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would be an instance of sweating of medical men such as can scarcelybe exampled in any other branch of the public medical service.That this meeting looks with the gravest apprehension upon the

effect of such inadequate fees as are suggested, feeling that publicvaccination in England and Wales cannot be maintained at its presentlevel of efficiency upon such terms.

I am, Sirs, yours faithfully,CHAS. GREENWOOD.

Mitre-court-buildings, Temple, E.C., June 19th, 1907.

OF MEDICO-LEGAL INTEREST.To the Editors of THE LANCET.

SIRS,-On June 8th a patient of mine was taken in labourat 1 A.M. with her first child. Her husband fetched the1, nurse " at 2 A.M. who said that she "would not be wantedfor hours " and left the house. At 5 A.M., while my patientwas standing, the baby was born and fell on the floor, thecord breaking. The poor woman jumped into bed, butneither she, the husband, or an old woman in the houseknew how to tie the cord. On my arrival at 5.25 I foundthere had been a good deal of bleeding from the cord, whilethere was an extensive bruise on the head of the infant.Had my patient been a single woman and had the babydied it is quite conceivable that her story might not havebeen believed and she might have had to stand her trial formurder. For this reason I think the case is of sufficientinterest to justify record.-I am, Sirs, yours faithfully,June llth, 1907.

~

A. G. P.

NEW VACCINATION LEGISLATION.(BY A PUBLIC VACCINATOR.)

THE two principal officials of the Local GovernmentBoard have both won their political positions as paidnominees of two of the most highly organised trade unionsin England. Perhaps the finished knowledge of tradeunionism possessed by both Mr. Burns and Dr. Macnamarahas enabled them to gauge the weakness of resistance of a

poorly paid but honourable profession which has not yetstooped to trade unionism. Nothing else could haveinduced these two gentlemen to compel public vaccinatorsto work for wages which no member of the AmalgamatedSociety of Engineers or the School Teachers Union would beallowed by those bodies to accept.

Imagine the storm which would have arisen in the Houseif Mr. Haldane had proposed to Parliament that the wagesof the artisans of Woolwich Arsenal should be suddenlyreduced from 30s. to 15s. per week. But without referenceto Parliament Mr. Burns lowers in this proportion theearnings of a large body of men by his own personalauthority. For though few of the public know that the"Local Government Board" is a non-existent body whichnever has met, they were reminded of this fact a few weeksago by Mr. Burns himself, who stated in answer to a ques-tion in the House that the Board had never been convenedsince it was established and he had no intention of everconvening it. Mr. Burns is the " us " of the new Orders andhis decisions, issued as Orders in Council, have the effect ofActs of Parliament. They can only be discussed in Parlia-ment on the Estimates, if they are ever discussed at all, andthey may be framed, as in the present instance, in directopposition to the findings of a committee of his owndepartment.

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I am well aware that THE LANCET takes no accountof politics, but it is inexplicable that such an autocraticmethod of bureaucratic administration should commenditself to professing democrats like the supporters ofthe present Government. There is every reason todoubt that the Local Government Board has any inten-tion of protecting the public vaccinators in their strugglefor a decent remuneration. The really important, infact the only important, clause in the new Orderis that which reduces the minimum fee for successfulvaccination of an infant from 5s. to 3s. 6d. in countrydistricts and to 2s. 6d. in urban districts of more than 50,000inhabitants. It may be urged that these fees are "minimum"

