A Century of Vaccination and What it Teaches.
a book by
W. Scott
Tebb, M.A., M.D. (Cantab.), D.P.H.
London: Swan Sonnenschein & Co, 1898
[Note: the chapter subheadings listed below are page headings in the original book, so don't sometimes correspond exactly to the text as a chapter sub-heading would do. Some have been moved slightly to aid in navigation.]
PREFACE.
CHAPTER 1.
A brief account of the Early History of Vaccination, showing how it was accepted by
the Profession on inadequate evidence
METHODS
OF SMALL-POX INOCULATION.
JENNERS VARIOLOUS TESTS.
THE VALUE OF JENNER'S TESTS.
WOODVILLE AND PEARSON.
"VACCINATION" WITH VARIOLOUS LYMPH.
LANGWORTHY AND ARSCOTT'S
EXPERIMENTS.
OPINION OF THE
ROYAL COMMISSION.
SPURIOUS COWPOX
CONDEMNED BY THE
COLLEGE OF PHYSICIANS.
CHAPTER 2. The Decline
in Small-pox since the Introduction of Vaccination
THE VACCINATION
ACTS.
SMALL-POX AND
VACCINATION SINCE 1872.
DECLINE OF TYPHUS FEVER.
CAUSE OF DECLINE OF
FEVERS.
AGE-INCIDENCE OF
SMALL-POX.
INCREASE IN ADULT MORTALITY
OF SMALLPOX
AGE-INCIDENCE
OF TYPHUS FEVER.
AGE-INCIDENCE OF
INFLUENZA.
AGE-INCIDENCE OF
SMALL-POX.
POCK-MARKED FACES.
CHAPTER 3. Some of the Causes of the
Decline in the Small-pox Mortality
SMALL-POX DIFFUSED
BY INOCULATION.
SALUTARY EFFECT OF
OPEN SPACES.
INCREASE OF
METROPOLITAN AIR-SPACES.
THE WINDOW-TAX
DOMESTIC INSANITARY
CONDITIONS.
EIGHTEENTH CENTURY PRISONS.
AGE-INCIDENCE AND
SANITATION.
BURIAL GROUNDS AND
MORTALITY.
COMMERCIAL DEPRESSION.
THE EFFECTS OF WAR.
MALTHUS
DISCOVERS A NEW PRINCIPLE.
THE ZYMOTIC DISEASES REPLACE EACH OTHER.
CHAPTER 4. The Incidence of
Small-pox on Vaccinated and Unvaccinated Communities.
CHAPTER 5. Does Vaccination Prevent Small-pox ?
CHAPTER 6. The
Mitigation Theory
CHAPTER 7.
Re-vaccination
CHAPTER 8. Influence of Sanitary Measures on the Incidence
and Mortality of Small-pox
CHAPTER 9. The Injurious Results of Vaccination
CHAPTER 10. Summary
and Conclusions
Diagram and Appendix
So long as the practice of vaccination remains established and enforced by law, it will be the duty of every citizen, who is also the father of a family, to form a judgment upon it; unless, indeed, it is to be held that the infallibility of the legislature and of the medical profession, which in this instance directed legislation, is so well assured that enquiry is superfluous, if not culpable. But it is a sounder doctrine that the existence of the law does not relieve parents of responsibility towards their children, and more especially parents (nowadays the majority) who have heard that the efficacy of this operation has been called in question by competent men, while its risks, so long denied, are now on all hands admitted. I am, therefore, not without hopes that among my readers will be included a fair number of the general public" interested in the subject by the pressure of compulsion, and anxious before they submit a child to vaccination to feel assured that they are doing the right thing, being also resolved to withhold the child from the operation if they cannot be satisfied of this.
But I here address myself more particularly to two classes—to my medical brethren, and to those whose business it is to legislate for the country on this subject. On the former I desire, with all respect, to urge the following considerations:—
Can it be said that the Jennerian doctrine of vaccination has ever been placed on a truly scientific basis? I specify the "Jennerian doctrine," for there are other aspects of the vaccination or inoculation theory, which I expressly rule out of my enquiry. It is a generally received opinion that in the case of certain diseases one attack affords some degree of immunity against a second. It is certain that there are exceptions to the rule, and it is further certain that the rule has never been scientifically established as such. Nevertheless, it is a generally accepted belief, with evidence in its favour, and in the pages that follow I do not reject or even attack that belief. Further, it is a postulate of the modern inoculation doctrine that a mild or modified attack suffices to secure this immunity. Whether this be so or not, I cannot tell. It is a matter into which I have not been led to enquire, and I am willing to grant it for the sake of argument, since it does not really concern the position which I am calling in question. What I do deny, as the result of my enquiries, is that an attack of cow-pox secures immunity against small-pox. To use technical terms in order to make the distinction clear: while I may allow within limits the truth of homoprophylaxy or homoeoprophylaxy, I am satisfied that there has never been shown any sort of scientific basis for heteroprophylaxy. If the reply be made that, granting it is wrong to teach that vaccination is homoprophylactic, it is fair to claim for it that it is homoeoprophylactic, I should deny that such a claim can be sustained ; and, though I am, of course, aware that variolous matter can be so modified by being taken at an early stage and passed once or twice through the calf as to produce, when inoculated, not an attack of small-pox, but local effects similar in appearance to those of vaccination, yet that is not what is done every day by medical men who vaccinate. What they are doing they really do not know, nor does any one know, for the ultimate origin of the vaccine lymph in common use has long ago been lost sight of; but if it be true that that ultimate origin is cow-pox, if, that is to say, when we vaccinate we are carrying out the teaching of Jenner, then, certainly, we are acting as if heteroprophylaxy had been established scientifically; for the investigations of Dr. Creighton and Professor Crookshank have proved conclusively that cow-pox is a disease radically different from that against which it is said to protect. Effects similar to those of vaccination can be produced in a variety of ways, and, therefore, to produce them as Dr. Klein and others claim to have done, by means of small-pox virus, attenuated or in other ways concocted, does not identify the disease on which Jenner relied for protection with the disease against which he claimed that it protected, any more than does the production of a vaccine vesicle from cattle-plague identify vaccination with that disease.
Many of my brethren, while willing to acknowledge that there is no true pathological relation between cow-pox and small-pox, fall back on the alleged evidence of statistics, and claim to find in them a scientific vindication of vaccination. The majority of the Royal Commissioners took this view, and rather deprecated the idea that any other scientific vindication was necessary. To the questioning of the position that trustworthy statistics do provide such a vindication my pages are partly devoted. I do not deny that the "century of vaccination" synchronises roughly with a century in which small-pox (in Europe, at any rate) has largely declined. But this coincidence by no means involves any connection in the way of cause and effect. Small-pox, like typhus, has been dying out since 1780. Vaccination in this country has fallen largely into disuse since people began to realise how its value was discredited by the great smallpox epidemic of 1871-72. So that, while small-pox has declined during the last one hundred and twenty years, twenty years may be cut off from each end of this period, as contributing no evidence whatever of the decline being due to vaccination, and as involving the conclusion that some other causes have been at work to promote this result. I am, of course, only speaking approximately. To the evidence afforded by detailed cases criticism of another kind is applicable, and to this I will presently refer. But, first, in passing, I would call attention to the ease with which an alleged protective operation can acquire a great reputation as successful, more especially if its adoption should coincide with a decline from other causes of the disease against which it is supposed to protect. A local epidemic of small-pox is seldom so severe as to attack more than 5 per cent. of the population. If, therefore, a small minority has adopted some alleged prophylactic, it is very unlikely that the disease will count among its victims any considerable proportion of those who are thus fortified, particularly as they would be likely to be more than ordinarily careful in matters relating to health. In this way their prophylactic will acquire a great reputation, and the vastly greater number who have equally escaped without having recourse to the protective operation will be overlooked. This is what happens in pretty nearly every epidemic in regard to re-vaccination and the security it is alleged to provide. In the case of primary vaccination other but not less misleading inferences are drawn. Should there be an epidemic of small-pox in a locality where 85 per cent, of the population are vaccinated, it is obvious that the 95 per cent. of the population who escape the epidemic (assuming, as before indicated, a maximum of 5 per cent, attacked by it) will largely coincide with the 85 per cent, vaccinated ; and vaccination thus gains credit. But it will be objected, if the 5 per cent, attacked coincide, in however small a degree, with the 15 per cent, unvaccinated, this is strong testimony to the risk of being unvaccinated ; and so, no doubt, it would be, but for the fact that in localities where the vaccination law is vigorously carried out, the unvaccinated, as a class, will be found to consist largely of the outcasts of society, nomads whom the law has failed to reach, and of weakly children who on account of their health have been excused the operation. This class, therefore, is likely to furnish a disproportionate number of the victims of the epidemic ; and thus again the prophylactic acquires reputation. Add to this the facts, often overlooked, that medical men, even if officials and highly placed, are still liable as men to err, and that their errors will probably accord with their cherished beliefs, and it will readily be understood that the evidence of detailed cases—which is really the only evidence on which the credit of vaccination depends—cannot be accepted wholesale as if it were not open to question. A vaccinated patient with no visible signs of vaccination is likely to be described as unvaccinated if his case is severe, and especially if death ensues ; while if the marks are not plainly visible, the explanation of "not properly performed" is an obvious one ; and the patient will be included as "belonging to the unvaccinated or imperfectly vaccinated class" in the list of cases, and, tout court, as "unvaccinated " or "having no marks" in the official summary. I think it would be advisable for my medical brethren to accept as authentic only published and tested cases, or such as have come under their own personal observation.
To those who are about to legislate for the country on this vexed question I also address myself particularly. The Queen, in her Speech at the opening of the present Session of Parliament, called for "earnest consideration" of the subject. Hitherto vaccination bills have been passed into law without adequate discussion or debate. Parliament has been assured (incorrectly) that there is complete unanimity in the medical profession concerning the nature, value, necessity, and safety of vaccination ; and that has sufficed. Lords and Commons have at once bowed before this alleged unanimity, with the result, as vaccinists claim, but cannot possibly prove, that small-pox has been practically stamped out, but undoubtedly also with the result that hundreds of infants have died from the effects of the operation, that thousands of otherwise blameless citizens have been lined or imprisoned for their very natural and proper resistance to this extraordinary law, and hundreds of thousands of pounds of public money have been spent on what I am satisfied is nothing but a useless and mischievous fallacy. It is strange that members of Parliament do not perceive that the strength of the pro-vaccinist party lies in the public endowment of the practice. Right through the century there has existed a body of officials, ostensibly paid to promote the practice of vaccination, but also, partly at least, paid to vindicate it theoretically, and to explain away its failures and its accompanying disasters. But for this State aid, vaccination would long ago have been consigned to the same limbo as has received a thousand other similar fads which, fortunately for the public, have not secured official recognition and support. I hardly expect that legislators will have time to read the numerous cases I adduce—some showing that immunity from small-pox exists without vaccination, others that mild attacks of small-pox were recorded long before there was any alleged mitigating power in vaccination to which to ascribe them, and, again, others proving that neither vaccination nor re-vaccination nor recent vaccination can be depended upon to protect from small-pox or even from death from that disease. But to the cases of injury and death resulting from vaccination I trust they will not refuse to give some attention. This evidence should be enough to determine any fair-minded enquirer that the enforcement of vaccination by law is indefensible. Take away first the compulsory law, and then take away (if vested interest is not too strong for you) the endowment of the practice, and, when this has been effected, medical men will find themselves for the first time since 1803 free to discuss the vaccination question as a scientific one on its own merits. To what result that unfettered discussion will lead I have myself (now that I have studied the matter carefully for some years) no sort of doubt.
In conclusion, I desire to express my obligations for the valuable assistance of Mr. A. W. Hutton, whose letters on "The Vaccination Question," addressed to Mr. Asquith and Mr. Balfour in 1894 and 1895, I can recommend as an introduction to the rational study of this vexed problem.
CHAPTER 1.
A BRIEF ACCOUNT OF THE EARLY HISTORY OF VACCINATION, SHOWING HOW IT WAS
ACCEPTED BY THE PROFESSION ON INADEQUATE EVIDENCE.
Dr. JENNER, in one of his later papers, "The Origin of The Vaccine Inoculation," informs us that his inquiry into the nature of cow-pox commenced shortly before the year 1776. There is, however, an incident alluded to by Baron,1 his biographer, which would seem to show that his attention was drawn to the subject during his apprenticeship, which lasted from 1762 to 1768. A young countrywoman came to seek advice; the subject of small-pox was mentioned in her presence; she immediately observed, "I cannot take that disease, for I have had cow-pox." This, we are told, riveted the attention of Jenner. Whether this was so or not, he apparently did not follow it up till the year 1788, when he repeated the tradition of the dairymaids in London, taking with him a drawing of the cow-pox eruption on the hand of a milker.
1. Baron's "Life of Jenner," vol. i., pp. 121, 122.
About the year 1791 Jenner appears to have seriously commenced to collect notes of cases of cow-poxed milkers who were said to have resisted smallpox inoculation. His first paper, which was shown to the Council of the Royal Society in 1797, and afterwards returned to him,1 gives ten such instances. In order to examine somewhat closely this claim—that those who had taken cow-pox were secure against the artificial introduction of small-pox—it is necessary to give a short account of small-pox inoculation as it was practised in the last century.
This practice, the forerunner of vaccination, was first brought to English notice by a letter from Dr. Timoni, a Greek physician practising in Constantinople; the letter was addressed to Dr. Woodward, Gresham Professor of Physic, who had it printed in the "Philosophical Transactions" for 1714. The credit of the introduction of the practice into this country is, however, due to Lady Mary Wortley Montague. Mr. Wortley Montague was appointed Ambassador to the Porte in 1716, and not long after their arrival his wife wrote to a friend about the invention of ingrafting. "Every year," Lady Montague says, "thousands undergo this operation; and the French Ambassador says pleasantly that they take the small-pox here by way of diversion, as they take the waters in other countries." Shortly afterwards, her son, aged five, was submitted to the operation, which was performed by a Greek woman under the supervision of Mr. Charles Maitland, Surgeon to the Embassy. In 1721, Lady Mary, who had returned to London, had
1 Letter from Jenner to Moore. Baron's "Life of Jenner," vol. ii., p. 364.
METHODS OF SMALL-POX INOCULATION.
her daughter inoculated by Maitland. In the same year this surgeon experimented on some condemned criminals at Newgate, and in 1722 variolation was encouraged by Royalty.
Another of the early inoculators was Thomas Nettleton, of Halifax, who recommended long and deep incisions, and the using of matter from ripe pustules. The severity of the disease induced was a great bar to the progress of small-pox inoculation, and by the year 1728 the practice had almost ceased. It was revived about 1740, and in 1754 was authoritatively sanctioned by the Royal College of Physicians, who pronounced it to be "highly salutary to the human race." About the year 1703 a milder method of procedure came into vogue; this was first introduced by Gatti, the French inoculator, and was taken up in this country by Daniel Sutton and Dr. Dimsdale, the latter of whom has published accounts of his practice. Dimsdale says :—
"It seems not improper to add, that the method I now generally use in performing the inoculation, as believing it to be the best, is simply this : The point of a lancet slightly dipped in the recent variolous matter, which I prefer taking during the eruptive fever, is introduced obliquely between the cuticula and the cutis, so as to make the smallest puncture possible, rarely producing a drop of blood." 1
1. "Tracts on Inoculation," p. 130. Hon. Baron T. Dimsdale. London. 1781.
Dimsdale preferred inoculating from mild cases and from arm to arm, for he says :—
" If neither an inoculated patient is at hand, nor anyone in the neighbourhood has a distinct kind of the natural disease, a thread may be used as in the common manner, provided the thread be very recently infected." 1
About the results he adds :—
" In general, the complaints in this state are very moderate, and attended with so little illness that the patient eats and sleeps well the whole time : a few pustules appear, sometimes equally dispersed."2
He also had some very mild cases which not only had little or no pustular eruption on the body or fever, but did not even present a pustule at the seat of inoculation, there being simply local inflammation; and in his book he gives a list of twelve such cases, which, however, he considered protected from any future attack of small-pox.
Another writer, Dr. Giles Watts, in referring to this new method of inoculation, says :—
"To say the truth, it is a fact well known to inoculators, in this way, and I have sometimes known the same happen in the old, that the patients pretty often pass through the smallpox so easily as to have no more than five pustules. Nay, it happens every now and then, in this way of inoculation, that even an adult patient shall pass through the distemper without having one, or even so much as a single complaint, other than, perhaps, a slight shivering, chill, or some such trifling disorder, which he would hardly have taken the least notice of at any other time." 3
1. ''The Present Method of Inoculating for the Small-pox," p. 29. Thomas Dimsdale, M.D. London. 1767.
2. Ibid., p. 37.
3. "A Vindication of the New Method of Inoculating the Small-pox," p. 10. Giles Watts, M.D. London. 1767.
Thus the inoculation-system of Sutton and Dimsdale, which produced such mild
results, depended upon getting matter from the eruption of small-pox at an
early
JENNERS
VARIOLOUS TESTS.
stage of the disease, using it when fresh, inoculating from mild cases or from arm to arm, taking the smallest quantity of matter and introducing it by a superficial puncture. This, it may be noted, is precisely the sort of inoculation Jenner recommended should be used in applying the variolous test in cases which had been vaccinated. Jenner says :—
" In some of the preceding cases I have noticed the attention that was paid to the state of the variolous matter previous to the experiment of inserting it into the arms of those who had gone through the cow-pox. This I conceived to be of great importance in conducting these experiments."1
Now, if we refer to the case of John Phillips, aged sixty-two, who had had the cow-pox at the age of nine years, we learn that the matter for inoculation was taken from the arm of a boy just before the commencement of the eruptive fever, and instantly inserted. A little further on he relates a story of a medical man who used stale small-pox lymph for inoculation, with serious results. Then he continues :—
"As a further cautionary hint, I shall again digress so far as to add another observation on the subject of inoculation. Whether it be yet ascertained by experiment that the quantity of variolous matter inserted into the skin makes any difference with respect to the subsequent mildness or violence of the disease, I know not; but I have the strongest reason for supposing that, if either the punctures or incisions be made so deep as to go through it, and wound the adipose membrane, that the risk of bringing on a violent disease is greatly increased."
1 "An Inquiry into the Causes and Effects of the Variolœ Vaccinœ." Jenner. London. 1798.
With regard to these ten cases of casual cow-pox in milkers who had been subsequently inoculated with small-pox, the method of inoculation then in vogue was probably used ; therefore, from the conditions under which the test was made, on Jenner's own showing, a slight and trivial result was the most that should have been anticipated. Jenner, however, admits a certain amount of local inflammation supervening in all the cases he describes, which, if we make allowance for the general looseness and ambiguity of his statements, may, not inconceivably, include the appearance of a local pustule at the seat of inoculation.
In 1796 Jenner vaccinated his first case, James Phipps. In less than seven weeks from the insertion of the cow-pox matter Phipps was inoculated with small-pox, with the result that "the same appearances were observable on the arms as we commonly see when a patient has had variolous matter applied, after having either the cow-pox or the small-pox."
Now, the question is, What appearances did Phipps actually have on his arms as the result of the variolous test ? And to guide us in forming an opinion, there is a letter of Jenner's to a medical man, Mr. John Shorter, who wrote to him about two cases in which he had applied the test six months after successful vaccination, with the result of producing a pustule at the seat of inoculation in each case. Jenner, in his reply, December 29, 1799, says :—
" Pray, recollect how seldom we find the skin insensible to the action of variolous matter in those who have previously gone through the small-pox. The cow-pox leaves it in the same state. The patients you mention were not insensible to the local action of the variolous virus." 1
THE VALUE OF JENNER'S TESTS.
Thus, if the skin is seldom insensible to variolous matter after cow-pox or small-pox, and these cases of Shorter's are samples of the result, it seems not improbable that when Jenner applied the variolous test in the case of Phipps he got a local pustule at the seat of inoculation ; for the same appearances, he says, were produced as commonly observed when variolous matter was applied to a person who had had cither cow-pox or small-pox.
Mary James2 is another of the few cases Jenner is known to have subjected to the variolous test. This was applied eight months after vaccination, with the result of a local pustule, fever, and the faint appearance of a rash about the wrists; matter taken from the arm of this case produced small-pox when inoculated on her brother.
To sum up the value of these tests. It amounts to this: that Jenner, in applying them, used a form of inoculation which produced little more than a local result, and the appearances he obtained were not very different from what would be produced by that form of inoculation when there was no question of cow-pox at all.
Apparently the test broke down, not only in the case of Mary James, but in other instances. Mr. Thornton,3 surgeon, of Stroud, published his experience. The cases are important as being the first independent evidence after the publication of Jenner's "Inquiry." He vaccinated a Mr. Stanton and four of his children
1. Medical and Physical Journal, vol. iii., p. 351. (April, 1800.)
2. ''Further Observations on the Variolœ Vaccinœ , or Cow-pox." Jenner. 1799.
