vac- cination alone is quite insufficient.

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THE VACCINATION QUESTION

mortality in Germany, as in Great Britain, has been reduced to a minimum, though sanitation in Germany, as well as vaccina- tion, must receive some of the credit. Still, I am quite prepared to admit that a complete system of universal vaccination and re-vaccination and repeated re-vaccination , if such could be effi- ciently carried out, would abolish smallpox from any country in the world.

The important question to consider in this connection, how- ever, is whether such a drastic measure is really necessary for the effective control of smallpox, for unless it can be shown that it is, it would be most unreasonable to expect a civilised community to submit to it.1 In the United Kingdom I am satisfied that such a measure is not necessary. We have done without it all these years and we are better prepared to-day to deal with smallpox by measures other than vaccination than ever before. Certainly, no Government is likely to incur the unpopularity of attempting to pass a compulsory re-vaccination law, nor is there any likelihood that such a law could be enforced even if it did succeed in finding its way on to the Statute Book. As a matter of fact, it is now frankly admitted, even by the most extreme pro-vaccinists, that general re-vaccination of the community is no longer a question of practical politics.

A further reference to the subject of re- vaccination is made in the final chapter.

1 It would appear that a revolt against vaccination is being threatened, even in Germany. A big debate took place in the Reichstag recently, and a motion to abolish compulsion was only defeated by a small majority.

CHAPTER III THE ROYAL COMMISSION ON VACCINATION

A Remarkable Inquiry — -The Terms of Reference — Findings of the Com- mission— Majority Report — Effect of Vaccination in Preventing Smallpox — Conclusions of Commissioners as to Protective Effect — Means other than Vaccination for Preventing Smallpox — Value of Hospital Isolation — Opinion of Buchanan and Thorne — Experience of London — Means for Preventing Ill-effects of Vaccination — Ques- tion of Compulsion — Minority Reportj

I propose to limit the scope of this book by confining myself as far as possible to the experience of smallpox which has been gained since the time of the Royal Commission on Vaccination.

We may regard the present inquiry, therefore, as starting at the point where the Royal Commission left off. I shall devote the present chapter to a consideration of the finding of the Com- mission, and of the conclusions arrived at.

Reference will be made in a later chapter to the part played by the town of Leicester in connection with the Royal Com- mission.

The Royal Commission on Vaccination certainly represents by far the most exhaustive inquiry ever held in connection with the subject of vaccination 1 and constitutes a landmark in the history of our subject. It was, indeed, one of the most remark- able inquiries ever held in connection with any subject. Ap- pointed in the year 1889, the Final Report was not published until 1896, seven years later. This delay is not surprising, con- sidering the enormous volume of evidence recorded. The Commissioners held 136 meetings, and examined 187 witnesses.

1 The following comment in The Lancet (April 13th, 1889) on the proposal to appoint a Royal Commission illustrates the " made-up " attitude of mind with which many regarded the question of vaccination :

" It is about as rational to investigate the merits and value of vaccina- tion as it would be to question the utility of lifeboats, or Davy lamps, or fire brigades."

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THE VACCINATION QUESTION

In addition, they caused important investigations to be made for their assistance. The examination of certain individual witnesses occupied several whole days. The total number of questions put and answered was over 18,000. Some idea of the mere bulk of the reports issued is obtained from the fact that the five principal reports, consisting of closely printed matter, together with the eight bulky appendices, weigh altogether over 14 lb. avoirdupois ! The Commissioners, under the able chair- manship of Lord Herschell, certainly did their work with com- mendable thoroughness, and their reports constitute a veritable storehouse of facts relating to vaccination ; but, unfortunately, much valuable evidence is virtually buried in this great mass of material.

The Terms of Reference

The Terms of Reference to the Commission were as follows : " To inquire and report as to :

" (1) The effect of vaccination in reducing the prevalence of, and mortality from, smallpox.

" (2) What means other than vaccination can be used for diminishing the prevalence of smallpox ; and how far such means could be relied on in place of vaccination.

" (3) The objections made to vaccination, on the ground of injurious effects alleged to result therefrom ; and the nature and extent of any injurious effects which do, in fact, so result.

" (4) Whether any, and if so, what means should be adopted for preventing or lessening the ill-effects, if any, resulting from vaccination, and whether, and if so, by what means vaccination with animal vaccine should be further facilitated as a part of public vaccination.

" (5) Whether any alterations should be made in the arrange- ments and proceedings for securing the performance of vaccina- tion, and, in particular, in the provisions of the Vaccination Acts with respect to prosecutions for non-compliance with that law."

The Finding of the Royal Commission

In spite of the pains taken to arrive at a unanimous verdict, the Commissioners were divided in their conclusions and re- commendations. Out of the thirteen Commissioners who sur-

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vived the inquiry, eleven signed the Final Report (often referred to as the Majority Report) though four with reservations ; whilst two — Dr. W. J. (now Sir William) Collins and Mr. J. A. Picton — issued an exhaustive statement (commonly referred to as the Minority Report) setting forth the grounds of their dissent. The two Reports may be regarded as constituting the most authoritative statement on the vaccination question available from the pro-vaccinist and anti-vaccinist point of view respectively. It is noteworthy that both are much more cautious and less extreme in tone than the statement of the case as often put forward by more irresponsible and reckless protagonists. Moreover, it will be found on close examination that there is comparatively little real difference between the two Reports as regards matters of fact.

The Majority Report extends to 141 pages, and the Minority Report to 65 pages. Both Reports are valuable scientific documents, and may be regarded to some extent as the comple- ment of each other.

The Majority Report

We will first consider the finding of the Majority Report.

Reference 1. The Effect of Vaccination in Reducing the Prevalence of, and Mortality from, Smallpox

This was the first and certainly the most important of the questions referred to the Commissioners. It raised at once the whole question of the utility of vaccination to the community, but not, be it observed, of its utility to the individual. To have referred to the individual the reference ought to have been worded something as follows : " The effect of vaccination in reducing the risk of attack by, or of death from, smallpox." It is probable that the importance of distinguishing between the effect upon the individual and upon the community was not at all appreciated at the time the Royal Commission was appointed. But, however that may be, it is certain that the problem set before the Com- mission to solve was the effect upon the community , and they approached it chiefly, if not entirely, by endeavouring to establish what the effect was upon the individual.

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That this was really the case is clearly shown by their answer to this first and most important reference. Instead of saying definitely that they believed vaccination was reducing the prevalence of, and mortality from smallpox, they evade the real issue by saying (Sect. 365) : " We proceed then to sum up the evidence bearing upon the question whether vaccination has any, and if so what, protective influence in relation to smallpox, and to state the conclusions at which we have arrived" (italics have been added).

Now, I would specially draw attention to the fact that this question " whether vaccination has any, and if so what, pro- tective influence in relation to smallpox," was not one of the terms of reference at all. Yet the greater part of the Majority Report is devoted to — I had almost said, wasted in — settling it. No doubt, the fact that the opponents of vaccination denied that it had any protective influence accounts for so much effort being made to establish this point, but none the less, I submit that the conclusion arrived at constitutes no satisfactory answer to the all-important question submitted as to the effect of vaccination in reducing the prevalence of, and mortality from, smallpox. 1

The Conclusions of the Commissioners as to Protective Effect upon the Individual. — The Commissioners then proceed to state their conclusions as to the protective effect of vaccination as follows (Sect. 377) : "It has appeared to us impossible to resist the conclusion that vaccination has a protective effect in re- lation to smallpox.

"We think :

" (1) That it diminishes the liability to be attacked by the disease.

" (2) That it modifies the character of the disease, and renders it (a) less fatal, and (b) of a milder or less severe type.

" (3) That the protection it affords against attacks of the disease

1 To make my meaning quite clear, let us assume that an inquiry was being held into the utility or otherwise of the practice of inoculation, and that the Commissioners were directed to inquire as to the effect of inoculation in reducing the prevalence of, and mortality from, smallpox. Would it have been any real answer to prove that inoculation had a pro- tective influence upon the individual against natural smallpox ? Obviously not ; yet this is practically all the answer that the Commissioners vouch- safed to the same question as regards vaccination.

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is greatest during the years immediately succeeding the opera- tion of vaccination. It is impossible to fix with precision the length of this period of highest protection. Though not in all cases the same, if a period is to be fixed, it might, we think, fairly be said to cover in general a period of nine or ten years. 1

" (4) That after the lapse of the period of highest protective potency, the efficacy of vaccination to protect against attack rapidly diminishes, but that it is still considerable in the next quinquennium, and possibly never altogether ceases.

" (5) That its power to modify the character of the disease is also greatest in the period in which its power to protect from attack is greatest, but that its power thus to modify the disease does not diminish as rapidly as its protective influence against attacks, and its efficacy during the later periods of life to modify the disease is still very considerable.

" (6) That re- vaccination restores the protection which lapse of time has diminished, but the evidence shows that this pro- tection again diminishes, and that to ensure the highest degree of protection which vaccination can give, the operation should be at intervals repeated.

" (7) That the beneficial effects of vaccination are most experienced by those in whose case it has been most thorough. We think it may be fairly concluded that where the vaccine matter is inserted in three or four places it is more effectual than when introduced into one or two places only — and that if the vaccination marks are of an area of half a square inch, they indicate a better state of protection than if their area be at all considerably below this."

Now, it is quite clear that every one of the above seven findings has reference to the effect of vaccination upon the individual, and I submit that though we may be quite prepared to subscribe to all these findings of the Majority Report, as I myself am (with the slight reservation already made as to the duration of the period of highest protective potency), it is still quite an open question what the effect of vaccination is upon the community, i.e. in reducing the prevalence of, and mortality from, smallpox.

1 As already stated, I think this period is too high, and that five years would be more correct.

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THE VACCINATION QUESTION

Reference 2. As to what Means, other than Vaccination, can be Used for Diminishing the Prevalence of Smallpox ; and how far such Means could be Relied on in Place of Vaccination

This reference is so important, and the finding of the Com- mission is so conclusive, that I am quoting from their Report at some length: —

" Another question upon which we are asked to report is, what means, other than vaccination, can be used for diminishing the prevalence of smallpox ; and how far such means could be relied on in place of vaccination.

" The means other than the inoculation of smallpox or cow- pox, which have been referred to by witnesses as being capable of diminishing the prevalence of smallpox, are such means as have been employed against infectious diseases generally ; they may be summarised as : (1) Measures directed against infection, e.g. prompt notification, isolation of the infected, disinfection, etc. (2) Measures calculated to promote the public health, the prevention of overcrowding in dwellings or on areas, cleanliness, the removal of definite insanitary conditions, etc.

" The principle underlying the practice of isolation, with its accompanying machinery, is obviously the very opposite of that which recommended the practice of inoculation ; it aims at exclusion of the disease, whereas inoculation aimed at universal acceptance by artificially ' sowing ' or ' buying ' the disease " (Sects. 451 and 452). (We may add that it is also the opposite of vaccination which aims at the universal sowing and re-sowing of another, but milder, disease. — C.K.M.)

" . . . In 1784 Haygarth, of Chester, published his Inquiry how to Prevent the Smallpox, and in 1793 A Sketch of a Plan to Exterminate the Smallpox from Great Britain. . . .

" In the Medico-Chirurgical Review for 1796 there appeared an account of a work by Dr. Faust of Leipsic, entitled An Essay on the Duty of Man to Separate Persons Infected with the Small- pox from those in Health, thereby to Effect the Extirpation of that Disease Equally from the Towns and Countries of Europe. . . .

" In 1798 Jenner's Inquiry was published, and in the early years of this century inoculation began to be discouraged ; for a while prospects of annihilating smallpox by vaccination

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appear to have superseded, in the minds of many, the plans of Haygarth and others. Some vaccinators, however, like Willan and Ring, still looked to methods of quarantine and to national and municipal regulations promoting isolation to ex- terminate the smallpox. . . .

" Prior to the year 1866 there was no provision made by law for enabling sanitary authorities to establish hospitals for infectious diseases, and thus to promote the isolation of such cases. The only institutions of that description then existing were the result of private effort. So far as regards smallpox there was, practically speaking, no provision for its treatment by means of isolation.

" The Sanitary Act of 1866 empowered, though it did not compel, local authorities throughout England and Wales, Scot- land and Ireland, to provide or to join in providing, isolation hospitals for the use of the inhabitants of their districts. There was further legislation on the subject by the Public Health Act, 1875 ; the Public Health (London) Act, 1891 ; the Public Health (Scotland) Act, 1867 ; and the Public Health (Ireland) Act, 1878 ; into the details of which it is not necessary to enter. The most recent Act relating to the matter is the Isolation Hospitals Act of 1893, which applies to the small towns and rural districts of England and Wales (Sects. 456-461).

"In 1879, by the Poor Law Act of that year, power was given to the Metropolitan Asylums Board to contract with the local authorities for the reception into the Board's hospitals of any persons suffering from smallpox or other dangerous infectious disorder within their districts, but it was not until 1889 that express power was given to the Asylums Board by the Poor Law Act of that year to admit persons reasonably believed to be suffering from smallpox who were not paupers. ..."

The Commissioners observe that in 1879 only about 18 per cent, of sanitary authorities had made any kind of provision for isolating cases of infectious disease, whilst as recently as 1892, when the Commissioners began their inquiry, the pro- portion was only 36 per cent. This shows how little prepared the country was at that time for dealing with smallpox by means of isolation of the disease. Vaccination, indeed, was at that time the only recognised preventive.

The Commissioners proceed : 3

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THE VACCINATION QUESTION

" The value of isolation in restricting the spread of smallpox has been long acknowledged by the Medical Officers of the Local Government Board.

" Dr. (afterwards Sir George) Buchanan, in a report made in 1874, expressed the opinion that ' smallpox as well as other in- fections,' is capable of being wonderfully limited by isolation in hospital, and the amount of provision made for such isolation may be expected to affect materially the rate at which an epidemic of smallpox becomes extinguished. . . .

" Evidence bearing on the same point was given by Dr. Thorne before the Royal Commission which in 1881-2 inquired into the subject of smallpox and fever hospitals in London. Speaking of hospitals for infectious diseases generally, he said : ' The evidence is so abundant that I could occupy you for hours in telling you of instances in which epidemics have evidently been prevented by the isolation of first cases of infectious disease.' . . .

