After the great surge of smallpox during the last quarter of the eighteenth century the disease relaxed its grip somewhat in the earlier years of the nineteenth, and the efforts of the medical profession were directed largely to weaning the lower classes away from variolation and selling them vaccination. The task was not easy; as Baron commented, the adoption by so many reputable medical men of vaccination left the field clear for the more unscrupulous practitioners who ‘took up the small-pox lancet and disseminated the disease in a very frightful manner’.
The profession did its best to fight back. In 1805 the Medical Council of the Royal Jennerian Society appointed a committee of 25 members to investigate cases that had excited prejudices against vaccination and also the ‘evidence respecting instances of small-pox alleged to have occurred twice in the same person’. The committee found that most of the alleged failures were ‘either wholly unfounded or greatly misrepresented’; that ‘nothwithstanding the most incontestable proofs of such misrepresentations, a few medical men have persisted in repeatedly bringing the same unfounded reports […] before the public; then perversely and disingenuously labouring to excite prejudices against vaccination’; that ‘many persons have been declared duly vaccinated, when the operation was performed in a very negligent and unskilful manner’; that ‘the Medical Council are fully convinced that the failure of vaccination as a preventive of the small-pox, is a very rare occurrence’; that ‘a few instances of failure either in the inoculation of the cow-pox as of the small-pox, ought not to be considered as objections to either practice, but merely as deviations from the usual course of nature’; that ‘it appears to the Medical Council that the cow-pox is generally mild and harmless in its effects’; with much more in the same vein, concluding with a solemn Declaration, signed by 50 members of the Medical Council:
That, in their opinion […] mankind have already derived great and incalculable benefit from the discovery of vaccination: and it is their full belief that the sanguine expectations of advantage, and security, which have been formed from the inoculation of the cow-pox, will be ultimately and completely fulfilled.
Some years after Simon's death a former colleague wrote of him that he never took part personally in any ‘close epidemic inquiry’, and failed to understand how much time and work was called for. This judgement was presumably based on personal observation, yet it is difficult to believe, studying the reports of the investigations carried out by his team of four vaccination inspectors, that he could have remained unaware of the labour involved in collecting the information.
One inspector's annual report showed that during the year under review his inquiries had extended over the counties of Cambridge, Derby, Huntingdon, Leicester, Northampton, Warwick and Notting - ham. This territory included 93 unions, subdivided into 457 vaccination districts. He had conferred with 373 public vaccinators, 235 sub-district registrars, the majority of the ministers of religion and with ‘many people of influence living in the different districts’. He had personally examined the conditions as to vaccination (i.e. the marks on the arms) of 46,871 children in national, parochial, workhouse and other schools, and of ‘a great many in and about the dwellings of the poor and neglected’, classifying them as ‘good, indifferent or bad’. In another year the same inspector, Dr Stevens, was allotted as his sphere of operation the 79 unions in the West Riding of Yorkshire, Lancashire, Cheshire and part of Cumberland, ‘embracing a population of 4,498,695, extending over 3,697,342 acres, divided into 507 vaccination districts [served by] 511 public vaccinators and 366 sub-district registrars’. In addition to the routine work of inspecting the quantity and quality of vaccination marks, if any, of all the children in this vast area,
I had interviews with the clerks to the guardians, several of the guardians and some magistrates in all the unions visited; and I have had conversations with 403 public vaccinators and 344 sub-registrars, as well as with clergymen and other persons having influence. In visits to schools I have carefully explained to the teachers […] the nature of my inquiry and the appearances that should be found on the arms of the successfully vaccinated, and I have pointed out to them the groundlessness of the prejudices against vaccination.
Although no legislation on the subject of vaccination was enacted between 1871 and 1898, apart from the short Act of 1874, which was designed to clarify the Act of 1871, the anti-vaccination movement continued to bring the opposition to compulsion before the House of Commons, concentrating mainly at first on the question of repeated penalties for default. Three attempts in six years to amend the law ‘so far as accumulating penalties are concerned’ made no progress. There was considerable astonishment and derision when in 1880 J. G. Dodson, President of the Local Government Board in Gladstone's second administration, appeared to be doing the anti-vaccinationists’ work for them by introducing a Bill to limit penalties, virtually along the lines of its predecessors. The Lancet explained that although it was generally regarded as ‘a Bill for the evasion of vaccination’ it had in reality ‘a different and more commendable object – namely the abatement of the nuisance of the so-called “vaccination martyrs”’. The Lancet was prepared to support the Bill: ‘Take away the element of “martyrdom” and interest in these self-cultivated sufferers will collapse […] Conscientious parents will continue to put their faith in vaccination.’ This degree of confidence was not widely shared and when the medical profession threatened all-out opposition to a ‘bill for promoting smallpox’ Dodson withdrew it.
