MEDICAL OFFICER'S REPORT.

MEDICAL OFFICER'S REFORT.

The following is an account of the proceedings which during the year 1865 were taken by the Lords of the Privy Council under the Public Health Act, 1858. It adverts also to other kindred. facts of the year, so far as Medicine was concerned with them, Vaccination. and particularly to certain questions which during the year came before me as their Lordships' medical referee in relation to the law of Quarantine.

I. VACCINATION.

In 1865, as in previous years, my Lords superintended public vaccination; including (1) the proceedings of local authorities under the statutes which relate thereto, and (2) the arrangements by which the national supply of vaccine lymph is maintained, and (3) the arrangements which give effect to the Order of Council regulating the qualifications of public vaccinators.

1. In Superintendence of Local Proceedings their Lordships or- District inspecdered the inspection of 787 vaccination districts, comprised in tions. 151 different unions or parishes. These inspections (made by Drs. Seaton and Stevens) represented the re-commencement of a systematic course, in which during the previous four years all the vaccination-districts of England and Wales had already been once inspected. The results of the first examination are recorded in my reports for the successive years (1860-4) during which it was in progress; and the results of the present examination, so far as it has gone, have been carefully compared with them. It is very satisfactory to me to report that each inspector bears witness to an improvement in the performance of public vaccination within the area which he has revisited. It is true that great, very great, improvement still remains to be made before the public will have nearly realized the advantages which Jenner's discovery can confer; but in the present most unsatisfactory state of the law (to which on previous occasions I have drawn attention) even a very little real progress deserves mention, certifying, I think, that, except for that state of the law, the progress would have been far beyond its present stage.

The improvement reported is particularly in the style of the vaccination. Thus, in respect of the amount of vaccination-scar

The amount of vaccination-scar (or scars) on the arm or arms of a successfully vaccinated person ought decidedly not to be less than half, and is probably the better for reaching three quarters, of a square inch. It does not practically matter whether this quantity is got by the existence of one very large scar, or by the existence of several smaller ones,-a difference which depends on inessential differences

MEDICAL OFFICER'S REPORT.

on the arms-one very important measure of the efficiency of the vaccination, Dr. Seaton reports that, whereas on his former inspections about 63 per 100 of the children he examined showed Vaccination. certain degrees of scantiness of scar, now only 42 per 100 showed the same degrees of scantiness*; and that often, when he compared in one school or district the children who had been vaccinated before his previous inspection with the children who had been vaccinated subsequently, he found that instances of scanty scar were twice or thrice or four times as numerous in the former group of children as in the latter. And as regards the other cardinal point-the quality† of the vaccination-scars observed, he also finds notable improvement. Thus he says: "In some districts which I had before specially noted for the very large proportion they exhibited of marks of imperfect character, the change was really very remarkable. In one district in Herefordshire in which the performance of vaccination had been so indifferent that 40 per cent. of the vaccinated children seen on the first inspection had very imperfect marks, and the great majority of the remainder had but passable marks, the proportion with thoroughly good or fine scars not exceeding 10 per cent. (it was in fact one of the worst districts I had ever been in) I now found, on examining a lot of young children, 65 per cent. of them with thoroughly well characterized marks, and only 14 per cent. with marks that were imperfect. In a district of the same kind in Hampshire I found, on comparing the elder with the younger children seen in this inspection, that 20 per cent of the former, but only 10 per cent. of the latter, had marks which were imperfect. Taking the group of unions (the unions in Cornwall) in which there had been the fewest changes of vaccinators since the first inspection-only seven changes in the 73 districts-the improvement in character of marks was very gratifying; for while in the former inspection I had noted above 18 per cent. of the children examined as having imperfect marks, on the present occasion the proportion with imperfect marks in the infant schools very little exceeded 6 per cent." Also Dr. Stevens, as regards the

area of his inspections, reports a marked general improvement in the quality of vaccination. Of 203 districts, in which he had

in the mode of vaccinating. Mr. Marson's method is to make, about three quarters of an inch apart, five punctures, not very superficial, each of which gives a vesicle, and eventually a cicatrix, of circular form, and of diameter varying from three to five eighths of an inch. Mr. Ceely, using G. Weir's vaccinator at four different spots, about three quarters of an inch asunder, raises on each spot a compound vesicle or group of vesicles; and the result at each spot is a cicatrix of oval or elliptical shape, averaging about half an inch long by a third of an inch broad.