" Dr. Thorne says : ' It is really more striking as regards smallpox than any other disease, because smallpox can be more easily isolated ; the friends of the patients, and they themselves, being so much more willing to submit to isolation than when suffering from any of the other specific fevers.'

" After the hospitals established by the Metropolitan Asylums Board had been employed for some time for the reception of persons suffering from smallpox, attention was called to the fact that the number of cases of the disease in the neighbourhood of the hospitals was apparently in excess of the number found in streets farther removed from them, and a suspicion was aroused that the hospitals themselves were causing a spread of the disease. . . .

" The matter was felt to be of so much importance that a Royal Commission was appointed to consider the prevention and control of epidemic infectious diseases in London and its neighbourhood.

" The Commission arrived at the conclusion that it ' appeared clearly established ' by the experience of the five hospitals maintained by the Asylums Board for smallpox patients, that ' by some means or other the asylum hospitals in their present shape cause an increase of smallpox in their neighbourhoods.' . . ." (Sects. 465-470.)

In consequence, the Metropolitan Asylums Board decided

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to treat their smallpox cases in the hospital ships at Long Reach, and in 1881 in the hospital camp at Darenth (for convalescent cases), and to discontinue treating any patients in the Metropolis itself. All cases of smallpox were finally removed from the Metropolitan area in 1885.

" We have already directed attention to the fact that it was, practically speaking, not until 1871 that hospital accommo- dation was provided in London, which rendered possible the removal from their homes of persons suffering from smallpox, and we have detailed the measures adopted from time to time for that purpose.

" As these facilities were augmented, the proportion of cases treated in the Metropolitan Asylums Board's hospitals steadily increased.

" The Royal Commission to which we have referred, in their Report made in July 1882, contrasted the amount of smallpox in London with that which had occurred in England generally. It will be well to bring such a comparison down to the present time and to notice the features which it presents.

" The following table affords a comparison between the mor- tality in London and that in England and Wales, with the Metro- polis excluded, the deaths being those from smallpox to every 100,000 living1 :

Mean Annual Deaths from Smallpox to every 100,000 living.

	England and Wales,	London.
	excluding London.
1838-42	• 54'5	77 -i
1847-56	. 23-6	34 '6
1857-66	. 20 '0	26-8
1867-76	. 223	41-9
1877-86	• 3'3	27 '4 "

(Sects. 491-492.)

In 1885, as already mentioned above, all cases of smallpox

1 The smallpox figures for the period since 1886, obtained from the Registrar-General's Reports, are as follows :

England and Wales, including London. I/)ndon. 1887-1896 . . . . 17 O'Q,

1897-1906 1-4.3-5

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THE VACCINATION QUESTION

were removed outside the Metropolitan area, and since then smallpox mortality has fallen as remarkably in London as it had previously done in the provinces.

The above figures bring out clearly the great importance of other factors than the efficiency or otherwise of vaccination in conducing to a high smallpox mortality. London was as well vaccinated as the provinces, but suffered far more severely from smallpox, the reasons, no doubt, being the greater aggregation of population and the presence of the London smallpox hospitals in London.

The Commissioners proceed :

" We have no difficulty in answering the question, what means other than vaccination can be used for diminishing the prevalence of smallpox ? We think that a complete system of notification of the disease, accompanied by an immediate hospital isolation of the persons attacked, together with a careful supervision, or, if possible, isolation for sixteen days of those who had been in immediate contact with them, could not but be of very high value in diminishing the prevalence of smallpox. It would be necessary, however, to bear constantly in mind as two conditions of success, first, that no considerable number of smallpox patients should ever be kept together in a hospital situate in a populous neighbourhood, and secondly, that the ambulance arrangements should be organised with scrupulous care. If these conditions were not fulfilled, the effect might be to neutralise or even do more than counteract the benefits otherwise flowing from a scheme of isolation.

" When we turn to the other branch of the inquiry, how far such means could be relied on in place of vaccination, we find ourselves involved in questions of a much more complicated nature. We have little or no experience to fall back upon. The experiment has never been tried (italics added).1

" . . . Who can possibly say that if the disease once entered a town, the population of which was entirely or almost entirely unprotected, it would not spread with a rapidity of which we have in recent times had no experience, or who can foretell what call might then be made on hospital accommodation if all those attacked by the disease were to be isolated ? " (The

1 We shall see later, when we come to deal with Leicester, that the experiment has now been tried and found to be very successful.

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experience of Leicester shows that these fears are hardly warranted. — C.K.M.)

" Even admitting fully the protective effect of vaccination, it does not, in our opinion, diminish the importance of measures of isolation or dispense with their necessity." 1 (Sects. 499-504.)

It is to be noted that all the above extracts are from the Majority Report, and I have quoted them to show what great importance the Commissioners attached to hospital isolation in the case of smallpox.

It should be observed that during the period prior to the Report of the Royal Commission, hospital isolation was only very imperfectly carried out, whilst in many towns it was not even attempted. The accommodation provided was generally quite inadequate, and often the hospital was so situated as to be a positive danger to the town it was supposed to serve. Moreover, those modern methods of hunting up and vaccinating contacts and of keeping them under surveillance, which have proved so valuable in recent epidemics, and which are essential in order to supplement hospital isolation, were then little under- stood or practised. We are justified in saying that undoubtedly hospital isolation had not been given a fair trial prior to the time of the Royal Commission ; hence the natural hesitation of the Majority Commissioners to admit that isolation alone could be relied upon. We shall see presently, when we come to consider the experience of individual towns, that wherever an epidemic of smallpox got out of hand, as at Sheffield, Gloucester, Dewsbury, Warrington, or Middlesbrough, the method of pre- vention by hospital isolation had not been given a fair trial.2

v 1 This last statement of the R.C.V. should surely be a sufficient answer to those who try to make out that the necessity for smallpox hospitals, and therefore the cost of maintaining them, is due to the neglect of vaccination.

2 We read very much the same story again and again : inadequate hospital accommodation quickly becoming overcrowded ; the hospital administration breaking down ; cases not promptly removed from their homes and spreading infection around them : the hospital itself improperly situated in a populous neighbourhood, and the overcrowded hospital becoming a centre for the dissemination of the disease ; a medical officer of health hampered by private practice ; the sanitary staff unequal to the enormous increase of work thrown upon them ; the Local Authority honestly anxious to do its best, but inexperienced, undecided, fearful of incurring unusual expenditure, and helpless in the face of a sudden

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Reference 3. The Alleged Dangers of Vaccination.- — "W e shall deal with this consideration in a later chapter.

Reference 4. Means for Preventing or Lessening the Ill-effects of Vaccination. — The Commissioners strongly recommended the substitution of calf lymph for humanised lymph, which recommendation, as is well known, was shortly afterwards carried into effect, with the result that calf-lymph vaccination has now entirely superseded arm-to-arm vaccination. They also recommended the raising of the age-limit for infantile vaccination from three to six months, and this, too, has been carried into effect.

Reference 5. The Question of Compulsion. — As regards the important question of compulsion, the Commissioners recom- mended a modified and much less stringent form of compulsion by recognising and exempting the " Conscientious Objector " on certain conditions. Two of those who signed the Majority Report, however, dissented from this concession ; but, on the other hand, two other Commissioners joined the Minority Com- missioners in objecting to the retention of the principle of com- pulsion in any form. There were thus two in favour of unrelaxed compulsion ; seven in favour of a greatly modified and reduced form of compulsion ; and four in favour of compulsion being abandoned altogether. It would only have required the transfer of three votes, therefore, to have secured a majority in favour of the entire abolition of compulsion.

It may be observed that in an Interim Report, published early in the inquiry, the Commissioners had unanimously re- commended the abolition of the harsh practice of inflicting repeated penalties for the same offence.

In conformity with the recommendations of the Commissioners, the Government passed the Vaccination Act of 1898, recognising and providing a means of escape for those " conscientiously " opposed to vaccination. It was hoped that this concession, by minimising prosecution and persecution, would greatly reduce the hostility to vaccination. Some even believed that

emergency ; a Government Department which regards its proper function to be that of merely giving advice and pressing for returns, rather than of giving material help and assistance. With such conditions is it to be wondered at that the result should be panic and disaster ? We shall consider the remedy for this state of things later.

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it would lead to an actually increased number of vaccinations ; whilst others regarded it as a sign of weakness which would ultimately lead to a great decline in vaccination and a corre- sponding increase in smallpox. The event has proved that the latter view was right as regards the effect upon vaccination, but quite wrong (up to the present) as regards the effect upon smallpox.

The Minority Report

I think no one who has carefully studied it will deny that the statement of the two Dissentient Commissioners (Dr. W. J. Collins and the late Mr. J. A. Picton) of the grounds of their dissent from the Commissioners' Report constitutes a very valu- able scientific document.

It is important to note, as already mentioned in the last chapter, that the Dissentient Commissioners did not attempt to deny the " temporary antagonism " between vaccinia and smallpox, testified to by Prof. Crookshank. Although, like the latter, they were undoubtedly hostile to vaccination, and therefore classed as anti-vaccinists, it must be admitted that there is a broad distinction — from the scientific point of view — between them and those anti-vaccinists who deny this " tem- porary antagonism," and describe the alleged protective in- fluence of vaccination against smallpox as a " myth " and a " delusion."

The Dissentient Commissioners, as might be expected, drew special attention to the injuries to health caused by vaccination. As the practice of arm-to-arm vaccination was at that time still in force, they naturally emphasised the reality of the danger of vaccino-syphilis, and they quoted with approval the words of Sir Thomas Watson, who, alluding to this risk, had said : " I can readily sympathise with, and even applaud, a father who, with the presumed dread or misgiving in his mind, is willing to submit to multiplied judicial penalties rather than expose his child to the risk of an infection so ghastly."

They dealt at considerable length with the question of the means other than vaccination for diminishing the prevalence of smallpox, and laid special stress on the part played by sanita- tion. They said : " We are quite unable to agree with those

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who have maintained that sanitary measures have little or no influence upon smallpox. We have already given our reasons for thinking that the teaching of the early sanitarians, like Howard and Haygarth, towards the close of last century, initiated a new line of thought in the prevention of disease, and we be- lieve the general improvement of the public health which then set in was due, in a large measure, to a greater sanitary activity, and that the falling off in the death rate of fevers and smallpox, as well as in the general death rate, is confirmatory of this view."

I shall refer again to this part of the Minority Report in the next chapter when contrasting vaccination and sanitation.

When considering the possibility of successfully combating smallpox epidemics by means of isolation, the Minority Com- missioners refer to Sir James Simpson's views, enunciated by him in 1868 in a paper entitled " A Proposal to Stamp Out Smallpox and Other Contagious Diseases." Sir James Simpson's contention in brief was : " For all that appears necessary for the purpose is simply the methodic temporary seclusion, segrega- tion or quarantine of those affected with smallpox until they have completely passed through the disease and lost the power of infecting and injuring others. The poleaxe was the chief and leading measure required to stamp out rinderpest. Isola- tion is the chief and leading measure required to stamp out small- pox."

The Dissentient Commissioners made some very trenchant remarks in discussing the question of alterations in the law as to vaccination. They wrote :

" It is apparent from the history of legislation on this subject that the assumption underlying every amendment of the law was a strong and general belief that, if only the absolute uni- versality of efficient primary vaccination could be secured, epidemics would be prevented, and practical immunity would be secured for the whole population throughout life. On the other hand we have it in evidence that the epidemic of 1871-3 was as severe and widespread as any experienced during this century, and that in the course of this epidemic ' a very large proportion of the total smallpox deaths of adults was amongst people who had at some time or other been vaccinated.' It would seem, therefore, that there is a certain amount of dis- crepancy at the present day between the theory on which the

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compulsory law is based and the actual state both of fact and opinion. Under these circumstances it has been suggested to us that the obvious remedy is to amend the law by making re-vaccination compulsory. But though such a course might receive a good deal of support from medical opinion, the evidence we have as to the condition of public feeling shows that it would be impracticable. This condition of things can hardly be con- sidered satisfactory. The law as it stands enforces, under penalty of fine or imprisonment, a practice once thought to be an effectual preventive of epidemics and a practical safe- guard for every individual vaccinated. But this prescription of the law is now generally recognised as insufficient unless primary vaccination be supplemented by secondary or repeated vaccination. The question thus arises whether it is just or expedient to enforce at the cost of much local discontent a preventive which does not secure the end proposed, and which confessedly cannot now be supplemented by the only measures which, according to the medical opinions quoted, could make it effective.

" It cannot be denied that the law as it stands is of a very exceptional character. It is the only instance under our Con- stitution of the universal enforcement by fine and imprison- ment of a surgical operation. ... In all other cases preventive sanitary law affects only outward circumstances. ... In all such cases the social interests are so direct and predominant, and the individual claims affected are so slight or so purely mercenary . . . that the reasons for compulsion are simple and uncomplicated by any delicate question of personal rights. But compulsory vaccination goes beyond outward circumstances, and invades the integrity of the healthy body. It requires a wound, however slight, to be inflicted on every healthy infant born, and the contraction of a disease, however slight. ... It may fairly be conceded that a compulsory law of this nature requires justification different both in kind and degree from that of laws affecting ordinary nuisances.

" The case as put before Parliament in 1853 seemed exceed- ingly strong. But, unfortunately, it did not receive much discussion. It rested, as we have seen, on the practical unanimity of the medical profession in the opinion that universal, primary vaccination would extinguish smallpox. It was argued that the

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THE VACCINATION QUESTION

plague of smallpox was such as to justify exceptional measures. ... In 1853 there were few or no signs of opposition amongst the population when called upon to submit to the law. There was a general acquiescence in the assumption that the abatement of the virulence of smallpox from the commencement of the nineteenth century had been due almost entirely to the voluntary and partial adoption of vaccination. Those who neglected it were reasonably suspected of doing so from mere carelessness and indifference to the social welfare. It seemed right in the opinion of the time, therefore, that they should be compelled to adopt an apparently harmless precaution, which was believed only to need universal enforcement to secure the whole nation against a deadly disease. If these anticipations had been realised there seems no reason to doubt that the law would have continued to be enforced with little or no friction." (Sects. 276-289.)

