of ensuring the activity and comparative purity of the lymph.
Glycerinated lymph, under proper conditions, usually retains
its potency for many weeks or months; but nevertheless, in
certain circumstances at present imperfectly understood, is liable
to become gradually weakened, and even eventually to become
altogether inert. Possibly the condition of the calves from which
the lymph is obtained, especially as regards their general health
and the suppleness or the reverse of their skins, or exposure
of the lymph to the action of light or to a high temperature,
are of special importance. Consequently, in order to ensure
the best results from its use, it is not only necessary that great care should be exercised in its manufacture, but it is also advisable that the lymph should be employed for vaccination as soon as possible after bacteriological examination has demonstrated its freedom from suppurative and other extraneous microorganisms. As regards the carrying out of the operation itself, it is somewhat unfortunate that there exists no official definition of what constitutes a “successful vaccination,” and in consequence it is open to any practitioner to give a certificate of successful vaccination in cases where but one minute vesicle may have been produced. It is to be feared that such certificates are too frequently given, and it cannot be too strongly urged that vaccination of this sort involves incomplete protection. The standard laid down by the Local Government Board—the production, namely, of a total area of vesiculation of not less than half a square inch, divided among four separate vesicles or groups of vesicles, not less than half an inch from one another has for the most part proved easily attainable in practice, and it is much to be desired that in private as in public work the attainment of this standard should be aimed at in every instance.
The protection afforded by a primary vaccination tends gradually to diminish, and eventually to disappear more or less completely, with the lapse of time. In consequence, it is desirable that the operation should be repeated at the age of from seven to ten years, and thereafter, if it be possible, at intervals during later life. The final report of the Royal Commission thus summarizes the evidence as to the value of such additional procedure:-
“Where re-vaccinated persons were attacked by, or died from, small-pox, the re-vaccination had for the most part been performed a considerable number of years before the attack. There were very few cases where a short period only had elapsed between the re vaccination and the attack of small-pox. This seems to show that it is of importance, in the case of any persons specially exposed to the risk of contagion, that they should be re-vaccinated, and that in the case even of those who have been twice re-vaccinated with success, if a long interval since the last operation has elapsed, the operation should be repeated for a third, and even a fourth time." It not infrequently happens that in the case of a re-vaccination the process runs a somewhat different course from that witnessed in a typical primary vaccination. In a successful re-vaccination, the site of the operation may be distinctly reddened and somewhat irritable by the second day, while papules will probably make their appearance about the third to the fifth day. The papules may or may not develop further into vesicles and pustules. Occasionally a re-vaccination appears to fail altogether; but, as pointed out by the Royal Commission, it is advisable, as in the case of a primary vaccination, to make further attempts with lymph of known potency before concluding that the individual is really insusceptible. In a certain small proportion of cases the operation of vaccination has been followed, after a longer or shorter interval, by various complications, of which by far the lnlurious most important are those of an inflammatory nature, such as erysipelas, which are not peculiar to vaccination, but which constitute the danger of any local lesion of the skin, however caused. During the many decades in which vaccination from arm to arm was practised, in many millions of children, a few authenticated cases were recorded in which there was reason to believe that syphilis could have been in vaccinated. Such an occurrence could at no time have happened if proper care had been taken by the vaccinator; and now that the use of calf lymph has become practically universal, the possibility of such occurrence in the future may be disregarded, since the calf is not capable of contracting this disease. Tubercle in its Various forms and leprosy have also been included in the list of possible complications of vaccination, though without any sufficient proof. The employment of calf lymph, treated with glycerin after the manner first advocated by S. Monckton Copeman, will obviate any such danger, for even if tubercle bacilli or the Streptococcus of erysipelas were by chance present in the lymph material when collected, it has been found experimentally that they are quite unable to survive prolonged exposure to the action of a 50% solution of glycerin in water. Leprosy is not 'communicable to the calf. In view of the frequency of various skin eruptions in infancy, it is to be expected that in a proportion of cases they will appear during the weeks following vaccination. Eczema been attributed to between the operation and the occurrence In section 434 of the final report of the on Vaccination the extent to which other are liable to complicate vaccination is thus summed up:—
“A careful examination of the facts which have been brought under our notice has enabled us to arrive at the conclusion that although some of the dangers said to attend vaccination are undoubtedly real, and not inconsiderable in gross amount, yet when considered in relation to the extent of vaccination work done, they are insignificant. There is reason, further, to believe that they are diminishing under the better precautions of the present day, and with the additions of the future precautions which experience suggests, will do so still more in the future!" (S. M. C.)
Legislation making vaccination compulsory was first introduced in Bavaria (1807), Denmark (1820), Sweden (1814), Wiirttemburg, Hesse and other German states (1818), Prussia (183 5), the United Kingdom'(1853), German pfifgmy empire (1874), Rumania (1874), Hungary (1876), ;;';;"F"" Servia (1881), Austria (1886). But in many cases there had been earlier provisions indirectly making it necessary. In the same way, though there is no federal compulsory law in Switzerland, most of the cantons enforce it; and though there is no statutory compulsion in France, Italy, Spain, Portugal, Belgium, Norway, Russia or Turkey, there are government facilities and indirect pressure, apart from the early popularity of vaccination which made it the usual practice. In the United States there is no federal law, but many of the separate states make their own compulsion either directly or indirectly, Massachusetts starting in 1809.
The benefit of vaccination proved itself in the eyes of the world by its apparent success in stamping out small-pox;, but there continued to be people, even of the highest competence, who regarded this as a fallacious argument-post hoc, ergo propter hoc. The cause of “ anti-vaccination ” has had many followers in England, and their persistence has had important effect in English legislation. Under the provisions of the Vaccination Act 1898, and of the Vaccination Order (1898) of the Local Government Board, with some minor changes in succeeding acts, numerous changes in connexion with vaccination administration and with the performance of the English legislation. operation were introduced, in addition to the supersession of arm-to-arm vaccination, by the use of glycerinated calf lymph. Thus, whereas by the Vaccination Acts of 1867 and 1871 the parent or person having the custody of any child was required to procure its vaccination within three months of birth, this period by the act of 1898 was extended to six months. Again, parents were relieved of any penalty under the compulsory clauses of the Vaccination Acts who afforded proof that they had, within four months of the birth of a child, satisfied a stipendiary magistrate, or two justices in petty sessions, that they conscientiously believed that vaccination would be prejudicial to the health of the child. Moreover, proceedings were not to be taken more than twice against a defaulting parent, namely, once under section 29 of the act of 1867, and once under section 31 of the same act, provided that the child had reached the age of four years. Finally, the