The leading anti-vaccinationists now decided to change their tactics and demand total repeal of the compulsory clauses of the Acts, not in the hope of achieving it at this stage but with the intention of arousing public interest and inducing the government to set up a Royal Commission to investigate the whole subject. In 1883 a Bill to repeal the compulsory clauses gave rise to a debate that roused the Commons from its customary torpor where vaccination was concerned. Thanks largely to a vigorous speech from the government side by Lyon Playfair the motion was rejected by 264 votes to 18. Yet only two years later the great Leicester demonstration showed the extent of public support that the movement could call on. Its growing strength became more obvious still in the late 1880s when a smallpox epidemic in Sheffield, generally regarded as ‘a well-vaccinated city’, resulted in 600 deaths in a matter of months.
Among the most prominent opponents of vaccination were two members of the medical profession, one more eminent than the other. Edgar Crookshank, Professor of Comparative Pathology and Bacteriology and Fellow of King's College, London, wrote a History and Pathology of Vaccination in two volumes (1889). The Preface to the first volume described how, following some investigations into an outbreak of cowpox, he became convinced that
the commonly accepted descriptions of the nature and origins of Cow Pox were purely theoretical […] I gradually became so deeply impressed with the small amount of knowledge possessed by practitioners concerning Cow Pox, and other sources of Vaccine Lymph, and with the conflicting teachings and opinions of leading authorities, in both the medical and veterinary professions, that I determined to investigate the subject for myself.
The essence of Crookshank's argument against vaccination was that the power of conferring immunity to smallpox, claimed for cowpox by disciples of Jenner, was a fallacy because what was injected under the guise of cowpox was in fact smallpox. The origins of this controversy lay in the earliest period when, with supplies of cowpox very scarce for lack of suitable outbreaks to draw on, some confusion had occurred over a consignment of alleged cowpox despatched by Jenner from London to a colleague in the country. Detractors claimed that, whether by accident or from lack of scruple, Jenner had in fact supplied his friend with smallpox lymph, and that since the material in question had formed the basis for thousands of ‘ingrafting’ operations carried out from arm to arm right down to Crookshank's own time, any immunity ascribed to cowpox should really be ascribed to the effects of smallpox. This theory was revived in recent times but has been investigated by Baxby who finds no basis for it.
Crookshank's general conclusion as a result of his investigation was that the medical profession had been misled by Jenner, by his biographer, Baron, by the Reports of the National Vaccine Establishment and by a want of knowledge concerning the nature of cowpox, horsepox and other sources of ‘vaccine lymph’:
the pathology of [cowpox] and its nature and affinities have not been made the subject of practical study for nearly half a century.
During the early part of 1716 a caravan of coaches and wagons, bearing an English family and their numerous retinue, rumbled across Europe towards Constantinople. The journey could have been more easily and cheaply made by sea, but Edward Wortley Montagu, newly appointed Ambassador Extraordinary to the Sublime Porte, had decided that the special mission he was entrusted with might stand a greater chance of success if he called in at Vienna on the way.
The Ottoman Empire at that time still thrust deep into south-east Europe. Attempts by the Turks to push the frontier even further westward had been foiled in 1683, when their assault on Vienna was repulsed. But the two imperialisms, Turkish and Austro-Hungarian, still faced each other with mutual antipathy, which in 1716 seemed likely to break out again into open hostility. For complex reasons the British government was anxious that the Austrians should not be caught up in a war in eastern Europe, and the new ambassador's task was to try to head them off and reach some form of settlement with the Turks.