In concluding their report, the Minority Commissioners wrote : " The whole principle of securing the protection of a community from smallpox by the artificial production of a mild disease (whether it be inoculation or vaccination) is based upon the thoroughness of the procedure in two directions : (1) in applying the inoculatory process to every individual, and (2) in securing to each individual operated upon the maximum of protection the process is capable of securing. The proposals of our col- leagues (the Majority Commissioners) appear to us to fail upon their own showing in both directions. They recognise the impossibility of securing the primary vaccination of every person, and open a means of escape for objectors. They are also not prepared to recommend that re-vaccination should be pressed in the same manner as the primary operation at a time when the vaccinated have lapsed into susceptibility to smallpox. This serves to prove that any such system must at best be a broken reed on which to rely for the protection of a community from smallpox epidemics. We believe the methods of isolation of the infected, disinfection, and the observance of strict cleanli- ness are both more effective and more legitimate methods for the State to encourage. They have the advantage of applying the preventive only where it is required ; and they do not necessitate the performance of an operation upon the person of^every healthy individual. We therefore recommend that

THE ROYAL COMMISSION

43

the law be amended by the repeal of the compulsory clauses of the Vaccination Acts." (Sects. 298-391.)

The Minority Report was signed, as already mentioned, by Dr. (now Sir William) Collins and Mr. Allanson Picton. It may well be regarded as the complement of the Majority Report, each Report representing in a moderate and scientific spirit the point of view respectively of the pro-vaccinists and the anti- vaccinists. Both Reports should be studied in conjunction with each other. I would suggest that the Majority Report attaches undue importance to the part played by infantile vaccination as a protection to the community against smallpox, and is too pessimistic as to the efficacy of isolation, etc., as a substitute for vaccination. The Minority Report, on the other hand, fails to recognise the practical value of vaccination in protecting the individual temporarily, but rightly emphasises the important part played by "sanitation" in helping to banish smallpox from the community.

CHAPTER IV

THE RELATIVE IMPORTANCE OF VACCINATION AND SANITATION

Meaning of the Word " Sanitation " : Includes Isolation, and Other Modern Measures — 'Definition of " Sanitation " given in Minority Report — 'Edwin Chadwick and Sanitation — The Experience of India — -Experience of Japan — Experience of Great Britain — Examples of Good Vaccination but Bad Sanitation: (i) Middlesbrough; (2) Warrington ; (3) Sheffield — Why not Vaccination plus Sanitation ?

In this chapter it is proposed to consider the relative import- ance of vaccination and sanitation in protecting the community from smallpox. I say "community" advisedly, because I frankly admit that sanitation, except indirectly, has little or no effect in " protecting " the individual, in the sense of conferring personal immunity. Individuals exposed to the infection of virulent smallpox will readily contract the disease, no matter how " sanitary " the conditions under which they may be living. So far as the individual who is exposed to infection is concerned " sanitation " is indeed a " broken reed " on which to lean. It would be utterly useless, for example, as a protection for small- pox nurses.

But at the same time I believe firmly in the great importance of sanitation in protecting the community. It is the failure to distinguish between the individual and the community which has been the cause of so much confusion and difference of opinion on this question of the influence of sanitation, just as we saw was the case with the question of the influence of vac- cination.

Before going further it will be well to define our terms. By " vaccination," as I am here using the word, I refer to infantile vaccination as established by law in this country. I do not refer to vaccination of smallpox staff, which is purely an administrative detail, nor to emergency vaccination. Nor do

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VACCINATION V. SANITATION

45

I refer to a repeated system of vaccination and re-vaccination as practised in Germany. The mere fact that the complete German system is effective in reducing smallpox mortality to a minimum,1 is no proof that our own incomplete system of infantile vaccination alone is of any real use, or that it may not even be productive of more harm than good. Moreover, if it should be found by experience that it is possible to obtain by sanitation alone results at least as good as those obtainable by a complete system of vaccination and re-vaccination, no impartial person can doubt as to which is the preferable and more ideal system.

As to our definition of the term " sanitation," I use this term in its very widest sense as including all those influences affecting the public health (other than infantile vaccination) over which a community has control. It therefore includes such essential measures as notification of disease, isolation, disinfection, sur- veillance of contacts, etc.2

In the Minority Report of the Royal Commission the term was used in a similar broad sense. The Dissentient Com- missioners gave the following comprehensive definition :

" In speaking of sanitation we use the word in its widest sense ; we are not speaking merely of drainage improvements, but we include the prevention of overcrowding on areas, or within houses and rooms, the proper construction of dwellings, so as to permit through ventilation, the promotion of cleanliness by adequate water supply and the prompt removal of filth accumulations. Related to these measures, but in a somewhat

1 Although the deaths from smallpox in Germany have been reduced to a minimum, it must not be assumed that the attack-rate has been reduced to quite the same extent. In a re-vaccinated community there may be many cases, which though of a mild type and very rarely proving fatal, may yet be productive of much sickness and economic loss.

2 Those who contend that " sanitation " is no safeguard against small- pox are apt to place a very narrow meaning upon the word, as though it only implied good drainage or an absence of filth nuisances. But those who rely on " sanitation " are quite entitled to use the word in its very widest sense. Nor is it unduly stretching the ordinary meaning of the term to make it include notification, isolation, and all modern measures for controlling disease. The definition of " sanitation " given in Murray's English Dictionary is, " The devising and application of means for the improvement of sanitary conditions," and the definition of " sanitary " is, "Of or pertaining to the conditions affecting health, especially with reference to cleanliness and precautions against infection."

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THE VACCINATION QUESTION

different category, are means directed against contagion, the speedy separation (in suitable hospitals) of the infected from the healthy, the disinfection of persons and things, and the prevention of the propagation of the disease by inadvertent carelessness or intentional inoculation." (Sect. 222.)

The Minority Report also quotes with approval the opinion of the great sanitary reformer, Edwin Chadwick, who main- tained " that cases of smallpox, of typhus, and of others of the ordinary epidemics, occur in the greatest proportion on common conditions of foul air from stagnant putrefaction, from bad house drainage, from sewers of deposit, from excre- ment-sodden sites, from filthy street surfaces, from impure water, and from overcrowding in private houses as well as in public institutions. . . . That the entire removal of such con- ditions by complete sanitation and improved dwellings is the effectual preventive of diseases of those species, and of ordinary as well as of extraordinary visitation."

As an illustration of the grossly insanitary conditions which prevailed in Chadwick's day I will quote the following extract from a report to the Poor Law Commissioners by Dr. Neil Arnott giving the results of an inspection he made in 1842 of the wynds of Glasgow in company with Mr. Chadwick and others.1

" We entered a dirty low passage like a house door, which led from the street through the first house to a square court immediately behind, which court . . . was occupied entirely as a dung receptacle of the most dis- gusting kind. Beyond this court, the second passage led to a second square court, occupied in the same way by its dunghill ; and from this court there was yet a third passage leading to a third court and third dungheap. There were no privies or drains there, and the dungheaps received all the filth which the swarm of wretched inhabitants could give ; and we learned that a considerable part of the rent of the houses was paid by the produce of the dungheaps. Thus, worse off than wild animals, many of which withdraw to a distance and conceal their ordure, the dwellers of these courts have converted their shame into a kind of money by which their lodging was to be paid. The interiors of these houses and their inmates correspond with the exteriors."

Three years before, Dr. Cowan had written :

" Many of the causes of the production and propagation of fever must be ascribed to the habits of our population ; to the total want of cleanliness

1 Quoted from a paper, " Vaccination or Sanitation," by J. C. McVail, published in Public Health, May 1896.

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47

among the lower orders of the community ; to the absence of ventilation in the more densely peopled districts ; and to the accumulation, for weeks and months together, of filth of every description in our public and private dunghills ; to the overcrowded state of the lodging-house resorted to by the lowest classes ; and to many other circumstances unnecessary to mention."

In 1818, Dr. R. Graham had written :

" If any man wonders at the prevalence of continued fever among the lower classes in Glasgow, or at its spreading from their habitations, let him take a walk which I did to-day with Mr. Angus, one of the district surgeons. Let him pick his steps among every species of disgusting filth, through a long alley from four to five feet wide, flanked by houses five floors high, with here and there an opening for a pool of water, from which there is no drain, and in which all the nuisances of the neighbourhood are deposited in endless succession, to float and putrefy and waste away in noxious gases. Let him look as he goes along into the cellars which open into this lane, and he will probably find lodged in alternate habitations, which are no way distinguished in their exterior, and very little by the furniture which is within them, pigs, cows, and human beings, which can scarcely be recognised till brought to the light or till the eyes of the visitant get accustomed to the smoke and gloom of the cellar in which they live."

In the light of such terribly insanitary conditions it is not surprising to learn that the mortality caused by zymotic, diseases, and especially by smallpox, was extremely high. Out of every hundred deaths from all causes about nineteen were due to smallpox. But if insanitary conditions such as are described above conduce to a high mortality from smallpox, it is surely logical to argue that the removal of such insanitary conditions will tend to reduce smallpox mortality, though the extent to which it will do so can only be decided by actual experience.

In contending for the paramount part played by " sanita- tion " in protecting a community from smallpox I do not wish to suggest that sanitation has an equal effect upon all epidemic diseases or that it acts upon all in the same manner. The effect can only be judged by experience and not a priori. It will be generally admitted that sanitation has played a great part in the abolition of such diseases as cholera, plague, and typhus fever, and that it is playing a great part at the present day in abolishing enteric fever. It will also be agreed that hitherto it has had comparatively little effect upon such diseases as measles and whooping-cough. Its effect upon scarlet fever may be a matter of some doubt, but I think it is reasonable to claim the

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reduced severity of the disease as, to some extent, the result of sanitation.

As regards smallpox, I cannot help thinking that there would have been much more readiness to give credit to sanitation for the great reduction in mortality which has been such a striking phenomenon during the past forty years, had it not been for the fear that such an admission would have detracted from the credit of vaccination.

There are two reasons why the part played by sanitation in the prevention of smallpox has not hitherto been more fully recognised :

(a) The narrow and restricted sense in which the term " sanita- tion " has been often used, as meaning little more than improved drainage, etc.

(b) The tendency to consider the case of the individual rather than that of the community. As we have already pointed out, sanitation can have but little direct effect upon the individual.

I would suggest that " sanitation " protects the community in two different ways, (i) By reducing the virulence of the infection. The exact modus operandi of this must at present be largely a matter of speculation, but it seems to me as reasonable to believe that overcrowding, filth (both personal and municipal), poverty, a low standard of living, and insanitary conditions generally may "generate" a severe and malignant type of smallpox as it is commonly believed they do in the case of typhus fever. There can be little doubt that there is some foundation of truth for the popular belief that insanitary con- ditions such as I have referred to will " breed a fever."

(2) But " sanitation " may also protect the community by so reducing the opportunities for infection that the disease cannot reproduce itself and so dies out. If we reflect, we must admit that this is really the way in which sanitation is causing enteric fever to die out. The infection of enteric fever is spread very largely, as we know, by means of infected water, infected shell- fish, etc. By abolishing the channels of infection, " sanitation " is preventing the disease.

Similarly, in the case of malaria. Sanitation, by destroying the channel of infection (mosquitoes), is preventing the disease. So also with plague. By destroying the channel of infection (rats), sanitation is preventing the disease. In certain other

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49

diseases we are still ignorant of the principal channels of infection, and in these cases it is not surprising that sanitation has not hitherto been very successful. But in the case of smallpox We are justified in saying that the principal channel of infection is direct personal infection.1

The Effect of Isolation in Smallpox and Other Diseases

We should expect then, a priori, in this disease that isolation would be very effective, and this is just what we find to be the case. I say, without fear of contradiction, that in no other epidemic disease met with in this country is isolation so effective as in smallpox. Indeed, it was the remarkable success which attended the isolation of smallpox in hospital (in spite of the faulty manner in which at first it was carried out) which estab- lished the reputation of isolation hospitals.2 This is made quite clear by a perusal of the Report on " The Use and Influence of Hospitals for Infectious Diseases " published by the Local Government Board in 1882.

One reason why hospital isolation is so much more effective in the case of smallpox than with other diseases lies in the fact that smallpox is very little, if at all, infectious before the appear- ance of the eruption, which is so characteristic (in an unmodified attack) that it can scarcely be overlooked. Moreover, the onset of the attack is sudden and severe, so that before the eruption appears the patient almost always has to take to his bed. Ex- perience shows that where the first case in a house is promptly removed to hospital, the danger to the other inmates is not very great. Moreover, even though other members of a house- hold have already been infected, it is still possible to protect them by vaccination. This vaccination of " contacts " is undoubtedly very valuable, and adds considerably to the effec- tiveness of hospital isolation. With a disease like scarlet fever,

1 We may exclude for the moment the very important question of "aerial" infection.

2 Personally, I believe that, in the case of scarlet fever, hospital isolation has been a failure, but it was the undoubted success of the measure in the case of smallpox that led to such sanguine hopes being entertained as to what its effect would be if extended to scarlet fever. See also an article by the writer on " The Influence of Hospital Isolation in Scarlet Fever," published in Public Health, April 1908.

4

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THE VACCINATION QUESTION

on the other hand, it only too frequently happens that where there are other susceptible persons in a house they will contract the disease in spite of prompt removal of the first case to hospital. Again, in scarlet fever any benefit gained whilst the patient is in hospital is neutralised by the tendency of many scarlet-fever patients to remain infectious for long periods and to carry the infection (possibly of a specially virulent type) home with them. The " return case " has long been recognised as one of the weak points in hospital isolation of this disease. But in smallpox, " return cases " are practically unknown. Although the disease is so highly infectious, and the infection so active whilst it persists, it appears to retain its vitality, under ordinary conditions, only for a short period.

Or let us consider the case of measles. The failure of notifica- tion and isolation to control measles is fully recognised, and this failure has sometimes been quoted as a reason why we should not trust to the same measures in the case of smallpox, which in certain respects resembles measles. But there is an all- important characteristic of measles which quite accounts for our failure to control it. In place of having the sudden and severe onset, which is such a help in the case of smallpox, the onset of measles is most insidious, so that it is difficult to say when it actually begins. Moreover, experience shows that the patient is highly infectious from the beginning and before the rash appears. In the meantime the patient is going about, attending school, etc., and spreading infection broadcast. In smallpox we only get a condition at all approaching this when we have to deal with the highly modified form of the disease met with in vaccinated subjects. In measles, therefore, hospital isolation is foredoomed to failure.

