LONDON SUPPLY INSUFFICIENT.

389

in rural and small town districts, under present arrangements, wholly preclude such a result. It appears that weekly vaccinations, even of a limited number of individuals in succession, are altogether impracticable in these less densely-populated districts. The provinces, therefore, have become more directly dependent upon the London Institution for the supply of recent lymph. And there are many valid grounds for doubting the advantage of such absolute dependence. It is very questionable whether the poor of the metropolis alone ought to furnish the pabulum of the vaccine disease for the entire population of the kingdom; and whether the purity and efficacy of lymph is best secured by reliance upon a single source in a monster city.

§ 19. These objections may be found to outweigh the probabilities of the National Vaccine Establishment being able adequately to sustain the demands now made upon it; for a reference to its reports shows how wide and vast its operations are in the colonies, the army and navy, the emigrant department, and merchant service.

or from But no one

This is not the place for inquiring whether the alleged diminution in the permanently protective influence of variola vaccina be founded in fact; nor, if so, whether it may arise from the careless and imperfect performance of vaccination, defects in the public source and system of supply. would question the extreme desirableness of such a local organization as would aid in maintaining a general supply of good and effective lymph. And I have now merely to show how completely that and other main objects of a public system of vaccination might be obtained through the medium of the sanitary organization suggested in these Essays.

§ 20. No further special legislation would be required, except

* See Memorial (1855) of Epid. Soc., pp. 6 and 9; also, Mr. Marson's paper, 1853, showing the superiority of continental vaccinations; also Medical Times and Gazette, Jan. 12, 1856.

+ See supplementary Note H.

390

PROVINCIAL VACCINE INSTITUTIONS.

the repeal of certain objectionable provisions of the Compulsory Vaccination Act.

In common with district medical attendance, vaccination ought to be removed from all connexion with the Poor-Law. The unpopular and irrational "three months" limitation should also be abrogated.

The two main objects of an amended system of public vaccination, to be inferred from the preceding remarks, are—(first) the establishment of local institutions for successional vaccination, and for the continual supply of pure and effective lymph, under scientific direction; and (secondly) the inspection of all vaccinated subjects by a third party-a medical referee, holding an office which would preclude all professional rivalry, and whose report would afford to the public that security which the law ought to require.

21. The first of these objects might be attained as follows:A station, in the proper sense of the term, i. c., an office at which vaccination is most carefully performed, with the purest lymph, and weekly throughout the year if possible; and at which the subjects for vaccination are accurately registered and scientifically inspected;-such a station, I say, could not be maintained by its own operation, and with advantage to the public, in any population of less than 60,000.* A population of that amount, even in crowded districts, would scarcely afford, on the average, more than twenty weekly applicants for gratuitous vaccination. While, during the winter months, the number attending at the station would probably be barely sufficient to keep up a succession of cases, and to perpetuate an unexceptionable form of the disease. A population of even 60,000 might not be always self-dependent for a provision of genuine lymph.

In all other districts, and for all those subjects who are not required to attend from time to time at the central station in

* Mr. Ceely stated this to be his opinion in his communications with the Secretary of State and the Registrar-General in 1853.

1

INSPECTION BY OFFICERS OF HEALTH.

391 order to keep up a succession of lymph, or who do not apply, at their own discretion, to private or public practitioners,-vaccination should be annual, as in continental States; and it should generally be performed in the spring quarter.

In rural districts,-only that portion of the population which surrounds the station within a moderate distance, should be expected to resort to it for vaccination. The remainder would. be attended to by the district vaccinators or medical officers, at temporary or tributary stations, or at their own houses, or at the residences of the patients themselves.