3. Letter dated February 7, 1799, and published in Dr. Beddoes' "Contributions to Physical and Medical Knowledge," p. 398.
from a milker on the Stonehouse Farm, a source used by Jenner himself. The matter was taken from a purulent pock, the only one which was not degenerated into a sordid and painful ulcer. In the four children the inflammation was severe and protracted, the scabs falling off about the twentieth day. "From the long continued local excitement," Mr. Thornton adds, " I began to entertain a hope that the virus might imperceptibly have crept into the habit, and proved a security against the variolous infection." So, to relieve his own doubts, and to ensure the safety of the patients, he inoculated them with smallpox, with the result that "all the children received the infection, and passed through the different stages of the disease in the usual slight manner." Mr. Stanton, in whom the inflammation had not been so severe, was the only one who resisted the variolous inoculation.
At the end of 1798, six months after the publication of Jenner's "Inquiry," the case for vaccination stood thus : Most of the children's arms had ulcerated, and the variolous test, in the few cases in which it had been applied, had produced equivocal results. Moreover, all Jenner's stocks of lymph had been lost, so that no further experiments could be made. Dr. Beddoes, of Bristol, in writing to Professor Hufeland, of Berlin, said :—
"You know Dr. Jenner's experiments with the cow-pox. His idea of the origin of the virus appears to be quite indemonstrable, and the facts which I have collected are not favourable to his opinion that the cow-pox gives complete immunity from the natural infection of smallpox. Moreover, the cow-pox matter produces foul ulcers, and in that respect is a worse disease than the mildly inoculated small-pox."
The celebrated Dr. George Gregory, Physician to the London Small-pox Hospital, in his lectures at St. Thomas's Hospital, has alluded to the inconclusiveness of Jenner's thesis. "When we were engaged in tracing the early history of vaccination, you must have been struck with the extraordinary contrast between the absolute scepticism concerning the prophylactic virtue of cow-pox which prevailed before the publication of Jenner's first essay and the unlimited confidence reposed in it, within two years afterwards, in all parts of the world. A calm and dispassionate examination of Jenner's first essay is calculated to awaken some surprise at this sudden conversion of men's minds." 1
1 " Lectures on the Eruptive Fevers," p. 207. London. 1843.
It can thus be quite understood that the profession required more satisfactory proof before accepting the new doctrine; and they shortly afterwards obtained evidence which to them appeared to support Jenner's theories.
On January 20, 1799, Dr. William Woodville, Physician to the London Small-pox Hospital, received intelligence of an outbreak of cow-pox among the cows at a dairy in Gray's Inn Lane. The disease on a milker's hand was compared with Jenner's plates and pronounced genuine. It was then decided to give it a trial; and the experiments were conducted by Drs. Woodville and Pearson at the Small-pox Hospital. The first inoculations were made from the cow and from the hand of a dairymaid, and the subsequent ones, to the number of five hundred, from arm to arm. With regard to the testing of the cases by small-pox inoculation, Dr. Woodville says :—
" Of all the patients whom I inoculated with variolous matter, after they had passed through the cow-pox, amounting to upwards of four hundred, none were affected with the small-pox."1
Concerning these tests M'Ghie says :—
" Suffice it to observe, that the trials which were made by the profession, to communicate variola to those whom they had vaccinated, completely failed. The cow-pox having thus triumphantly undergone the experimentum crucis, vaccination was soon eagerly adopted by the unprejudiced and disinterested in every country to which the vaccine lymph was conveyed." 2
If we analyse these so-called vaccinations, we find that three-fifths of the patients had pustules about the body—and it is no longer disputed that these pustular cases were cases of small-pox—and hence the subsequent variolous tests were of no value in settling the question of the protective value of cow-pox. Let us now consider the remaining two-fifths, which only presented a local pustule at the seat of inoculation; and to do this it is important to discuss the means by which Woodville's cases became contaminated. As the Vaccination Commissioners3 have pointed out, small-pox may have been introduced—
(1) By infection at the Hospital or at the patients'
homes.
(2) By the inoculation of small-pox; several patients
being purposely inoculated with small-pox a few days after " vaccination."
(3) The lymph with which the patients were " vaccinated" may have become contaminated with small-pox.
1. Reports of a Series of Inoculations for the Variolœ Vaccinœ, on cow-pox. William Woodville, M.D. London. 1799.
2. "Thoughts on Vaccination," p. 11. Dumfries. 1827.
3. Final Report, Royal Commission on Vaccination, p. 147.
This pedigree shows that Woodville's lymph passed exclusively through Collingridge, inoculated direct from the cow, and Streeton, Smith, and Meacock, inoculated from a cow at one remove, from a pustule on the hand of a dairymaid at the Gray's Inn Lane dairy. All had a large number of small-pox pustules, and hence Woodville's cases were from first to last hopelessly contaminated with small-pox.
In the case of Buckland, "vaccinated " direct from the cow, on the seventh day two pustules exactly resembling those of small-pox appeared near to the inoculated part, and on the tenth, several pustules on different parts of the body; the symptoms strongly suggesting that the patient was inoculated when he was supposed to have been vaccinated. In Streeton, Smith, and Meacock the facts are consistent with the small-pox being acquired in the same manner as in the case of Buckland.
Besides these three persons, Collingridge was the only other case through which Woodville's strain continued. She was inoculated at the same time and with the same matter as Buckland, and, the margin of the inoculation swelling, was beset with minute confluent pustules, suggesting inoculated small-pox. The difficulty, however, in this case is that on the fifth day after "vaccination" she was purposely inoculated with small-pox (on the opposite arm to the "vaccination"), and the pustules which appeared about the body on the thirteenth day may possibly have been due to this inoculation. The usual day for the eruption to appear in ordinary inoculated small-pox was the tenth or the eleventh, and thus the pustules on the thirteenth day were rather late if due to the first inoculation, and early (eighth day) if
"VACCINATION" WITH VARIOLOUS LYMPH.
due to the second ; and therefore it is just as likely as not that Collingridge was variolated on her first inoculation.
Hence it is probable that the whole of Woodville's "Hospital matter" was contaminated at its sources, and the absence of pustules in two-fifths of the cases does not prove that these were of other than variolous origin ; for, as Dr. Collins and Mr. Picton1 say, "on the assumption that Woodville was dealing with arm-to-arm variolation, he only succeeded in obtaining what inoculators before and since claimed to have obtained when working with undoubted small-pox matter."2 There is the further argument that matter from secondary small-pox pustules in several instances produced only a local pustule in the next remove.
Woodville's lymph, when used by others away from the Hospital, produced eruptions : thus Jenner was supplied with a thread from Bumpus, who had three hundred and ten variolous pustules. In the first case inoculated by him, "spots" appeared on the face; and in the second, the local vesicle assumed "more perfectly the variolous character than is common with the cow-pox at this stage," and the areola was studded over with 'minute vesicles." Baron tells us that "the eruptions which attended many of the early cases of vaccination in London were unfortunately also propagated in different parts of the country, where the contaminated matter had been distributed by Dr. Pearson."3
Moore says:— '
'Variolous matter, under the denomination of vaccine lymph, was spread widely through England, and transported
1 Ibid.
2 Baron's "Life of Jenner," vol. i., p. 245.
3 Ibid, p. 339.to Germany, and even to the Island of Madeira, where a physician described the vaccine as a pustular disease."1
Woodville's lymph, or the "world's vaccine," as it has been called, had an enormous circulation both in England and abroad, at a time when Jenner had no stocks; it was this lymph, in fact, which convinced the world of the efficacy of vaccination.
In summing up the value of the Woodville evidence, Dr. Collins and Mr. Picton say:—
" It is, therefore, probable that the whole of Woodville's five hundred cases, which appeared to confirm Jenner's thesis, and secured the support of professional authority, were, in fact, only a series of mild variolations. It is certain that they were, from first to last, contaminated with small - pox. We agree with Professor Crookshank that, in either case, they must be set aside for the purpose of arriving at a decision as to whether uncontaminated cow-pox confers immunity towards small-pox. Woodville's cases, therefore, which did so much to establish the practice of vaccination, and which for nearly a century have been cited as demonstrating the truth of Jenner's doctrine, must be rejected as furnishing false evidence, and valueless as a scientific experiment."2
Although at first some of the cases inoculated with Woodville's lymph were undoubtedly infectious, after a time, whether from attenuation or dilution of the original matter, from the selection of mild cases, or from other causes, the number of pustules
1 "History of Vaccination," p. 36.
2. Royal Commission on Vaccination. Dissentient Commissioners' Statement, section 51
LANGWORTHY AND ARSCOTT'S EXPERIMENTS.
diminshed. Thus Woodville, writing in June, 1799, with reference to three hundred and ten cases subsequent to the Reports, says:—
"Out of the first hundred, nineteen had pustules, out of the second thirteen, and out of the List hundred and ten only seven had pustules."1
The pustular eruptions ultimately ceased, and the appearances came to assume the ordinary phenomena of vaccination.
That small-pox matter may, by a judicious selection of cases or lymph, be so attenuated as to produce restricted effects, which might be mistaken for the appearances generally recognised as pertaining to ordinary vaccination, is illustrated by the experience detailed by Mr. John Mudge, of Plymouth ; but these cases differ from Woodville's recorded results, in that when they were subsequently inoculated with small-pox, they were found unprotected.
Mr. Mudge2 relates that Messrs. Langworthy and Arscott, surgeons at the neighbouring town of Plymton, inoculated forty patients in 1776. In thirty the operation was performed "with crude matter from the arm of a young woman, five days after she herself had been inoculated with concocted matter. (She had smart fever and eruption later.) The other ten were done with concocted matter from a pustule of the natural small-pox. All the forty took, "and the latter ten, after the eruptive fever, had the small-pox in the usual way," but "of the other thirty, though the infection took place on their arms so as to inflame them considerably, and to produce a very large prominent pustule, with matter in it, on
1 Medical and Physical Journal, vol. i., p. 417. (July, 1799.)
2 "A Dissertation on the Inoculated Small-pox," pp. 20, 21. London. 1777.
each of them, yet not one had any eruptive fever or a single subsequent eruption on any part of the body ; but about the eighth, in some the ninth, and in others the tenth day, the inflammation began to disappear, and about the twelfth or thirteenth the pustules on their arms scabbed off." Matter from those pustules inoculated on others "produced on them exactly the same appearances, unattended also with either fever or smallpox."
The whole thirty were re-inoculated (no date given), this time with concocted matter taken subsequently to the eruptive fever, five being done from natural and twenty-five from artificial small-pox. The result was that "every one of them had the eruptive fever, and succeeding eruptions; in short, they had the small-pox in different degrees, but all in the usual way of inoculated patients."
These experiments differ from those described by Woodville. In criticising variolous tests in general we must always remember, as the Commissioners have pointed out, "that, in this as in other things, a sanguine hasty person might be led by the desire of seeing his expectations fulfilled to minimise the effect of the operation ; he might be led to overlook results which a more cautious observer would regard as evidence that smallpox had been really produced."
Now Woodville's tests are by no means perfectly satisfactory. In some of the early cases,1 which he described individually and in more detail, he obtained
1 In the case of George Reed (No. 33) Woodville says: "He was afterwards {i.e., after the fourteenth day) inoculated with variolous matter, which formed a pustular appearance; but no disorder was produced."
OPINION OF THE ROYAL COMMISSION.
slight local appearances, whereas in the latter ones the results of the tests are for the most part given collectively, and we obtain such vague expressions as "no disease ensued ;" concerning Nos. 89, 90, and 91 we read, "none of the above three patients took the small-pox," and in referring to sixty-seven tests (Nos. 132 to 200, omitting Nos. 193 and 194), all the information we have is that "the above patients . . . had variolous matter inserted in their arms . . . but it produced no disorder." If Woodville had given details in each instance, it seems probable that a considerable number would have been described as presenting some local manifestation, and if, as suggested by the Commissioners, we are to make allowance for the expectant attitude of mind betrayed by the sanguine experimenter, these cases were evidently not so immune as generally believed ; but, as shown above, even if we accept the position that the whole of Woodville's four hundred cases were immune to inoculated small-pox, this proves nothing in favour of Jenner's thesis.
Instances of the variolous test breaking down were not uncommon. Thus a surgeon, named Boddington, found in the case of his own child that the inoculation test produced not only a local pustule, but also a general small-pox eruption. He wrote to Jenner on the subject, who replied, "How a gentleman, following a profession the guardian angel of which is Fame, should have so committed himself as to have called this a case of smallpox after cow-pox, is not only astonishing to me, but must be so to all who know anything of the animal economy."1
1 Baron's " Life of Jenner," vol. i., p. 445.
Baron refers to this as a sample of Jenner's method of dealing with "rumours" of this kind. Ultimately Jenner discarded the test, for in 1804 he writes:—
"I will just remark that the fairest of all tests is exposure to variolous contagion. This is the natural test; inoculation is not. Who does not know (all medical men ought to know) that the insertion of the variolous poison into the skin of an irritable person will sometimes produce great inflammation, disturbance of the system, and even eruptions ? " 1
1. Letter from Jenner to Dunning, July 22, 1804. Baron's "Life of Jenner," vol. ii., p. 339.
Any other evidence brought forward by Jenner is entirely discounted by his invention of the term "spurious cow-pox." This was first used to describe cases of cow-pox which did not originate from grease in the horse, and subsequently as an excuse when it was discovered that the vaccinated were liable to be attacked by small-pox. In his paper on "The Origin of the Vaccine Inoculation," he gives the following ingenious explanation:—
"In the course of the investigation of this subject, which, like all others of a complex and intricate nature, presented many difficulties, I found that some of those who seemed to have undergone the cow-pox, nevertheless, on inoculation with the small-pox, felt its influence just the same as if no disease had been communicated to them by the cow. This occurrence led me to enquire among the medical practitioners in the country around me, who all agreed in this sentiment— that the cow-pox was not to be relied upon as a certain preventive of the small-pox.
" This for a while damped, but did not extinguish, my ardour; for, as I proceeded, I had the satisfaction
to learn that the cow was subject to some varieties of spontaneous eruptions upon her teats ; that they were all capable of communicating sores to the hands of the milkers, and that whatever sore was derived from this animal was called in the dairy the cow-pox.
" Thus I surmounted a great obstacle, and in consequence was led to form a distinction between these diseases, one of which only I have denominated the true, the others the spurious cow-pox, as they possess no specific power over the constitution."
I may here remark that Jenner never gave any signs by which the true and spurious cow-pox could he distinguished, and the mystery remains unsolved until this day.
In some concluding remarks of the "Inquiry," he relates the cases of Hannah Pick and Elizabeth Sarsenet, who contracted cow-pox with all the other servants at a farm in the parish of Berkeley. These cases fairly puzzled him; for Hannah, when inoculated with smallpox, was found protected; but Elizabeth, on exposure to the infection, contracted the disease. In the latter case, although there were multiple vesicles, there was no glandular or constitutional affection. Jenner says:—
" This impediment to my progress was not long removed before another, of far greater magnitude in its appearances, started up. There were not wanting instances to prove that, when the true cow-pox broke out among the cattle at a dairy, a person who had milked an infected animal, and had thereby apparently gone through the disease in common with others, was liable to receive the small-pox afterwards."
Baron observes—
"Most men would, at this stage, have abandoned the investigation in despair. It was not so with Jenner."1
Jenner continues—
" This, like the former obstacle, gave a painful check to my
fond and aspiring hopes; but reflecting that the operations of nature are
generally uniform, and that it was not probable the human constitution (having
undergone the cow-pox) should in some instances be perfectly shielded from the
small-pox, and in many others remain unprotected, I resumed my labours with
redoubled ardour.
"The result was fortunate, for I now discovered that the virus of cow-pox was
liable to undergo progressive changes, from the same causes precisely as that of
smallpox, and that when it was applied to the human skin in its degenerated
state, it would produce the ulcerative effects in as great a degree as when it
was not decomposed, and sometimes far greater; but, having lost its specific
properties, it was incapable of producing that change upon the human frame which
is requisite to render it unsusceptible of the variolous contagion; so that it
became evident a person might milk a cow one day, and, having caught the
disease, be for ever secure, while another person milking the same cow the next
day might feel the influence of the virus in such a way as to produce a sore or
sores, and in consequence of this might experience an indisposition to a
considerable extent; yet, as has been observed, the specific qualities being
lost, the constitution would receive no peculiar impression."
1 Baron's " Life of Jenner," vol. i., p. 132.
CONDEMNED BY THE COLLEGE OF PHYSICIANS.
Only think of the absurdity of it. One day matter from the nipple of the cow, when inoculated on a human being, produces true cow-pox, and renders that person for ever afterwards secure from small-pox ; the very next day matter from the same cow will produce identical symptoms, but the cow-pox having lost its specific properties, the second person remains entirely unprotected !
The " spurious cow-pox " cry contributed largely to establish vaccination; for before the Committee appointed by the House of Commons to consider Jenner's claim for reward, some of the leading medical men gravely asserted that cases of failure must have been done with spurious matter.
It is only fair to mention that this explanation was condemned by the College of Physicians. "Some deviations from the usual course have occasionally occurred, which the author of the practice has called spurious cow-pox, by which the public have been misled, as if there were a true and a false cow-pox."1 This condemnation, however, came too late to arrest the mischief, for cow-poxing had already become an established practice.
It was also unfortunate that the early opponents of vaccination were almost entirely an interested opposition, being pledged to small-pox inoculation ; and it was especially unfortunate that if they had questioned the validity of the variolous test they would have exposed their own nostrum, which, as I have shown, was in some cases little else than an imposture.
1 Report of the Royal College of Physicians of London on Vaccination. (Ordered to be printed by the House of Commons, July 8, 1807.)
Another thing which largely contributed to establish vaccination was the misleading name of " variolœ vaccinœ" or small-pox of the cow, given to the disease by Jenner; and this, giving as it did a truly scientific ring, most materially assisted the cow-pox propagandists in their innovation. The theory that cow-pox was smallpox of the cow was quite new to the veterinary surgeons and other practical people of that time, and was objected to by one of Jenner's leading contemporaries, Dr. George Pearson, on the ground that "cow-pox is a specifically different distemper from the small-pox in essential particulars, namely, in the nature of its morbific poison, and in its symptoms." Dr. George Gregory, a more recent authority, was also entirely opposed to the identity theory. "On all these grounds, I demur to the theory of identity, and hold that small-pox and cow-pox are antagonistic affections—that cow-pox, instead of being, as Dr. Baron maintains, of a variolous, is, in fact, of an anti-variolous nature—that it alters and modifies the human constitution so as to render some individuals wholly, others partially, and for a time, unsusceptible of small-pox."1 The total unlikeness of cow-pox to smallpox in all respects, save their names, has been much dwelt upon by several modern pathologists,2 to whose writings I refer my readers.
1 "Lectures on the Eruptive Fevers," p. 207. London. 1843.
2 " Vaccine et Variole" p. 100. Chaveau. Paris. 1865. "Human
and Animal Variolce" p. 4. George Fleming, F. R.C.V. S. London.
1881. " The Natural History of Cow-pox and Vaccinal Syphilis." Charles
Creighton, M. D. London. 1887. " History and Pathology of Vaccination." Edgar M. Crookshank, M.B. (2 vols.) London. 1889.
CHAPTER 2.
THE DECLINE IN SMALL-POX SINCE THE INTRODUCTION OF VACCINATION.
The argument that small-pox has declined since the introduction and more efficient enforcement of vaccination is an important one. It is commonly asserted that in former times this disease raged like the plague,1 but a careful examination of the London Bills of Mortality will show the absurdity of the claim. In the whole history of small-pox it never raised the total deaths so as to make them stand out conspicuously among surrounding years ; but this was very far from being the case with the plague.
Burials within the London Bills of Mortality from plague and "all causes" for the plague years 1603, 1625, 1636, and 1665.2
Years. Deaths from plague. Deaths from all cause
1603 30,561 ....
37,294
1625 35,417
54,265
1636
10,400 ....
23,359
1665 ... 68,596
97,306
1 ''Your Committee, however, believe that, ... if vaccination had not been general, this epidemic (1871-72) would probably have become a pestilence, raging with destructive force, like the plague of the Middle Ages." (Draft Report proposed by the chairman of the Select Committee on the Vaccination Act, 1867.)
2 Second Report, Royal Commission on Vaccination, pp. 289, 290.
For the non-plague years, 1604-24, the average annual number of deaths from all causes was 8,548 ; for the years 1626-35, 8,986; and the years 1637-64, 12,554. It is thus evident that the plague made an enormous difference to the total mortality, which was never the case with small-pox.
Let us now see what small-pox was at its worst. The only continuous set of figures we have extending over a long period of time are those for London, and, in the absence of any reliable information about the population, we are forced to the imperfect method of comparing the ratios of deaths from small-pox to those for all causes. The following figures give the highest years for small-pox in the seventeenth, eighteenth, and nineteenth centuries :—
Deaths Deaths Ratio per 1,000
Years. from from from
small-pox, all causes. small-pox.
Seventeenth century (1634) 1,354 10,400 130
Eighteenth century (1796) 3,548 19,288 184
Nineteenth century (1871) 7,912 80,430 98
Although there is not a great difference between the maxima of the seventeenth and nineteenth centuries, a sensible decline has nevertheless taken place, for the small-pox epidemics appear at much less frequent intervals than formerly.
Since the commencement of the Registrar-General's returns in 1838 we have the advantage of exact figures, and the interval from this date to the present time may be conveniently divided by the great epidemic of 1871-72. It was during the first of these periods that all the important laws relating to vaccination came into force.
THE VACCINATION
ACTS.