The Experience of India

The Minority Commissioners gave some remarkable quotations from official reports on India, emphasising the difficulty of con- trolling smallpox by vaccination without sanitation. In the Report on Sanitary Measures in India, 1879-80, (p. 142) it was stated :

" The vaccination returns throughout India show the same fact, that the number of vaccinations does not necessarily bear

VACCINATION V. SANITATION

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a ratio to the smallpox deaths. Smallpox in India is related to season and also to epidemic prevalence : it is not a disease, therefore, that can be controlled by vaccination in the sense that vaccination is a specific against it. As an endemic and epidemic disease it must be dealt with by sanitary measures, and if these are neglected, smallpox is certain to increase in epidemic times."

Again, in the Report of the Army Commission of the Punjab for 1879 (p. 186) : " Vaccination in the Punjab, as elsewhere in India, has no power, apparently, over the course of an epidemic. It may modify it and diminish the number of fatal cases, but the whole Indian experience points in one direction, and this is that the severity of a smallpox epidemic is more closely con- nected with sanitary defects, which intensify the activity of other epidemic diseases than is usually imagined, and that to the general sanitary improvement of towns and villages must we look for the mitigation of smallpox as of cholera and fever."

They also quoted from the Report for the Central Provinces (p. 206) : " The past comparative immunity of the population had been attributed to efficient vaccination, and the people had accepted this protection, but their confidence has been shaken by the reappearance of a severe form of this disease. ..."

Also from the Report for 1884-5 (p. 203), referring to the Sanitary Measures of the North- West Provinces and Oudh, where it is noted : " The facts already stated show conclusively that the smallpox of 1884 was one of the most severe epidemics on record, and by far the most severe in these provinces since deaths were registered. We are thus brought face to face with the fact that, notwithstanding the existence of an active vaccina- tion service, smallpox swept over the provinces just as if there had been none. No doubt attacks and deaths had been pre- vented by the service, but it is clear that it has been incompetent to deal with the disease in its epidemic form. . . . These remarks are not intended to call in question the utility of vaccination. But in the presence of the facts the question is a perfectly relevant one, namely, whether dependence can henceforth be placed on vaccination as a protection against a smallpox epidemic ? The question of course answers itself. In ordinary years lives are no doubt saved. . . . But this and similar experience appears to show that the remedies . . . will have to

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THE VACCINATION QUESTION

be extended beyond vaccination, and will have to deal with epidemic causes affecting localities and their inhabitants. If sanitary work be neglected no more dependence against smallpox epidemics can be placed on vaccination than can be placed on quarantine against invasions of cholera. The true remedies lie elsewhere altogether." 1

The Experience of Japan

Japan is a country in which for a number of years vaccination has been carried out very thoroughly. At the same time it is probable that, being a very "young" country so far as modern science is concerned, she has not yet had time to arrive at any- thing like the condition of sanitary efficiency obtaining in this country. The result is instructive. In spite of a very great deal of vaccination, smallpox is still able to cause extensive and very fatal epidemics.

An official bulletin has been recently issued by the Statistical Department of the Commonwealth of Australia 2 from which the following quotations are taken :

" Occurrences of Smallpox in Japan

" That smallpox may become epidemic not only when vaccina- tion is restricted, but also in spite of vaccination, re- vaccination, and further ' extraordinary ' vaccination, is shown by comparing statistics of England and Wales and Japan in Tables VIII. and IX. and VII. Compulsory vaccination was instituted in Japan in 1876, and was rigorously enforced throughout the country by Imperial Ordinance No. 34, issued in Nov. 1885. This requires vaccination every five to seven years. The last ordinance was repealed by that of April 14th, 1909, which requires that every child shall be vaccinated before the June of the year following

1 At the same time, in order to prevent misunderstanding, I wish to make it quite clear that I consider that so long as " sanitation " remains in so backward a condition in India, and smallpox in consequence remains so prevalent, every one going to India w ill be well advised to protect him- self against the disease by vaccination and re-vaccination.

2 Appendix to Monthly Summary of Australian Statistics, Bulletin No. 18, June 191 3 : " Statistics of Smallpox and Vaccination in Australia and Other Countries." Published under the authority of the Minister for Home Affairs, by G. H. Knibbs, C.M.G., Commonwealth Statistician.

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its birth ; if unsuccessful, vaccination must be effected before December of the following year. These provisions are said to be rigorously enforced. The following Table shows that Japan is still subject to well-marked smallpox epidemics. The table shows the varying percentage of deaths . . . the range being from 2 per cent, to 41 \ per cent., and averaging 30 per cent."

Tables are then given showing the number of successful vaccinations and the number of smallpox cases and deaths in recent years. From these it appears that during the fifteen years, 1895-1909, there were 19,000,000 first vaccinations, nearly 13,000,000 re- vaccinations, and 8,000,000 " extraordinary" vaccinations. This is exclusive of unsuccessful vaccinations. Yet, in spite of this great amount of vaccination, it appears that during the fifteen years, 1896-1910, there were 80,000 cases of smallpox and 23,000 deaths. The great majority of these cases occurred in two epidemics. The epidemic of 1896-7 accounted for 53,000 cases with 15,000 deaths, and that of 1907-8 for 19,000 cases with 6,000 deaths. The very high proportion of deaths is remarkable, but as regards the first epidemic it must be admitted that it occurred too soon after compulsory vaccina- tion began to be enforced (1885) to require much explanation. The last epidemic, however, with its equally high case mortality, is certainly rather surprising, and must have been a great disappointment to the vaccination authorities.1 However, if Japan continues her vaccinating campaign long enough and is able to carry it out sufficiently thoroughly, no doubt she will cease to have fatal smallpox epidemics, and will obtain results as good as those obtained in Germany by a similar method. Whether she is yet advanced enough in " sanitation " to safely abandon vaccination and trust to sanitation alone, I cannot say, as I know nothing of the conditions obtaining in Japan or of the behaviour of smallpox in that country. But I think it is at least probable that if she continues to make as rapid progress in sanitary science as she has made in other fields of Western know- ledge, the time will come before long when she will be able to dispense with all this vaccination and re-vaccination, with its

1 At the same time, I have little doubt that if the necessary informa- tion were available we should find that the great majority of the cases which proved fatal were in persons who were either unvaccinated or not re vaccinated.

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THE VACCINATION QUESTION

attendant dangers and injury to health, and trust rather to sanitation.

The Experience of the United Kingdom

I propose to illustrate the relative importance of vaccination and sanitation in the United Kingdom by quoting the experi- ence of towns in which vaccination was efficiently carried out but " sanitation " was neglected. I shall take as examples of such towns :

x. Middlesbrough.

2. Warrington.

3. Sheffield.

All three of these towns have suffered from extensive and fatal epidemics in spite of their well-vaccinated condition. In later chapters we shall consider the experience of a compara- tively un- vaccinated town (Leicester), where sanitation has been comparatively well attended to, and we shall find that, in spite of the neglect of vaccination, smallpox has caused but little mortality. We shall also consider the case of towns (Gloucester and Dewsbury) where both vaccination and sanitation have been neglected, and where the result was disastrous.

1. The Case of Middlesbrough

The Middlesbrough epidemic of 1897-8 was a very interesting one, and it was unfortunate that it occurred just too late to be of value to the Royal Commission.

Middlesbrough was a particularly well- vaccinated town. From a vaccination census which he caused to be taken, the Medical Officer of Health, Dr. Dingle, estimated the proportion of un- vaccinated persons in the population to be only about 2 per cent. In other words, the Vaccination Acts had been carried out as effectively as we can ever expect them to be. The town had grown with extraordinary rapidity, the population in 1851 being only 7,000, whilst in 1897 it was 90,000. As often happens in such cases, its sanitary condition was most unsatisfactory, and the public health organisation far from adequate. Dr. Dingle 1 said that " Middlesbrough might without much fear of contradiction be termed the ' home of epidemics,' for during the past ten years

1 In a paper published in Public Health, December 1898.

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it has gone through epidemics of nearly all the principal zymotic diseases. There had been very serious epidemics of infectious pneumonia, enteric fever, scarlet fever, and now of smallpox. How far these epidemics have been due to such local causes as damp, sewage-polluted ground, defects in construction of sewers, defects in excrement disposal, overcrowding, and the dirty habits of a portion of the inhabitants, I am not in a position to say ; but from recent experience I have found an utter carelessness on the part of the working classes to protect themselves against infection, or to adopt the most elementary rules of sanitation, such as cleanliness or fresh air."

As regards preparedness for dealing with smallpox apart from the vaccinal condition of the population, we are told that Middles- brough had no separate smallpox hospital, but at the general infectious-diseases hospital a small block containing 14 beds was set aside for smallpox, this block being only 10 or 15 yards away from the main building. Even by emptying the whole hospital and using it for smallpox alone, as was done when the epidemic occurred, accommodation could only be provided to the extent of 60 beds. The epidemic began early in 1897, and by February 6th the 60 beds became exhausted. It was not until March 3rd that there was sufficient accommodation to isolate all the cases, and in the meanwhile only the worst cases as regards surroundings were removed, about 129 cases being left to be dealt with at home. The work of erecting new buildings was pushed on day and night, and eventually provision was made for no less than 822 beds ! Altogether the epidemic gave rise to 1,411 cases, and as proving — if proof be needed — that it was not the neglect of infantile vaccination which was responsible for this serious epidemic, I may mention that no less than 1,213 of these cases, or 86 per cent., had been vaccinated. Yet if Middlesbrough had happened to be a badly vaccinated town, like Gloucester or Dewsbury, it is probable that the neglect of vacci- nation would have been regarded as the cause of the epidemic.

As a matter of fact, much the same influences were at work in all these towns, especially the inadequate hospital accom- modation, spread of the disease from the hospital, inability to isolate all the cases, and finally a complete breakdown in isola- tion. In each case resort had to be made ultimately to general vaccination of the population, and this, no doubt, largely con-

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THE VACCINATION QUESTION

duced to arresting the epidemic. Fortunately there is always this measure to fall back upon if an epidemic really gets out of hand, but it should be regarded as evidence of failure, and with proper care and management it should very rarely, if ever, be called for.

Of course, where an epidemic is allowed to become an un- checked " conflagration," as was for a time the case at Middles- brough, the mortality will be greater in proportion to the number of un- vaccinated persons in the population.1 But as showing how futile infantile vaccination alone is to prevent death from smallpox we have the fact that in well-vaccinated Middlesbrough no less than 108 vaccinated persons lost their lives in this one epidemic ! Against this we can set the fact that in un-vaccinated Leicester, with more than double the population, the total number of deaths, amongst both vaccinated and un-vaccinated persons, during the past 40 years (i.e. since the dawn of the sanitary era) has only been 69 ! Even if we

1 It is probably an erroneous, though common, assumption to suppose that if all the patients in an epidemic were unvaccinated, the same high fatality rate would occur which has been so often observed amongst the unvaccinated class in epidemics in which the great majority of the patients are vaccinated. It is almost invariably the case that there is a very great difference between the fatality of smallpox in the once- vaccinated and the unvaccinated classes, and this fact has repeatedly been urged as demon- strating the great advantage of infantile vaccination. It constitutes, indeed, one of the " stock " pro-vaccinist arguments.

I am doubtful whether the argument is quite so convincing as is generally supposed. I will set aside for the present the question, to be discussed later, whether it might not be easier under modern conditions to control a smallpox epidemic in a population entirely unvaccinated, and will assume that the same number of cases would occur. I suggest then that it is not safe to assume that the same high fatality (case mortality) would obtain as is so often found when only a very small proportion of the total cases occurring are unvaccinated. In such epidemics it is not unusual for the unvaccinated to show a case mortality of 30 to 50 per cent.

Thus in the Sheffield epidemic, 1887-8, the unvaccinated fatality was 49"6 per cent.; in the Warrington epidemic, 1892, it was 3 5 '3 ; in the Middlesbrough epidemic, 1897-8, it was 47-4. It is difficult to believe that in pre- vaccination times such terribly high fatality rates frequently occurred, otherwise the mortality from smallpox would have been much higher than it was in view of the prevalence of the disease. It is not easy to explain these high fatalities in the small unvaccinated remnant, but no doubt there is something in the anti-vaccinist contention that the un- vaccinated residue in a vaccinated community are as a class physically inferior to the vaccinated portion of the population.

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compare cases only, ignoring the deaths, we find that in Middles- brough in this single epidemic there were 1,213 cases in vaccin- ated persons alone, whilst in Leicester in 40 years there have been only 1,227 cases, including both vaccinated and un- vaccin- ated ! One has to admit that, after all, there may be something in the anti-vaccinists' contention that it is better to rely upon efficient " sanitation " than upon infantile vaccination.

2. The Case of Warrington

Warrington was one of the towns which suffered severely from smallpox in 1892-3, when the disease was prevalent throughout the country, and the epidemic of those years was specially reported upon by Dr. Savill for the Royal Commission. In a population of 54,000 persons 667 cases occurred, of which 62 proved fatal. Ten years later the Medical Officer of Health, Dr. J. G. Gornall, in his Annual Report for 1903, referring to smallpox, remarks: "Warrington is now in a peculiarly favourable position with regard to smallpox ; having on the one hand a hospital two miles outside the town, in a sparsely populated district, and on the other hand a well-vaccinated population" (italics added).

I cannot help observing that this suggestion that Warrington is now in a peculiarly favourable position because it has a well- vaccinated population seems rather strange, and, to say the least, uncalled for. The uninitiated might reasonably conclude that at the time of the serious epidemic referred to, the vaccinal condition of the town was at fault. But any one familiar with the report of the Royal Commission on Vaccination will know that Warrington, like Middlesbrough, was one of the well- vaccinated towns of the country. The proportion of persons who had been vaccinated was unusually high. Dr. Savill found that the Vaccination Acts had been so thoroughly carried out at Warrington, prior to the epidemic, that no less than 99^2 per cent, of the population, according to his census, were vaccinated.1

1 Dr. Savill writes : " Turning to the subject of Primary Vaccination, it might perhaps, at first sight, be a matter of surprise that a comparatively well-vaccinated town like Warrington should have been the scene of such a severe epidemic of smallpox. I estimated that nearly 99/2 per cent, of the inhabitants had been vaccinated once in their lives before the outbreak " (Final Report, R.C.V., Appendix V., p. 5).

