16 
LAT Cael 
[NovEeMBER 5, 1896 
operation at the time undesirable. The following recom- 
mendations are also made. The vaccination vesicles should 
not be opened unless for some adequate reason. The pre- 
servation of lymph in tubes instead of dry points (the storage 
of calf lymph in glycerine?), the careful sterilisation of all 
instruments used (which should be as simple as possible), 
and the exercise of care that the insertions of vaccine matter 
be not placed too close together, so that the vitality of the 
tissues between them may not be injured. It is thus suggested 
that greater latitude should be given to the medical man in 
deciding as to when vaccination should take place. On the 
other hand, along with compulsion of the parent, compulsion 
on the medical attendant to attend (should any unfavourable 
symptoms occur prior to the time fixed for inspection) should be 
made, and that notice should be given to parents that they are 
empowered to summon the public vaccinator. 
out that in any case where a child requires medical attendance 
owing to illness supervening on vaccination, that it should be 
the duty of the vaccinator to render such attendance if required 
by the parent, and that he should receive a fee in respect thereof. 
The Commissioners go on to state that ‘‘in our opinion, if the 
precautions we have suggested were adopted, untoward incidents 
of vaccination, already rare, would become much rarer.” 
Concerning the conditions of vaccination that obtain in 
Scotland (p. 135 of the Report), it is probable that any legal 
action that may be taken as a result of the report of the Com- 
mission will be based, to a large extent, at any rate, on the 
provisions of the Scottish Vaccination Act. As pointed out 
in the Gritish Medical Journal, the essential features in which 
this system differs from that in vogue in England are the follow- 
ing. Almost the entire work of vaccination is carried on by the 
family doctor, who is paid for the operation and for the suc- 
ceeding visit, just as he would be paid for an ordinary visit to the 
child ; so that the parents, and not the rates, are charged with 
the expense. This, however, is a matter of detail, and the 
Commission recommends that any medical attendance required 
in consequence of vaccination, is not to be charged against the 
parents, but against the State. Ina few large cities, especially 
in those where medical schools are located, public vaccination 
is resorted to. In these cities the public vaccine stations are 
in most cases in connection with the medical schools, though 
in some instances they are subsidised by municipal funds. 
State registration of vaccination is associated with birth regis- 
tration. When the birth of a child is registered, the registrar 
hands to the person registering a notice requiring that the 
child shall be vaccinated within six months of its birth; 
the notice is accompanied by the usual certificate forms for 
successful vaccination, postponement, and_ insusceptibility. 
Every half-year the registrar sends a note of all who 
have not complied with the vaccination regulations to the 
inspector of poor under the Parish Council (Board of Guar- 
dians). This list of defaulters is placed in the hands of the 
public vaccinator, who visits those children who have not been 
vaccinated at their own home, or sees them at the office or dis- 
pensary of the Parish Council. Should the parents refuse to 
accept vaccination at the hands of the public vaccinator, but not 
tll then, legal pressure may be brought to bear upon the parents, 
asin England. Of course it is contended that vaccination under 
these conditions cannot be inspected by a public inspector, and 
that very great latitude is allowed to the medical man as to what 
may constitute efficient vaccination ; but, on the other hand, the 
vaccination being done by a trusted medical adviser does not 
arouse the same opposition that it does in England, with the result 
that in Scotland vaccination is accepted almost as part of the con- 
dition of registration of the birth of the child. A most important 
consideration in the Scotch system is that, as the period is six 
months instead of three, many of the dangerous illnesses of very 
early life, during which such a large proportion of children die, 
are not put down to vaccination, as they so frequently are in 
England. It has been suggested, indeed, that this period of six 
months might, with advantage, be extended to twelve, except 
when small-pox is epidemic, when vaccination should be done as 
early as possible. It is a striking fact that during eleven years 
(between 1884 and 1894) the number of unvaccinated children, 
z.e. those unaccounted for to the registrar, never rose to more than 
2] percent., and in 1894 this wasaslowas about 2} percent. In 
the second half-year of 1892 only twenty-two prosecutions were 
instituted. There can certainly be little doubt that, although 
there may be slight disadvantages connected with the perform- 
ance of vaccination by medical men at the homes of the children, 
NO. 1410, VOL. 55 | 
It is also pointed | 
these are of such a nature that they could very soon be got over, 
whilst the enormous advantages far more than outweigh any 
possible disadvantages. It has been pointed out there would be 
no need to take the child away from its home; consequently 
it would not be necessary to expose it to inclement weather, or 
to rough treatment of any kind, with the result that chills 
and broken vesicles would be of less frequent occurrence than 
under the present system. The possible danger of contracting 
erysipelas, scarlet fever, measles, and like diseases from other 
children at this time, would also be done away with. could. 
attendance at public vaccination stations be dispensed with. 