* In some parts of England the custom of half-vaccinating had been very current. Thus in Herefordshire (except at and about Hereford) it had been the habit of vaccinators to make only one or two punctures or small scarifications; so that Dr. Seaton, on his first inspection of this county, found that of all the children he examined, including those seen at Hereford, only 10 per cent. had more than two average scars; whereas, on re-inspection, the proportion with more than two scars was 47 per 100.

The quality of vaccination-scar, to which too much importance cannot be attached, is that it shall be slightly depressed, and in its whole extent be dotted over with minute pittings.

sufficient data for comparison, 118 gave him evidence of such improvement. I regret that I cannot report of either area of observation that the inspector found improvement universal, or, where existing, always as great as was to be desired.*

As regards mere number of infantine vaccinations in proportion to number of births, probably no important general change has occurred. The inspectors cite many districts in which there had been progress, but, unfortunately, also others in which the nonperformance of vaccination has been scandalous.† Cases of the latter kind involve such injurious results that I think it right to mention some of them in detail. Thus, on the present re-inspection, Dr. Stevens finds the union of Northampton in little better condition than when in 1860 Dr. Seaton spoke of it, “as affording the most remarkable illustration of the neglect of vaccination" which had yet come before him he states, namely, that the public infantine vaccinations of this union are still only 10 per cent. of the births; that the county of Northamptonshire, as a whole, "is the most deficient in quantity of vaccination of any seen during the inspection;" and that, of this least-vaccinated county, the Northampton union is the least-vaccinated part. In the decennial period, 1851-60, the small-pox death-rate of children in this union was 4 times as high as the average small-pox death-rate of England, and exceeded that of any union in England except Merthyr Tydfil and Plymouth in 1856 nearly a third of the entire mortality of the union, and in 1860 nearly a fourth of it, was due to that one discase: Dr. Stevens now reports of the union that "from 1860 to the present time little or no improvement has taken place, and it has been and still is a centre in which smallpox is almost constantly present, and from which that disease is largely distributed to the neighbouring towns and villages." Dr. Seaton refers particularly to the great small-pox

Of the five counties in which, or parts of which, Dr. Seaton made his re-inspection-Sussex, Hants, Hereford, Cornwall, and Devon-Devonshire was, on the whole, that which exhibited the least improvement. He states that in several districts in this county vaccination is still exceedingly ill-performed; as especially in parts of the Tiverton and Torrington unions, in the district of Bideford, and (below all) in the districts of Hatherleigh and Swymbridge. Dr. Stevens says that in parts of the populous manufacturing districts of Staffordshire, Shropshire, and Worcestershire, generally known as the "Black Country," the quality of vaccination is still "really infamous."

†Thus Dr. Seaton, who is in the habit of distinguishing his districts into four classes according to the degree in which the number of infantine vaccinations approaches to the number of births in each district, found the proportion of districts deserving to be placed in his first class on the present re-inspection more than double what it was on the previous inspection. Still these districts did not amount to more than one sixth of those included in his re-inspection, and, though comprising several of from 6,000 to 10,000 inhabitants, did not include any of the larger towns. A great many other districts exhibited improvement in less but varying degrees. Others showed no advance whatever, the neglect in many being of the grossest kind. Dr. Stevens's general results were not materially different. As illustrating neglect of public vaccination, he enumerates 42 districts in which for a year or more no infants had been vaccinated by the public vaccinator. And Dr. Seaton cites numerous districts in which he found a fifth or more of the children in the infant schools unvaccinated; or (as in the town of Ross and in Redruth) a third; or even (as at Combe-martin, Hatherleigh, Okehampton and Camborne) nearly or more than half.

Third Ann. Rep. of the Medical Officer of Privy Council, Appendix, page 71,

MEDICAL OFFICER'S

REPORT.

Vaccination.

MEDICAL OFFICER'S REPORT.

mortality of Portsea Island, and of the town and district of Leominster:-of Portsea Island he says that, when the epidemic began, the number of unvaccinated children amounted to thouVaccination. sands, and the deaths from small-pox in one year were nearly a fourth of the total average mortality of the union; and in Leominster district, where also vaccination was very greatly in arrear, there were in a few months between 40 and 50 deaths from small-pox. Besides the mortality which the inspectors report as having resulted from neglect of vaccination in these and many other unions, other evidence may be quoted of the sufferings to which that neglect had led:-"of 1,526 unvaccinated children. whom I examined in schools and workhouses," says Dr. Seaton, "292 or 19 per cent. had unequivocal marks of having sufferedsome of them recently, others at an earlier period-fiom smallpox of 11,061 vaccinated children only 12, or scarcely more than one in a thousand, had traces, and these generally very slight traces, of having had small-pox.”