In 1840 an Act (3 and 4 Victoria, cap. 29) was passed making it the duty of
Guardians to provide facilities for vaccination ; but it was not until 1853
(16 and 17
Victoria, cap. 100) that neglect of vaccination was made punishable by fine, or
imprisonment in default of distress.
The effect of this law was seen in the large increase of the number of vaccinations in 1854. By the Act of 1861 (24 and 25 Victoria, cap. 59), Guardians were authorised to appoint officers to institute and conduct proceedings for the purpose of enforcing obedience to the law. The most important Act of all, however, was that of 1867 (30 and 31 Victoria, cap. 84), which imposed on the Guardians the duty of seeing that children were duly vaccinated, and empowered them to pay any officer appointed by them to prosecute persons charged with offences against the Act.1 It also introduced a provision (section 31) to secure the vaccination of children born before the Act came into force ; but the most important provision of all was that relating to repeated penalties for the non-vaccination of the same child, and this harsh process of the law could hardly fail, in the then state of public opinion, to greatly increase the number of vaccinations. Referring to this Act, the Select Parliamentary Committee say—"Your Committee are glad to find that wherever the Guardians endeavour to carry out the law, it is very generally, and indeed almost universally, enforced;" and they proposed an amendment to the effect that the appointment of vaccination officers should be made obligatory—a suggestion which was embodied in the Act of 1871 (34 and 35 Victoria, cap. 98).
1. Dr. Seaton informed the House of Commons' Committee of 1871 that of two hundred and sixty Unions, inspected in 1870, only one hundred and twenty were reported as not having vaccination officers; a large number of these, however, had appointed officers since (before May, 1871).
The Act of 1871 made other alterations. By the 27th section of the 1867 Act, it was provided that the Guardians shall make inquiry, and " if they find that the provisions of the Act have been neglected, shall cause proceedings to be taken against the persons in default." This clause was repealed by the Act of 1871. The repeal of this section absolved the Guardians from the duty of prosecuting for the time being; but in 1874 an Act was passed (37 and 38 Victoria, cap. 75) empowering the Local Government Board to make "rules, orders, and regulations prescribing the duties of Guardians and their officers in relation to the institution and conduct of proceedings to be taken for enforcing the provisions of the said Acts (1867 and 1871)." The Local Government Board have acted on this power, and in their General Order, dated October 31, 1874, have introduced a clause (art. 16) which takes the place of the repealed 27th section of the Act of 1867.
If we refer to the diagram in the Appendix, which gives the proportion of public vaccinations under one year of age to the births, from 1845 to 1895, we find that the Act of 1853 doubled the number of vaccinations; after this the number diminishes, to increase again in 1863-64. This increase was probably due to an outbreak of smallpox. After another decline, there is an increase of vaccinations in 1868-69, which may be attributed to the Act of 1867; and a still further rise in 1871, due, no doubt, to the great epidemic of small-pox then prevailing.
SMALL-POX AND VACCINATION SINCE 1872.
The effect of the legislation of 1871 is not apparent, for there is no further increase in the number of vaccinations in 1872, when the Act came into operation.
Another method of testing the increasing efficiency of the Vaccination Acts is the proportion of the small-pox cases vaccinated. The figures for the London Small-pox Hospital work out as follows :—
Percentage of small-pox
Years. cases vaccinated.
1826-34 35
1835-45 44
1845-55 64
1855-65 78
1867 ...... 84
1871 92
An examination of the diagram referred to shows that with the gradually increasing proportion of the population vaccinated there is no diminution in smallpox, and the epidemic of 1871-72, coming when England was thoroughly vaccinated, points forcibly to the inutility of the operation.
Let us now examine the history of small-pox and vaccination subsequent to the great epidemic. The same diagram shows that the infantile public vaccinations remained practically stationary until 1881 or 1882, when they began to decline; from 1881 to 1895 they decreased from 57-3 to 35-1 per cent, of the births, which is a considerable reduction. It will be seen that since the great epidemic (1871-72), and coincident with the decline in vaccination, small-pox has diminished, and quite recently markedly so.
An examination of the statistics for London, since the opening of the hospitals of the Metropolitan Asylums Board, also shows conclusively that the enormous decline in the small-pox mortality in recent years cannot be attributed to vaccination. The figures are taken from the last published reports of the Metropolitan Asylums Board (1895) and the Local Government Board (1895-96).
Estimated Smallpox Percentage of births
population in the Deaths from death-rate not finally accounted
Years- middle of each small-pox. per million for in regard to
year. ' vaccination.
1871 3,267,251 7,912 2,421 No return.
1872 3,319,736 1,786 537 8.8
1873 3,373,065 113 33 8.7
1874 3,427,250 57 16 8.8
1875 3,482,306 46 12 9.3
1876 3,538,246 736 207 6.5
1877 3,595,o85 2,551 709 7.1
1878 3,652,837 1,417 387 7.1
1879 3,711, 517 450 120 7.8
1880 3,77i,i39 471 124 7.0
1881 3,824,964 2,367 617 5.7
1882 3,862,876 430 110 6.6
1883 3,901,164 136 34 6.5
1884 3,939,832 1,236 307 6.8
1885 3,978,883 1,419 347 7.0
1886 4,018,321 24 5 7.8
1887 4,058,150 9 2 9.0
1888 4,098,374 9 2 10.3
1889 4,138,996 — — 11.6
1890 4,180,021 4 1 13.9
1891 4,221,452 8 2 16.4
1892 4,263,294 41 10 18.4
1893 4,306,411 206 48 18.2
1894 4,349,166 89 22 Returns not yet
1895 4,392,346 55 13 published.
Thus it will be seen that with an increasing proportion of the population vaccinated, up to the great epidemic of 1871-72, there was no corresponding decline in the small-pox mortality, and more recently, while the reduction in small-pox has been enormous, the vaccinations have also declined.
As pointed out above, however, if this century be compared with the two previous ones, a large decline in small-pox has taken place; and this has been accompanied by an equal if not a greater decline in another zymotic disease, which is spread by overcrowding and insanitation—viz.: typhus fever. In 1685-86 the country suffered from a severe epidemic of a fever which has been described by Sydenham, and, according to Dr. Murchison,1 presented all the symptoms of typhus—viz.: headache, pains in the limbs, dry brown tongue, delirium, and an eruption resembling that of measles, and often accompanied by true petechiae. According to the London "Bills" there were 3,832 deaths from fever in 1685, or a rate of 165 per 1,000 of the total deaths (23,222) in the year; and 4,185 deaths in 1686, or one of 185 per 1,000 (total deaths, 22,609).
1 "The Continued Fevers of Great Britain," p. 30. Second edition. 1873-
The most severe fever year was in 1741. In London 7,528 died, or a rate of 234 per 1,000 from all causes (32,169). This considerably exceeds the figures for small-pox, which, at its worst, in 1796, had only a rate of 184 per 1,000 total deaths. Dr. Murchison, in speaking of the fever epidemic in 1741 (p. 34), says:—
In London it is said to have broken out among the poor, who had been half-starved for two years, and obliged to eat uncommon and unwholesome things. In all the accounts mention is made of the eruption : in some cases it is described as like that of measles, in others as like so many small flea-bites, while in a few instances it is said to have been mixed up with petechiae and vibices."
From the description given by one of the writers at the time—Barker,1 of Salisbury—there can be but very little doubt that this epidemic was one of true typhus. The patient, after having languished for several days, was seized with rigors or cold chills, and with a heavy pain in the forehead or over the eyebrows, which rendered him stupid and dejected. About the seventh day petechiae or spots sometimes appeared upon the breast or arms; these were commonly of a pale red colour, like measles, and sometimes purple, like so many small flea-bites. In a very few the eruption was of a deep violet colour, and in others very broad, like scurvy spots or bruises. In the later stages the patient became delirious, the breathing was often laboured, and there was also convulsive twitching of the tendons, and fumbling with the bedclothes.
1 " An Inquiry into the Nature, Cause, and Cure of the present Epidemic Fever," pp. 39-42. J. Barker, M.B. London. 1742.
In 1837-38, epidemics of small-pox and typhus took place simultaneously. In England and Wales, during the eighteen months ending December 31, 1838, 27,822 died from typhus, and 22,079 from small-pox ; while in the Metropolis, during the same period, there were 6,011 deaths from typhus, and 4,580 from small-pox. In London we know that this epidemic of fever was almost wholly typhus. Of sixty cases in 1837-38, of which notes were kept by West, under Latham, at St. Bartholomew's Hospital, none that died and were examined post-mortem had ulcerations of Peyer's patches, pathognomonic of enteric or typhoid fever, although some had congestion of Peyer's patches, the cases being all reckoned typhus exanthematicus.1 Sir Thomas Watson has also testified to the nature of this epidemic :—
" Fever is very rife in St. Giles's, and in other crowded parts of this town, just now (1838). Our wards at the Middlesex are full of it; and scarcely a case presents itself without these spots. We speak of it familiarly as the spotted fever, or (from the resemblance which the rash bears to that of the measles, hereafter to be described) as the rubeoloid fever."2
1 "A History of Epidemics in Britain," vol. ii., p. 194. Creighton.
2 " Lectures on the Principles and Practice of Physic," vol. ii., p. 732.
The 1847 epidemic of fever in England was almost entirely one of typhus, there being 30,320 deaths, or a number considerably exceeding any year for smallpox over the whole period of registration. Since this epidemic, typhus fever has largely diminished ; but it has been noticed that at the London Fever Hospital all the great annual rises in the deaths from fever in London since 1849 (after which year enteric fever and typhus were first separated in the returns of the Hospital) have corresponded to a greatly increased admission of typhus, and not of enteric cases.
In the returns of the Registrar-General it was separated from enteric fever in 1869; and from 1871-75 to 1891-95 the average annual typhus death-rate in England and Wales has declined from 81 to 4 per million, or a fall of 95 per cent, on the earlier rate. The fact that this complaint, which was formerly more prevalent than small-pox, should have diminished to such an extent as to have become practically extinct, has a very important bearing on the decline of small-pox, for it is admitted that typhus fever is a disease which is spread by overcrowding and insanitation, and in a subsequent chapter it will be seen also that small-pox is largely disseminated in the same manner.
The following table shows the decline that has taken place in small-pox, fever, typhus fever, and scarlet fever since the commencement of registration. It is divided into five-year periods.
England and Wales.—Average annual death-rate per million living, from small-pox, fever,1 typhus fever, and scarlet fever, in five-year periods from 1838-95.2
Years. Small-pox.3 Fever. Typhus fever. Scarlet fever.
1838-42 576 1,053 — —
1847-50 (4 years) 292 1,246 — —
1851-55 248 983 — —
1856-60 198 842 — —
1861-65 219 922 — 982
1866-70 105 850 — 960
1871-75 408 599 81 759
1876-80 82 380 34 680
1881-85 83 273 23 436
1886-90 16 202 7 241
1891-95 24 185 4 182
Over the whole period it will be found that the small-pox death-rate declined 96 per cent., while fever declined 82 per cent. But the most extraordinary feature of the table is the large small-pox death-rate in 1871-75,
1 The term "fever" includes typhus, typhoid, and simple and ill-defined fevers.
2 From 1843-46 the causes of death were not abstracted.
3 The figures for small-pox include chicken-pox.
twenty years after vaccination had been made compulsory. Thus, between 1838-42 and 1871-75 the death-rate from small-pox had only abated 29 per cent., while fever diminished 43 per cent.; and, therefore, since the commencement of registration there was practically no important decline in small-pox until after the 1871-72 epidemic, although the death-rate from fever had materially diminished. Let me call attention to what has happened with the other diseases in the table. Since 1871-75, typhus (for which we have no State-enforced preventive inoculation) has declined 95 per cent, or a fall as great as there has been in small-pox over the whole period of registration ; and scarlet fever shows the important reduction of 81 per cent, since 1861-65.
An objection has been made to the fever figures, on the ground, it is said, that formerly fever included other diseases, such as pneumonia, influenza, etc., which now appear under their respective headings. The following quotation, however, from the Registrar-General's forty-second annual report (1879) proves that this is not the case to any large extent. The cause of the decline is also explained. The Registrar-General says (p. xxx.):—
" Had the deaths from one or more of this group of causes fallen, while those from others in the same group had risen, or had the fall been trifling, or the totals dealt with insignificant in amount, it might have been suspected that the alteration was a mere alteration in name. But as the deaths under each heading have declined, as the fall in the death-rate from them has been enormous— 62.4 per cent, in the course of ten years—and as the totals are by no means small, it may be accepted as an indisputable fact that there has in truth been a notable decline in these pests, and it may be fairly assumed that the decline is due to improved sanitary organisation."
I will now allude to the alterations that have taken place from time to time in the age-incidence of the small-pox mortality. Dr. Creighton has pointed out that, in all probability, in the seventeenth century smallpox was more a disease of adults than in the eighteenth century, when it was largely a disease of children ; at any rate, it was on account of its incidence on adults that the disease obtained its evil repute. In the diary of John Evelyn, we read that he himself had small-pox when a young man. His two daughters died of it in early womanhood within a few months of each other; and a suitor for the hand of one of them died of it about the same time. Among the medical writers, Willis gives four cases, all in adults ; and Morton, sixty-six clinical cases of small-pox, twenty-three of which were under twelve and the rest over twelve years of age.1
Again, in their writings the physicians of that time indicated that small-pox was a mild disease in infants. Willis says, "There is less danger if it should happen in the age of childhood or infancy;" again, "the sooner that anyone hath this disease, the more secure they are, wherefore children most often escape."2 Dr. Walter Harris, in a treatise on the acute diseases of infants, says :—
" The small-pox and measles of infants, being for the most part a mild and tranquil effervescence of the blood, are wont to have often no bad character, where neither the helping hands of physicians are called in, nor the abounding skill of complacent nurses is put in requisition." 3
1 "A History of Epidemics in Britain," vol. ii., pp. 443, 444. Creighton.
2 Thomas Willis, M.D., on "Fevers." Translation by S. Pordage, pp. 139, 142. London. 1681.
3. "A History of Epidemics in Britain," vol. ii., pp. 441. Creighton.
In the eighteenth century, on the contrary, the incidence of the small-pox mortality, especially in the manufacturing towns, was almost entirely on infants and young children, as is shown in the following table :1
Small-pox Small-pox Percentage
Years. deaths at deaths under under five years
all ages. five years of age. of age.
Kilmarnock, 1728-63 ... 622 563 90.5
Manchester, 1769-74 ... 589 559 94.9
Warrington, 1773 ... 209 197 94.3
Chester, 1774 ... 202 180 89.1
Carlisle, 1779-87 ... 241 229 95.0
In country districts, however, where small-pox appeared at less frequent intervals, there was time for the children to grow up without having the disease; and thus, in some instances, there were very few cases and deaths in the early years of life. Aynho, a small market town in Northamptonshire, is an instance in point. The following figures are recorded by the rector of the parish for fifteen months in 1723-24 : 2
Ages. Cases. Deaths.
0-1 ... — ... —
1-2 ... — ... —
2-3 3 - 2
3-4 4 1
4- 5 ... 6 ... 0
5-10 ... 15 ... 1
10-15 33 3
15-20 14 ... 1
20-25 16 ... 3
25-30 9 3
30-40 ...12 ... 3
40-50 . 10 ... 4
50-60 ... 4 ... 1
60-70 ... 4 ... 2
Above 70 ..2 ... 1
Total, 132 251 "A History of Epidemics in Britain," vol. ii., p. pp. 527, 536, 538, 554. Creighton.
2 Ibid., p. 520.
Thus, in the eighteenth century, although there may have been exceptions in some country districts, in towns the rule was for small-pox to be almost entirely a children's disease. This continued to be the case until after the 1837-38 epidemic. The Registrar-General first separated ages for all England in 1847, and the following table gives the proportion of small-pox deaths under five years of age from that time.
England and Wales.—For small-pox1 the deaths at all ages and under five, and the percentage of deaths under five to deaths at all ages in five-year periods from 1847-95.
Small-pox deaths Small-pox deaths Percentage
Years. at under under
all ages. five years of age. five years of age.
1847-50
(4 years) - 20,439 14,307 70.0
1851-55 ... 22,801 15,091 66.2
1856-60 ... 19,270 11,010 57.1
1861-65 ... 23,007 12,477 54.2
1866-70 ... 11,779 6,403 54.4
1871-75 ... 47,696 14,929 31.3
1876-80 ... 10,243 2,938 28.7
1881-85 ... 11,025 3,002 27.2
1886-90 ... 2,320 820 35.3
1891-95 ... 3,515 1,313 37.41 These figures include chicken-pox; if this disease be omitted from the calculations, 26 .9 per cent, of the total deaths from small-pox were under five years of age in the period 1891-95, or a percentage reduction of 62 since 1847-50.
INCREASE IN ADULT MORTALITY OF SMALLPOX
The figures in this table are corrected for chicken-pox; this disease was included with small-pox until 1874, but since that date chicken-pox deaths have been separately classified. My authority for adding them is contained on page x. of the fifty-second annual report of the Registrar - General (1889): —
"There were, however, eighty-three deaths ascribed to chicken-pox, and it is very probable that most of these were in reality cases of modified small-pox, true chicken-pox being an ailment that is rarely, if ever, fatal."
It will be seen from the table that over the whole period the percentage of deaths from small-pox under five years of age has declined from 70.0 to 37.4, or a percentage reduction of 47.
Not only has the children's share of the small-pox death-rate diminished, but at ages above ten the mortality has actually increased ; that is to say, there has been an age-shifting of the small-pox death-rate. This is shown by the following figures taken from the forty-third annual report of the Registrar-General (1880, p. xxii.).
England and Wales.—Mean annual deaths from small-pox at successive life-periods, per million living at each life-period.
Age periods 5. 5- 10- 15- 25- 45 and upwards.
Vaccination optional, 1847-53... 1,617 337 94 109 66 22
Vaccination compulsory, 1872-80 323 186 98 173 141 58
The increase in the adult mortality of small-pox during the period of compulsory vaccination has been urged by Dr. Bridges as a sufficient ground for altering the law. He thought that, if these facts had been generally known at the time, the Legislature would have hesitated before making vaccination compulsory. Dr. Collins and Mr. Picton1 have also shown that since the last century there has been an alteration in the share borne by children of the small-pox deaths independently of vaccination. From 1881 the Registrar-General has classified the small-pox deaths into three groups—the vaccinated, the unvaccinated, and those in which there is no statement. In the unvaccinated class, from 1881-93, there were in all 3,746 deaths, 1,483, or 39.5 per cent., of which were under five years of age ; during the last century, as pointed out above, the proportion under five years of age was more than double this figure. It is not easy to understand how vaccination can have brought about this change in the unvaccinated.
1 Royal Commission on Vaccination. Dissentient Commissioners' Statement, section 147.
Comparisons have been instituted with other diseases. In this connection Dr. Ogle, the late Superintendent of Statistics to the Registrar-General, informed the Royal Commission (Q. 516 and 518) that the zymotic diseases were the better ones with which to compare small-pox; but he said, "It is impossible to make similar comparisons in the case of scarlet fever or measles, and diseases that only affect children. Fever is the only one of the zymotic headings that you can take, because it is the only one that affects all ages to any extent. Fever is, therefore, the only one which it is possible to subject to this kind of investigation."
AGE-INCIDENCE OF TYPHUS FEVER.
The following table gives the children's proportion of deaths for fever in five-year periods from 1847-95. Corrections have been made for remittent fever. From 1869 to 1880 the deaths from remittent fever, under five years of age, were classed with typhoid, and therefore I have added these deaths to fever for the other years in the table—viz.: from 1847-68 and from 1881-95.
England and Wales.—For fever the deaths at all ages and under five, and the percentage of deaths under five to deaths at all ages in five-year periods from 1847-95.
Fever deaths Fever deaths Percentage
Years. at under under
all ages. five years of age. five years of age.
1847-50 ... 88,093 15,880 18.0
(4 years)
1851-55 ... 92,440 19,539 21.1
1856-60 ... 82,847 19,072 23.0
1861-65 95,723 19,166 20.0
1866-70 ... 94,057 17,352 18.4
1871-75 ... 70,109 12,994 18.5
1876-80 ... 47,524 8,375 17.6
1881-85 37,005 4,692 12.7
1886-90 ... 28,698 2,908 10.1
1891-95 ... 27,628 2,180 7.9
Over the whole period the children's proportion of deaths from fever has declined from 18 to 7.9 Per cent., or a percentage reduction of 56. This is greater or less than the figure for small-pox, according to whether the chicken-pox deaths are included or not in the smallpox totals.
Not only has there been an alteration in the age-incidence of fever as a whole, but there is every reason to believe that the same change has taken place in the several diseases composing the group. Except in quite recent years this is difficult to prove in the case of typhoid fever; but in typhus there is very little doubt that such has been the case. In order to compare present-day typhus with some former period, it is necessary to find, not only years of undoubted typhus, but also years in which the ages are separated. The epidemic years, 1837-38, are out of the question, because deaths were not classified at different ages ; but the epidemic took place later in the North of England, and for 1839 we have the figures for Manchester and Liverpool. I also give the statistics for all England and London for the epidemic of 1847, which was almost exclusively typhus fever.