(D) ‘* As to what means, other than vaccination, can be used 
for diminishing the prevalence of small-pox ; and how far such 
means could be relied on in place of vaccination." In connec- 
tion with isolation the Commissioners confess that they can see 
nothing to warrant the conclusion that in this country vaccina- 
tion might safely be abandoned, and be replaced by a system of 
isolation ; but whilst fully admitting the protective effect of 
vaccination, the Commissioners maintain that it does not 
diminish the importance of measures of isolation, or dispense 
with their necessity. They hold, moreover, that steps should. 
be taken to procure a more general division of the isolation of 
small-pox patients than exists at the present time; and they 
recommend ‘‘(1) that common shelters which are not now 
subject to the law relating to common lodging-houses should be 
made subject to such law ;'(2) that there should be power to the 
local authority to require medical examination of all persons. 
entering common lodging-houses and casual wards to see if they 
are suffering from small-pox, and to offer a reward for prompt 
information of the presence of the disease ; (3) that the local 
authorities should have power to order the keeper of a common 
lodging-house in which there has been small-pox to refuse 
admission for such time as may be required by the authority ; 
(4) that the local authority should be empowered to require the 
temporary closing of any common lodging-house in which small- 
pox has occurred; (5) that the local authority should have 
power to offer free lodgings to any inmate of a common lodging- 
house or casual ward who may reasonably be suspected of being 
liable to convey small-pox; (6) that the sanitary authority 
should give notice to all adjoining sanitary authorities of the 
occurrence of small-pox in common lodging-houses or casual 
wards ; (7) that where the disease occurs the public vaccinator 
or the medical officer of health should attend and vaccinate the 
inmates of such lodging-houses or wards, except such as should’ 
be unwilling to submit themselves to the operation.” 
One’ remarkable fact in connection with this part of the 
question is that even the minority reporters against vaccination 
(only two innumber, although at least four members of the Com- 
mission were supposed, originally, to be adverse to its use) can 
offer no new light on the question ; any argument brought forward, 
in a half-hearted fashion, against the efficacy of vaccination, is. 
based not so much upon actual statistics as upon a purely hypo- 
thetical basis. 
The alternatives, improved sanitation and isolation, that are’ 
advanced in the minority report as being sufficient to take the place 
of vaccination, were of no avail during the Gloucester epidemic, 
during which vaccinators and non-vaccinators alike competed with 
one another in their zeal to have vaccinations and re-vaccinations 
performed at as early a date as possible ; only as the popula- 
tion became well vaccinated did other measures appear to have 
any material effect in limiting the spread of small-pox. Of the 
extent of the vaccination that went on in this city, an idea may — 
be gathered from the fact that during one period of seven days: 
four public vaccinators operated on 548 patients for the first 
time, and re-vaccinated 1683. No medical man would for a 
moment desire to minimise the importance of improved sanitary 
surroundings and immediate isolation of small-pox patients in 
dealing with any outbreak of small-pox, and with the prevention: 
of small-pox epidemics, but from the nature of the disease and 
the period during which the infective nature of the disease makes 
itself felt, it is almost impossible to prevent the transmission ot 
small-pox by patients who are suffering from this disease during 
the earlier periods of its course. Small-pox is undoubtedly 
seldom transmitted from town to town except through tramps or 
through people who cannot be readily reached for inspection, 
simply because they do not apply for medical advice until the 
disease is well developed ; whilst in regard to the cases that are 
not recognised during the earlier stages of the disease, it is prob- 
able that these will, from time to time, become more and more 
numerous from the fact that as there are periods during which 