Wortley Montagu was accompanied by his wife, Lady Mary, and their three-year-old son, Edward junior. Lady Mary enjoyed travelling and was said to be ‘charmed with thoughts of going into the East’, which was just as well. The initial appointment was for a period of five years, but for all they knew they might be going into a long and possibly permanent exile.
The ambassador's negotiations in Vienna were largely unprofitable and after a brief stay the party set out towards the end of March 1717 on the next stage of their journey. This took them as far as Adrianople (now Edirne), at that time the capital of the Turkish empire, to which the Sultan usually retired in order to escape the summer heat of Constantinople. From the time of their entry into Turkey, Lady Mary embarked with enthusiasm on the course known to later generations as ‘going native’. She learned Turkish. She took to dressing Turkish style and had her portrait painted in Turkish costume. She became friendly with Turkish ladies of standing and seized every opportunity of being admitted to the intimacy of the harem, coming to the unexpected conclusion that Turkish women led freer and more pleasurable lives than did English women.
For many years isolated voices had been hinting, some more discreetly than others, at the need for some kind of state intervention to enforce vaccination of the lower classes, but seldom using the blunt word ‘compulsion’. The fear that inhibited stronger pressure was that enforcement might fail, not on medical but on political grounds. Warning that ‘John Bull is jealous of the liberty of the subject’, the Lancet, ‘on the low ground of expediency, irrespective of right’, called upon hasty legislators to pause. The legislators scarcely needed the warning: in spite of the manifest inadequacy of the Acts of 1840/41 no serious attempt was made for nearly a decade to pass beyond the voluntary principle into the dangerous waters of coercion.
Towards the middle of the century the balance decisively shifted. The medical profession, tired of having its hands tied by indifferent politicians and obstructive civil servants, turned from individual protest to concerted action. In September 1848 an anonymous letter to the Lancet urged the formation of a society for the study of the behaviour of epidemic disease. In July of the following year a public meeting, attended by 200 members of the medical profession and prominent figures from other walks of life, took place in Hanover Square under the presidency of the Earl of Shaftesbury, and the Epidemiological Society of London was inaugurated. The precisely stated objects of the Society were
to institute a rigid examination into the causes and conditions which influence the origin, propagation, mitigation, prevention and treatment of epidemic diseases. It will be a part of the Society's province to ascertain the operation of existing enactments [and to] point out such alternatives as may be necessary for the protection of the public health […] The Society propose to communicate with the Government and the Legislature in matters connected with the prevention of epidemic disease.
Numerous committees were set up to investigate subjects ranging from cholera to ‘disease appertaining to the Vegetable Kingdom’ and ‘the question of supplying the labouring classes with Nurses in Epidemic and other Diseases’, but there can be little doubt that the topic of immediate concern was the province of the ‘Committee on Small-Pox and Vaccination’. The Commemorative Volume of the Society, published to mark its fiftieth anniversary in 1900, describes the efforts of this committee as ‘almost epoch-making’.
Opening their account of the campaign conducted by the World Health Organization that in 1979 finally extinguished, or, as their forerunners might have said, ‘extirpated’ smallpox from the earth, the authors remark: ‘The majority of people – including the majority of physicians – now living have never seen a case of this once dreaded disease’. In the years since that number will have declined even further, and it therefore seems desirable to recall something of the history and characteristics of the disease which once inspired so much dread.
The early history of smallpox is one of the areas in which the uninstructed traveller trying to find his way is most likely to lose it. Accounts are littered with signposts indicating paths that ‘may’ lead in the right direction, or destinations that ‘could have been’ the one being sought. Dates hazarded for remote events, such as the emergence of smallpox as a disease of animals, or its transference to human beings, may vary by several thousand years. ‘Plagues’ or ‘pestilences’ referred to could have been examples of any one of a number of diseases incorporating some sort of rash, a difficulty complicated over the centuries by what one authority describes as ‘the uncertainties of translation’. The most common candidates for confusion include smallpox, measles, chickenpox, scarlet fever and erysipelas, any one of which the puzzled pathfinder may conclude is interchangeable with any of the others. Students of etymology may be interested in the attempt of Creighton, the great historian of epidemics, to unravel some of the more recondite examples.