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On the other hand, he says : " It will be gathered from the foregoing narrative that insufficient or imperfect isolation was an extremely important factor. . . . This was owing, in some instances, at the commencement, to a non-recognition of certain cases by a doctor's assistant,1 but it was also due in a much

1 Dr. Savill also writes : "As regards the immediate causes which led to this outbreak, the evidence seems to show that the three leading factors in the causation of the Warrington epidemic, 1892-3, were as follows:

1. " Non-recognition of three of the earlier cases, viz. the 2nd, 3rd, and 4th persons who developed the smallpox eruption in August. They were seen by a doctor's assistant (alleged to be qualified) acting in the absence of his principal. Two of them, though apparently well-marked types of smallpox, were treated at home by him as ' German measles ' for ten and seven days respectively ; meanwhile the visits of friends and neighbours were unrestricted ; and their relatives went to work as usual, or played daily with other children in the adjacent streets or open spaces back and front of the house in that row. Finally the Medical Officer of Health, hearing rumours of these cases, visited them, and they were promptly removed to hospital, where one of them, the un-vaccinated child, at. 10, died three days later. Three of the children of the older case contracted the disease, and altogether twenty-three cases resulted in their immediate neighbourhood . . . The third unrecognised case was a mild one, and altogether escaped detection and isolation. This man gave the disease to his wife and an indefinite number of other persons."

2. " Deficient hospital accommodation for the isolation of smallpox and other infectious diseases. Sixty-four beds represent the minimum require- ments of the Borough of Warrington based on the number of cases of infectious diseases needing isolation which have actually arisen and were notified in the community during the four years 1889-1892 ; and the total provision at the commencement of the epidemic was thirty beds for all diseases, or less than half the very lowest estimate. ... As a con- sequence of this only thirteen cases of smallpox could be received into the Borough Fever Hospital by dangerously overcrowding every available space. The cases therefore, about sixty in number, which arose between August 25 th and September 19th, when additional temporary hospital pro- vision was made, were of necessity left in their own homes scattered over the town. Consequently the town became so saturated with infection, and the cases arose so rapidly that the limit of hospital accommodation, even with the additional 159 beds crowded into the temporary hospital, was, for a second time, reached early in November, and large numbers again had to be left in their homes."

3. " Deficiency of re-vaccination among the inhabitants before this outbreak. My inquiries in a typical district . . . revealed the fact that only 27 per cent, of the inhabitants had been re-vaccinated prior to the epidemic. ..."

(In view of the fact that there is not a town in the whole country of which it could not be equally said that re-vaccination was deficient, this last- mentioned " cause " seems rather far-fetched. — C. K. M.)

VACCINATION V. SANITATION

59

larger degree to an absence of ordinary hospital accommodation for the reception and isolation of the patients as soon as they were attacked and identified. The sanitary authority had neglected to act on the recommendation of their Medical Officer of Health in this matter of hospital provision. . . . It is rendered evident by a close examination of the facts of the epidemic that if the town of Warrington had possessed adequate hospital accom- modation for infectious diseases, the epidemic would probably have never reached the dimensions it did, and the disease would in all probability have been limited to a few cases in certain quarters of the town" (italics added).

As a matter of fact, at the commencement of the epidemic the total provision for the hospital isolation of all infectious dis- eases was only thirty beds, and as a consequence of this we are told that " only thirteen cases of smallpox could be received into the Borough Fever Hospital, by dangerously overcrowding every available space."

Moreover, the hospital was situated in a rather thickly populated part of the town. In May, 1892, the Medical Officer of Health had reported that " there was very great danger in treating smallpox in close proximity to a populous neighbour- hood . . . and two full wards of scarlet fever in our own grounds."

Owing to deficient hospital accommodation, 91 cases were left at home, either altogether or for periods varying from 2 to 22 days after the appearance of the rash. Dr. Savill traced 410 cases to lack of hospital accommodation at the time these cases had to be left at home. As regards the influence of the crowded hospitals (other hospitals were opened as the epidemic advanced) upon the surrounding neighbourhood, Dr. Gornall states : " I do not think there can be any doubt that these places (the hospitals) have been centres of infection to the surrounding populations." 1

Under all these circumstances I think we can agree with Dr. Savill that " it is not to be wondered at that on this account the smallpox epidemic of 1892-3 reached the alarming proportions which it did."

1 Dr. Savill also wrote : " A larger number of cases arose, at first, in the neighbourhood of the Old Borough Fever Hospital when smallpox cases were there admitted. Subsequently, a temporary smallpox Hospital was provided in the northern part of the town, and then an undue pro- portion of houses became infected in its neighbourhood."

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THE VACCINATION QUESTION

3. The Case of Sheffield

Sheffield was another town in which vaccination had been well carried out, but in which " sanitation " — so far at least as notification and isolation were concerned — had been neglected.

The following is taken from the Final Report of the R.C.V. (Sect. 487) :

" At Sheffield, during the epidemic of 1887-8, there was no compulsory notification, though a voluntary system of notifica- tion by medical men had been in vogue since 1885. Only one- fourth of the thirty-two cases of smallpox known to have occurred during the first three months of the epidemic were thus notified. Though the proportion of notified cases increased as the epidemic progressed, it is evident that during the most important period the system must be regarded as having failed. The borough hospital in Winter Street, which for a considerable period was the only hospital in use, did not provide adequate accommoda- tion for patients, and became overcrowded ; moreover, being in proximity to a densely populated area, it became the means of spreading the disease. Cases of smallpox were accordingly treated in buildings or huts in connection with the Sheffield and Eccleshall Unions' Workhouses, and the disease spread to inmates of the workhouses. Nevertheless, evidence is forth- coming from Sheffield of the great advantage to individual households of early removal of first cases. Dr. Barry says :

" ' The advantages arising to individual households from the early removal of smallpox cases to hospital were clearly seen in the earlier months of the epidemic. From its commencement to the middle of July, during which period, with comparatively few exceptions, all cases of smallpox which came to the knowledge of the Health Department were at once removed to hospital, it was exceptional to have a recurrence of the disease in the same household. After the middle of July, in consequence of the inefficiency of hospital accommodation, a large and increasing proportion of smallpox cases had to be treated in their own homes, and multiple cases in families became of frequent occur- rence. . . .' "

" The experience gained in 1887-8 has borne fruit ; in 1889 Sheffield adopted the Compulsory Notification Act, and when smallpox broke out there in 1892-3 all cases were promptly

VACCINATION V. SANITATION

61

removed to the new hospital at Lodge Moor, four miles from the centre of the town and in an isolated position. So convinced is the medical officer of the need for isolating those attacked that he is in favour of insisting on removal in any case.

" Sheffield had obeyed the Vaccination laws better even than the average of large towns. Had there been prompt removal of first cases to adequate and suitable hospital accommodation in 1887, it is in the highest degree improbable that the disease would have run riot as it did. It is important to notice that the rapid spread of the disease at the commencement of the epidemic in 1887-8 seems to have been due to the fact that some of the early cases were of so mild a character that they passed unobserved." (Italics have been added.)

We may well contrast with the above the statement made by the Medical Officer of Health for Sheffield seven years later. In his Annual Report for 1903 (p. 26), he writes : " During the whole of the year 1903 Sheffield continued to suffer from impor- tations of the disease from outside districts, and in none of these instances did the disease spread. Indeed, with our means of dealing with this infection — re-vaccination, isolation, and general supervision — it has come to be regarded by the staff as the infectious disease which is of all others the most satisfactory to deal with, as by vigilance and the proper use of the means at our disposal it is not a difficult matter, in the majority of instances, to prevent its spread" (italics added).

Vaccination plus Sanitation

It may reasonably be urged that whilst the facts we have been considering above make it evident that infantile vaccination as provided by law is inadequate, without " sanitation," to safe- guard a community against smallpox, they constitute no argu- ment against the principle of trusting to infantile vaccination plus sanitation. If we believe in both " sanitation " and vaccina- tion separately, why not combine the two, and so, presumably, obtain the advantage of both ?

Whilst at first sight such a proposition seems plausible, there are certain considerations which put a different complexion upon it.

(1) If it can be shown that " sanitation," thoroughly carried

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out, is alone sufficient for the effective control of smallpox in this country, why inflict upon the community universal vaccina- tion with all its inseparable drawbacks ? Moreover, what justification can there be any longer for compulsion ?

(2) It has to be considered whether infantile vaccination — and especially the present incomplete system of infantile vac- cination under which a large proportion of the community remain un- vaccinated — may not be an actual hindrance to " sanita- tion " ? In the next two chapters I shall adduce evidence to show that infantile vaccination in mitigating smallpox also masks it, and thereby positively tends to encourage the spread of infection. Assuming for the moment that this is the case, the suggestion that infantile vaccination may be a hindrance to " sanitation " is obviously quite a reasonable one.

CHAPTER V

THE TENDENCY OF VACCINATION TO SPREAD SMALLPOX BY MASKING THE DISEASE

This Aspect of the Question hitherto Overlooked — In Mitigating Small- pox Vaccination also Masks the Disease — Apparent " Mildness " of Smallpox Modified by Vaccination is not Transmitted (being an Acquired Character) — Authoritative Opinions as to the Role of the Unrecognised Case: J. Niven ; A. K. Chalmers; G. F. McCleary; W. E. Armstrong ; Ernest Hart — Frank Admissions : P. Boobbyer ; Ricketts and Byles ; J. H. C. Dalton— Unrecognised Cases in the Un- vaccinated — Experience of Individual Towns — Leicester.

I now propose to consider somewhat fully an aspect of the vaccination question which, hitherto, has received but little attention. I refer to the tendency of vaccination to spread smallpox through its effect in modifying and at the same time masking the disease.

This tendency, though no doubt always existent, only attained its present importance since notification, isolation, and other modern measures came into active operation. Probably this accounts for the otherwise surprising fact that this aspect of the question was entirely ignored by the Royal Commission, so far at least as the Majority Report was concerned ; and it was only casually referred to in the Minority Report.

Another reason why so little has hitherto been heard about this serious drawback to the practice of infantile vaccination is that anti-vaccinists, by a strange irony, are debarred from making use of this argument against vaccination ! This is owing to the fact that the use of it involves the admission that vaccination does indeed modify smallpox, which hitherto they have strenuously denied.

Any one familiar with the history of smallpox in recent years is aware how frequently outbreaks arise through unrecognised cases of the disease occurring in persons who had been vaccin-

63

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ated many years ago. Such cases are often of a very trivial character, so far at least as the actual illness is concerned. The person attacked is only slightly ill and quickly recovers, whilst the eruption — so characteristic in persons who have never been vaccinated — is very sparse and highly modified. So much is this the case that the diagnosis of smallpox becomes extremely difficult, especially for those who have not had much experience of the disease. It is well known that the great majority of the mistakes in diagnosis made by medical men in connection with smallpox occur with this type of case. The disease may easily be mistaken for chickenpox, impetigo, acne, scabies, " pimples," rupia, etc. Moreover, since the constitutional symptoms quickly disappear as soon as the " spots " come out, it not infrequently happens that the patient thinks it unnecessary to consult a doctor, and returns to work after a few days at home. It may be observed that in the case of un-vaccinated patients it is extremely rare for no doctor to be called in, and with the greater facilities arising as a consequence of the National Insurance Act it will become still more rare in the future.

I have said that these cases are trivial in character. This is true so far as the particular individual attacked is concerned, but from the point of view of the community they are highly dangerous. Owing to the cases not being reported to the authorities, no precautions are taken, and it is only at the end of a fortnight or three weeks, when further cases develop from them, that the mischief is discovered. It may be too late then to prevent a serious outbreak. Moreover, although the cases appear to be of such a very mild type, they are not naturally mild. The mildness is only an " acquired " characteristic, due to the individual having been vaccinated. Consequently the mildness is not transmitted. It has often been noted that these cases do not " breed true," and if the infection happens to be given to an unprotected person — either one who has never been vaccinated, or one in whom the protection conferred by vaccina- tion has entirely worn out — it frequently causes a very severe and possibly fatal attack.

It is true that these mild unrecognised cases are probably not so infectious, other things being equal, as severe unmodified cases, but other things are not equal. Severe cases which are promptly recognised and at once removed to hospital, as is always the

Plate II

{Photo by the Author.)

UNMODIFIED SMALLPOX. Unmodified smallpox occurring in an im-vaccinated man, aged 30. This type of smallpox is highly characteristic and is usually very easy to diagnose.

04]

Plate III

(Photo by the Author.)

SMALLPOX MODIFIED BY VACCINATION. Smallpox in a vaccinated youth, age:l 17. This type of smallpox is very indefinite and easily escapes recognition. Disastrous spread of the disease in a fatal form has often been traced to such " mild " cases.

64]

Plate

(Photo by the Author.)

SMALLPOX IN A VACCINATED CHILD. Smallpox in a vaccinated child, aged 5. In this case there were only about half a dozen " spots " and the child was never really ill. Such a case might easily go about and attend school without the true nature of the disease being recognised, in which event a serious outbreak might result. These cases are highly dangerous to other persons.

64]

Plate VI

(Photo by Allan Warner, M.D., D.P.H.)

WHICH IS THE GREATER DANGER TO THE COMMUNITY ? Two lads, each aged 16, infected from the same source, on the same day. One was vac- cinated, the other un-vaccinated. The latter had a well-marked attack which could not fail to be recognised. The former — the vaccinated case — had such a " mild and trilling " attack that it might easily have escaped recognition and in consequence have been the cause of a

serious outbreak.

TENDENCY TO SPREAD SMALLPOX 65

practice now, have no opportunities for spreading infection however infectious they may be, whilst these unrecognised cases, though admittedly less infectious, often have unlimited opportunities for spreading infection broadcast.1 I shall show presently that this is what frequently happens. It would seem, indeed, that vaccination, by its very success in mitigating small- pox, largely defeats what is now our principal object, viz. that of preventing the spread of the disease.2

1 It has long been realised that it is the unrecognised rather than the recognised cases in an epidemic which are the greater danger so far as spreading infection is concerned. Defoe pointedly emphasised the fact in his Journal of the Plague Year, written nearly 200 years ago. He wrote :

" Here also I ought to leave a further remark for the use of posterity, concerning the manner of people's infecting one another ; namely, that it was not the sick people only from whom the plague was immediately re- ceived by others that were sound, but the well. To explain myself, by the sick people I mean those who were known to be sick, had taken their beds, had been under cure, or had swellings or tumours upon them, and the like ; these everybody could beware of ; they were either in their beds or in such condition as could not be concealed.

