Vaccination Reform.

The prevalence of small-pox in London for some years, and its present attack on the good people of Sydney, point to some defects in the existing machinery which it is of the last importance to the health of the community should be discovered and remedied. It is vain to expect that we in New Zealand can always enjoy immunity page 13 from this unwelcome disease. Whether its visit will be short-lived or permanent will depend on the fidelity with which vaccination is here performed. For our own part, we know that in New Zealand we have a soil rich for the propagation of the pest, viz., a large proportion of the community wholly unprotected by vaccination. We know scores of children who have not been vaccinated at all; and there are many in whose cases the vaccination has been most imperfect. We shall therefore proceed to briefly indicate the measures which ought to be adopted, in our opinion, in order to guarantee to the community the full benefits and security of vaccination.

1st. It is essential that the penal clauses of the Compulsory Vaccination Act be strictly enforced. Every child on the register of births should, within the period prescribed by the Act, be registered as vaccinated, as dead, or as insusceptible of vaccination. Should every birth registered not be so accounted for, the Registrar should take steps to trace the child, and compel compliance with the Act.

2nd. The Vaccination Act in the Colony should be amended so as to restrict the period within which primary vaccination must be performed to three months There are serious objections against prolonging the period to six months. Parents, as a rule, delay getting their children vaccinated till near the expiry of the period. It then often happens that it has to be delayed owing to illness from dentition, diarrhoea, or mal-nutrition, all which ailments are more prevalent during the later age. It will thus be seen that by delaying the operation until the sixth month, there remains in the community a large number of unprotected infants who, were smallpox once in our midst, would become a standing menace, since through their agency small-pox would probably become epidemic. In every populous country there are many thousands of children under six months old. In Dunedin and suburbs there must be about 500, while at three months there would be but half that number. Statistics lend weight to our argument, as it has been proved in recent epidemics in London that 11 per cent, of the victims of small-pox die before their fourth month. Moreover, by reducing the period to three months, we are sure that a serious objection to vaccination—noticed by us above—would be almost entirely removed, inasmuch as it has been found that eruptions on the skin rarely follow vaccination when performed in the early weeks of infancy, and thus vaccination would be freed from the unjust imputation of having caused such eruptions. Three months of age is recommended by the principal vaccinators in Great Britain, and many practitioners perform the operation much earlier than this. Having performed page 14 hundreds of vaccinations between six weeks and three months, we have come to the conclusion that the younger the child the greater the safety and effectiveness of the operation, and we have every confidence in recommending the adoption of the third in place of the sixth month.

3. Uniformity of Operation.—Steps should be taken by Government to insure as far as possible a fixed standard of successful vaccination, anything short of which would not be recognised as vaccination in the sense of the Act. At present, the manner of performing the operation is left to the fancy or discretion of the operator. Under this system, or rather want of system, it happens that the vaccination of one man is something quite different from that of another operator. One surgeon scratches the arm; another punctures, but at his option puts two, three, four, or more punctures. The same rule prevailed at home before the Commissioners' report, after which Government adopted a uniform system for all public vaccination. That this is not a matter of indifference has been proved by recent observations in several epidemics of smallpox. According to these vaccination is efficient as a protection from smallpox in proportion to the number of sores produced on the arm. Of the patients admitted into the London Small-pox Hospital in the two last epidemics the great majority had never been vaccinated, and the rate of mortality was high. Next to the unvaccinated came those who had been vaccinated in infancy, and whose arm bore only one scar. In this class the mortality was still high, but very much less than in Class 1. The third class bore two scars, and amongst these the disease was greatly modified, and the mortality small. The fourth class bore three or four scars; the disease ran a mild course, there was no pitting, and a death was very exceptional. Lastly, none were admitted whose arm bore six good scars, thus showing that such persons enjoyed an absolute immunity from smallpox.