§ 22. Now, it should be observed, that the minimum amount of population assumed to be necessary for the maintenance of a permanent station, is very nearly equal to that which, for other reasons, I have estimated as the most suitable to be comprehended in a SANITARY JURISDICTION; and thus my second main object would be secured. For every such sanitary district, it is presumed that an independent OFFICER OF HEALTH, free from the entanglements and responsibilities of private practice, would be appointed. Here, then, we at once possess the proper means for scientific inspection and impartial report. And by this means, also, many of those important functions which the Epidemiological Society would assign to ONE medical Superintendent of Vaccinations, might be easily and thoroughly carried into effect.* Three hundred Officers of Health would effectively promote and superintend the diffusion of vaccination in all parts of England and Wales; while, in any matter requiring superior direction, they might refer to the Circuit Inspectors, hereafter to be suggested, or even to the Council of Health, to which their reports of vaccination would be made.

The central or permanent vaccine station of each sanitary district would be under the special superintendence of the Officer of Health; and he would attend weekly to inspect the vaccinated subjects. If possible, every such station should be identical with the. chief public Dispensary, belonging to the same sanitary

*See pp. 5 and 6 of their Memorial, 1855.

392

ADAPTATION OF SANITARY MACHINERY

jurisdiction. At this Dispensary, on the system proposed in the Fourth Essay, there would always be a resident dispenser, who would be precisely the person to act as REGISTRAR OF VACCINATIONS, under the Officer of Health.

§ 23. The medical officer of that visitation district in which the central dispensary might be situated, would naturally hold the office of CHIEF VACCINATOR of the sanitary jurisdiction; while the surgeons of other visitation districts would, on the principle here laid down, be the local vaccinators within their own spheres of duty, unless these were so closely adjacent to the central station as to render some arrangement with it more desirable.

In remoter districts, it might be left either to the proposed sanitary court, or to the Officer of Health, or to the medical officer himself, to appoint one or more temporary places for vaccination as tributary stations, both in times of epidemic small-pox, and at other favourable seasons. But supposing, as I have suggested in the Fourth Essay, that the greater number of sanitary jurisdictions would contain more than one dispensary (and many might require several dispensaries), these would obviously be the places for local vaccination; standing in much the same relation to the central station, rendering similar aid, and making similar returns, as the stationary vaccinators of the National Vaccine Establishment afford to it.

§ 24. All medical officers and practitioners should be required to report, or certify to the Officers of Health of their respective sanitary districts, every vaccination which they may perform; but the parents or guardians of the children so vaccinated should be made responsible for the delivery of the vaccinator's certificate to the Officer of Health. The vaccinator would thus be relieved from further responsibility about the case. The success or non-success of the operation should be determined and registered by the Officer of Health, who would himself, or by deputy, visit the tributary or district dispensaries on the appointed days. If required to call at private houses, he should be remunerated

TO PUBLIC VACCINATION.

393

accordingly by the persons thus accommodated. Every child publicly vaccinated, and not brought to the central station or district dispensary for inspection, should be immediately reported to the Officer of Health, who should be empowered to make (or to direct to be made) an inspecting visit to the residence of the patient, at the cost of the parties neglecting or declining to attend at the station.

§ 25. The Registrars of Births-whether themselves medical officers of vaccination districts, or mere Registrars co-operating with the medical officers on an improved local system of registration—might render most important aid in bringing the whole infantile population, by gentle and hortatory measures, under the influence of this invaluable sanitary protection.

In no department of the public health would the orderly cooperation of the three descriptions of sanitary agency mentioned in these Essays, (p. 137 in particular,) be more fully and harmoniously displayed than in the promotion of public vaccination.

NOTE TO p. 375.

1. "Eighth day after the operation." The Bill of 1854 substituted the seventh day for the eighth. The Epidemiological Society and Mr. Brady still adhere to the eighth day. The last official Bill would confirm the seventh day.

Non nostrum inter vos tantas componere lites.

2. "Nor is any provision made to insure its performance." The RegistrarGeneral has stated his belief that the refusal to grant a certificate would render the practitioner liable to indictment for misdemeanour (see official letter from Mr. Mann, October 6, 1853);-although no opinion is pronounced as to the justice of punishing a private practitioner for not performing a public duty gratuitously.