"

fees and that larger sums may be paid (as they are nowpaid) in excess of those minimum fees. But in spite of therecommendations of the Departmental Committee of 1904the public vaccinators have been given no permanent tenureof their offices. They are therefore liable to termination

of their contracts at a month’s notice, and where boards ofguardians choose to enforce the minimum rate of pay there isno power to compel them to pay more except the LocalGovernment Board, which is Mr. Burns. The agitation in1904, which led to the appointment of the Commission onExpenses, clearly showed the attitude which was, and will be,adopted by the bulk of boards of guardians, and I regret tosay that the new Order indicates too clearly the attitudewhich will be adopted by the Local Government Board.Consider the work which has to be undertaken and com-

pleted for 2s. 6d. The public vaccinator has to check offand copy Form H which contains four columns of detail andreturn it to the vaccination officer, then to fill in and sendnotice of intended visit to each parent to call by appoint-ment on a given day to vaccinate the child, and revisit thecase the week after, as well as to fill in and despatch acertificate, and keep a register (which must be filled upevery day) containing 19 columns of details. If the parentsrefuse his services the vaccinator gets nothing for histrouble. If they are out he must call again, and inmany districts they always are out, of malice prepense. Ifthe child is unfit to be vaccinated the vaccinator must fill inanother certificate and call again. The 9?tinimum number ofvisits which must be paid is two; the time occupied invaccination is at least 20 minutes, for scrupulous antisepticprecautions must be observed; and the outgoings in dressingsamount to about 6d. per head, and an .average of ld. perhead in postage. From the evidence laid before the Com-mission it was clear that an average of three and a half tofour visits is made by public vaccinators for every fee whichthey receive, so that in urban districts these gentlemen areto be paid 6d. per visit when their out-of-pocket expensesare deducted; in addition to the time taken to reach thechild’s home, which averages a quarter of an hour each way,the actual operation takes 20 minutes per case and theclerical work 15 minutes, for after vaccination is completethere are forms to despatch as to result and forms for

demanding fresh lymph. A trade union joiner earning 5d.an hour is better paid.The subclause (e), Article 1., 3, is just in principle but goes

too far. Under the original Order of 1898, payment was madefor each case of vaccination or revaccination irrespectively ofthe number vaccinated at one sitting and under one roof.This had practically no bearing upon primary vaccinationbut had a very important bearing in epidemics of small-pox,when whole families were revaccinated together. Thus avaccinator who received an extra-distance fee of 7s. 6d. perhead for the journey and operation received E3 7s. 6d. forrevaccinating a family of five persons at the same time.This rate of payment was in most instances excessive. Butthe extravagance might bave been entirely prevented ifboards of guardians had been properly alive to their powersand established temporary stations in rural districts. Theymade no attempt to do so, and the Local Government Boardmade no attempt to instruct them, with the consequence thatduring the epidemic of 1901-02 the bills for revaccination inmany areas were 300 per cent. higher than they should havebeen. Owing to its obscurity it will be as well to quotein extenso the article which seeks to remedy this undueexpenditure, and (if I read it aright) it effects its purposein a trenchant manner.

A1’(’icle 1., 3, (e).-Except so far as this subdivision otherwise provides,nothing in paragraphs (b), (c), and (d) of this subdivision shall apply inany case in which during a period of twenty-four consecutive hourssuccessful vaccination or successful revaccination has been performedby the public vaccinator upon two or more persons at one and thesame house, or on any premises (other than the surgery of the publicvaccinator) whereon those persons were together present at any timeduring the aforesaid period.In every such case the amount to be paid to the public vaccinator

shall, in respect of the iirst person vaccinated or revaceinated, be thesum which being not less than the sum specified in such one of therules hereinbefore set forth as is applicable to the case of thatperson is fixed in the contract approved by us, and in force for the timebeing, or, in any case to which subdivision (1) of Article 5 applies, isfixed by an instrument executed in pursuance of that subdivision, andin respect of every other person vaccinated or revaccinated the amountto be paid to the public vaccinator shall be such a sum as is fixed in thecontract approved by us and in force for the time being, or such sum asin any case to which subdivision (1) of Article 5 applies is fixed by aninstrument executed in pursuance of that subdivision.

The reference to Article 5 subdivision (1) applies to thearticle in the Order of 1898, not the present Order, thoughthis fact is not named. If this clause means anything itmeans that whereas a vaccinator is to get 2s. 6d. a

head for vaccinating at his own house, if he goes elsewhere-to revaccinate a family he will only get the 2s. 6cl. forgoing there and vaccinating the first person and such a sum