The most commonly accepted sequence of events is that smallpox emerged as a disease of some species of animal in Africa in prehistoric times, was somehow transferred to human beings and eventually found a route to the Far East. Creighton disposed of this earlier migration somewhat summarily: ‘the evidence of the antiquity of smallpox in China and India may be accepted and for the rest left out of account’.
As has been noted, condemnation of compulsory vaccination dates from shortly after the passage of the Act of 1853, with the letter from John Gibbs to the President of the Board of Health. Born in Ireland in 1811, Gibbs was described by an acquaintance as ‘sagacious, bright, earnest and independent’, with a passion for ‘such things as made for human welfare and improvement’. He became interested in hydro - pathy and in particular in its use in cases of smallpox. In later life he made his home in St Leonards, in Sussex. His influential letter to the Board of Health was based on a pamphlet that he had published in 1854 under the title ‘Our Medical Liberties’.
‘The partisans of compulsory vaccination,’ he wrote, ‘cast away every gentlemanly feeling, disregard every principle of justice, violate the spirit of freedom, outrage the precepts of Christianity, trample upon common sense, betray their own rights and dearest interests.’ After this comprehensive denunciation he took each item in turn and expanded it, occasionally in the repetitive fashion that became one of the continuing characteristics and weaknesses of the whole long campaign.
The compulsory Vaccination Act, he asserted, was the first direct aggression upon the person of the subject in medical matters which has been attempted in these kingdoms. It invades in the most unexampled manner the liberty of the subject and the sanctity of the home […] it sets at nought parental responsibility and constrains the parent either to violate his deliberate convictions, and even his religious scruples, or to defy an unjust law.
Why was vaccination held in horror by so many parents and others?
They do not believe that it affords an efficient and assured protection against the invasion of small-pox: they have a natural disgust of transferring to the veins of their children a loathsome virus derived from the blood of a diseased brute and transmitted through they know not how many unhealthy mediums [i.e. by the arm-to-arm method]: they have a dread, a conviction, that other filthy diseases, tending to embitter and shorten life, are frequently transmitted through and by the vaccine virus [a reference to the dread of syphilis] […] and further they have a conscientious conviction that voluntarily to propagate disease is to fly in the face of God and to violate that precept which says ‘Do thyself no harm’.
If the language of eighteenth-century figures is to be relied on, a surprising state of affairs is revealed. By the end of the third decade the contentious novelty inoculation had virtually died out, while the number of deaths from smallpox, as recorded in the London bills of mortality, remained at a steady level. Why had inoculation fallen out of favour? In 1749 the physician Frewen looked back over its vicissitudes during the period:
it is wonderful with how great an expectation it was received, with how much industry it was cultivated, and how soon it became incredibly famous […] Yet, notwithstanding, it made but a slow progress for several years, as gaining but little credit among the common sort of people, who began to dispute among themselves about the lawfulness of propagating disease and whether or no the small-pox produced by inoculation would be a certain security against taking it again by infection, and also whether other diseases or morbid contaminations of the blood might not be likely to be engrafted along with it.
These questions, Frewen commented, had been answered long ago ‘to the satisfaction of men of learning and candour’, but not, as he avoided saying, to that of the common sort of people, mainly because they were neither consulted nor offered the opportunity to try out the new discovery for themselves. Access to inoculation was and remained for many years the expensive privilege of the well-off, with the corollary pointed out in the early days of controversy by Isaac Massey, apothecary and uncle of the Revd Edmund, in a scornful dismissal of Jurin's conclusions concerning the relative dangers of natural smallpox and the inoculated variety. Those inoculated were, in accordance with Jurin's advice to medical practitioners, selected almost exclusively from the healthy, well-cared-for children of the upper classes, with all the implied built-in statistical bias. ‘He forgets,’ Massey complained, ‘that the inoculated are picked lives. If that's fair: Hang fair!’
Several treatises published towards the middle of the century, when inoculation was recovering from a decade of unpopularity, showed how far in this, as in so much else, the faculty had found ways of improving on the system thought to be adequate by the old Greek women of Constantinople. The operation, in so far as it was carried out at all, had become a time-consuming and costly business.