" By the well I mean such as had received the contagion, and had it really upon them, or in their blood, yet did not show the consequences of it in their countenances ; nay, even were not sensible of it themselves. . . . These breathed death in every place, and upon everybody who came near them ; nay their very clothes retained the infection, their hands would infect the things they touched. . . .

" Now it was impossible to know these people, nor did they sometimes, as I have said, know themselves to be infected. . . . These were the dangerous people of whom the well people ought to have been afraid ; but then, on the other side, it was impossible to know them.

" And this is the reason why it is impossible in a visitation to prevent the spreading of the plague by the utmost human vigilance, viz. that it is im- possible to know the infected people from the sound, or that the infected people should perfectly know themselves " [Everyman' s Library Edition, p. 219).

It may be observed in reference to the above that fortunately in the case of smallpox the disease, in the vast majority of cases, is very easily recognised. In no other infectious disease are the " tokens," as Defoe calls them — i.e. the outward manifestations — of the disease so characteristic and easily discerned. This, however, is only true so far as smallpox un- modified by vaccination is concerned. When we come to deal with post- vaccinal smallpox the disease is often so highly modified that its recognition, in place of being easy, becomes extremely difficult, and the patients them- selves, although perhaps highly infectious, may not even know that they are ill.

2 Illustrations of modified and un-modified smallpox occurring in vaccinated and un-vaccinated subjects are shown in Plates II — VI

5

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THE VACCINATION QUESTION

We will now see how far the testimony of others supports this contention.

The great importance of the role played by the " missed " or unrecognised case of smallpox at the present day is fully recog- nised. Almost every smallpox report refers to it and affords striking examples.

A few authoritative opinions may be quoted :

Dr. J. Niven, M.O.H. for Manchester : " It is not too much to say that by far the most important factor in the spread of smallpox in Manchester has been the overlooking of cases. . . ." {Health Report, 1902.)

"The overlooking of mild cases was the chief cause of the spread of the disease. . . . The attack as a rule was so mild that no medical advice was sought, or, as happened in not a few instances, was not recognised as smallpox by the medical attendant. In fact this matter is of so much importance that it is not too much to say that if there had been no case overlooked, there would have been practically no smallpox outbreak in Manchester" [Health Report, 1903).

Dr. A. K. Chalmers, M.O.H. for Glasgow: "As in past out- breaks, we are again finding that one of the greatest obstacles to effectively coping with the disease is the occurrence of an extremely mild and modified form, which escapes recognition until, as a result, secondary cases of a graver nature arise" {Smallpox Report, 1900-2).

Dr. G. F. McCleary, formerly M.O.H. for Battersea (now Medical Adviser to the National Health Insurance Commission, England) : " The spread of the disease was very largely due to unrecognised or concealed cases. This is the usual experience, and constitutes the chief difficulty in dealing with an outbreak of smallpox. In some cases the disease was of so mild a type that the patient thought he had merely caught a ' heavy cold ' and, not troubling to see a doctor, went about his work after a few days at home, as if nothing had happened" {Annual Report for Battersea, 1902, p. 77).

Dr. W. E. Armstrong, late M.O.H. for Newcastle-on-Tyne : " With respect to the more positive means by which the spread of smallpox has been favoured, probably the failure to recognise the disease in its mildest forms is entitled to first place. A large number of localised outbreaks have been traced back to such mild

TENDENCY TO SPREAD SMALLPOX 67

unsuspected cases, where persons affected had for weeks been going about in a highly infectious state" [Smallpox Report, i903-5) •

Having established, I think, the great danger of unrecognised cases, I will proceed to show that these usually occur in persons who have been vaccinated, and because they have been vac- cinated.

It should hardly be necessary to insist upon the effect of vac- cination in modifying smallpox after its power to protect against attack has worn out. The " mitigating" effect of vaccination has been constantly insisted upon as one of its (supposed) great advantages.

Thus, the late Mr. Ernest Hart, editor of The British Medical Journal, and a recognised authority on vaccination, wrote 1 : " But it should be borne in mind that in those cases in which smallpox occurs after vaccination the disease is, almost without exception,2 so far modified that its identity in its earliest stages is frequently unrecognised. ... In Blackburn, the Medical Officer of Health met with a number of cases of smallpox in vaccinated persons where the disease was so far modified that the patients went about their work without being aware of the nature of the illness that was upon them."

The Medical Officer of Health for Carlisle, in his Annual Report for 1903 (p. 27), writes : " A very remarkable and important feature of the outbreak was the extreme mildness of many of the cases. In several instances the disease was so little marked as to escape recognition until a late period of convalescence, when, as a result of an examination of all the inmates of the infected houses, the cases were detected. Such cases were invariably associated with efficient vaccination in the person in whom they occurred, thus bearing impressive evidence of the power of vac- cination in mitigating the severity of smallpox. The modified character of many of the cases increased the difficulty in dealing with the outbreak, inasmuch as many of the patients had freely mixed with people for the greater part of a week before the cases came under observation" (italics added).

Moreover, it has hitherto been a common practice in reports

1 Allbutt's System of Medicine, First edition.

2 It was no doubt an exaggeration to say " almost without exception," but if we substitute the words " very often " the statement is correct.

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THE VACCINATION QUESTION

on smallpox epidemics to show statistically how very much milder smallpox is amongst vaccinated patients than is the case amongst the unvaccinated. Tables have been compiled to show the large proportion of mild and trivial cases amongst the vac- cinated, and it has often been pointed out that the more " effi- cient " the vaccination, i.e. the larger and the more numerous the vaccination scars, the greater the proportion of these trivial cases. Examples of these tables are given in Appendix VII.

A brief reference to them may be made here. Dr. Davies, M.O.H. for Bristol, in his Smallpox Report for 1893-4 (p. 14) gives a table in which he classifies the cases of smallpox into four groups : Trivial, Discrete, Confluent, and Hemorrhagic. His definition of the " trivial " group is as follows : " very mild discrete cases, in which, after the initial fever (which may be severe) and the eruption of a very sparse crop of papules, sometimes not more than one or two, all constitutional symptoms at once and finally disappear, no secondary fever supervenes, and, but for the presence of a few abortive vesicles and pustules, the patient is quite convalescent."

Without doubt this is just the type of disease which provides the unrecognised cases which we are considering. Dr. Davies found that amongst vaccinated patients 30 '9 per cent, of all those attacked belonged to this " trivial" group, whilst amongst un- vaccinated patients only 7 '3 per cent, could be so classified. Moreover, amongst those who had been what is generally called "well vaccinated" — i.e. with four or more marks — the proportion of these " trivial " cases was as high as 41 "7 per cent.

At Manchester, in 1892-3, where the cases were divided into mild, discrete, confluent, and haemorrhagic, Dr. Coupland found that there were no mild cases amongst the un- vaccinated ; amongst the vaccinated the proportion was 25^4 per cent.; whilst amongst those with four vaccination scars there were as many as 477 per cent.

At Bradford, for the same period, Dr. Coupland found the proportion of mild cases was 27*5 per cent, amongst the vac- cinated, and only 3*9 per cent, amongst the un- vaccinated. Amongst the " well- vaccinated " it was as high as 45^4 per cent.

TENDENCY TO SPREAD SMALLPOX 69

Frank Admissions

A few medical officers of health have not hesitated to admit openly that vaccination has the tendency which we are now considering.

Thus Dr. P. Boobbyer, M.O.H. for Nottingham, has written : " One of the principal difficulties encountered in the preventive treatment of smallpox at the present time is due to the effect of vaccination, or rather insufficient vaccination. Vaccination not sufficiently recent or thorough to produce complete immunity . . . may yet so modify the eruption of smallpox as to render diagnosis extremely difficult, especially to those with small experience of the disease. It may also render an attack so mild as to allow the person affected to pursue his ordinary occupation without intermission, and particularly during the most infectious period, the period of rash ; for while most people, even with the mildest of attacks, feel somewhat poorly in the earlier stages — with feverishness, sweating, sickness, back pain, etc. — relief is in all cases experienced on the appearance of rash, and in mild cases there is seldom any illness afterwards. It may be noted that it was as much because of the extreme danger to the public through infection emanating from mild cases, as for any other reason, that inoculation for smallpox was made penal in the last century. . . ." {Health Report, 1902.)

No doubt Dr. Boobbyer would say — or he would have said so at the date when the above lines were written — that the remedy for this detrimental effect of vaccination was compulsory re- vaccination. But at the present day it is admitted that there is not the slightest prospect of getting compulsory re- vaccination in this country. So that to suggest compulsory re- vaccination is scarcely a satisfactory answer.

Drs. Ricketts and Byles, in the opening paragraph of their ex- haustive work, The Diagnosis of Smallpox, write : " The times have changed since the days of Jenner. Besides that we have less practice in the art, several circumstances cause the diagnosis of smallpox to present to us more difficulties than to our fore- fathers. To Jenner we owe the chief of these difficulties. Through him, smallpox has become a different disease, easier to suffer, but harder to distinguish. ..." (Italics added.)

The most emphatic and outspoken utterance, however, which I

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THE VACCINATION QUESTION

have yet come across occurs in an article published in The Medical Chronicle in 1893, by Dr. J. H. C. Dalton, entitled, " Smallpox in its Relation to Vaccination." After summarising the effect of vaccination upon the individual, he wrote as follows : " That the community are benefited, however, is a much more doubtful point. In the first place it may be asked, Does vaccination prevent epidemics ? That it does not absolutely prevent them is seen by the Sheffield epidemic ; the recent mild epidemic at Leicester also shows that careful attention to sanitary matters, even in an un-vaccinated district, may keep the disease under control. But it may even be urged . . . that infantile vaccination may promote rather than arrest an epidemic, for two reasons. In the first place, it has often been observed that the origin of an epidemic has been in two or three vaccinated persons, who had the disease in such a mild form that it was not recognised until late. During their infective period, therefore, they have been spreadinginfectionin their neighbourhood, andhence the epidemic has originated. Now vaccination undoubtedly causes the cases to be mild; if vaccination had not been systematically performed . . . prompt means of isolation could have been at once taken, and pos- sibly the epidemic could have been stamped out before it had com- menced to rage For these reasons I am inclined to doubt

whether infantile vaccination is such an unmixed blessing to the community that the State should enforce it by legal penalties" (italics added).

Unrecognised Cases in the Un-vaccinated

Since attention was first called to this unfortunate tendency of vaccination to encourage the spread of smallpox by masking the disease, it has been urged that unrecognised cases of smallpox may occur in persons who have never been vaccinated.

This is undoubtedly true. Such cases, however, are very rare in comparison with unrecognised cases in vaccinated subjects. Moreover, unrecognised cases in un-vaccinated subjects may be divided into two classes : (1) Cases where a medical man is called in, but fails to diagnose the disease. Here it is certainly the fault of the medical man, because it is admitted that the diag- nosis of smallpox in un-vaccinated subjects is a comparatively

TENDENCY TO SPREAD SMALLPOX 71

simple matter.1 (2) Cases where no medical man is called in. In practice these cases only occur when the prevailing " strain " of disease is exceptionally mild and favourable. In these in- stances, the mildness, being a natural characteristic, is trans- mitted, i.e. it " breeds true." Consequently only a mild and favourable type of disease is spread by them, which causes little or no loss of life. There is, therefore, a great difference between an outbreak of smallpox originated by an artificially mild unrecognised case occurring in a vaccinated subject, and an outbreak originated by a naturally mild unrecognised case occurring in an un- vaccinated subject.

The Experience of Individual Towns

LEICESTER

We will now see how far the above statements are supported by actual facts drawn from the experience of individual towns, and it will be well to begin with my own town, Leicester, although we shall deal with Leicester more fully in a later chapter.

A number of striking examples illustrating the danger of unrecognised cases occurring in once- vaccinated subjects were recorded by my predecessor, Dr. J. Priestley, in his reports on smallpox in Leicester in 1892-3. The whole outbreak originated in unrecognised cases, as we shall see later, but one of these may be quoted here. George H., aged 21 years, vaccinated in infancy and described by Dr. Priestley as " well vaccinated," was taken ill with headache and pains in the back. A day or two after- wards spots appeared, and he stayed away from work for about a fortnight. Unfortunately his medical attendant failed to recog- nise the real nature of the disease, and no precautions were taken. He was allowed to be about the house as usual, dining, etc., with the rest of the family. The result was as might be expected, and it well illustrates how serious these unrecognised cases are. There were seven other persons in the house, including his wife, his brother, a lodger, his brother-in-law and sister-in-law, and two children. Every one of these contracted the disease, and, as Dr. Priestley carefully points out, the un-vaccinated suffered

1 The only exception to this is in the case of malignant or hemorrhagic smallpox, which occasionally does give rise to real difficulty. Fortunately these cases are very rare.

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severely and the vaccinated very lightly, so that the credit of vaccination from the orthodox point of view was fully upheld. In addition to the actual inmates of the house, other persons who had visited the house were infected, and they in turn infected others. Moreover, when one of the children in the house was taken ill and developed spots, he was sent to another house in another street to be nursed, with the result that four persons in this house caught the disease ; here again we are told that two of these, being well vaccinated, had very mild abortive attacks ; whilst two others, being un- vaccinated, suffered very severely, one having a semi-malignant attack and being left badly marked. The father of this family also infected a fellow workman, who had been vaccinated, and who had a very mild attack. The nature of this was not recognised at the time ; and he in turn infected his two unvaccinated daughters.

Dr. Priestley concludes : " We have thus seen how, from an unrecognised case, George H., have arisen twenty-six other cases of smallpox."

The etiology of the outbreak is shown graphically in Diagram V.

Now I suggest that if George H. had never been vaccinated, he would have had a more severe, but at the same time a more definite attack, and the chances of the medical man failing to recognise the case as smallpox would have been very greatly reduced.