Supply of Vaccine Lymph

It may be added that, during the year 1865, the Lords of the Council, being informed of outbreaks of small-pox in the three unions of Shepton-Mallet, Elham, and Gravesend and Milton, ordered letters on the subject to be addressed to the Board of Guardians of these unions respectively.

2. In answer to 18,504 applications made during the year for Vaccine Lymph, there were supplied, under their Lordships' orders, 142,430 charged ivory points, 2,438 charged squares of glass, and 5,352 charged capillary tubes. Particulars as to the sources whence this lymph was derived are given in Appendix No. 1. Of the 18,504 applications, in answer to which lymph was given, 15,698 came from medical practitioners (including 1,513 Poor Law medical officers) in England and Wales; 1,696 from Ireland; 512 from Scotland; 312 from the army; 117 from the navy and emigration department; 102 from colonies; and 67 from diplomatic and other foreign services.

Besides the above-mentioned 18,504 applications, there were cases where lymph was desired for the purpose of vaccinating horned cattle. Some crude speculations which had been published as to the nature of the prevailing cattle-plague, with still cruder half promises that vaccination would prove protective against the disease, had, very naturally, filled the cattle-owners of the country with eagerness to provide the suggested security for their herds; and for a while (beginning towards the end of December) the demand for vaccine lymph was insatiable. As this demand, with the public hopes which created it, continued till after the end of 1865, and indeed did not reach its maximum till about the middle of January in the present year, I perhaps ought not, strictly speaking, to say more of it in this report. But as it would be useless to refer again next year to the subject, I may say that during the early part of January the applications for lymph (among which it was not generally possible to discriminate the applications of cattle-vaccinators) were so numerous as

MEDICAL OFFICER'S REPORT.

to endanger the solvency of the establishment. In the previous ten years, including periods when human small-pox had been most widely epidemic, the average number of applications in the month of January had been 932, and the highest number had not Vaccination. reached 1,500. But in this January the applications exceeded 3,000; among which only 279 could be discriminated as for veterinary purposes; and on the 18th of the month, when this great demand culminated, the total of the one day's applications were as high as 178. Of course, whenever I learnt from the terms of an application that to vaccinate cattle was the object for which the lymph was wanted, my duty was to consider the applicant's claim as subordinate to that of persons who wanted lymph for human vaccination; and, as the lymph-supply at my disposal was not more than enough to provide for the latter purpose, I felt obliged to refuse lymph to the 279 applicants whom I could discriminate as cattle-vaccinators. There must, however, have been many other hundreds of cases where also the applicant's object was to vaccinate cattle, but where this object, being undeclared in his application, could not be discriminated and made a ground for refusal. Under these circumstances there was great reason to fear that the innumerable inconclusive trials which amateurs were making in all parts of the country as to the value of cattlevaccination, and the consequent enormous waste of vaccine lymph, would cause such an exhaustion of the national lymph-supplies as must seriously derange human vaccination throughout the United Kingdom. Fortunately, the truth as to the uselessness of the proposed cattle-vaccination became known before that great mischief was produced; and the demand for lymph subsided as rapidly as it had risen. It may be proper for me to add, that, if the scientific observations which were being made under the auspices of the Cattle Commissioners, and otherwise, had justified an opinion that the vaccination of cattle ought to be recommended, special arrangements would have been necessary to supply lymph for that purpose; and that, had the case arisen, I should have submitted to the Lords of the Council suggestions which I had in readiness for such arrangements.

In 1865, as in preceding years, my Lords took special means to satisfy themselves as to the undiminished efficiency of the lymph which is supplied under their direction. Dr. Seaton, whom I, under their Lordships' orders, instructed to make this inspection, visited all the stations whence the public lymph-supply is derived, and reported quite satisfactorily of the quality of the lymph which was in use. The list of stations supplying lymph was increased by the addition of one of the parochial stations at Salford. And lymph has also been supplied from an important vaccinating-station at Glasgow.

3. All the Educational Vaccinating-Stations of England were Educational Vaccinatingcomprised in the just-mentioned inspection. The only change Stations. which took place in regard to these stations in 1865 consisted in the appointment of Dr. Edward Lowe Webb to the Pimlico station in the place of Mr. W. P. Jorden, deceased.