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It is common knowledge that the occurrence of one case of inflammation of the central nervous
system in every thirty thousand people vaccinated in the last fifteen years or so led to official reexamination
of the method of preparing and applying vaccine lymph. As a result, the traditional
four scarifications were reduced to one.
The widespread occurrence in this country of mild smallpox which appears to be a genuine
variant of the classical disease, breeding true, the traditional objection in certain parts of the country
to compulsory vaccination, the prominence given on the official vaccination form to, and the ease
with which, exemption can be secured, the absence of genuine Eastern smallpox (still a dread and
fatal malady, sporadically imported), together with the rare occurrence of vaccinal encephalitis
alluded to in the previous paragraph, clearly furnish grounds for re-examination of the established
ritual of vaccination.
They furnish in the opinion of many experienced observers, grounds for a change in policy and
for a belief that vigorous supervision and vaccination of contacts of cases of the disease would control
smallpox with more efficiency and economy.
Here clearly is the dominating factor in determining policy. Vaccination does one thing and
one thing only, namely, if applied before contact or within a certain limited period after contact, it
prevents smallpox. The rapidity of modern communications not only allows the easier importation
of smallpox, either active or incubating, but gives immediate knowledge, even foreknowledge, of its
arrival. There is, therefore, a prima facie basis for the view that the isolation and supervision of
these sporadic cases and the prompt vaccination of every contact will stamp out the disease.
I am not personally convinced that these facts justify a change in policy. Smallpox, like most
other infectious diseases, is in natural conditions a disease of infancy and childhood. There is no need
to reproduce here the figures which show the undoubted effect of universal vaccination in reducing
the incidence of smallpox and in changing it to a disease of later life. The latter effect is, of course,
due to the fact that full immunity from vaccination persists only for about seven years, and exposure
after this time, in the absence of re-vaccination, may lead to an attack. Such figures have been often
reproduced, arc well known and are unchallengeable. Equally certain is the fact that universal
vaccination and re-vaccination, as on the Continent, diminishes the seriousness of smallpox to the
point at which sporadic cases can be nursed without concern in a block attached to an ordinary fever,
or even a general hospital.
The difficulty of an ad hoc policy of vaccination appears to me to be that of control of contacts.
Every medical officer is familiar, either by personal experience or by tradition, with the tramp, with
ambulant smallpox, who scatters infection in his peregrinations. Large liners bring hundreds of
passengers who disperse to the four corners of the land, to tour daily, during a precious leisure, from
place to place. Post-contact vaccination in these cases, with the difficulty of ascertaining precisely
when exposure began and ended, will not always prevent an attack; compulsory powers of segregation
will merely be an incentive to concealment and escape, and knowledge of daily destination is not
always obtainable. Even when obtainable, medical officers and sanitary inspectors are not available
in every hamlet.
I recently had the temporary supervision of four Australians who had for at least two weeks
been in continuing contact on shipboard with serious cases of typhoid fever. The trip to England
was to them the event of a lifetime and any interference with their liberty, owing to contact with
any sickness, would have been intolerable. Before the incubation period was over, they scattered
to unknown addresses in known places, warning me of their intention in advance. Communication
with the local medical officer of health was clearly valueless, but I could fortunately rely on their
intelligent co-operation on the appearance in themselves of the slightest sign of illness.
It is not a flight of fancy to substitute smallpox for typhoid fever and to visualise an exact
duplication of this incident. A train journey, a visit to a cinema or cricket match, any one of a
thousand normal occupations during the three days preceding the appearance of a smallpox eruption
opens up weary vistas of unsuccessful contact ascertainment, supervision and vaccination. Nor can
the possibility of illicit entry by aeroplane be ignored in the consideration of this subject