Had the case been recognised, all the chapter of accidents related above, which led to the infection of so many innocent persons, could easily have been prevented. Instead of moving about the house and infecting his family, the man would have been promptly removed to hospital ; the rest of the family could then have been at once vaccinated, and it is almost certain that none of them would have been attacked.1 Other persons would have been prevented from visiting the house ; the inmates of the house would not have visited other houses ; and the baby would not have been sent out to nurse. Few diseases can be more easily controlled than smallpox, provided always that the first case is promptly recognised and proper preventive measures at once applied.

1 The value of vaccination if it can be performed within the first few days of the exposure to infection will be referred to in Chapter IX.

TENDENCY TO SPREAD SMALLPOX 73

Dr. Priestley gives a number of other similar examples where mild overlooked cases in vaccinated subjects spread the disease to un-vaccinated persons, and usually in a severe form.

I now come to my own experience of the part played by un-

DIAGRAM V

M CcoBCtH nY o^'"

O

l\ \

■B 0

o

is.

1		Tom
		Sheppard 0
/I °o	05

V Undertakers

'0

00

O NOTIFIED CASES

• UNRECOGNISED CASES

Smallpox in Leicester, 1893 Disastrous Effect of Unrecognised Cases.

recognised cases of smallpox in Leicester. The first serious out- break with which I had to deal was at the Leicester Workhouse in December, 1902. A tramp, aged 60, vaccinated in infancy, who had walked from Yarmouth to Leicester, was admitted to

74

THE VACCINATION QUESTION

the Workhouse and began to sicken the next day with a mild modified attack of smallpox. Unfortunately the nature of his illness was not recognised, and for six days he was not isolated and no precautions were taken. In the meantime he was living in close contact with some sixty other inmates. The result was that six of these contracted the disease, and in turn infected fourteen other inmates before the outbreak was stamped out. Thus, owing to this man's illness being unrecognised — and this, I submit, was largely owing to the disease being masked by vac- cination— twenty other persons contracted the disease, of whom two died. Again I suggest that if this man had never been vaccinated, he would have had without doubt a more severe attack, which would have been worse for him personally, but very much better for every one else concerned.

At the same time, I frankly admit that unrecognised cases may, and occasionally do, occur in un- vaccinated persons, as the next cases I shall relate will prove ; but I want first to emphasise again the very important point that whenever unrecognised cases of smallpox occur in un-vaccinated persons, it is almost invari- ably for one of two reasons : Either (i) the medical man called in has failed to diagnose the disease (this is the usual reason), or (2) the prevailing type is so mild and benignant that even in un- vaccinated persons the symptoms are not severe enough to call for medical attendance. It may reasonably be expected that when more attention is paid to the subject of smallpox diagnosis in medical education 1 the first reason will almost entirely dis- appear ; whilst, as regards the second, comparatively little harm results so far as danger to life or permanent disfigurement is concerned.

I will now relate an outbreak which did originate in an un- vaccinated case, or rather in two such cases. A young woman, Elizabeth C, aged 18, un-vaccinated, had a discrete attack of smallpox of a mild type. She was sufficiently ill to require a medical man, but unfortunately the symptoms were so mild that the latter mistook the case for one of chickenpox, and consequently no precautions were taken. She stayed at home but continued to mix with the rest of the family, and after a week she returned to work in a boot factory. At the end of twelve days, as the eruption did not clear up, she went as an out-patient to the 1 I am dealing with this question in my final chapter.

TENDENCY TO SPREAD SMALLPOX 75

General Infirmary, where the real nature of her illness was dis- covered, and the case was then reported. The result of the failure to diagnose this case was as follows : The young woman infected every member of her family, consisting of father and mother, and seven brothers and sisters ; she infected two neigh- bours ; also (presumably) a man who had been in the neighbour- hood ; also six employees at the factory where she worked ; also an out-patient at the Infirmary. Two of her sisters who attended Sunday-school whilst she was at home ill — but before they themselves sickened — carried the disease to the school, and infected five scholars and a teacher. Altogether, twenty-five cases were clearly traceable to this one case. I think it will be admitted that this was giving the disease a fairly good start, especially in an un-vaccinated town. Fortunately we got on the track of all these cases just in time, the usual steps were promptly and energetically taken, and only two further cases resulted from these twenty- five cases — a striking illustration of what can be done by modern methods, even in the presence of an un-vaccinated population.

We were informed, through Elizabeth C, that a friend of hers, Eliza F., was ill with a similar attack, which was also thought to be chickcnpox, and that she had sickened about the same time. We at once visited the case, and found that this second girl was also suffering from smallpox of a similar mild character. She had not consulted a doctor. We were, of course, too late to save her family, five of whom developed the disease ; and she also infected four friends or neighbours who had visited the house, an uncle whose house she had visited, and an insurance agent. The latter was not a known contact, so was not under observation. He had been vaccinated in infancy, and had such a mild attack that he consulted no doctor and returned to work after a couple of days in bed.

He infected two out of three of his un-vaccinated children, and also his vaccinated wife, who had an attack of " varioloid " without eruption.

Eliza F. also infected two men from Derby who had visited her house, thus making sixteen cases in all infected by her. No further cases, so far as was known, resulted from this out- break, so that altogether Elizabeth C. and Eliza F. gave rise, directly and indirectly, to forty-one cases. Fortunately, how-

76 THE VACCINATION QUESTION

ever, the mildness of the two original cases, being a natural characteristic and not due to vaccination, was transmitted, with

DIAGRAM VI

IVJNWCO

o notified cases • unrecognised cases

Smallpox in Leicester, 1903

Disastrous Effect of Unrecognised Cases.

the result that most of the secondary cases were also mild, and only one out of the forty-one proved fatal.

Eliza F. and Elizabeth C. were friends ; they worked at the

TENDENCY TO SPREAD SMALLPOX 77

same factory, and sickened almost simultaneously. No doubt they were infected from the same source, but this was never dis- covered. Had the first case, Eliza C, been diagnosed by the medical man who was called in, we should have discovered the other case also (as we subsequently did as soon as the first case was reported) and the whole double outbreak could almost certainly have been cut short at the outset.

The mischief done by the two unrecognised cases in this out- break is shown graphically in Diagram VI.

CHAPTER VI

THE TENDENCY OF VACCINATION TO SPREAD SMALLPOX {Continued)

The Experience of Other Towns — London : Fatal Outbreak at Mile End Infirmary Caused by Vaccinated Child — Kirkcaldy : Fatal Outbreak Caused by Vaccinated Child — Ossett : School Outbreak of Very Mild Type Caused by Unvaccinated Child — Newhaven : Fatal Outbreak Caused by Sailor (presumably Vaccinated) — Halifax : Disastrous Effect of Unrecognised Cases in Vaccinated Persons— Coventry — Cardiff.

In order to show that the experience of Leicester related in the last chapter is in no way exceptional I will now give the experi- ence of some other towns.

LONDON

Dr. W. McC. Wanklyn, Assistant Medical Officer, London County Council, in a valuable little work entitled How to Diagnose Smallpox — which might well be made a text-book in every medical school 1 — devotes the first two chapters to the spread of smallpox by unrecognised cases. His opening lines are as follows :

"It is essential to realise the mischief which may be done by unrecognised cases of smallpox. There is hardly any disease of which the prompt recognition is more important to the general community. Almost every outbreak in London in recent years has been started, or propagated and prolonged, by unrecognised cases. Epidemics teem with examples, which only cease to be recorded because they become trite."

He then proceeds to give examples, the first three of which may be briefly summarised here:

(i) Smallpox broke out in a crowded locality in Shoreditch.

1 A larger and more exhaustive work is Ricketts and Byles' The Diagnosis of Smallpox, which ought to be studied by every candidate for a Public Health Diploma.

78

TENDENCY TO SPREAD SMALLPOX 79

The source of infection was a child who fell ill with smallpox, but was diagnosed as a case of chickenpox. From her the disease spread to the other inmates of the same house, and thence rapidly to the surrounding population.

(2) A young man suffers from " influenza with spots." He infects a fellow workman who was supposed to have " chicken- pox." These two cases between them were the direct cause of eight cases of definite smallpox.

(3) A man is taken ill and is supposed to be suffering from " blood poisoning," accompanied by an " eruption of spots." He infects a woman who is supposed to have " chickenpox." She infects, directly or indirectly, six persons who have definite smallpox.

It is unfortunate that the vaccinal condition of these unrecog- nised cases which originate outbreaks is frequently omitted. I am quite satisfied that in the great majority of them the patients will be found to have been vaccinated many years before, and to have become partially " de- vaccinated." They no longer possess sufficient protection from the vaccination to save them from attack, but they only get a mild and often highly modified illness, which easily escapes recognition.

Possibly the medical men responsible for recording these cases really think the fact that the patients have been vaccinated many years before is of no importance, and so they make no mention of it. But it may be observed that if by chance the patients happen to be un-vaccinated, this fact is almost invariably recorded, and usually considerable prominence is given to it. So much is this the case, that I believe it is fairly safe to assume, where the vaccinal condition is not stated, that the patient has been vaccinated.

Dr. Wanklyn says that such instances as he quotes " could be multiplied to fill a volume." This is certainly true, and as their serious significance has not yet been sufficiently appreciated, I think it would be a very good thing if some one would take the trouble to fill a volume and press home the lesson to be learnt from them.

Dr. Wanklyn's remedy for this most regrettable state of things is better education of medical students in the diagnosis of small- pox. Undoubtedly this would be a most important step. In- deed, I venture to say such a step is imperative if the profession

8o

THE VACCINATION QUESTION

is to do its duty by the public, and also to uphold its own dignity and reputation ; but I shall say more of this at a later stage. In the past, this part of a medical student's education has un- doubtedly been very much neglected.

The Case of Annie Levy and the East End Outbreak, 191 1

This outbreak, which threatened at one time to become exceedingly serious, illustrates very well both the extreme danger arising from overlooked cases, and also the remarkable success attending modern methods of prevention vigorously and promptly applied. The outbreak occurred in the East End of London early in 1911, in connection with the Mile End Poor Law In- firmary.

The facts were as follows : A girl named Annie Levy, aged 12, was living in Key Street, Stepney. It is important to note that she had been vaccinated in infancy. Dr. Wanklyn, in another excellent little book recently published by him — The Administrative Control of Smallpox — devotes seven pages to the consideration of this outbreak, but entirely omits any reference to the fact that this child, the cause of the outbreak, had been vac- cinated ! Did he imagine that the fact was of no significance ? and would he have made no reference to it if she had happened to have been un- vaccinated ? I would not have dwelt on this, but I have so frequently found, in the course of my inquiries, the same omission as to the vaccinal condition of persons who have spread infection that I cannot help thinking that medical men have a reluctance to mention anything which might seem to reflect — unfairly, no doubt, as they believe — upon vaccination. I wish to emphasise, then, the fact that this child, Annie Levy, aged 12, the sole originator of the outbreak we are now considering, had been vaccinated in accordance with law.

The attack, as we should expect in the case of a vaccinated child, was a modified one, and although she was taken to the Out-patient Department of the London Hospital on three different dates (twice after the appearance of the eruption) the case was diagnosed as one of chickenpox. The patient was given some medicine and was eventually removed to the Mile End Poor Law Infirmary, being admitted to a ward containing sixty women and children.

TENDENCY TO SPREAD SMALLPOX 8l

She was there seen by the Medical Superintendent and Assistant Medical Officer, and they also failed to recognise the real nature of the case. This is not really so astonishing when we consider how difficult the diagnosis of smallpox in vaccinated children often is. Although modified in its character, the attack in this case appears to have made the child seriously ill and she was placed on the visiting list. She was seen by her friends fre- quently, and a large number of the public also visited this ward and were allowed to go inside.

The consequences of this error of diagnosis were about as dis- astrous as they possibly could have been. Annie Levy remained in the open ward for a whole fortnight, from February 5th to 20th, and the real nature of her attack was only discovered when other patients in the ward began to sicken with unmistakable smallpox. First, two patients sickened and were removed to the Smallpox Hospital, together with Annie Levy. The next day, February 21st, two other patients sickened in the same ward ; also an Infirmary scrubber living outside in her own home. Also a sister of Annie Levy, aged 10, was found to be suffering from smallpox at Annie's home. On February 22nd, two more sisters, aged 8 and 15, were certified ; also another patient (fatal) from the Infirmary, and a nurse. On February 23rd, ten more patients (one fatal), were certified, and a second nurse ; and then a brother of Annie Levy. It may be observed that her family had been visiting her daily whilst she was in the Infirmary, and so would be very much in contact with her. On February 24th, two further patients (one fatal) were certified, and a third nurse (fatal). On February 25th, five more patients (one fatal) and a friend of Annie Levy who had visited her in the Infirmary. On February 26th, a patient who had been discharged from the Infirmary was certified. On the 27th and 28th two more patients (both fatal), one each day, were reported. Altogether, up to March 9th, there were fifty-two cases, ten of which proved fatal. Further cases occurred before the outbreak was stamped out, bringing the total to about seventy. No less than five of the persons attacked were nurses.

For the benefit of those who believe that the complete im- munity enjoyed by nurses in smallpox hospitals is not due to the fact that they have been recently vaccinated, but to some peculiarity in a nurse's calling, I would draw attention to the 6

82

THE VACCINATION QUESTION

fact that, where nurses have not been recently vaccinated (and none of the five nurses attacked in this outbreak had been recently vaccinated), they are just as liable to contract smallpox, and in a serious form, as the rest of the community.

It is to be noted that all the Levy children appear to have been duly vaccinated in infancy, the youngest being Rebecca, aged 8, and she appears to have had the ordinary mild modified attack usually seen in vaccinated children. After the eruption appeared, she also was taken to the London Hospital, where she was seen by a different doctor from the one who had seen Annie. He also diagnosed chickenpox. She returned to school, but fortunately she only attended one day before she was re- moved, in consequence of the discovery of her sister's case at the Infirmary. Otherwise a school outbreak would almost cer- tainly have followed.

Considering what a start the disease was given, in the very heart of the East End, it is really astonishing that the outbreak was got under control and stamped out as quickly as it was. As a writer at the time put it : " If we were asked to invent a prize method for disseminating a fell disease, could one have discovered anything more likely to scatter smallpox throughout London ? " I think we may say that, but for the extremely energetic measures that were taken when once the real nature of the disease was discovered, more especially the prompt notifi- cation and removal to hospital of all cases as they occurred, together with the hunting up and keeping under surveillance of all the enormous number of contacts, it is virtually certain that a serious epidemic in the Metropolis would have resulted. That it was stamped out, in the way it was, constitutes a striking proof of the efficacy of modern methods of checking the spread of smallpox, even under most serious difficulties.