In his life of Leslie Stephen, The Godless Victorian, Noel Annan describes ‘the new experts’, the reformers and administrators who dominated and defined the emerging society of early and mid-Victorian Britain:
They were men of inexhaustible energy, of disinterested probity, of indefatigable industry; but tact, compromise and suavity were foreign to their natures. They had the strength of mind to establish principles for dealing with the problems they were set, but once formed they could admit no other and closed their minds because the administrative structures they had invented seemed to them the only feasible way of dealing with the problem…
The most obvious example of this breed of ‘formidable men’, as Annan calls them, was Edwin Chadwick, one of the principal architects of the New Poor Law of 1834. This had replaced a ‘ramshackle and extravagant contrivance’, but Chadwick remained impervious to the outcry that his reform was harsh and ‘inhumane’. John Simon had worked with Chadwick as his ‘noble disciple and friend’, in the words of one commentator, and in his own study of English Sanitary Institutions, written when he was himself no longer playing an active part in public life, he went out of his way to defend Chadwick from some of the more severe charges levelled against him:
In the earlier stages of Mr. Chadwick's career, when the essence of his work was to force public attention to the broad facts and consequences of a great public neglect, it mattered comparatively little whether, among his eminent qualities he possessed the quality of judicial patience; but in his subsequent position of authority demands for the exercise of that virtue were great and constant…
Among the faults for which Chadwick was then criticized were ‘a liability to one-sidedness on questions of science and administration, a failure to listen duly to dissentient voices […] and a too despotic tone in affairs of local and personal interest’; but these might be generalized as ‘faults of over-eagerness [that] fall into moral unimportance as compared with his sincere and disinterested zeal for the public service’. Confronted with evidence of unnecessary human suffering, ‘the indignation which he was entitled to feel […] is a not ignoble excuse for such signs of over-eagerness as he may have shown’.
Following the mass demonstration the Leicester guardians voted by 26 to eight to cease prosecutions. There was no response from the Local Government Board, but a carefully worded passage in a report by its Medical Officer of Health, written before the demonstration took place, illustrated clearly the Board's awareness of the dilemma with which the advocate of compulsion was confronted:
Whether or not, in face of the accumulated evidence of the import - ance of vaccination to children, who cannot judge for themselves of its value, it may be expedient to relax those provisions of the Compulsory Vaccination Acts which allow of repeated penalties on such parents as refuse vaccination, is a question which lies within the province of the statesman rather than the physician to settle. To the physician, who realises the powers of vaccination, and who knows the malignity of the disease against which it protects, the notion of enforcing the acceptance of such a boon is distressful. But the distress is akin to that with which he himself has at times to force nourishment down the throat of a lunatic who is starving himself; and in the case of vaccination he sees that it is for the security of children otherwise helpless, not the recalcitrant himself, that compulsion is wanted.
In England, however, ‘compulsory vaccination’ has never meant, and probably never will mean, taking a child out of the custody of its parent and returning it to him vaccinated; and if it does not mean this it may by some persons be judged advantageous, in order to avoid gratifying the sheer love of martyrdom that influences the conduct of misguided people, to alter the Compulsory Vaccination Acts in such a way as to limit the number of penalties that can be imposed for disobedience to them. I express no opinion on this proposal, but if it should be adopted it would appear as a corollary that the Acts be so further altered as to mark by law the sense of the community that a parent will have committed an offence whose child dies of small-pox without having been vaccinated […] Such parents will have failed to give the security that the law provides for their helpless children, and will be in the same position as if they had failed to provide their children with any other security important to their lives.
Allen v. Worthy opened the floodgates. Parents objecting to the vaccination of their children found themselves in court time and time again, paying fines and costs that for many of them amounted to a severe financial burden. Refusal or inability to pay could result in their possessions being seized or sold off, or even a prison sentence. Typical of those who faced what was for them a desperate moral dilemma was a parent who ascribed his eldest child's death to vaccination, no doubt without justification, and felt he must resist the compulsory vaccination of a second child. He was summoned, convicted and paid the full penalty, only to be forced through the same train of events a second time. ‘What am I to do? I am a young man and cannot afford to pay 34 shillings every two or three months. I must either stifle my parental convictions and have my child poisoned or be ruined by continuing to refuse. They have threatened me again’. As an opponent of the compulsory legislation remarked, what it accomplished in practice was that a parent might be ‘imprisoned for ever’.