It has been our frequent practice to employ six punctures, in this respect following the practice of the Faculty Hall Vaccination Station at Glasgow, where during a three months' apprenticeship, we witnessed or performed many hundred operations, all by six punctures, not one of which was followed by a bad symptom.

Mothers often object to this number, but when it is explained to them that there are less risk and suffering from six small punctures than from two or three large blotches, and that the former method gives absolute immunity, their scruples usually give way. No. 2 of the Instructions for Vaccinators, issued by Her Majesty's Most Honourable Privy Council, recommends:—In all ordinary cases of primary vaccination, if you vaccinate by separate punctures, make such punc page 15 tures as will produce at least four separate good-sized vesicles; or, if you vaccinate otherwise than by separate punctures, take care to produce local effects equal to those just mentioned. This rule we beg to recommend in the strongest terms for adoption in New Zealand. If Government would insist on all public vaccinators operating by four—or, better still, six—separate punctures, the practice of this method would soon extend to private practitioners, and there would be thus secured a uniform standard, which could not fail to produce good results in the course of time.

4th. A supply of pure vaccine lymph should be provided by Government for all regular medical practitioners. A consideration of this recommendation opens up a vexed, but highly important, question, on which the highest authorities differ. The question is this: Does vaccine lymph, after being repeatedly transmitted from one human being to another, lose any of its prophylactic power? As early as 1809, Mr Brown, of Musselburgh, published the opinion that the prophylactic virtue of cowpox diminished as the time from vaccination increased. Dr Jenner dissented from this view, and ever since medical opinion has been divided on this point. In our judgment, Mr Brown was right, although he missed the explanation, which we shall here give. Humanised lymph deteriorates because in the course of time a large quantity of imperfect lymph passes into circulation. And to this want of care or skill in the selection and storing of lymph do we attribute any impairment of its protective power, and not to the mere fact of its having passed through many subjects. But let us see what is the opinion of the best authorities, dead or living. In the opinion of the permanent members of the National Vaccine Board, it maintains its quality undiminished; and in this opinion Sir Thomas Watson coincides (1871), declaring that he had opportunities of satisfying himself that lymph which had been transmitted without interruption from person to person ever since the time of Jenner, continued to generate what seemed a very perfect cow-pox vesicle.

On the other hand, Mr. Simon, who will be recognised as the highest authority on the subject, came to the conclusion "that the occasional impermanence of protection may depend upon impairment in the specific power of vaccine contagion, an impairment arising in the transmission of that contagion through many generations of men." M. Brîsset, in France, as early as 1818, alleged that the past ten years had made a marked difference in the visible characters of the vaccine vesicle. Dr. Meyer, of Kreutzburg, states that he has found the older scars much better marked than the more recent ones. Frequent opportunities of our own of testing this observation of Meyer, have convinced us of its truth.

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According to the testimony of many vaccinators, the proportion of unsuccessful to successful vaccinations is every year increasing. Dr. Gregory and Mr. Estlin, in England, have adduced similar facts in evidence that the vaccine lymph, by passing through the bodies of many persons, loses in process of time some essential part of its activity.

The experience furnished by the Prussian Army shows very clearly that vaccine lymph undergoes a gradual deterioration. It appears that where vaccine supply has seldom or never been renewed from the cow, the proportionate resusceptibility of vaccine disease at a given age has undergone a progressive increase. "And (in the words of Mr. Simon) it is difficult to conceive how the infantine generations of a country could, crop by crop, successively derive less permanent constitutional impressions from vaccination, unless the efficient causes of those impressions—the vaccine contagion itself—had year by year undergone enfeeblement of its powers."Moreover, the statistics of the Prussian Army in regard to revaccination of its recruits tells the same story. When the system of re-vaccination was adopted in 1833, the proportion of successful results was thirty-three in every hundred. Now the annual percentage is seventy. This proves conclusively either that vaccine lymph has deteriorated very materially, or that primary vaccination is not so efficiently performed now as in the early days of the operation, a hypothesis we have no ground to sustain.