As regards the way in which the first case, Annie Levy, con- tracted the infection, it was believed that she was infected through visiting, on January 21st, another girl, also supposed to be suffering from chickenpox. No statement being made as to this girl's vaccinal condition, we may assume, I think, that she, too, had been vaccinated in infancy.

In spite of the fact that there had been a good deal of vac- cination default in the East End during the few preceding years, it was remarkable that such a large proportion of the cases which

TENDENCY TO SPREAD SMALLPOX 83

occurred were in once- vaccinated persons. Thus, out of the first fifty-four cases, no less than forty-one were in vaccinated persons. Of these forty-one no less than eight were persons under fifteen years, whilst of the latter, three were under five years.

After these facts, it seems fatuous to suggest that the outbreak we are studying was in any way clue to the fact that numbers of the children in the neighbourhood had never been vaccinated.

Yet the pro-vaccinist Press did not hesitate to do this. The following paragraphs appeared in The Pall Mall Gazette, and they illustrate well the extreme views that are held in some quarters :

" The feeling has of late been gaining ground in well-informed circles that the anti-vaccination campaign, and the deplorable effect it has had upon legislation, would before very long lead to the reappearance of the hideous disease which vaccination had practically stamped out." [Pall Mall Gazette, February 25th, 1911.)

" The outbreak of smallpox at Mile End is regarded by medical authorities ... as a result of the prejudice that has long existed in the district against vaccination. For years the Mile End Guardians have been anti-vaccinators, discouraging vac- cination in every direction, and refusing to allow the children of pauper parents to have the benefit of this preventive treatment. The result has been that a large unprotected population has grown up, and the soil has been waiting only for the seed. The agitation against vaccination is one of the most idiotic things which even our sentimentalists in their record of imbecility have ever carried on." {Pall Mall Gazette, February 24th, 1911.)

At the time this was written there had been twenty-five cases, and only two of these cases were in un- vaccinated persons, one of the two being a baby only a month old, and therefore below the age limit for compulsory vaccination. Moreover, the out- break had originated, as we have seen, in a vaccinated child.

One other Press opinion is worth quoting, and is perhaps a good deal nearer the mark than the above :

" One fact about the outbreak should be carefully noted by local authorities. The infection began, as usual, in one of the most insanitary districts of the East End, and is a stern reminder of the danger which such unhealthy regions are to London's vast population."

84

THE VACCINATION QUESTION

I wish to draw special attention to the difference between the type of the disease which was spread by this vaccinated child, Annie Levy, in London (a comparatively well- vaccinated town), and the type of the disease spread by the un-vaccinated girls, Elizabeth C. and Eliza F., in Leicester (a very badly vaccinated town). Annie Levy is the cause of some seventy cases, ten of which prove fatal (i.e. 14 per cent.) ; the two Leicester girls are the cause of forty-one cases, one of which proves fatal. Is it quite certain that this was pure coincidence ?

KIRKCALDY

A very interesting outbreak of smallpox, which attracted considerable attention, occurred in 1912 in Kirkcaldy, a Scotch burgh of 40,000 inhabitants.

The outbreak began in September, and resulted in the occur- rence of forty-two cases, no less than fourteen of which, or 32 '5 per cent., proved fatal.

Prior to the outbreak, infantile vaccination had been some- what neglected in Kirkcaldy, only about 61 per cent, of the births having been vaccinated since the passing of the Scottish Con- science Clause in 1907. As no case of smallpox was known in any part of Scotland at the time, it was surmised by the Medical Officer of Health that the infection had been introduced into the town through the medium of flax, the first case which occurred being in a boy employed at a flax-mill. It is in connection with this first case that the great interest of the outbreak, from our present point of view, centres. This first case was apparently the only one infected by the flax, or whatever the real source of infec- tion was. Now, had this first case been an unmistakable one — such as usually occurs in an un-vaccinated subject — and been promptly recognised, the usual precautionary measures, such as isolation, surveillance and vaccination of contacts, disinfection, etc., would have been carried out, and there is reason for thinking that the outbreak would then have been nipped in the bud and have spread no farther. What actually happened, however, was as follows : The first case happened to be a boy, 14^ years of age, who had been vaccinated in infancy, in accordance with the law of the land. Having been vaccinated, the attack, instead of being of a very definite character, was considerably modified, and

TENDENCY TO SPREAD SMALLPOX 85

although a medical man was called in he failed to recognise the case as one of smallpox but regarded it as one of chickenpox. In consequence of this most unfortunate mistake no precautions were taken, and for about three weeks the lad was disseminating the infection of smallpox broadcast without any attempt being made to check it. The result was most disastrous. Four other members of the family of this first case, and a large number of contacts, developed the disease. Altogether forty-three cases occurred before the outbreak could be extinguished, and very great expense (for a town of this size) was incurred. What was most serious, however, was the fact that so many of the cases proved fatal, showing that although the first (vaccinated) case was apparently so " mild," the type of disease spread by it was really very severe.

Now it is necessary to emphasise the fact that, humanly speaking, the cause of this unfortunate outbreak was the failure to recognise the real nature of the first case, and that this failure was due possibly to lack of skill and proper training of the medical man who was called in to attend the case, but also, as I submit, to the fact that the real nature of the disease was masked, owing to the patient having been vaccinated. It is almost certain, from our knowledge of what this type of smallpox is like in un- vaccinated subjects, that, had this lad of fourteen years not been vaccinated, the nature of his attack would have been easily and at once recognised, and in all probability the outbreak would have been cut short at the outset.

I am not making this statement recklessly or without due consideration of all it implies as regards the practice of infantile vaccination. We now know that smallpox is a comparatively easy disease to control and prevent from spreading, provided only that the nature of the disease is recognised early, i.e. within the first few days of the appearance of the eruption. Infantile vaccination tends inevitably, by its very success in mitigating smallpox, to thwart our efforts to stamp it out. It may be urged that it was better for the lad himself that he had been vaccinated. Undoubtedly ! Better for that one lad, but how much worse for the forty other persons whom he infected, fourteen of whom lost their lives !

Before leaving the Kirkcaldy outbreak, it may be well to refute any suggestion that the fact that vaccination had been neglected

86

THE VACCINATION QUESTION

in the burgh had anything to do with the rapid spread of the disease. In spite of the fact, already stated, that during the preceding five years only about 61 per cent, of the births had been vaccinated, no un- vaccinated case occurred in a child under five years of age, with the solitary exception of a baby infected by its mother before birth (and which, of course, could not have been protected by vaccination in any case) ; and there were only two un -vaccinated cases between five and ten years. Moreover, thirty-three cases, or 77 per cent., were found to have been vaccinated. Of these vaccinated cases, eight, or 24^2 per cent., proved fatal.

The Medical Officer of Health for Kirkcaldy (Dr. Mcintosh) suggests that other unrecognised cases, besides the first one, played a part in the spread of infection, and says that it is only thus that the source of infection in some of the cases can be accounted for.

In spite of the fact that the Kirkcaldy outbreak affords evidence so adverse to the practice of infantile vaccination, demonstrating so clearly its drawbacks and also the absence of very serious danger amongst the un-vaccinated children, Dr. Mcintosh still adheres faithfully to the orthodox views on the subject, and writes in his Report on the outbreak as follows : " Six school children contracted smallpox. Two of these . . . were un-vaccinated, the other four . . . had been more or less efficiently vaccinated in infancy. . . . Had this outbreak of smallpox been delayed another five years a large number of un-vaccinated children, exempted through the loophole of the conscientious objection clause, would have been attending these schools, and the con- sequences would have been appalling to think of."

When we come to consider the experiences of Leicester and Dewsbury, where so many of the school children were un-vac- cinated, we shall see how little ground there appears to be for Dr. Mcintosh's apprehension.

Again I wish to draw a comparison between the type of disease spread by the vaccinated lad, 14J years old, in Kirkcaldy, and the type of disease spread by the two un-vaccinated young women in Leicester. The former gave rise to forty-two cases, fourteen of which proved fatal ; the latter to forty-three cases, only one of which proved fatal. Was this also a coincidence ?

TENDENCY TO SPREAD SMALLPOX 87

The Ossett School Outbreak

Lest it be thought that I am making too much of the mildness of the Leicester cases, I will mention here the case of a school outbreak which occurred in 1904 in the Borough of Ossett, part of the Dewsbury Union.

Infantile vaccination in Ossett, as in Dewsbury, had been very much neglected, and in the year mentioned the district was invaded by a mild type of smallpox. Owing to the failure of hospital isolation and the occurrence of unrecognised cases the disease became very prevalent, and the public elementary school at Commonside became infected by the attendance of an un- vaccinated scholar suffering from a very mild type of the disease. Had the prevailing type of disease been otherwise than extremely mild, an un-vaccinated child suffering from smallpox would not have been able to continue attending school. As the child had never been vaccinated, the mildness of her attack was transmitted,1 and although no less than forty- two other scholars were attacked (showing how intensely infec- tious smallpox can be), not one of these cases proved fatal !

NEWHAVEN

Another outbreak which caused considerable stir occurred in Newhaven early in 1913 ; it received considerable notice both in the lay and medical press, and as several of the cases were in un-vaccinated children (for which exemptions had been obtained) and proved fatal, the foolishness of neglecting vaccination was duly emphasised. The Jennerian, the official organ of the Association of Public Vaccinators, naturally made the most of it, coming out with a bold headline as follows :

" Exemption — and Death !

" As we go to press, further details of the outbreak of smallpox at Newhaven have reached us from a reliable source. A parent who had taken out exemption from vaccination for five children has,

1 In order to prevent possible misapprehension let me repeat that I am not arguing that the type of infection spread by un-vaccinated cases is usually mild ; I am only referring to cases overlooked because of their trivial character. Such cases in the un-vaccinated do tend to spread a mild form of the disease, which is not so with similar cases in vaccinated subjects.

88

THE VACCINATION QUESTION

we are informed, had the terrible experience of seeing no less than three of these die on successive days from smallpox. Sympathy can be extended to the parents, who will now be repenting what they have done for so-called conscience' sake, at the instigation of professional agitators and others. We do not think the masses are to blame for the extensive outbreak of pseudo-conscientious- ness at present in evidence throughout the country. The blame can be divided between the authorities and the National Anti- Vaccination League."

Altogether there were twenty-two cases, with five deaths. Ten of the cases had never been vaccinated, and all the deaths occurred amongst these ten. Could there be stronger testimony as to the value of vaccination ! If we study the whole facts of the outbreak, however, it is possible that vaccination will appear in a different light. The following particulars are ex- tracted from the Report of Dr. Parkhurst, the Medical Officer of Health. It appears that on January 18th, 1913, at a time when no thought of smallpox in the town existed, the Medical Officer of Health received notification of no less than eight cases of smallpox in one house, No. 14, Clifton Terrace. The house con- tained in all twelve persons, and those found to be suffering from the disease were the occupier, his wife, five children, and an adult lodger. The children, who had never been vaccinated, had severe attacks, and, as already stated, three of these proved fatal. On January 23rd another case of smallpox was notified from No. 13, Clifton Terrace, in a person who had been in constant communication with No. 14 ; and another of the inmates of No. 14 was discovered to have the disease on the following day. On January 25th two more of the inmates of No. 14 sickened with the disease ; also one at No. 17, and a second case at No. 13. Another case was also discovered on this day on the opposite side of the road. Energetic measures for the suppression of the out- break were taken by the Medical Officer of Health, and in spite of the considerable opportunity given to it for spreading it was quickly stamped out.

It is, of course, a deplorable fact that five un- vaccinated persons should have lost their lives from smallpox, and it may reasonably be contended that, had they been vaccinated, the chances of the attacks proving fatal would have been greatly reduced.

TENDENCY TO SPREAD SMALLPOX 89

But the really important point, I submit, is the cause of the out- break. Why should this large number of cases have occurred almost simultaneously and without warning in and around one house ? The explanation was soon discovered by Dr. Parkhurst in the course of his inquiries. It appears that a sailor, a brother of the occupier of the house, had arrived from abroad on a visit some weeks previously, and had left again on another vessel ten days before the outbreak was discovered. Dr. Parkhurst states

DIAGRAM VII

West View

o notified cases • unrecognised case

Smallpox in Newhaven, 1913 Disastrous Effect of Unrecognised Case.

in his Report : " During the period of his visit I am informed that he developed an illness, the symptoms of which were aching in the back, and giddiness, followed by an eruption of blotches and pimples, but apparently he did not consult a medical man." This kind of history is so familiar to Medical Officers of Health who have had experience in investigating smallpox outbreaks, that it has become quite commonplace. The man was after- wards discovered, but he denied that he had had any illness at Newhaven. Dr. Parkhurst states, however :

go

THE VACCINATION QUESTION

" At the same time there is not the slightest doubt, in my mind, that he did have some illness while at No. 14 Clifton Terrace, as not only his brother, but some of the neighbours have informed me of the fact ; I have not been able to trace any other possible source of the disease."

We are not informed as to this man's vaccinal condition, but no one who knows smallpox will suggest that he was un-vac- cinated. The history of his illness, and the fact that he was a sailor, fully warrant the assumption that he had been vaccinated. This class of case practically only occurs in people who have been vaccinated. Had he been un- vaccinated he would almost cer- tainly have suffered from a much more definite attack, he would have been obliged to consult a medical man, the disease would have been recognised (or ought to have been), and the whole outbreak would have been cut short ; for as the Medical Officer of Health for Sheffield remarks : " Few diseases are more easily prevented from spreading than smallpox, provided the nature of the disease is promptly recognised."

So much has been said in the medical press about the neglect of vaccination in connection with the Newhaven outbreak that it has seemed only fair to point out another side of the question.

Incidentally, I may observe that this outbreak illustrates once again that the " mildness " in these unrecognised cases in vaccinated subjects does not " breed true," but may spread the disease in a most virulent form.

There is yet another aspect of this unfortunate outbreak which must not be overlooked. It has been already mentioned that eight cases were notified to the Medical Officer of Health on one day, this being the first intimation he had of anything amiss. As a matter of fact, however, several of these cases had occurred some time previously ; yet although a medical man had