Deaths from typhus fever at all ages and under five, with percentage under five years of age, for Manchester and Liverpool in 1839, and for England and Wales and London in 1847.
Typhus Typhus deaths Percentage
Years. deaths at under five under five
all ages. years of age. years of age.
Manchester1 ... 1839 323 51 15.8
Liverpool1 ...- ... 1839 305 46 15.1
England and Wales2 1847 30,320 4,364 14.4
England and Wales2
(excluding London) l847 27,136 3,823 14.1
London2 ...............1847 3,184 541 17.01 Third Annual Report of the Registrar-General, pp. 194 and 206.
2 Tenth Annual Report of the Registrar-General.
In 1869 the typhus deaths were separated from typhoid in the returns of the Registrar-General. The following gives the figures for typhus from 1871-95 for England and Wales and for London :—
Typhus
Typhus deaths
Percentage
Years
deaths at
under five
under under five
all ages
years
of age
years of age
England and Wales 1871-95 18,206
1,040
5.71
England and Wales"
(excluding London) l871-95
15,955
848
5.31
London ... ... 1871-95
2,251
192
8.53
Thus it would appear that there has been a great alteration in the age-incidence of typhus fever from the commencement of registration. Since the separation of typhus and typhoid fevers in the returns of the Registrar-General, both diseases have shown a change in this particular. The percentages under five years of age are as follows1:—
1871-75. 1876-80. 1881-85. 1886-90. 1891-95.
Typhus................ 6.4 6.1 3.5 3.4 5.1
Typhoid ... 17.4 16.0 11.2 8.4 6.6
In typhoid, there has been a marked change in the age-incidence ; but in typhus, the quinquennium, 1891-95, shows only a slight decline in the children's share of deaths as compared with the earlier period, 1871-75.
The age-shifting of the small-pox death-rate—that is to say, the lessened death-rate in children combined with an increased death-rate in adults—has been claimed as a "phenomenon" which is " without a parallel in the history of human mortality."2 Mr. Alfred Milnes3 has, however, pointed out that a similar "phenomenon " has occurred in the case of influenza.
1. The figures up to 1890 are those given by Mr. Alfred Milnes in The Vaccination Inquirer for February, 1893. The last column has been calculated by me from the returns of the Registrar-General. The typhoid fever percentages have been corrected for remittent fever deaths under five years of age.
2. "Vaccination Vindicated," p. 18. John C. M'Vail, M.D. 1887.
3. The Vaccination Inquirer, May, 1893.
The Registrar-General, in his fifty-fourth annual report (1891, p. xx.), gives the death-rates per million living at different ages in the influenza epidemics of 1847-48 and 1890-91.
Age-periods. Under 5- 5- 10- 15- 25- 35- 45- 55- 65- 75- 85-
1847-48... 713 80 49 51 79 139 284 809 2,372 5,510 11,243
1890-91... 306 55 46 115 197 347 595 1,060 1,985 3,355 4,821
On comparing this table with that on page 45, it will be seen that both small-pox and influenza show a decline up to ten years of age. In the next age-period, 10-15, the death-rate at both periods is nearly the same, while from fifteen onwards the later period shows a greater mortality from both diseases ; but the influenza mortality in persons aged sixty-five and upwards shows a decline in the later epidemic of 1890-91 as compared with the earlier one of 1847-48.
Before leaving the subject of age-incidence, I would draw the attention of my readers to a table in section 171 of the Final Report of the Royal Commission. It gives for England and Wales the deaths from smallpox at certain age-periods to 1,000 deaths from smallpox at all ages. The figures under one year of age are as follows :—
Deaths from small-pox under one
Years. year of age to 1,000 deaths from
small-pox at all ages.
1848-1854 ... 251
1855-1859 ... 231
1860-1864 ... 237
1865-1869 ... 231
1870-1874 ... 143
1875-1879 ... ............. 112
1880-1884 ... 113
1885-1889 112
1890-1894 166
From 1848-54 to 1855-59 the proportion of infantile small-pox deaths declined from 251 to 231, or a reduction of 8 per cent. The successful public vaccinations of infants under one year of age are given in the Appendix.1 On calculation it will be found that from 1848-54 they averaged 36.9 per cent, of the births, and from 1855-59,. 51-5 per cent.; that is to say, that between the two periods the proportion increased from 36.9 to 51.5 Per cent., or a percentage increase of 39.6. By a similar calculation, from 1865-69 to 1870-74 they increased from 48.5 to 55-6 per cent., or a percentage increase of 14.6. Between the latter periods the proportion of small-pox deaths under one year of age declined from 231 to 143, or a reduction of 38.1 per cent. To put it in tabular form :
Percentage increase
Percentage decline in the
in the proportion of
proportion of small-pox
successful public
deaths under one year
From the period vaccinations under
of age to 1,000
deaths
one year of age to from small-pox at
the births, all ages.
1848-54 to
1855-59...............
39.6
8.0
l865-69 to
1870-74................
14.6
38.1
It is obvious from the above that there is some cause other than vaccination contributing to the alteration that has taken place in the age-incidence of the smallpox mortality.
1 It will be observed in the Appendix that the returns are made up to September 29, but for the purposes of these calculations, the proportion of successful public vaccinations under one year of age to the births has been estimated to December 31 for the years in question.
There is another point on which the Commissioners have laid considerable stress. They show that at Leicester and Gloucester the proportion of small-pox deaths under ten years of age is greater than in the well-vaccinated towns of Sheffield and Warrington. The figures given are as follows :—
Small-pox Small-pox deaths Percentage
Epidemics. deaths under ten under ten years
at all ages. years of age. of age.
Warrington, 1892-93 ... 62 14 22.5
Sheffield, 1887-88 ... 500 128 25.6
London, 1892-93 ... 182 67 36.8
Dewsbury, 1891-92 ... 110 57 51.8
Gloucester, 1895-96 ... 434 280 64.5
Leicester, 1892-93 ... 21 15 71.4 (or 66.6) 11 At Leicester, in consequence of the proximity of a scarlet fever ward to the hospital in which small-pox cases were treated, several children in that ward were attacked by small-pox, of whom three died. The 66 .6 per cent, is obtained by deducting these three deaths.
If the reader will consult the diagram in the Appendix, he will find that England and Wales, for seventeen years previous to the epidemic of 1871-72, was very well vaccinated. In that epidemic there were 42,220 deaths from small-pox, of which 20,094, or 47.6 per cent., were under ten years of age. This is double the proportion at Warrington and Sheffield, and very nearly the same as at Dewsbury, where, according to the Commissioners, vaccination had been greatly neglected. In 1892, the second year of the Dewsbury epidemic, the percentage of children born and not finally accounted for with regard to vaccination was 377. In England and Wales, in 1872, the default was only 5.1 per cent.
As the Commissioners have, in two of the towns named, based their conclusions on a small number of deaths, perhaps I may be forgiven if I add the following :—
Small-pox Small-pox deaths Percentage
Epidemics. deaths under five under five years
at all ages. years of age. of age.
Mold,1 1871-72 ... 44 15 34.1
Willenhall,2 1894 ,.. 47 16 34.0
Keighley, 1893 ... 7 0 0.01 The local Registrar has kindly supplied me with the figures for the registration sub-district of Mold.
2 At Leicester, in 1892-93, of twenty-one small-pox deaths, nine were under five years of age. Two of these were among the children who suffered from the proximity of the scarlet fever ward to the hospital in which small-pox cases were treated. If these be deducted, 36.8 per cent, of the total deaths from small-pox were under five years of age, a proportion not much higher than that of Willenhall or Mold.
I shall have occasion to refer to Mold and Willenhall in subsequent chapters. It is sufficient to say here that at the time of their respective epidemics, both were very well-vaccinated districts. With regard to Keighley, there is no reason to believe it to be better vaccinated than Leicester or Gloucester ; indeed, evidence points to the contrary. I do not wish to infer from the experience of these districts that vaccination increases the share of the small-pox mortality borne by children ; the figures are too small for accurate inferences, as also are those of the Commissioners.
To sum up the contents of the present chapter, it will appear that, although there has been a marked decline in small-pox since the last century, there has been an equal, if not a greater, reduction in typhus fever. It has also been shown that since the commencement of registration the vaccination of a gradually increasing proportion of the population previous to the great epidemic of 1871-72 had very little effect on the smallpox death - rate, although there was an appreciable diminution in fever. From this epidemic to the present time, with an increasing neglect of vaccination since 1881, an enormous decline in small-pox has taken place, and a corresponding diminution in typhus and scarlet fevers ; the reduction in all three diseases being due, no doubt, in large measure to the sanitary improvements introduced by the Public Health Act of 1875.
With regard to the age-incidence, when small-pox first began to be much known, in the Stuart period, it was chiefly as a malady attacking adults ; as it became more generally diffused, in the eighteenth century (except in a few country districts where epidemics came infrequently), it was almost entirely a disease of childhood; and more recently it is recognised again as a disease attacking adults as well as children. That this is not due entirely, or even principally, to vaccination, seems clear from the fact that a similar alteration of incidence has taken place in the unvaccinated. Another notable point is that, since the commencement of registration, the most important decline in the proportion of infantile small-pox deaths has not coincided with the period representing the greatest increase in the public infantile vaccination; nor is there sufficient evidence to show that the children in well-vaccinated towns suffer less than in those districts where vaccination has been largely neglected. When we come to compare the behaviour of other diseases in this particular, we find that in the only group which are fairly comparable with small-pox a similar change has been observed.
Before concluding the chapter, I must allude to a favourite argument in defence of vaccination, which seems to weigh with a large number of people—that is, the rarity of pock-marked faces at the present time, as compared with some former period. As to the disfigurement of the population in the seventeenth and eighteenth centuries, there is little or no evidence; but it is significant that in the issues of the London Gazette,1 from 1667-1774, of one hundred advertisements for runaway apprentices, servants who had robbed their masters, horse-stealers, highwaymen, etc., only sixteen were described as more or less marked with small-pox, four being black men or boys. This consecutive hundred included only those who were so particularly described in feature that pock-marks would have been mentioned had they existed. Apparently pock-marked faces were not so common as is generally imagined.
1 "A History of Epidemics in Britain," vol. ii., p. 454. Creighton.
The argument that vaccination has lessened the number is an old one, for in their annual report for 1821 the National Vaccine Board say : "We appeal confidently to all who frequent the theatres and crowded assemblies, to admit that they do not discover in the rising generation any longer that disfigurement of the human face which was obvious everywhere some years since." In the report for 1825 we read: "What argument more powerful can be urged in favour of vaccination, than the daily remark which the least observant must make, that in our churches, our theatres, and in every large assemblage of the people, to see a young person bearing the marks of small-pox is now of extremely rare occurrence ?" Haifa century afterwards, in 1872, The Lancet, of June 29 (vol. i., p. 907), lamented "the growing frequency with which we meet persons in the street disfigured for life with the pitting of small-pox. Young men and, still worse, young women are to be seen daily whose comeliness of appearance is quite compromised by this dreadful disease."
Thus, while with the limited vaccination of 1825 the disfigurement of the young was extremely rare, yet, after nineteen years of compulsion, pock-marked faces had conspicuously increased. It is difficult to construct any scientific theory of protection from these facts, and we may therefore conclude that the argument so often brought forward as conclusive is illusory and untrustworthy.
CHAPTER 3.
SOME OF THE CAUSES OF THE DECLINE IN THE SMALL-POX MORTALITY.
In the last chapter attention was directed to the fact that although some of the epidemics of small-pox in the present century have been nearly as severe as those of the two previous ones, yet they took place at longer intervals; and thus there has been an important reduction in the mortality from this malady. The disease began to subside, however, before the introduction of vaccination, and was part of a general improvement in the public health which was taking place about this time. This is seen in the following table compiled by Dr. Farr.
London.—Average annual death-rates per 100,000 living at six different periods, from 1629-1835.1
All causes. Small-pox.2 Fever.
1629-35 ... ... 5,000 189 636
1660-79 .................. 8,000 417 785
1728-57 ...................... 5,200 426 785
1771-80 ... ... 5,000 502 621
1801-10 ... ... 2,920 204 264
1831-35 ............. 3,200 83 1111 "M'Culloch's Statistical Account of the British Empire," vol. ii., p. 579. Second edition. London. 1839.
2. In a pamphlet by Mr. Ernest Hart, entitled "The Truth About Vaccination" (1880, p. 35), it is stated that "In Dr. Farr's valuable article on Vital Statistics in M'Culloch's 'Account of the British Empire,' it is shown that in the twenty-seven years, 1629-35 and 1660-79, the annual mortality from small-pox in London was equal to nearly 16,000 per million persons living; and in the forty years, 1728-57 and 1771-80, to nearly 18,000 per million living." It is not at first sight apparent how these high rates have been deduced from Dr. Farr's figures.
Commenting on these figures, Dr. Farr says :—
" Smallpox attained its maximum mortality, after inoculation was introduced. The annual deaths of small pox registered 1760-79 were 2,323 ; in the next twenty years, 1780-99, they declined to 1,740; this disease, therefore, began to grow less fatal before vaccination was discovered, indicating, together with the diminution of fever, the general improvement of health then taking place."
Considering, also, that since the commencement of registration smallpox has completely ignored the fluctuations in the amount of vaccination, it is begging the question to assume that this is in any way relevant to the diminution that has been recorded. I propose, therefore, in the present chapter, to indicate some of the causes which have led to the decline of the disease.
It will be convenient at this juncture to consider the effect produced on the small-pox mortality in the displacement of small-pox inoculation by vaccination. As it was only in rare instances, that the inoculated were subjected to any form of isolation, it cannot be denied that they must often have acted as centres of infection and have diffused the disease. Dr. Wagstaffe,1 writing in 1722, related an instance where, in consequence of a few inoculations, small-pox was spread in the town of Hertford, and occasioned a considerable mortality. In Paris, in 1763, the unusual severity of small-pox was attributed
1 A Letter to Dr. Freind, p. 38. London. 1722.
SMALL-POX DIFFUSED BY INOCULATION.
to increased infection from inoculation, and a decree was issued prohibiting the practice. The advocates of vaccination were almost unanimous in their opinion, that inoculation was responsible for much loss of life from small-pox; thus Moore1 declared, that the neglect of the precaution of preventing the spread of infection from the inoculated had "occasioned the loss of millions of lives." The last statement must, however, for obvious reasons, be received with caution.
If we consult the London Bills of Mortality, we find that the small-pox mortality in the eighteenth century exceeded that of the seventeenth century. There are reasons, however, for believing that other causes besides inoculation must be sought for to explain the high small-pox rates in the eighteenth century. One of these is, that small-pox rose to a higher level of mortality about the year 1710; whereas inoculation was not introduced into this country until 1721. Dr. Creighton2 informs us, that "from 1721 to 1727 the inoculations in all England were known with considerable accuracy to have been 857; in 1728 they declined to 37; and for the next ten or twelve years they were of no account." In London inoculation was revived about 1740, and after a few years became a lucrative branch of surgical practice, but was restricted almost exclusively to the well-to-do.
1 "History of Small-pox," pp. 232, 233. James Moore. London. 1815.
2. " A History of Epidemics in Britain," vol. ii., p. 504.
Gratuitous inoculation commenced with the opening of a hospital in 1746; but it was not till 1751-52, that any considerable number of people were inoculated in connection with the charity.
According to the London Bills it does not appear that the few inoculations which took place during the years 1721-28 had any appreciable effect on the smallpox mortality, nor should we expect them to do so ; but if a diagram be prepared showing year by year the rates of small-pox deaths to those for all causes, it will be found that from 1751 to 1781 a still higher level of small - pox mortality was reached than that which prevailed from 1710 to 1751 ; this seems to suggest an inoculation factor in the case. After 1781 smallpox was certainly at a lower level than that obtained between 1751 and 1781 (although in the one year, 1796, it touched the highest point in the century). This diminution, as Dr. Farr has pointed out, was associated with a decline in the general death-rate, and was no doubt brought about by the sanitary improvements introduced at that period ; and thus small-pox became less prevalent, in spite of the fact that inoculation still remained in full operation.
To sum up the case, it is evident that the large mortality from small-pox in the last century cannot be wholly attributed to inoculation ; but from the facts here presented I am led to believe that the augmentation which took place in 1751, and continued for a large number of years, might with fairness be put down to this cause. The first sign of any diminution in the small-pox death-rate commenced after 1781. This cannot be due to any falling off in the amount of inoculation, but must be associated with a general improvement in the public health then observable ; the further decline after the introduction of vaccination was in part probably brought about by the substitution of a non-infectious process.1
FLUCTUATIONS IN SMALL-POX MORTALITY.
One of the causes of the spread of small-pox is overcrowding and want of air-space in and around houses. The fifth annual report of the Registrar-General gives the country and the town mortality from various causes for the four years 1838-41 ; in the case of small-pox the former is 507, and the latter 1,045 Per million ; for all causes the figures are 19,300 and 27,073 respectively. This shows, that small-pox is much more influenced by the aggregation of the population than by all other causes of disease combined. The mortality from smallpox appears to vary according to the greater or lesser proportion of open spaces in towns. The following table illustrates this point.
1 As most of the lymph with which the early " vaccinations" were performed was of variolous origin, it is important to show that after a time the cases inoculated with Woodville's lymph ceased to be infectious. The following, in a letter from Jenner to Lord Egremont (Baron's " Life of Jenner," vol. i., p. 342), is very much to the point. Referring to the threads distributed by Dr. Pearson, Jenner says : "In many places where the threads were sent, a disease like a mild small-pox frequently appeared ; yet, curious to relate, the matter, after it had been used six or seven months, gave up the variolous character entirely, and assumed the vaccine; the pustules declined more and more, and at length became extinct. I made some experiments myself with this matter, and saw a few pustules on my first patients ; but in my subsequent inoculations there were none."
For twenty large towns1 the acres of town area to one acre of park and the average annual death-rate per 1,000, for the ten years 1870-79, from small-pox, measles, scarlet fever, fever and whooping cough.
| Acres of Town area to one acre of park | Average annual death-rate per 1,000 living, for the ten years 1870-79. | |||||
| Smallpox | Measles | Scarlet Fever | Fever | Whooping Cough | ||
| Bristol | 10 | .21 | .45 | .99 | .50 | .54 |
| Liverpool | 10 | .58 | .76 | 1.35 | .95 | .88 |
| Brighton | 22 | .13 | .29 | .47 | .26 | .49 |
| London | 23 | .48 | .52 | .71 | .42 | .79 |
| Leicester | 32 | .33 | .38 | .84 | .48 | .49 |
| Bradford | 34 | .09 | .46 | 1.12 | .65 | .58 |
| Manchester | 34 | .19 | .57 | 1.02 | .69 | .88 |
| Birmingham | 38 | .37 | .42 | 1.15 | .48 | .84 |
| Leeds | 47 | .18 | .48 | 1.11 | .73 | .65 |
| Plymouth | 63 | .39 | .71 | .32 | .49 | .73 |
| Nottingham | 66 | .40 | .30 | .65 | .69 | .34 |
| Salford | 74 | .55 | .81 | .97 | .68 | .86 |
| Oldham | 78 | 16 | .53 | 1.53 | .48 | .66 |
| Sunderland | 115 | .92 | .33 | 1.19 | .74 | .72 |
| Hull | 117 | .25 | .27 | .84 | .83 | .48 |
| Newcastle-on-Tyne | 153 | .65 | .30 | 1.19 | .67 | .55 |
| Sheffield | 249 | .42 | .40 | 1.50 | .85 | .66 |
| Portsmouth | 280 | .52 | .38 | .62 | .75 | .40 |
| Norwich | 1,067 | .70 | .26 | .55 | .52 | .57 |
| Wolverhampton (no parks) | .68 | .31 | .93 | .56 | .60 | |
This table indicates generally, that towns with the greatest amount of park space have low small-pox death-rates, and vice versa. Liverpool appears to be an exception, but it will be noticed that in this town the rates for the other zymotic diseases are also very high, due to overcrowding and sanitary neglect. It must be
1 Fortieth and Forty-second Annual Reports of the Registrar-General.
SALUTARY EFFECT OF OPEN SPACES.
remembered, that with regard to air supply, small towns would have the advantage of large ones. A single dwelling would be surrounded on all sides with air; but suppose we have a group of houses of equal sizes arranged symmetrically in the form of a square, with five houses to a side, there will be sixteen outside houses with twenty-five altogether, and the fraction 16/25 will represent the external aerial supply ; with one hundred houses to a side, this will be shown by the smaller fraction 396/10,000; and hence the difference in the external ventilation of the two groups of houses would be very large, being represented by the difference between the two fractions 6,400/10,000 and 396/10,000. Thus, independently of park space, a small town would have better external ventilation for its houses than a large one; this may to some extent explain several exceptions in the table.
It may be, that there are other causes than the amount of park space to account for the difference in the small-pox mortality in the several towns specified, but the figures, in comparison with those of the other zymotic diseases, appear to be so striking as to suggest that external ventilation really exercises an important influence on the prevalence and mortality of this disease.