Mr. Marson's (the highest authority in England) testimony agrees with this. According to him, vaccine lymph becomes humanised, and consequently weakened as a prophylactic, by passing many times through the human body; the scars are not so good as they were formerly; and the mortality after vaccination, estimated on a large scale, shows a considerable increase.

All which consensus of opinions points to the desirability of renewing the supplies of vaccine lymph directly from the cow.

Having more than three years ago recognised the desirability of introducing an entirely new supply of vaccine matter into our practice, we made application for a supply of pure calf-lymph, such as is used in Germany under Government supervision. This we obtained through Messrs. Hilliard and Sons, Surgical Instrument Makers, Glasgow and Edinburgh. Since receiving which we have operated with it in several cases with the result:—1st. That the percentage of failures is higher than with ordinary lymph. 2nd. That the vesicle produced in successful cases differs materially from the common vesicles in being smaller and less active, and leaving a deeper scar. 3rd. That after this calf-lymph has passed once or twice through the human system, its great superiority to old humanised lymph becomes apparent, as it shows page 17 such activity as to make it necessary to use the lymph more sparingly, comes to maturity more rapidly, and leaves a much deeper cicatrix, the separate pits of which are well marked. We have therefore formed a highly favourable opinion of animal as opposed to humanised lymph; and as the use of such calf-lymph would remove the strongest objection of parents to the operation, viz., the fear of introducing disease, it is in our opinion the clear and urgent duty of the government to afford a supply of such lymph to all registered practitioners. For the question of introducing calf-lymph is ripe for consideration; and, if left to individual action, mischief will undoubtedly arise, the propagation and storing of calf-lymph being beset with difficulties and dangers only to be adequately realised by those who have made or may make the attempt.

The advantages of having a lymph supply free from all suspicion of taint or impairment of energy will be admitted by all, and are simply incalculable at a time when the growing distrust of human lymph threatens to oppose a serious difficulty in the proper enforcement of the Compulsory Vaccination Act. Meanwhile we are content to claim for ourselves the merit of having, as far as we can ascertain, successfully introduced into this Colony a new supply of lymph derived directly from the original source.

5th. Re-vaccination.—The question of re-vaccination crops up ever and anon, as often as the public mind takes alarm at a threatened invasion of small-pox. Of its utility there cannot be a question, as the statistics of the British Army and Navy adduced by us in a previous page abundantly testify. Tn some Continental States re-vaccination has been made compulsory, and the results have been highly satisfactory. Indeed we have no hesitation in affirming, that were re-vaccination thoroughly carried out, in two generations small-pox would only be known from historical records. Apart from the question of the deterioration of the lymph now in use, it has been satisfactorily established that while one primary vaccination in infancy protects the great majority of individuals throughout life, there still remains a numerous class who become resusceptible to small-pox. As these individuals cannot in any way be distinguished from protected persons, it is necessary to re-vaccinate the entire population. This secondary vaccination ought to be performed about the age of puberty, with pure calf-lymph or with humanised infantine lymph, never with lymph drawn off are-vaccinated person.

As in all probability the country is not ripe for compulsory re-vaccination, the way might be paved for its becoming general by its being made compulsory in the case of every candidate for the public service, including teachers and railway officials.

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6th. We have, lastly, to recommend that Inspectors of Vaccination he appointed, whose duty should consist in visiting the different public vaccination stations throughout the country, watching the Public Vaccinator's mode of operation, inspecting the results attained as seen on the arm on the eighth day, examining the cicatrices, testing the quality of the vaccine lymph, and taking measures to correct whatever might appear to him faulty. This has been carried out in Great Britain for several years, and has resulted in a vast improvement in the quality of the vaccination. In connection with this inspection a system of extra payments by results was introduced, which has had the desired effect in reconciling public vaccinators to the inspection, and has stimulated them to obtain the best results possible. These extra payments take the form of grants, and do not interfere with the regular remuneration per head, which is paid to all public vaccinators alike.