Shortly after the Act of 1867 was passed, but before Allen v. Worthy had revealed its full implications, the office of Vice-President for Education had changed hands again. Lord Derby had been supplanted as Prime Minister by Disraeli, and Disraeli, in December 1868, by Gladstone, for whom the pros and cons of compulsory vaccination were among the least of his preoccupations. The new Vice-President was W. E. Forster, the Quaker MP for Bradford, who by August 1870 was emerging from his long-drawn-out battle to secure the passage of his eponymous Education Act. As this struggle was reaching its climax a Bill was introduced by the anti-vaccinationist MP for Sunderland, John Candlish, which proposed that ‘no more than two orders shall be made, under the thirty-first section of the Vaccination Act of 1867, for the vaccination of any one child’, and also attempted to remove some confusion over certificates of unfitness for vaccination.
Even when the complex series of alliances and wars against the French ended with the final overthrow of Napoleon (an ardent admirer of Jenner), social unrest and the urgent need to contain it remained a constant preoccupation of successive governments. The year of the serious epidemic of smallpox in Norwich, 1819, was also the year of the Peterloo massacre in Manchester, with all that it implied for the current state of the nation, and there can be little doubt as to which event ranked as the more important in ministerial minds. During these years, when smallpox appeared, albeit slowly, to be loosening its grip on the population, apart from occasional displays of violence such as the epidemic that swept the country in 1825, the most insidious sickness affecting British society, more significant in its long-term effects perhaps than the electoral reform of 1832, was the steadily increasing growth of poverty. This was leading in many areas to chronic pauperism, especially in the southern agricultural counties, and a correspondingly increasing cost of trying to address this with an outmoded and creaking system of relief.
Random legislation first codified in late Elizabethan times prescribed measures for lightening the burden of the poor both on themselves and on their better-off compatriots. These had worked tolerably well for the better part of two centuries, but the stresses and upheaval created by the rapid evolution of an industrialized society, especially in rural communities, disrupted what had always been a somewhat uneven balance. By the 1820s the complaint heard in many quarters was that the national economy was in danger of collapsing beneath the burden of taxation in the form of poor rates levied on householders, which it was claimed were steadily reducing them to poverty themselves. The upshot, following the devastating report of the royal commission set up to investigate the situation, was the legislation known officially as the Poor Law Amendment Act of 1834 but popularly referred to as the New Poor Law. As with the report of the royal commission it was drafted almost entirely by the energetic reformer Edwin Chadwick and the radical economist Nassau Senior, who claimed to have written most of it himself. It does not call for detailed analysis here but certain of its major provisions need to be singled out.
Simon's assessment of the four-year campaign of inspection was that it provided ‘an account of the working of our present vaccination laws which […] offers such a basis as there has never yet been for effective legislation against small-pox’. Stevens, speaking for those who, like himself, had been doing the arduous leg-work, took the less complacent view that it was entirely hopeless to attempt to secure to the people ‘such an amount of protection as they have the right to claim […] from the law as at present administered’. The cause lay with no one person or with any one union – it was simply ‘the system’ that was at fault. ‘Gentlemen of influence’ in every district had without exception expressed to him their opinion that ‘no improvement could possibly be effected under the existing Vaccination Acts’. There could be no disagreement, except perhaps from the anti-vaccination lobby which had shown its head above the parapet a few years earlier, but had still to get itself organized; the mass of parents, unconsulted as usual, continued to treat the whole issue with the ‘indifference and idleness’ of which Seaton had recently accused them.
In February 1866 a Bill to ‘consolidate and amend the statutes relating to vaccination in England’ was brought forward, sent to a select committee and returned in a revised form in June. In normal circumstances the Act would probably have been on the statute book by the end of the year; but the circumstances, once again, though not abnormal, were unfavourable: a change of government caused it to be lost, but only temporarily. The incoming government, although not viewing it with much enthusiasm, revived it in 1867, a development that had a profound bearing on the history of compulsory vaccination. To understand why, a few steps must be retraced.
In 1864 the partnership of Simon and Lowe was dissolved for practical purposes following Lowe's departure from the administration. His only formal contribution to vaccination in the immediately preceding years was the passing of the Act of 1861, with which the lost clause of its predecessor of 1859 was retrieved. The effect was minimal.
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