The epidemic of 1871-72, which largely dominates the small-pox figures in the last table, was conspicuously severe in the mining districts, which, as a rule, are most overcrowded. Durham was one of the most devastated counties, eleven of the thirteen registration districts having enormous small-pox death-rates.
| Registration districts | Population in 1871 | Deaths from small-pox in the 1871-72 epidemic.1 | Smallpox death-rate per million |
| Darlington | 40,812 | 152 | 3,724 |
| Stockton | 99,705 | 432 | 4,333 |
| Hartlepool | 39,970 | 175 | 4,378 |
| Auckland | 69,159 | 536 | 7,750 |
| Durham | 91,978 | 835 | 9,078 |
| Easington | 33,694 | 293 | 8,696 |
| Houghton-le-Spring. | 26,171 | 193 | 7,375 |
| Chester-le-Street | 33,300 | 209 | 6,276 |
| Sunderland | 112,643 | 1,011 | 8,975 |
| South Shields | 74,949 | 744 | 9,927 |
| Gateshead | 80,271 | 514 | 6,403 |
Dudley, in Staffordshire, had a small-pox death-rate of 8,977, Newcastle one of 6,456, and Bedwellty, Pontypridd, Merthyr, Swansea, Abergavenny, rates of 8,520, 7,492, 6,380, 5,627, and 4,768 per million respectively. Thus we see that small-pox picks out its victims from thickly-populated centres, and more especially towns which are imperfectly aerated, and where, as in mining districts, the industrial conditions predispose to overcrowding.
That our ancestors had a less plentiful supply of fresh air in and around their houses goes without saying. It is a well-known fact that our towns have increased in area quite out of proportion to the increase in the population. Mr. John Timbs2 observes, that the majority of the London squares were the growth of the last century, and that few of those in the western district existed before 1770, their sites being then mostly sheep-walks,
1 The epidemic was not limited to the years 1871 and 1872, in some cases it extended over several years.
2 " Curiosities of London," pp. 746, 747. John Timbs, F.S. A. 1867.
INCREASE OF METROPOLITAN AIR-SPACES.
paddocks, and kitchen - gardens; but we know that several of the London squares existed in the seventeenth century, and there is a reference to Bloomsbury Square in " Evelyn's Diary," under the date February 9, 1665 :—
" Dined at my Lord Treasurer's, the Earle of Southampton, in Blomesbury, where he was building a noble square or piazza, a little towne ; his owne house stands too low, some noble roomes, a pretty cedar chapell, a naked garden to the north, but good aire."
At the beginning of the eighteenth century Grosvenor, Cavendish, and Hanover Squares were laid out, the last two about the year 1718. Portman, Manchester, Finsbury, and Fitzroy Squares were constructed at the end of the last century; and at the beginning of the present century, about 1804, Russell Square, one of the largest in London, was finished, and about this time, also, Bedford and Euston Squares were opened. In 1829 a variety of important improvements were made immediately around St. Martin's Church; a whole labyrinth of close courts and small alleys were swept away, a district including places known as the Bermudas, the Caribbee and Cribbe Islands, and Porridge Island, notorious for its cook-shops;1 this wholesome and wholesale clearance prepared the site for the construction of Trafalgar Square. Other squares, such as Lowndes and Woburn Squares, were made about 1836; while Blandford, Harewood, and Dorset Squares are of more recent construction.
1 See Cassell's " Old and New London," vol. iii., p. 141.
Besides a deficient aeration of towns, our ancestors suffered under an insanitary tax upon light and air, known as the window-tax. This was imposed in order to make good the deficiencies of the clipped money. Its origin, in 1695, has been described by Lord Macaulay:—"It was a maxim received among financiers that no security which the government could offer was so good as the old hearth-money had been. That tax, odious as it was to the great majority of those who paid it, was remembered with regret at the Treasury and in the City. It occurred to the Chancellor of the Exchequer that it might be possible to devise an impost on houses, which might be not less productive nor less certain than the hearth-money, but which might press less heavily on the poor, and might be collected by a less vexatious process. The number of hearths in a house could not be ascertained without domiciliary visits. The windows a collector might count without passing the threshold. Montague proposed that the inhabitants of cottages, who had been cruelly harassed by the chimney men, should be altogether exempted from the new duty. His plan was approved by the Committee of Ways and Means, and was sanctioned by the House without a division. Such was the origin of the window-tax, a tax which, though doubtless a great evil, must be considered as a blessing when compared with the curse from which it rescued the nation."1
1 "History of England," vol. iv., p. 641. Macaulay.
The tax first fell largely on the landlord, but by the 20th of George II. (1746) it was levied upon the several windows of a house at so much per window, and consequently fell more cruelly upon the tenants of the tenement houses. By the 21st of George II., cap. 10, all skylights, the lights of staircases, garrets, cellars, and passages, were to count for the purpose of the tax ; and it was further enacted (11th section) that "no window or light shall be deemed to be stopped up unless such window or light shall be stopped up effectually with stone or brick, or plaister upon lath, etc." The law was enforced by a corrupt machinery of commissioners, receivers-general, and collectors, who were paid by results, and thus could hardly fail to act injuriously. In 1803 the law was altered, the houses being rated as a whole according to the number of their windows, and at the same time the tax for tenement houses was made recoverable from the landlord ; it thus became a sort of modern house-tax rated on windows.1
The great speculative builder of the Restoration was Nicholas Barbone, and his method of procedure may be inferred from the following:—" He was the inventor of this new method of building by casting of ground into streets and small houses, and to augment their number with as little front as possible, and selling the ground to workmen by so much per foot front, and what he could not sell, built himself. This has made ground rents high for the sake of mortgaging; and others, following his steps, have refined and improved upon it, and made a superfoetation of houses about London." 2
1 For the above description of the window-tax, I am indebted to Dr. Creighton's " History of Epidemics."
2 Quoted by Dr. Creighton from "Lives of the Norths." "A History of Epidemics in Britain," vol. ii., p. 86.
" In these mazes of alleys, courts or rents,'" Dr. Creighton says, "the people were, for the most part, closely packed. Overcrowding had been the rule since the Elizabethan proclamation of 1580, and it seems to have become worse under the Stuarts. On February 24, 1623, certain householders of Chancery Lane were indicted at the Middlesex Sessions for sub-letting, 'to the great danger of infectious disease, with plague and other diseases.' In May, 1637, one house was found to contain eleven married couples and fifteen single persons; another house harboured eighteen lodgers. In the most crowded parishes the houses had no sufficient curtilage, standing as they did in alleys and courts. When we begin to have some sanitary information long after, it appears that their vaults, or privies, were indoors, at the foot of the common stair. In 1710, Swift's lodging in Bury Street, St. James's, for which he paid eight shillings a week, had a 'thousand stinks in it,' so that he left it after three months. The House of Commons appears to have been ill-reputed for smells, which were specially remembered in connection with the hot summer of the great fever-year, 1685."
In the days of the Tudors and the Stuarts, the personal habits even of the upper classes left much to be desired. Fresh linen being a luxury, the clothes were seldom changed, and the dyer was more often in requisition than the laundress. Sir John Falstaff thus describes the contents of the buck or linen-basket:— " Foul shirts and smocks, socks, foul stockings, and greasy napkins ; that, Master Brook, there was the rankest compound of villainous smell that ever offended nostril."1
1 " The Merry Wives of Windsor," act iii., scene v.
DOMESTIC INSANITARY CONDITIONS.
From a washing tally found behind some oak panelling in the old chaplain's room at Haddon Hall, in Derbyshire, it would appear that towels had not always belonged to the domestic arrangements of this establishment, for in place of that word, which was scratched out, "laced bands " had been written on the horn of the tally.
Some interesting relics called "scratch-backs" have come down to us, the name sufficiently indicating the habits of the aristocracy of the time. A scratch-back is a hand or claw set in a long handle, which was sometimes made of silver elegantly chased, and there is one instance where a ring on the finger of the hand is set with brilliants. At one time these implements were as indispensable to a lady of fashion as her fan or her patch-box. They were kept in her toilet, and carried with her even to her box at the play. They belong to a period when personal cleanliness was not considered essential, when the style of dress worn was anything but conducive to comfort and ease, and when ladies wore immensely high head-dresses, which, when once fixed, were frequently not disturbed or altered for a month, and not until they had become almost intolerable to the wearer and to her friends.
In the sixteenth and seventeenth centuries, the state of the public health in London was at a very low ebb. The town ditch was a receptacle for all kinds of rubbish and decomposing organic matter ; the streets were unpaved and saturated with slops and other filth. Instead of regular highways, the out-parishes were reached by a maze of narrow passages and alleys. The dwellings of the poor were as bad as they well could be ; the houses projected over the roadway, which was so narrow that they almost met at the top ; there was no attempt at ventilation, and up to and even beyond the time of Queen Elizabeth, the floors were strewn with rushes, and, if we may trust to an epistle from Erasmus to his friend Dr. Francis, physician to Cardinal Wolsey, it would appear that these were seldom thoroughly changed, and, the habits of the people being uncleanly, the smell soon became intolerable. He speaks of the lowest layer of rushes (the top only being renewed) as sometimes remaining unchanged for twenty years, a receptacle for beer, grease, fragments of victuals, excremental and other organic matter. To this filthiness, Erasmus (one of the most acute observers) ascribed the frequent pestilences with which the people were afflicted.
Even as late as the beginning of the present century thing's were very different to what they are now. Thus, Willan, writing of fever, says :—
"Among the poor the mortality from this cause (contagious malignant fever) was nearly one in four of all persons affected, notwithstanding the attentive administration of proper articles of diet, and of suitable remedies, with plenty of wine.
" The good effects of all these applications are almost wholly superseded by the miserable accommodations of the poor with respect to bedding, and by a total neglect of ventilation in their narrow, crowded dwellings. It will scarcely appear credible, though it is precisely true, that persons of the lowest class do not put clean sheets on their beds three times a year ; that, even where no sheets are used, they never wash or scour their blankets and coverlets, nor renew them till they are no longer tenable ; that curtains, if unfortunately there should be any, are never cleaned, but suffered to continue in the same state till they drop to pieces ; lastly, that from three to eight individuals, of different ages, often sleep in the same bed ; there being, in general, but one room, and one bed for each family. To the above circumstances may be added, that the room occupied is either a deep cellar, almost inaccessible to the light, and admitting of no change of air; or a garret, with a low roof and small windows, the passage to which is close, kept dark in order to lessen the window-tax, and filled not only with bad air, but with putrid, excremental, or other abominable effluvia from a vault at the bottom of the staircase. Washing of linen, or some other disagreeable business, is carried on while infants are left dozing, and children more advanced kept at play whole days on the tainted bed ; some unsavoury victuals are from time to time cooked. In many instances idleness, in others the cumbrous furniture or utensils of trade with which the apartments are clogged, prevent the salutary operation of the broom and whitewashing brush, and favour the accumulation of a heterogeneous, fermenting filth. The rooms do not change their condition till they change their tenants. Often, indeed, so little care is taken that enough of the old leaven remains to infect all the inmates who successively occupy the same premises. I recollect a house in Wood's Close, Clerkenwell, wherein the fomites of fever were thus preserved for a series of years ; at length a friendly fire effectually cleared away the nuisance. A house notorious for dirt and infection, near Clare Market, afforded a further proof of negligence ; it was obstinately tenanted till the walls and floor giving way in the night crushed to death the miserable inhabitants. From all these causes combined there is necessarily produced a complication of fetor, to describe which would be as vain an attempt as for those to conceive who have been always accustomed to neat and comfortable dwellings.
" The above account is not exaggerated. For the truth of it I appeal to the medical practitioners, whose situation, or humanity, has led them to be acquainted with the wretched inhabitants of some streets in St. Giles's parish, of the courts and alleys adjoining Liquor-pond Street, Hog Island, Turnmill Street, Saffron Hill, Old Street, Whitecross Street, Grub Street, Golden Lane, the two Brick Lanes, Rosemary Lane, Petticoat Lane, Lower East Smithfield, some parts of Upper Westminster, and several streets of Southwark, Rotherhithe, etc.
" It cannot be wondered at, that in such situations contagious diseases should be formed, and attain their highest degree of virulence. The inhabitants of the second storey in houses occupied by the poor are usually better accommodated, and therefore experience, during sickness of any kind, the best effect from public and private charities. But persons thus stationed suffer from contiguity, and from their friendly attentions to those above them, or to the tenants of the cellars ; so that in whatever part of the house a fever commences, it is soon diffused among all the inmates and their occasional visitors, especially in seasons which favour its progress like the last autumn and winter. ... It is a melancholy consideration that in London and its vicinity hundreds, perhaps thousands of labourers, heads of families, and in the prime of life, are thus consigned to perish annually, being often so situated that medical applications or cordial diet cannot in any wise alleviate their distress."1
The sanitary condition of the prisons in the last century, as discovered by the great prison reformer, John Howard, gives some indication of the ignorance that prevailed in regard to the public health at that time. In the Introduction to his book,2 he tells us that in his inspection of gaols, he noticed a complication of distress, but his attention was principally arrested by the gaol fever and the small-pox, which he saw prevailing to the "destruction of multitudes," not only of felons in their dungeons, but of debtors also. On page 8, in describing the air in prisons, he says :—
" My reader will judge of its malignity, when I assure him that my clothes were in my first journeys so offensive, that in a post-chaise, I could not bear the windows drawn up, and was therefore often obliged to travel on horseback. The leaves of my memorandum book were often so tainted, that I could not use it till after spreading it an hour or two before the fire ; and even my antidote, a vial of vinegar, has, after using it in a few prisons, become intolerably disagreeable. I did not wonder that in those journeys many gaolers made excuses, and did not go with me into the felons' wards.
" From hence anyone may judge of the probability there is against the health and life of prisoners, crowded in close rooms, cells, and subterranean dungeons, for fourteen or sixteen hours out of the four-and-twenty. In some of those caverns the floor is very damp ; in others there is sometimes an inch or two of water, and the straw, or bedding, is laid on such floors, seldom on barrack bedsteads. Where prisoners are not kept in underground cells, they are often confined to their rooms, because there is no court belonging to the prison, which is the case in most city and town gaols."1 Dr. Willan's "Observations on Diseases in London." Medical and Physical Journal, vol. iii., pp. 298-300. (April, 1800.)
2 " The State of the Prisons in England and Wales." Second Edition.1780. John Howard, F.R.S.
There was much overcrowding. On page 21 we read :—
"Debtors crowd the gaols (especially those in London) with their wives and children. There are often by this means ten or twelve people in a middle-sized room, increasing the danger of infection."
John Howard observes the effect of the window tax (p. 9):—
"One cause why the rooms in some prisons are so close, is perhaps the window tax, which the gaolers have to pay; this tempts them to stop the windows, and stifle their prisoners."
Concerning the water supply and drainage, we read (pp. 8,9):—"
Many prisons have no water. This defect is frequent in bridewells and town gaols. In the felons' courts of some county gaols there is no water ; in some places where there is water, prisoners are always locked up within doors, and have no more than the keeper or his servants think fit to bring them. In one place they were limited to three pints a-day each—a scanty provision for drink and cleanliness! . . . Some gaols have no sewers, and in those that have, if they be not properly attended to, they are, even to a visitant, offensive beyond expression. How noxious, then, to people constantly confined in those prisons!" Under these conditions, is it to be wondered at, that typhus and small-pox prevailed to the "destruction of multitudes "?
Howard's attention was arrested by the insanitary state of the prisons, but it is doubtful whether the poor, especially in the large towns, lived in a much healthier atmosphere than the prisoners. Dr. William Buchan, in his work on "Domestic Medicine," says:
"Whenever air stagnates long, it becomes unwholesome. Hence the unhappy persons confined in jails not only contract malignant fevers themselves, but often communicate them to others. Nor are many of the holes, for we cannot call them houses, possessed by the poor in great towns much better than jails. These low, dirty habitations, arc the very lurking-places of bad air and contagious diseases. Such as live in them seldom enjoy good health, and their children commonly die young."1
Thus, Dr. Buchan connects the high mortality of children in the last century with overcrowding and filth. From these facts we may infer, that sanitary reform would tend to alter the age-incidence of zymotic disease. This has been fully recognised by the Regrstrar-General in the following notable words :
" That the sanitary efforts made of late years should have more distinctly affected the mortality of the young is only what might be naturally anticipated; for it is against noxious influences to which the young are more especially sensitive that the weapons of sanitary reformers have been chiefly directed."2
1. "Domestic Medicine," p. 86. Tenth edition. 178S. William Buchan, M.D.
2. Forty-second Annual Report of the Registrar-General, p. xxiii. 1879.
There is no reason to believe that small-pox is any exception to this general law, and in this connection the following table quoted by Dr. Collins and Mr. Picton is not without interest.1
|
Fatal small-pox in Scotland, 1871 |
|||
| Smallpox deaths at all ages | Smallpox deaths under 5 years of age | Percentage under 5 years of age | |
|
Principal towns (population above 25,000) |
886 |
195 |
22.0 |
|
Large towns (population from 10,000 to 25,000) |
143 |
32 |
22.3 |
| Small towns (population from 2,000 to 10,000). | 209 | 55 | 26.3 |
|
Mainland rural districts |
183 |
0 |
13.6 |
|
Insular rural districts |
11 |
|
0.0 |
The larger proportionate small-pox mortality of children in the towns, compared with rural and insular districts is certainly not due to any difference in the amount of vaccination, and it is difficult to resist the conclusion that the young are more injuriously affected by overcrowding and other insanitary conditions associated with town life than adults.2
1 Royal Commission on Vaccination, Dissentient Commissioners' Statement, section 148.
2 See Paper read by Mr. Alfred Milnes before the Statistical Society, June 15, 1897.
While discussing the subject of sanitation, it is necessary also to allude to the influence of burial grounds on mortality. In the last century it was usual to establish these in the midst of populous towns, and there can be no question, that the constant inhalation of effluvia from dead bodies, had a deleterious effect on the living.
Buchan observes (p. 85):
"Certain it is, that thousands of putrid carcases, so near the surface of the earth, in a place where the air is confined, cannot fail to taint it; and that such air, when breathed into the lungs, must occasion diseases."
With the growth of sanitary institutions, reforms have been made with regard to the disposal of the dead, and, in nearly all urban districts, the dead are now buried in outlying cemeteries. The next generation will no doubt witness a great extension of the still more sanitary practice of cremation, already introduced in London, Glasgow, Manchester, Liverpool, and other places.
Besides insanitation, other causes have probably had their effect on the small-pox mortality.
A number of typhus and small-pox epidemics have been intimately associated with periods of scarcity and want. The winter of 1683-84 was very severe. This was followed by a long drought in the summer of 1684, and another severe winter in 1684-85, and not until the spring of 1685 was there plentiful rain.1 In 1685-86 the country was visited by a terrible epidemic of fever, and in 1685 small-pox was above the average, with 2,496 deaths in London, or a rate of 107 per 1,000 deaths from all causes. The winter of 1708-09 was excessively severe, frost lasting all over Europe from October to March. This was followed by a bad crop of cereals in 1709, the price of wheat per quarter running up from 27s. 3d. on Lady-day, 1708, to 81s. 9d. on Lady-day, 1710.2 In 1710,the proportion of small-pox deaths was 127 per 1,000 deaths from all causes (3,138 small-pox deaths). 2,810 died from small-pox in 1714, or a rate of 106 per 1,000 from all causes. This followed a rise in the price of wheat.
1 "A History of Epidemics in Britain," vol ii., p. 23. Creighton.
2 Ibid., pp. 54, 55.
In 1718 the harvest was a bad one; and about this time there was scarcity of employment amongst the weavers in the east end of London ;1 during the year 1719, there were 3,229 deaths from small-pox in London, or a rate of 114 per 1,000 from all causes. Up to the month of February, 1756, the season had been a forward one, but the early promise of spring was blighted by cold. This was succeeded by a wet summer and autumn ; the fruit crop was ruined, and the corn harvest spoilt by long, heavy rains ; dearth and bread riots followed.2 In 1757, the proportion of small-pox deaths rose to 155 per 1,000 from all causes (3,296 small-pox deaths).
A bad harvest in 1794 raised the price of wheat to 55s. (January 1,1795); by August, 1795, it rose to 108s., falling in October to 76s., owing to the action of the Government, in order to avert famine, causing neutral ships —bound to French ports with corn—to be seized and brought to English ports. In the spring of 1796, the acme of distress was reached, wheat being sold for 100s. per quarter.3 Mr. Pitt admitted in Parliament that the condition of the poor "was cruel, and such as could not be wished on any principle of humanity or policy ;"4 in this year, the mortality figures showed the largest number of small-pox deaths of any year within the London Bills, being 3,548, or 184 per 1,000 deaths from all causes.
1 "A History of Epidemics in Britain," vol. ii., pp. 62, 64. Creighton.
2 Ibid., p. 125.
3. Ibid., pp. 158, 159.
4 Eighth Annual Report of the Registrar-General, p. 12.
The harvest in 1816 proved deficient in quantity, and inferior in quality. Prices rose from 66s. a quarter in 1815, to 78s. in 1816, and 98s. in 1817.1 This was succeeded by epidemics of small-pox, relapsing fever, and typhus in 1817-19.
From the Registrar-General's eighth annual report we learn that the year 1837 was one of great commercial depression. In referring to joint stock banks, Major Graham says :—
" Many of the companies were got up by speculators, for the sole purpose of selling shares. The signal of collapse was given by the failure of the Agricultural Bank of Ireland in November, 1836. The Bank of England assisted the Manchester Northern and Central Bank in December, the large American houses in February and March, 1837. It was in vain. Commercial credit fell to its lowest point of depression in the first half of the year 1837."2 Again—"In 1837 the price of bread rose rapidly, while trade was depressed, and speculation sat exhausted in the midst of ruin."3
During the several years commencing in 1837, one of the most disastrous small-pox epidemics of the nineteenth century occurred, and also a very severe epidemic of typhus.
1 Eighth Annual Report of the Registrar-General, p. 16.
2. Ibid., p. 23.
3 Ibid., p. 24.
Another cause of the diffusion of small-pox, as well as of typhus and dysentery, is probably war. Dr. Guy writes :—
" War is a special cause of that more general condition of overcrowding, so destructive to health, so productive of disease. It consists in bringing one crowd of trained, armed, and disciplined men into collision with another, under circumstances highly unfavourable to health. It reaches its climax in civil war, in prolonged siege operations, and when armies are quartered among civil populations."1
The shock of battle also, with its attendant anxiety and the high tension of the organism, are important and undeniable factors in the production of epidemic diseases.
Mr. Alexander Wheeler pointed out before the Royal Vaccination Commission (Q. 7,994) that during almost the whole of the last century Europe was one huge battle-ground, and wars continued on and off until the year 1815. The fact, that small-pox was declining during the opening years of the present century, does not exclude war as one of the causes of this disease.
As to the effects of war. In a work by Mr. William F. Fox, entitled "The Losses of the American Civil War," we read:—
"110,070 were killed, 249,458 died of other causes, making 359,528 in all in the Northern army."
In speaking of the 249,458 who died from disease, Mr. Fox says :
" One-fourth died from fever, principally typhoid ; one-fourth from diarrhoea or other forms of bowel complaint; one-fourth from influenza and lung complaints ; and one-fourth from small-pox, measles, brain diseases, erysipelas, and various other forms of disease common to the masses."2
With regard to the Franco-Prussian war, Mr. Wheeler, in his evidence before the Royal Commission, quoted some of the commissioners sent to Eastern France to aid the peasantry. One of these, Dr. Robert Spence Watson, has published his experiences,3 from which the following have been extracted. I may state that in 1870 there was not more small-pox than usual until the later months of the year. Its increase was at the time of the terrible slaughter following the invasion of France.
1 Journal of the Statistical Society, December, 1882, p. 579.
2 Third Report, Royal Commission on Vaccination, Q. 8056.
3 "The Villages Around Metz." Newcastle-on-Tyne. 1870."November 6, 1870. Then I went to Lessy and Chatel St. Germain, hearing everywhere the same state of distress. All the crops gone, all the winter's firewood gone, many houses destroyed, and numbers needing help in every village. . . . When the mare's hoofs sunk deep, she knocked up bits of flesh, and the stench was so sickening that 1 should have fainted but for my smelling salts. It was a strange and sad sight; sometimes twenty-five heaps of graves within sight at once. These graves are in a bad state, many of them were too shallow to begin with. The heavy rains have caused them to sink in, and they are covered with an inch or more of black, oily water, which has, when disturbed, a most disgusting stench" (pp. 22, 23).
" November 7th. All men and officers alike speak of the terrible loss of blood. At Rezonville, and in its neighbourhood, the people say 18,000 Germans are buried. This I doubt, but the number must be enormous" (p. 25).
" November 9th. Metz was literally crammed with soldiers. The Germans—strong, hearty, conscious of victory ; the French—cowed, worn, starved, and miserable. ... In one place there were fifteen long streets of railway vans, filled with typhus patients ; in another as many streets of canvas tents, also filled with sick. I visited these places, and found them in the filthiest state ; but the Germans had begun to put them into order. At first, you might see soldiers, in full small-pox, walking about the streets, but this was soon forbidden " (p. 28).
Dr. Watson concluded his last letter with the observation that
" unless England puts forth her hand liberally and wisely, the coming winter must see in that beautiful and fertile land an amount of misery, famine, and plague which it is too dreadful to contemplate " (p. 36).
Another commissioner has kindly furnished me with the following statement:—
" Mr. William Jones, of Sunderland, was one of those who went out on behalf of the Society of Friends to relieve the sufferings of the people. He was present at Metz when Marshal Bazaine's army surrendered. The main body were encamped outside the walls of Metz, on low ground near the Moselle, the wetness of the season having converted the camping-ground into a morass. In some places the impress of the men's bodies was left as a cast in the mud in which they had lain. Their clothes and their blanket were saturated with mud. Their food for weeks had only been a biscuit and a bit of horseflesh without salt. Dysentery was universal, and typhus and smallpox raged. Over a wide area around the camp the carcases of dead horses were left to rot and contaminate the air. On the 29th of October, 1870, Mr. Jones and his companion, Mr. Allen, were permitted to enter the city, which had opened its gates to admit the German army, which marched through in triumph. The narrow streets were crowded with French soldiers disarmed, and looking diseased and hunger-bitten. Numbers of them were going about the streets with confluent small-pox fully out over their faces. Black typhus raged in the hospitals. Ultimately the worst cases were removed into 320 railway vans drawn up in the 'Grande Place.' No one was allowed to pass the German sentries into the square, but the constant cry of the wretched sufferers for water was distinctly heard by Mr. Jones outside the square in which they were isolated. It was stated that all these black typhus patients perished, and were buried in huge trenches outside the walls of the city.
" Mr. Jones's companion, Mr. Allen, who was vaccinated, and, he believes, re-vaccinated, took the small-pox, and his own sister, who came over to nurse him, caught the disease from him and died there, and was buried in the cemetery at Plantieres outside the walls of Metz.
" N.B.—Mr. John Bellows, of Gloucester, who followed Mr. Jones to Metz, states in his pamphlet, 'The Track of the War round Metz,' that, of the twelve commissioners of the Society of Friends who were present in Metz, eight were at one time ill, five being down with small-pox, and one (Miss Allen) died of small-pox."
MALTHUS DISCOVERS A NEW PRINCIPLE.
There is, indeed, some reason to believe that this war was the starting point of the great European pandemic of small-pox in 1871-72.
Another cause of the decline in small-pox during the present century, especially among children, remains to be told. Malthus, in 1803, wrote :—
" For my own part, I feel not the slightest doubt, that, if the introduction of the cow-pox should extirpate the small-pox, and yet the number of marriages continue the same, we shall find a very perceptible difference in the increased mortality of some other diseases."1
1 "An Essay on the Principle of Population," p. 522. T. R. Malthus. London. 1803.
Malthus, thus early, clearly saw that even if cow-pox had possessed all the virtues that were claimed for it, the reduction in the mortality from one zymotic disease would, other things being equal, have no appreciable effect on the death-rate.
This principle was first worked out experimentally by Dr. Robert Watt, lecturer on the theory and practice of medicine at Glasgow. He examined the Glasgow burial registers over a space of thirty years, from 1783-1812, and divided the thirty years into five periods of six years each. The following table gives his figures for small-pox, measles, and whooping-cough, as percentages of the deaths from all causes :—1
|
|
Of the total deaths The percentage |
||||
|
Periods |
Total deaths from all causes |
Under 10 years of age |
From smallpox |
From measles |
From whooping cough |
|
1783-88 |
9,994 |
53.48 |
19.55 |
0.93 |
4.51 |
|
1789-94 |
11,103 |
58.07 |
18.22 |
1.17 |
5.13 |
|
1795-1800 |
9,991 |
54.48 |
18.70 |
2.10 |
5.36 |
|
1801-06 |
10,034 |
52.03 |
8.90 |
3.92 |
6.12 |
|
1807-12 |
13,354 |
55.69 |
3.90 |
10.76 |
5.57 |
These statistics proved that while small-pox had diminished, measles and to a lesser extent whooping-cough had increased, so that a child had no better chance of reaching its tenth year in the last period2 than in the first. Dr. Watt was somewhat staggered at the result.
1 An Inquiry into the Relative Mortality of the Principal Diseases of Children, and the numbers who have died under ten years of age, in Glasgow, during the last thirty years (p. 49). Robert Watt, M.D. 1813.
2 Dr. Watt remarks that in Glasgow during the last period (from 1807-12) vaccination may be said to have been pretty fully established, "perhaps, as much so, as in any other city in the Empire."
THE ZYMOTIC DISEASES REPLACE EACH OTHER.
He says (p. 6):—
"Taking an average of several years, I found that more than a half of the human species died before they were ten years of age, and that of this half more than a third died of the small-pox, so that nearly a fifth part of all that were born alive perished by this dreadful malady. I began to reflect how different the case must be now! In eight years little more than 600 had died of the small-pox ; whereas, in 1784, the deaths by that disease alone amounted to 425, and in 1791 to 607, which, on both occasions, exceeded the fourth of the whole deaths in the year.
" To ascertain the real amount of this saving of infantile life, I turned up one of the later years, and by accident that of 1808, when, to my utter astonishment, I found that still a half or more than a half perished before the tenth year of their age! I could hardly believe the testimony of my senses, and therefore began to turn up other years, when I found that in all of them the proportion was less than in 1808 ; but still, on taking an average of several years, it amounted to nearly the same thing as at any former period during the last thirty years."
Dr. Farr was a firm believer in Watt. He writes :—
"The zymotic diseases replace each other; and when one is rooted out it is apt to be replaced by others, which ravage the human race indifferently wherever the conditions of healthy life are wanting. They have this property in common with weeds and other forms of life : as one species recedes, another advances. By improving the hygienic conditions in which men live, you fortify them against infection ; and further, by isolating the infected, the chances of attack are diminished." 1
1 Thirty-fifth Annual Report of the Registrar-General, p. 224.
In this chapter, I have attempted to deal with some of the principal causes of the diminution of small-pox. Firstly, I have shown that a part of the decline, and especially that part which has taken place in children, is not necessarily a saving of life, but only a shifting of the mortality on to some other disease, such as measles or whooping-cough, which happens for the time being to be more predominant.
The residue of the diminution is a real gain, and is probably due partly to the displacement of small-pox inoculation by a non-infectious malady; and to this extent was vaccination an advantage as compared with the old variolous inoculation. Other causes have been due to the more abundant air supply in and around houses ; the greater cleanliness of the people in their persons, their houses, and their towns ; and last, but not least, the greater material prosperity and freedom from war, which has been the lot of those who have been fortunate enough to be born into the present century.
CHAPTER 4.
THE INCIDENCE OF SMALL-POX ON VACCINATED AND
UNVACCINATED COMMUNITIES.
The experience of Leicester has proved conclusively that small-pox
can be kept from spreading in un-vaccinated districts. In 1872, Leicester was a
well-vaccinated town, and had an epidemic of small-pox, with 346 deaths
registered from the disease. This failure to protect led to a revolt against the
practice. The default commenced after 1874, and since 1885 the percentages of
vaccinations to births have been as follows :—l
Years Births
Primary Percentage of vaccina-
te3™- Birtns.
vaccinations. tions to births.
1885 ... 4,682 ... 1,842 ... 39-3
1886 ... 4,858 ... 1,122 ... 23-1
1887 ... 4,689 ... 474 ... io'i
1888 ... 4,787 ... 314 ... 6-6
1889 ... 4,789 ... 172 ... 3-6
1890 ... 4,699 ... 131 ... 2-8
1891 ... 4,790 ... 92
... 1-9
1892 ... 5,816 ... 133 ... 2-3
1893 ... 6,006 ... 249 ... 4-1
1894 ... 5,995 ... 133 ... 2-2
1895 ... 5,962 ... 75 ... 1-3
As far as the children are concerned, therefore, Leicester is
practically unvaccinated. Let us see what
1 Report of the Medical Officer of Health for the year 1895, pp. 31, 38.
law, says:—
" I made a point of enquiring during my stay there, in August last, as to what had been the subsequent course of affairs. I learned on the very best authority that the objections of the French Catholics had been completely overcome. . . . Vaccination being now (1883) as well carried out in Montreal by its officers of health as in the other great cities of the Dominion, smallpox has become almost entirely extinct." 1
The causes of the epidemic in 1885 were not far to seek. Towards its close a member of the staff of the Montreal Herald interviewed Dr. Garceau,2 of Boston, a supporter of vaccination, but who was declared by the editor to be one of the best-informed sanitarians on the American continent. When asked to what cause he attributed the extent of the epidemic, Dr. Garceau replied—
" One cause is the fact that the people have not been properly vaccinated, but I attribute the chief cause to the frightful system of cesspits which prevails, and the insanitary condition of the place generally. It is unclean ; and unless some action is taken to clean the privy vaults and remove all garbage, the city will next season be in excellent shape for cholera, or any other equally contagious disease."
The Secretary of the Citizens' Committee (Mr. Michaels) appointed to enquire Into the epidemic, said—
"The streets and lanes are in a disgraceful condition. Not only in the distant portions of the city, but within the most aristocratic quarters mid in the heart of the commercial portion, the lanes, and even portions of the streets, are reeking with filth."
1 A letter to the Right Hon. Lyon Playfair, C.B., pp. 13, 14. 1883.
2. Vaccination Inquirer, vol. viii., p. 179. (February, 1887.)
MR. REDHEAD'S CASES.
proportion to the proximity of the vaccination; nor docs tht; incidence of
small-pox seem to be regulated in this manner, for the National Vaccine Board
says :— " It appears to us to be fairly established, that the disposition in
the vaccinated to be thus affected by the contagion of small-pox, does not
depend on the time that has elapsed after vaccination ; since some persons have
been so affected who had recently been vaccinated; whilst others, who had been
vaccinated eighteen and twenty years have been inoculated, and fairly exposed to
the same contagion with impunity."1 This evidence is, 1 venture to suggest, more
valuable than present-day experience, for these theories of prevention and
mitigation had not then obtained the same hold on the medical mind.
Mr. Redhead also gives several instances of small-pox being taken by means of
inoculation after vaccination. One of these, James Shepherd, was vaccinated at
fifteen months of age by Mr. T. Carter, and when a year and a half old, i.e.,
three months after vaccination, was inoculated with matter from Elizabeth James,
above-mentioned. Mr. Redhead notes that the patient was very feverish, the arm
much inflamed, but the pustules not very large.
Mr. Harrison, in referring to Mr. Redhead's cases, says (p. 10):—"We cannot but
feel our confidence in the preventive power of the cow-pox to be somewhat
shaken." He also relates three instances in one family; these excited
considerable interest among medical men, from one of them having been vaccinated
at a public institution in London by Jenner himself, who, after having inspected
the vaccination, pronounced the child secure from small-pox.
1 Report of the National Vaccine Establishment for 1819.
There is every reason to believe that about this time vaccination was rapidly
falling into disrepute. Thus, Jcnner's old friend, Gardner, writing to him from
Frampton, on May 21, 1817, says:—"From some unaccountable causes, the fame of
vaccination seems to decline in this part of the country : I find my offers of
gratuitous service very frequently rejected even by those whose former children
have undergone the operation."1
In the London Medical Repository for July, 1817, the editors, Dr. G. M. Burrows
and Mr. A. T. Thomson, in their observations on prevailing diseases, say: "
Variola, above all, continues and spreads a devastating contagion. However
painful, yet it is a duty we owe to the public and the profession to apprise
them, that th'e number of all ranks suffering under small-pox who have
previously undergone vaccination, by the most skilful practitioners, is at
present alarmingly great. This subject is so serious, and so deeply involves
the dearest interests of humanity, as well as those of the medical character,
that we shall not fail in directing our utmost attention to it."2
In the August number the editors remark: "Generally, the diseases of last month
partake of that nature usual to the season ; hence there is nothing but variola
particularly demanding notice. Smallpox, however, still forces itself upon our
observation. It has, we believe, been more prevalent than for many years past,
and has assumed a more than usually virulent character; many of the cases having
been of the confluent kind. This may in some degree account for so many, who
1 Baron's "Life of Tenner," vol. ii., p. 203. "London Medical Repository, vol.
viii., p. 95.
OFFICIAL EXCUSES FOR FAILURE. I43
had previously undergone vaccination, being infected by small-pox, as we
remarked in our last report; and we are concerned to find, from the increasing
testimonies of medical practitioners, that these instances have been much and
widley extended. So little modified has the disease in some cases appeared to
have been by the influence of the vaccine inoculations, that death has ensued ;
an effect which, as far as our information goes, was never before produced by
small-pnx, after the patient had been subject to the action of the vaccine
virus."1
Baron informs us that in 1818 "there was great clamour about the prevalence of
small-pox after vaccination," and that " the greatly exaggerated statements on
the subject of the vaccine failures, and the hesitating manner in which
respectable individuals spoke on the subject, threatened to lead to a
considerable abandonment of the practice."2
About this time we even find failures recorded by the National Vaccine
Establishment, coupled with ingenious but far-fetched explanations. Thus, in the
report of 1818, we read:—"Five cases have been reported to the Board, of
vaccinated persons who have subsequently died of small-pox. In one of these
cases, it was clearly ascertained, that the only vaccine vesicle which had been
excited, was disturbed and broken in its progress, which there is great reason
for believing has been a frequent cause of the insecurity of vaccination ; in
the other cases, no detail respecting the vaccination could be obtained, and
they were, moreover,
i- London Medical Repository, vol. viii., p. 183. 2 Baron's "Life of Jenner,"
vol. ii., pp. 237, 238.
all vaccinated at a period of time when the mode of vaccination, and the
management of the vesicle, were not well understood."
In the report of 1819 it is stated :—"The testimonies of some of our
correspondents in this country, are by no means so favourable. They concur in
showing, that great numbers of persons who had been vaccinated, have been
subsequently seized with a disease presenting all the essential characters of
small-pox ; but that in the great majority of such cases, the disease has been
of comparatively short duration, unattended by symptoms of danger. In several of
these cases, however, the malady has been prolonged to its ordinary period ; and
in eight reported cases it has proved fatal."
In the London Medical Repository^ for August, 1819, Mr. William Gaitskell,
surgeon of Rotherhithe, was " truly sorry to report two cases of malignant
smallpox subsequent to vaccination." The first, a stout young man, eighteen
years of age, contracted small-pox two years after vaccination, and died on the
twelfth day, a mass of putrefaction. The second, about twenty-two years old,
took small-pox of a very malignant description, twelve years after vaccination,
but recovered. Both patients were supposed to have gone through a regular
vaccination; they were pronounced safe (according to their own statement), and
presented distinct impressions of the disease on their arms.
In the Medical and Physical Journal*1 for July, 1820, Dr. Macleod, physician to
the Westminster General Dispensary, contributed a communication,
entitled,
^London Medical Repository, vol. xii., pp. 113, 114. 2 Medical atid Physical
Journal, vol. xliv., pp. I -12.
DR. MACLEOD'S EXPERIENCES. 145
" Remarks on the Small-pox, as it has occurred in London subsequent to
Vaccination." He gives the following cases (pp. 10-12) illustrating some of the
appearances assumed by small-pox after vaccination. (See next page.)
Dr. Macleod says (p. 6) :—" I have seen too many instances of small-pox in
children vaccinated in London, where that process was carried on in the way
which the National Vaccine Establishment has recommended as the most
efficacious, to retain much faith in its preventive powers, in whatever manner
conducted." Again he remarks (pp. 8,9):—"The history of vaccination altogether
forms a severe satire upon the mutability of medical doctrines. In the first
ardour of discovery, not contented with its blessings to mankind, its benefits
were also extended to the brute creation. It was to annihilate small-pox, prove
an antidote to the plague, to cure the rot in sheep, and preserve dogs from the
mange. These good-natured speculations, however, were soon abandoned ; and more
recently all had agreed in acknowledging its anti-variolous powers, which, we
were told, were as well established as anything human could be.
" But the present epidemic shows too clearly the mortifying fallibility of
medical opinions, though founded on the experience of twenty years, and
guaranteed by the concurring testimony of all the first physicians and surgeons
in the world."
In 1820 we have also further official admission of vaccine failures. " It is
true, indeed, my Lord, that we have received accounts from different parts of
the country, of numerous cases of small-pox having
At e
when
. t ,, !
Name. infected
Vaccination.
Nature of the small-pox.
Thomas Lucas - 5 Vaccinated when six months of age.
Smart fever, followed by copious pustular eruption
on face, neck, chest, and limbs.
Selina Duve 9 Vaccinated when seven years of age, at
Attacked with fever, headache, and delirium. Copi-
thejenneriau Institution in Holborn. ous pustular eruption on face,
chest, and extremities. Eruption particularly crowded on the face.
Henry Oldfield 7 Vaccinated at the Small-pox Hospital
Considerable fever, and pustular eruptions on the
when a few months old, had a perfect face, chest, and back, cicatrix on
the arm. Lucy Stillwell - 22 Vaccinated 14 years previous to
attack, Small-pox ushered in with considerable fever, but
and had a perfect cicatrix on the arm. the number of pocks was
inconsiderable.
William Pyihe - 8 Vaccinated at the Small-pox Hospital
Violent fever, headache, and delirium, accompanied
when a few months old, and had a by extreme restlessness and fits of
screaming. A
perfect cicatrix on the arm. copious pustular eruption appeared
on different
parts of the body. On the face the eruptions were confluent round the mouth and
under the eyes, and coherent in other parts. Many of the pocks on the forearms
were surrounded with a narrow purple areola, giving the appearance of pustules
arising from the centre of petechife. Several of the pocks were filled with a
purple fluid.
Robert Page - 21 month.1- Vaccinated, and supposed to have had The
disease ushered in with fever, and followed in
the disease in a satisfactory manner. several days by a rash resembling
measles. The
child continued restless and feverish, and vesicular eruptions, with central
depressions, appeared on the back. The vesicles were first of a pearly
appearance, and afterwards became more opaque. The constitutional symptoms did
not abate, and occasional convulsions supervened; these became more severe, and
the child died about the tenth day of the illness.
— Page - - 3 Vaccinated, and supposed to have had
Was affected in a similar manner to his brother, but
the disease in a satisfactory marmer^ldisease milder.
COW-POX KAILUKES KXTKNS1VK. I47
occurred after vaccination ; and we cannot doubt that I lie prejudices of the
people against this preventive expedient arc assignable (and not altogether
unreasonably perhaps) to this cause. These cases the Board has been
industriously employed in investigating ; and though it appears that many of
them rest only on hearsay evidence, and that others seem to have undergone the
vaccine process imperfectly, some years since, when it was less well understood,
and practised less skilfully than it ought to be, yet, after every reasonable
deduction, we are compelled to allow that too many still remain on undeniable
proof, to leave any doubt that the pretensions of vaccination to the merit of a
perfect and exclusive security in all cases against smallpox, were admitted at
first rather too unreservedly."1
It was the small-pox epidemic of 1817-19 which, however, demonstrated the
failure of vaccination on a large scale, for a majority of the cases were
admittedly " protected." Dr. John Thomson writes :—" It is to the severity of
this epidemic, I am convinced, that we ought to attribute the greatness of the
number of the vaccinated who have been attacked by it, and not to any
deterioration in the qualities of the cow-pock virus, or to any defects in the
manner in which it has been employed. Had a variolous constitution of the
atmosphere, similar to that which we have lately experienced, existed at the
time Dr. Jenner brought forward his discovery, it may be doubted whether it ever
could have obtained the confidence of the public."2
1 Report of the National Vaccine Establishment for 1820. - " Historical Sketch
of Small-pox," p. 394. John Thomson, M.D., F.R.S.E. London, 1822.
each case, were read. The account stated that in the last year twelve persons
had died of small-pox whose deaths were presumed to be subsequent to
vaccination. The Duke of York here interposed, and observed that the fact of the
cases having previously been vaccinated was distinctly stated in copy of the
report sent to him ; and the Home Secretary, Mr. Peel, who was also present,
said that, after reading his copy of the report, he became uneasy about his own
children, all of whom had been vaccinated.
Dr. Gregory, the physician to the hospital, stated that the copies alluded to by
his Royal Highness had been sent before they had been finally settled by him. He
wished to add notes, but finding that the copies had been made, and that the
words could not be introduced without the making of fresh copies, he did not
think the omission of any great consequence, and therefore he let them go as
they were. He regretted he had not inscribed the word ''presumed" but one
reason was that it was not a term generally used by the profession.
It is fairly evident what Dr. Gregory thought of the cases. They were, however,
the subject of inquiry by the National Vaccine Establishment,1 and, as we might
have expected, the result was so satisfactory " as to leave no cause to doubt
that these individuals had not been properly vaccinated."
From this time onwards medical criticism became less acute, but neither then nor
at any other time has it subsided, and there was a strong undercurrent of
scepticism amongst able and trustworthy observers at
1 Baron's " Life of Jenner," vol. i., pp. 273, 274.
UNM1TU1ATKI) BY PREVIOUS VACCINATION. I 5 I
t he period with which we are engaged. Thus, in a letter from Mr. Edward
Greenhow, of North Shields, to the London Medical Gazette of February 2, 1833,
vol. xi., p. 590, we read :—" And not only is the small-pox after vaccination
becoming much more frequent, but it is becoming also much more virulent. It is
true, in the greater number of cases, the disease is modified, often turning on
the fifth and sixth day ; but cases are by no means rare where the disease is
confluent, and runs its full course, unmitigated by the previous vaccination,
and death occasionally ensues.
" From what I have above stated, it would appear that vaccination is losing its
protective influence ; and it becomes a matter of serious consideration to
ascertain to what causes we are to attribute this failure. Is it that its
protective power wears out after a certain number of years, and that it becomes
necessary to repeat the operation ? Or is it that the vaccine virus loses
wholly, or in part, its virtues, by passing so repeatedly through the human
system ? The latter is the opinion that has forced itself upon my conviction,
because the disease has principally attacked young persons, and such as have
been vaccinated within the last ten or twelve years, and by far the largest
portion have been done much within that period, so that the numbers attacked are
in the inverse ratio to the number of years which have elapsed since they were
vaccinated." I may observe that the age-incidence of this disease did not begin
to alter very much until after the epidemic of 1837-38, which would account for
the large proportion of young persons attacked at an earlier date. The same
fact was noticed by one of Dr.
John Thomson's correspondents, Mr. William Gibson,1 in his experience at New
Lanark, where, of 251 vaccinated cases of small-pox, 191, or y&i per cent.,
took the disease at intervals up to ten years after vaccination. In 1837 the
reviewer in the British Annals of Medicine, in criticising certain statements
.^bout vaccination, pertinently inquired, " Will it not "b"e better to collect
facts patiently, and to remain a little longer in suspense, than assume a
dogmatical tone, or assert a blind belief, and thus silence inquiry?"2
Sir Henry Holland, in his "Medical Notes and Reflections,"3 writes (p. 401)—"Not
only in Great Britain, but throughout every part of the globe from which we have
records, we find that small-pox has been gradually increasing again in frequency
as an epidemic ; affecting a larger proportion of the vaccinated; and inflicting
greater mortality in its results." Again he says (p. 414)—"It is no longer
expedient, in any sense, to argue for the present practice of vaccination as a
certain or permanent preventive of small-pox. The truth must be told, as it is,
that the earlier anticipations on this point have not been realised."
Dr. George Gregory was also known to be somewhat sceptical as to the merits of
vaccination, and this fact comes out clearly in his writings. In 1823 he
wrote,
1 Letter from Mr. William Gibson to Dr. John Thomson, dated
January II, 1819. "An account of the varioloid epidemic which has
lately prevailed in Edinburgh, and other parts of Scotland," pp. 251-258.
John Thomson, M.D., F.R.S.E. London, 1820.
2 "British Annals of Medicine, Pharmacy, Vital Statistics, and General
Science," vol. i., p. 235. (February 24, 1837).
3 "Medical Notes and Reflections." Henry Holland, M.D., F.R.S.
London, 1839.
<>VKk-SANGUINE PATHOLOGISTS. 153
I'hr acknowledged frequency of cases of small-pox uli'ici|ii(-iit to
vaccination, in all parts of the country, is ucli iih to liiivc excited, in no
inconsiderable degree, the i'-art of many, and the anxieties of all. No one can
Ionic buck upon the history of the last few years without ii'dinjjf sensible
that these unpleasant occurrences are ■ hi the increase."1 In 1837 he says,
"Many of the physicians and surgeons who flourished at the com-nii'iiccmcnt of
this century, and to whose generous efforts in behalf of vaccination the world
is deeply indebted, are passed from this scene. A few still ■■iirvive, who, when
they call to mind the strong hopes which were held out, in their day, of the
ultimate extermination of small-pox, will probably be surprised In find that,
after the lapse of thirty-six years, smallpox still prevails; that the same
necessity exists now as formerly for studying its various aspects ; and that I
ho benevolent anticipations of 1800 receive no countenance from the facts of
1836. It is impossible to deny, and useless to conceal, that these bright
prospects were originally built upon very slender foundations. The wish was
father to the thought." 2
I n 1840 Dr. Gregory writes :—" It is often noticed that persons (vaccinated
persons, for instance) who resist small-pox in common years, though fully
exposed to the contagion, are attacked by it in years of epidemic prevalence.
These and other facts, which bear on the epidemic origin and diffusion of
small-pox, were overlooked by those sanguine pathologists, who
1 " Mcdico-Chirurgical Transactions," vol. xii., p. 324, 1823. v " British
Annals of Medicine, Pharmacy, Vital Statistics, and General Si'ience," vol. i.,
p. 193. (February 17, 1837.) 11
imagined that in vaccination nature had provided us with means adequate for the
complete extermination of small-pox from the earth."1
Increased experience does not appear to have modified Dr. Gregory's views, for
twelve years later we find him writing, " When we look around us,—when we
observe the quantity of small-pox, now (at the close of the first half century
from the promulgation of vaccination) diffused through this and other countries,
—when we see the practice of revaccination almost universal on the continent of
Europe, and greatly increasing in this country, we are led irresistibly to the
conclusion, that these broadly-urged claims in favour of vaccination have not
been substantiated. Small-pox does invade the vaccinated, and the extirpation of
that direful disorder is an event as distant now as when it was first heedlessly
(and, in my humble judgment, most presumptuously) anticipated by Jenner."2
In the Report of the Vaccination Section of the Provincial Medical and Surgical
Association, it is stated, " It will be observed in subsequent parts of our
Report, that failures are noticed at all periods, from a few weeks after
vaccination up to thirty or more years. It has been supposed that they are most
common at and after the age of puberty ; but this is certainly not the opinion
of our correspondents in general. Some, it must be admitted, do affirm that
small-pox has more frequently occurred in persons
1 Article by Dr. Gregory on "Small-pox" in Tweedie's "Library of Medicine," vol.
i., p. 310. London, 1840.
''Medical Times and Gazette. New series, vol. iv., p. 633. (June 26, 1852.)
ADMISSIONS OF THE "LANCET." 155
recently vaccinated, than in those at a remote period, while others assert that
time makes no difference."1
Even the Lancet, which has generally been known as a thorough-going advocate of
vaccination, reluctantly writes:—"In the public mind extensively, and, to a more
limited extent, in the profession itself, doubts are known to exist as to the
efficacy and eligibility of the practice of vaccination. The failures of the
operation have been numerous and discouraging. It has failed frequently by
producing no effect at all; it has failed by producing a vesicle by no means
clearly indicative of the existence of the vaccine disease ; and it has failed
in protecting persons so vaccinated from a future attack of small-pox."2
Thus, in the early epidemics, the cases of smallpox after vaccination were
numerous; but, in estimating the number, we must take account of some of the
cases which have been ascribed to chicken-pox. Sir Thomas Watson, writing in
1848, said, "These mild and irregular forms of variola, both parents and medical
men, wishing, I suppose, to believe nothing in disparagement of the protecting
power of vaccination, are very apt to consider, and to call chicken-pox."3 In
the early days, however, it was by no means only the mild cases that were thus
designated.
In a report on the cow-pox inoculation from the practice at the
Vaccine-pock Institution, during the
1 " Transactions of the Provincial Medical and Surgical Association," vol.
viii., pp. 35, 36. (1840.)
- The Lancet, May 21, 1853. (Vol. i., p. 476.)
3" Lectures on the Principles and Practice of Physic," vol. ii., p. 805. Third
edition. 1848.
years 1800-02, we read (pp. 19, 20):—"It may be also useful to notice that we
have been alarmed two or three times with the intelligence of the small-pox
occurring several weeks or months after our patients had undergone the cow-pock.
We thought it our duty to visit and examine these patients, and also to inquire
into their history among their attendants, and by these means we obtained the
completest satisfaction that the pretended small-pox was generally the
chicken-pox.'' They gave the following instance as an illustration in which the
eruptions were, by their resemblance, mistaken for small-pox by the friends of
the patient, and even by a medical practitioner, "who accordingly gave a
representation of the case by no means advantageous to the Institution." The
child was vaccinated on April 1, 1S00; a genuine vaccine scab was formed, which
fell off and left a cicatrix. Four months afterwards the child was attacked with
fever, followed by an eruption, which when seen at the Institution, presented
over one hundred eruptions of blackish scabs and red spots, " apparently the
chicken-pox, in the scabbing state." Small pits were observed some months
afterwards.
Dr. John Walker,1 the resident vaccinator of the Royal Jennerian Society,
related that a father called on him and informed him that, of two children he
had vaccinated the previous spring, one was now covered with small-pox, and the
other sickening, and that he (the father) was advised to advertise it. On
consulting the register, Dr. Walker found both the cases marked perfect, and he
told the father that it was impossible for
1 Medical and Physical Journal, vol. xii., p. 543. (December, 1804.)
' \SI«:s ATTRIBUTED TO CHICKEN-POX. 157
i-illii-i nl the cliildren to be infected with small-pox ; he linn railed on the
vice-president, Mr. John Ring, and i li,illcii|;c(l him to come and detect his
(Dr. Walker's) l.iilurc. " Me had the goodness to accompany me, mil mi our
seeing the child, he immediately declared 11 i hicken-pox."
I >i. William Farquharson, Mr. James Bryce, and Mr. \. (iillcspie, of Edinburgh,
in a joint letter to Dr. Walker,1 remark on many children who had passed
K'Hiilarly through the process of vaccination, but on whom eruptions appeared at
different periods afterwards, which by some ignorant people were supposed i" he
variolous; but which, upon investigation, uniformly i Mined out to be
chicken-pox. In some of these cases i lie eruptive fever was very severe,
sometimes even iilended with convulsions; and the consequent erup-i ii his very
numerous, and in a few cases the last of i he pustules did not disappear until
the fifth or sixth
■lay. "These cases," they add, "were repeatedly visited
l>\' many medical practitioners of this place, as well as
l>v ourselves, and none of them entertained any doubt
■pi the disease being chicken-pox."
A case is recorded in the Medical and Chirurgical h'rvitrwi1 A child was
operated on by Mr. Ring in May, 1804, who expressed himself as perfectly
satisfied with the progress of the vaccination, saying that "he would forfeit a
hundred guineas if the child ever took I he small-pox afterwards." A distinct
scar was left on each arm as the result of the operation. In October or
1 Medical and Physical Journal, vol. xiii., pp. 286, 287. (March, 1805.,
'Medical and Chirurgical Review, vol. xi., pp. cvi.-cviii. (March) 1 hi
15.)
November of the same year it was taken ill, and the pustules were pretty
numerous, particularly on the scalp, two of them leaving pits ; the patient was
seen repeatedly during the progress of the eruption by Mr. Ellis, apothecary, of
Drury Lane, who asserted it to be small-pox. The child was next taken to Mr.
Soley, apothecary, in Bloomsbury Square, about the ninth day. He declared
immediately, and without hesitation, that it was undoubtedly small-pox, and he
chided the mother for not having taken means to prevent it by vaccination. She
replied that she had done all in her power by having the child vaccinated by Mr.
Ring. "Then," said Mr. Soley, "it cannot be small-pox, for small-pox never
occurs after cow-pock. It must be a rank kind of chicken-pox ;" and he sent her
to Mr. Ring. On calling at Mr. Ring's house, she first saw his assistant, who
declared it to be small-pox, and upbraided the mother for not having had the
child vaccinated. When Mr. Ring was informed of this unusual circumstance, and
on seeing the child, he remarked that it could not be small-pox, for this
disease was never attended by itching, nor did it appear in clusters, as in this
case. He told the mother she might rest satisfied that it was not small-pox, and
he begged her to say nothing about it, as it might excite alarm. In a foot-note
on p. cvii., the editors remark on the above case :—" This attempt to conceal
everything that appears unfavourable, so frequently resorted to by certain
pretended friends of vaccination, cannot be too much reprobated. It shows the
business to have got into very bad hands. Were truth their only object, they
would court investigation, not endeavour to suppress it."
CASKS OK CONFLUENT CHICKEN-POX. 159
Mr. John Ring, in the Medical and Physical Journal? Have a description and
drawing of a case of confluent chicken-pox in a boy four years of age, who had
been vaccinated some time before. He added : "When the chicken-pox broke out in
so formidable a manner, it was mistaken for the small-pox."
In the Medical and Physical Journal11 for November, 1X05, Mr. R. Hall, of
Clement's Inn, related instances in I lie family of a Mr. Ross. An eruption
appeared on two of his children, one of whom had been vaccinated about a year
before. In both cases, the eruption was extremely copious, but the pustules were
much larger and more confluent in the one which had not been vaccinated. Mr.
Hall says : " In both, the pustules so exactly resembled—in form, figure, and
other circumstances—those of small-pox, that, had we founded our opinion on the
external character alone, we should most unquestionably have deemed them both
cases of genuine small-pox ; but, as they neither went through the regular
course, nor were attended with any of those symptoms which uniformly accompany
violent cases of small-pox, .... we did not hesitate to consider them as cases
of confluent varicella."
In the twentieth volume of the Medical and Physical Journal, on pp. 257, 258
(September, 1808), Mr. Thomas Hardy relates the case of a patient who, four
years after he had vaccinated her, was much indisposed, and had a considerable
eruption, which he supposed to be the chicken-pox, until the fourth day of the
eruption,
1 Medical and Physical Journal, vol. xiv., pp. 141, 142. (August, 1^05.)
when the phenomena, both local and general, induced him "reluctantly" to alter
his opinion.
Dr. Richard Pew, of Sherborne,1 also saw a post-vaccinal case, in which the
pustules " bore so general a resemblance to real small-pox, that anyone
acquainted with the subject must immediately acknowledge them to be a branch of
the same family."
In 1818 there was published the Substance of a Correspondence between the
Directors of the Cow-pock Institution, Sackville Street, Dublin, and their
subscribers or other medical practitioners; and also with the Irish Medical
Staff and Militia Surgeons, being replies to certain queries circulated by the
Directors, occasioned by alleged failures in vaccination. A number of the
replies testified to the occurrence of chicken-pox after vaccination.
Mr. Heron, of Lucan, remarked "that in the summer and autumn of 1810 a very bad
kind of pustular eruption made its appearance among the children about Banagher
and its neighbourhood, which many of the practitioners in these places took for
small-pox, and inoculated with matter from it as such. From observations,
however, then made, it appeared to Mr. Heron to be nothing more than a malignant
chicken-pock, of which some died."2
Dr. Little, of Ballina, stated that, " about three years ago, the regiment to
which he belonged, being quartered in Tuam, a very severe form of confluent
varicella prevailed epidemically, and he was repeatedly called
1 Medical and Physical [ournal, vol. xxi., p. 250. (March, 1809.)
2 " Historical Sketch of Small-pox," p. 252. John Thomson, M.D.,
F.R.S.E. London, 1822.
DR. P. MUDIE'S EXPLANATION. l6l
upon to see children as well of the townspeople as the soldiers, whom he had
vaccinated, and who were marked in his journal as having gone regularly through
the disease; but in no instance could he hesitate as to the nature of the
disease, which, though often of a mixed nature, was genuine, and of the conoidal
form, as described by Dr. Bateman."1
Dr. P. Mudie, in a letter to Dr. Thomson, dated October 18, 1818, freely
acknowledges a bias in his own mind with regard to the prevalence of small-pox
after vaccination. " Of late years," he says, " I have remarked, that the
disease called chicken-pox has been much more severe than it used formerly to
be, and many of the cases, occurring after vaccination, so much resembled
small-pox, that if my mind had not been prejudiced against the possibility of
such an occurrence, I would have pronounced the eruption to have been of a
variolous nature."2
Thus there were a large number of vaccine failures in the early years of the
century ; and, if we include some of the chicken-pox patients, there must have
been thousands of such cases in the epidemic of 1817-19. Secondly, these
failures took place at all periods after vaccination, even within a few weeks or
months of the operation. Thirdly, post-vaccinal small-pox, according to these
early records, did not seem to be an especially mild disease; and lastly, there
did not appear to be any
1 "Historical Sketch of Small-pox," pp. 252, 253. John Thomson, M.D.,
F.R.S.E. London, 1S22.
'* An account of the varioloid epidemic which has lately prevailed in Edinburgh
and other parts of Scotland, p. 240. John Thomson, M.D., F.R.S.E. London,
1820.
relation between the severity of the disease and the length of time which had
elapsed since the operation.
Vaccination was first made compulsory in 1853. It is difficult at this day to
understand how the promoters of vaccination managed to get this Act on our
Statute Books, except on the assumption that the overwhelming evidence of the
early failures of vaccination had been overlooked or forgotten.
Mr. George Canning declared, in 1808, that although he considered the discovery
(vaccination) to be of the very greatest importance, he could not figure any
circumstances whatever that could induce him to follow up the most favourable
report of its infallibility, which might be brought forward, with any measure of
a compulsory nature.1
We have it on the authority of Mr. T. S. Duncombe, M.P. for Finsbury, that in
1840, Sir Robert Peel, being urged to make vaccination compulsory, expressed his
opinion that such a course would be repugnant to the habits and feelings of the
British people, and to that freedom of opinion and action to which they were
well accustomed.2 Mr. Duncombe quotes Sir Robert as saying that:—" The proposal
to make it compulsory was so contrary to the spirit of the British people, and
the independence in which they rightly gloried, that he would be no party to
such compulsion."3 Sir Robert Peel, however, died in 1850, and in 1853 a measure
involving an enormous curtailment of the liberty of the
' Hansard's Parliamentary Debates. First series, vol. xi., p. S44. (June 9,
1808.)
-Ibid., third series, vol. cxliii., p. 552. (July 10, 1856.) "Ibid., vol.
clxiv., p. 674. (July IO, 1861.)
VACCINATION MADE COMPULSORY. 163
subject, without any demand for such legislation, and without previous inquiry,
was passed through both Houses of Parliament with very little discussion.
Lord Lyttelton introduced the Bill into the House of Lords, and, on the motion
to go into Committee, explained that, having no scientific knowledge of the
subject himself, he was indebted for almost all his information to some able and
learned members of the Epidemiological Society. " It was unnecessary," he
informed the House, " to speak of the certainty of vaccination as a preventive
of the small pox, that being a point on which the whole medical profession had
arrived at complete unanimity."1
If we refer to the Return on "Small-pox and Vaccination,"2 prepared by the
Committee of the Epidemiological Society, and from which Lord Lyttelton obtained
his information, we find certain extraordinary and wholly unwarrantable
statements (p. 4). " Small-pox is a disease," say the authors, " to which every
person is liable, who is not protected by a previous attack or by vaccination."
Again : " Every case of it is a centre of contagion, and every unvaccinated or
imperfectly vaccinated population is a nidus for the disease to settle in and
propagate itself."
' Hansard's Parliamentary Debates. Third series, vol. exxv., p. 1002. (April 12,
1853.)
" Copy of " Letter from Dr. Edward Seaten to Viscount Palmerston, with enclosed
Copy of a Report on the State of Small-pox and Vaccination in England and Wales
and other Countries, and on Compulsory Vaccination, with Tables and Appendices,
presented to the President and Council of the Epidemiological Society by the
Small-pox and Vaccination Committee, the 26th day of March, 1851."
Parliamentary Paper, No. 434. Ordered, by the House of Commons, to be printed,
3rd May, 1853.
The two latter propositions, we are seriously informed, " do not admit of being
controverted." We will suppose, for the sake of argument, that none of these
propositions are capable of refutation. We then read : " If it admit of doubt,
how far it is justifiable in this free country to compel a person to take care
of his own life and that of his offspring, it can scarcely be disputed that no
one has a right to put in jeopardy the lives of his fellow-subjects."
Here the question presents itself, if vaccination is a preventive of small-pox,
as asserted by Lord Lyttelton, how could the unvaccinated put in jeopardy the
lives of their protected fellow-subjects? Thus, there is no argument for
compulsion, even if it be admitted that vaccination protects for life; if
vaccination does not protect for life, and it is evident from the numerous cases
I have quoted, that it does not do so, then the profession should show how long
its protective value lasts. Of the various medical experts who have been
examined before the recent Vaccination Commission it is important to remember
that none have endorsed the opinion of Jenner, Sir John Simon, and others, that
vaccinated persons are for ever afterwards secure from the infection of
small-pox. Although some have maintained that vaccination protects for
considerable intervals, one prominent official expert, Dr. Wiiliam Gayton,
thinks that "primary vaccination is a very fleeting protection indeed. As to the
time that that primary protection lasts, I do not know, but I think it is a very
short time" (Q. 1,755). Another authority, Dr. R. A. Birdwood, with an
experience of 12,000 cases of small-pox, emphatically stated that vaccination
cannot
DR. JAMES COPLAND'S VIEWS. 165
be relied on as an absolute protection up to any age whatever (Q. 31,191). And
lastly, there have been witnesses of the very highest professional standing and
scientific attainments, who have maintained that vaccination exerts no specific
protective influence at all. When the profession are agreed on this important
point, then the vaccinated will be able to make themselves secure by periodical
re-vaccinations, and their lives will not be placed in peril by anti-vaccinists.
It is interesting to note that the first compulsory Act of Parliament entirely
failed to remove the honest doubts of some distinguished members of the medical
profession. Thus Dr. James Copland expressed the opinion that vaccination " will
never be generally adopted, and that, if it were so adopted, it could never
altogether banish small-pox, nor prove a complete or lasting preventive of
variolous infection."1
Again he writes (p. 829):—"At the time of my writing this, just half a century
has elapsed since the discovery and introduction of vaccination ; and after a
quarter of a century of most transcendental laudation of the measure, with
merely occasional whisperings of doubt, and, after another quarter of a century
of reverberated encomiums from well-paid vaccination boards, raised with a view
of overbearing the increasing murmurings of disbelief among those who observe
and think for themselves, the middle of the nineteenth century finds the
majority of the profession, in all latitudes and hemispheres, doubtful as
to the preponderance of
lf'A Dictionary of Practical Medicine," vol. iii., part ii., p. 831. James
Copland, M.D., F.R.S. London, 1858.
advantages, present and prospective, to be obtained either from inoculation or
from vaccination."
I now propose to show that the unvaccinated when exposed do not necessarily take
small-pox, and also, that since the population has been more ■ largely "
protected," it is the vaccinated who form not only an overwhelming proportion of
the sufferers, but in a large number of instances they are the means of
propagating the disease.
Some very remarkable cases are recorded by Dr. William Baylies in his little
book, entitled, " Facts and Observations Relative to Inoculation in Berlin"
(1781, pp. 132-144). The King of Prussia having given his sanction to
inoculation in February, 1775, eight orphan children were chosen to commence the
series, and only those were selected who were perfectly free from all marks or
signs of their having gone through the smallpox before ; a thread was used,
which had been charged with fresh variolous matter at the London Small-pox
Hospital; the matter was inserted into both arms of the patients, and Dr.
Baylies had not the least doubt the disease would come on as it ought to do; yet
we are informed that " neither fever nor any other symptom followed in
consequence of it, though the arms of two of them, on the third or fourth day
from the operation, had a degree of inflammation for a day or two" (p. 138).
He then used a thread of much older matter, and re-inoculated these eight
children, and also inoculated, for the first time, four others, with a similar
result; and lastly, having learnt that the child of a baker was down with the
disease, he resolved to inoculate them with fresh
UK. MICHAEL UNDERWOOD'S OPINIONS. 167
vui'iolouK matter. The twelve children before-mentioned, willi seven others,
were conducted to the baker's house, ami they were all inoculated with warm
fluid matter limn ripe pustules, and for nearly an hour the children were kept
in the infected atmosphere, and " not one of all the nineteen children
manifested the least symptom nf the disease in consequence of it" (p. 143).
As Dr. Baylies was a practised inoculator, we are forced to the conclusion that
either the children had had Min.ill-pox before — the conclusion arrived at by
Dr. Hay lies himself—or that they were naturally immune to the* disease ; but,
considering that the most careful examination was made for marks of small-pox,
the latter view appears to be the more probable.
In this connection some remarks made by Dr. Michael Underwood, in his work on
the diseases of children, are not without interest. Dr. Underwood
observes:—"Though the small-pox is a complaint so incident to the early part of
life, that comparatively lew children living to the age of eight or ten years,
arc found to escape it, yet it is not so readily communicated, in the state of
early infancy, as hath been |.;rnerally imagined, unless by immediate infection.
The poor furnish frequent instances of the truth of I his observation. I have
attended where children born In an air, saturated as it were, with the miasma
(or Infectious particles) of this disease (as well as of the measles), and even
lying continually in a cradle in which another child has died a few days before,
have, nrvcrtheless, escaped the disease, and sometimes, when I hey have slept
together in the same bed with one loaded with it. Hence it appears, that
highly tainted
air, and even personal contact, are often insufficient t< communicate the
poison. Yet we know that infant; are very easily infected, receiving the
small-pox b\ inoculation as readily as adults ; though neither are a all times
equally susceptible of it."1
In the Medical and Physical Journal2 for April, 1803 Mr. C. Dennett, of Soho
Square, related the following
instances :—In August, 1800, Mr.----- had two childrei
who were laid up with confluent small-pox, one of whorr died ; an infant, three
weeks old, was exposed to th< infection the whole time, being always in the same
room and sometimes in the same bed. Mr. Dennett says hi could not persuade the
parents to have the baby inocu lated, and to vaccination they positively
objected. I did not take the infection ; later in the year, the chile was
inoculated with fresh variolous matter withou' effect, and this was repeated
three times with no bette; success.
Another child in the same family, born later, escapee the disease, although it
had slept in the same bed witr the former child, who had now contracted
confluen1 small-pox. Mr. Dennett inoculated the infant on foui separate
occasions with small-pox matter without effect These cases were evidently not
very uncommon, for Mr Dennett remarked that " every practitioner must have met
with cases when, under some peculiar constitution the habit is not susceptible
of the disease, either bj infection or inoculation " (p. 364).
1 "A Treatise on the Disorders of Childhood, and Management o
Infants from the Birth," vol. i., pp. 299-301. Michael Underwood, M.D.
Physician to Her Royal Highness the Princess of Wales. London, 1797.
2 Medical and Physical Journal, vol. ix., p. 365.
IMMUNITY IN THE UNVACCINATED. 169
Dr. Lionel Beale gives the following on the authority of the Lady Superior of
St. John's House :—" S. L., aged 1.3, Westminster, took the small-pox in March,
1871. The rash was fully out all over face and body March 10th. The mother and
baby of a week old slept in the same bed and continued to do so. The baby has
never been vaccinated, and is now nine weeks old, and has been sleeping in the
bed night and day. The mother was vaccinated as a child thirty-five years ago.
The other children in the room had been vaccinated. The father has never been
vaccinated at all, and slept in the same room. No other member of the family has
had the small-pox."1
Dr. W. N. Thursfield, Surgeon to the Wellington Dispensary, refers to the
following cases in the Lancet of June 1, 1872 (vol. i., p. 754):—"On the 25th of
March of this year, I was sent for to see a Mrs.
W----- , a lady I had attended in her confinement five
months previously, and whose child had not been vaccinated in consequence of the
express prohibition of both parents. I found the lady suffering from a severe
attack of small-pox. The eruption, which was said to have appeared four days
previously, was then in the pustular stage. She had not discontinued nursing the
infant, and it was taking the breast at the time of my visit. The child was at
once removed from the mother, but not from the house, where it
remained
throughout. Before Mrs. W---- could be said to have
completely recovered, she, in spite of remonstrance,
1 " Disease Germs ; their Nature and Origin," p. 441. Second edition. Lionel S.
Beale, M.B., F.R.S. London. 1872.
resumed suckling the child, and continued to do so for some time. At the present
date (May 2Oth) the child is quite well, and has had no eruption or feverish
symptoms whatever, and is still unvaccinated. This lady's husband contracted
small-pox during his wife's illness ; both had been vaccinated in infancy, and
both recovered.
"In another case, a young man, lodging in a house near to where small-pox had
been for some time, was taken with a moderately severe attack of the disease,
and came under my care as a dispensary patient on Good Friday last. The old
woman of the house, who nursed and looked after the patient, was bringing up by
hand an illegitimate infant, then ten weeks old, which had been put out to nurse
with her. This infant had not been vaccinated; and, though in constant contact
with the nurse, and sleeping with her in the room next to the small-pox patient,
did not take the disease, and through the neglect of the woman to take it to the
public vacci-nator, it remained unvaccinated. About five weeks after the
recovery of the young man, the nurse-child died of general debility. I kept it
under my observation until its death, and know that it had not small-pox.
" In both these cases, there certainly was no error in diagnosis, nor was either
of the infants vaccinated or out of my personal observation at any time."
In the Sheffield Report (p. 46, foot-note), Dr. Barry, in referring to the case
of Mary P., aged twenty-four, who took small-pox after vaccination, says :—" Of
five other children in this family, three, aged eleven, fifteen, and sixteen,
who had been vaccinated in infancy, all suffered from small-pox ; the last two
were badly pitted.
DR. COUPLAND'S REPORT. 171
'I'wo other persons, aged fourteen and twenty, who had never been vaccinated,
and who slept with the others, did not contract small-pox."
The above instances appear to show that immunity in the unvaccinated, even when
strongly exposed to .mall-pox, is not nearly so rare as has been generally
believed. It is also instructive to note that Dr. Coupland,1 in his report on
the Leicester outbreak, ■hows, with regard to 193 invaded households, that at
cveral specified age-periods, the small-pox attack-rates were much the same,
although, according to his census (if the inmates, the proportion of the
unvaccinated at 1 liese age-periods vastly differed. The figures cited are as
follows :—
Of the total inmates, the percentage.
Age-periods. inmates.2 Unvaccinated.
Attacked.
Under 1 year ... ... 33 (pro
21'2
1-10 years............................... 328 74^0
28^9
10-30 years ... ... 534 15-5 28'i
30 years and upwards ... 330 27 2C5
With these figures before him, it is not surprising that Dr. Coupland should
have come to the conclusion that " the natural liability to small-pox,
unaffected by vaccination, was not so great as has been supposed."
To resume our inquiry into the question as to whether vaccination prevents
small-pox, the following cases, extracted from the Sheffield Report, are of
importance as showing that recent vaccination of the most approved fashion will
not secure immunity from this disease. (See next page.)
1 Final Report, Royal Commission on Vaccination, Appendix vi., p.
3.
2 In nine of the inmates the age was not ascertained.
R&n. Di^<- N°- N—
tftLIed" Vaccination. Results of vaccination. J%^
41 Btightside - - 27 Mary H. - - 10 months
Vaccinated Five foveated cicatrices, two- Very slight, not
in infancy thirds square inch in area. pitted.
41 Brightside - - 41 Sarah C. - - 6 months
Vaccinated Four foveated cicatrices, one- Very slight, not
in infancy half square inch in area. pitted.
42 Brightside- - 102 Sarah Ann L. - 10 months Vaccinated
Four plain cicatrices, one- Very slight indeed,
in infancy half square inch in area. not pitted.
62 North Sheffield - 79 Ernest C. - - 9 months Vaccinated
Four foveated cicatrices, one- Very mild, one
in infancy half square inch in area. pit.
97 South Sheffield - 29 Gertrude 2 months Vaccinated
One plain cicatrix, one-eighth Slight, not pitted.
Hoskins M. - when square inch in area.
6 weeks old
150 Nether Hallam - 18 Frank S. - ' - 6 months Vaccinated
Four foveated cicatrices, two- Very slight, play-
when
thirds square inch in area. ed about all the
6 weeks
old
time, not pitted.
150 Nether Hallam - 57 Hedley V. H. - 8 months Vaccinated
Three foveated cicatrices, Very mild, not ill
in infancy one-third square inch in at all, not pitted,
area.
I ATM, SMALL-POX IN VACCINATED CHILDREN. 173
Kxamples of more absolute failure to protect could liardly be imagined than
these seven cases contracting •.mall-pox from a fortnight to seven or eight
months after vaccination of the most correct type. Altogether the -re were about
450 vaccinated cases under ten years of age at Sheffield in the 1887-88
epidemic, and yet a prominent defender of compulsory vaccination deliberately
maintained that " vaccinated children under ten years of age are . . . wholly
and entirely immune from small-pox, and cannot be infected."1
Since writing the above, it appears that the editor of the British Medical
Journal has somewhat shifted his ground, for in a recent article on "Vaccination
as a Branch of Preventive Medicine," he maintains that in certain epidemics
(referred to) " vaccinated children under ten have been almost immune from death
by small-pox,"2 which I venture to suggest is a considerable modification of his
original statement. It is a pity that Mr. Ernest Hart did not have an
opportunity of consulting Dr. John MacCombie's article on " Small-pox " in the
same volume (Allbutt's " System of Medicine," vol. ii.), for he would then have
discovered . the following figures (p. 221):—
Vaccinated.
Fatality
Age-periods. Cases.
Deaths. per cent.
Under 5 years ... ... 385 30
7'8
5-9 years............................. 1,468
59 4-0
It must also be presumed that Mr. Hart's attention has not been arrested by
the following experience of the
1 Letter ot Mr. Ernest Hart to the Times of August 31, 1894.
■ Allbutt's " System of Medicine/' vol. ii., p. 664. London. 1897.
Metropolitan Asylums Board* in the epidemic of 1870-72:—
Vaccinated.
Number Number of Fatility
Age-periods. admitted.
deaths. per cent.
Under 5 years ... ... 195 38 I9'5
5-10 years 786 60
76
These two tables prove that "vaccinated children" under five years of age (let
alone ten years) are not even "almost immune from death by small-pox."
What could be more emphatic than the following experience of Mr. T. Massey
Harding?2—"All practitioners are acquainted with cases disproving the immunity
of the vaccinated, such as the following :—I attended a man, aged 40, with
confluent small-pox, of which he died. He had been vaccinated twice, according
to his own statement. In the house were his sister, her husband, and two
children, all unvaccinated. I vaccinated them all, and it took effect. In three
weeks from the day of vaccination, the woman, Mrs. G., and one of her children
had small-pox, distinct, but slight."
Nor can it be truthfully said that epidemics originate with the unvaccinated,
for in a number of notable instances the first unvaccinated case is a long way
down the list. Thus, at Neuss, in Germany, from 1865-73, there were 247
cases of small-pox, all of
1 " Report of the Committee appointed on the 1st June, to collate and
report upon the Returns obtained from the several Hospitals of the
Managers, with regard to the cases of Small-pox treated therein." Pre
sented to, and adopted by, the Managers of the Metropolitan Asylum
District, at their meeting on the 13th July, 1872. P. 5 ; Table 2.
2 British Medical Journal, November 21, 1857, p. 974.
STATISTICS OF VACCINATED SMALL-POX. 175
llicin vaccinated; at Bromley, in 1881, 43 cases, all vaccinated ; and in the
1870-72 epidemic at Bonn, 1 he first unvaccinated case was forty-second on the
list.1
The following table shows the large proportion of vaccinated cases in some
well-vaccinated districts:—
Small-pox epidemics. Years. Attacks.2 Va"lnilt«d
of attacks
attacks. vaccinated.
liavaria3................................... ...
1S71 30,742 29,429 957
lierlin4
1871-72 20,391 17,038 83-6
Cologne4
1871-73 2,282 2,248 98-5
Ncuss4
1865-73 247 247 ioo-o
I,ondon Small-pox Hospital6 1852-67 13,581
10,661 78-5
Metropolitan Asylums Board j l8y(>86
SOj668 ^^ gro
1 lospitals 6 ... ... J
Uromley7
1881 43 43 ioo'O
Sunderland8 ... ... ...
1884 100 96 96^0
Sheffield
1887-88 7,066 5,891 83-4
Warrington ... ... ...
1892-93 674 601 89^2
Kirmingham................................................ 1893-94
2,945 2,616 88'8
Willenhall .....
1894 828 739 89-3
In an epidemic, it is not possible, on any theory of protection, for the
population to be vaccinated to any
1 " Beitrage zur Beurtheilung des Nutzens der Schutzpockenimpfung,"
p. 143. Berlin. 1888.
2 Cases in which there was a doubt about the raccinal condition of the
patient have been excluded.
a Second Report Royal Commission on Vaccination. Q. 1,489. 4 " Beitrage zur
Beurtheilung des Nutzens der Schutzpockenimpfung," pp. 152, 154, 168.
Berlin. 1888.
0 Report from the Select Committee on the Vaccination Act (1867) 1871,
1>- 237-
0 Third Report Royal Commission on Vaccination, Appendix, p. 204. Table L.
''Lancet, August 27, 1881, vol. ii., pp. 372, 373.
8 Lancet, February 23, 18S4, vol. i., pp. 363, 364.
lesser extent than the cases of small-pox, or it would show that small-pox
picked out the vaccinated for its victims. The figures for Bavaria and Cologne,
with 957 and 98-5 per cent, of the cases vaccinated respectively, hardly leave
any margin for the population to be vaccinated to a greater extent. Considering
that in these two instances the proportions approximate so closely, there is
every reason for scrutinising very carefully any estimate of the vaccination of
the population which differs largely from the ratio of the vaccinated cases of
small-pox.
Such estimates have been made for Sheffield by Dr. Barry, and for the houses
invaded by small-pox at Warrington, Dewsbury, and Leicester, by medical men
appointed by the Vaccination Commission. As, in the latter instances, there was
no opportunity for examination of these experts, it will be more satisfactory
if I confine myself to the case of Sheffield.
In his report on the Sheffield epidemic, Dr. Barry estimated that 97^9 per cent,
of the population was vaccinated. It was pointed out to him before the Royal
Commission, that the house-to-house inquiry, on which his estimate was based,
was taken after the epidemic had reached its height, during the course of which
a transfer had been taking place from the unvaccinated to the vaccinated class.
A new estimate was therefore made, which is included in the Report of the Royal
Commission, at 973 per cent.; but even this cannot be justified. In his
examination before the Royal Commission, Dr. Barry admitted that in the
Sheffield Union, the house-to-house inquiry was enumerated by men under the
supervision of the vaccination officers
Till': SHEFFIELD "CENSUS." 177
' '■ 2,389), and that its primary object was to secure, fur as possible, the
discovery of all unvaccinated iiiltlrcn (Q. 2,390). These were reported to the
vac-'M.ition officers, whose duty it was to take steps to ■ 'lire their
vaccination (Q. 2,391). The "census," Dr. I Liny informs us, was a "secondary
affair" (Q. 2,390). I In's inquiry, therefore, was instituted in order to hunt
up the unvaccinated, and it is obvious that a census < 1 inducted on these lines
could not have the slightest I net fusion to accuracy. It would have been the '.implcst
matter in the world for the householder to omit the mention of the unvaccinated,
and, as the inquiry lasted nearly six weeks, to evade the enumerators, who, in
the Sheffield Union, were not even supplied with the names of the occupiers.
Moreover, in 764 houses, information was altogether refused, and 1 1'8 per cent,
of the population, or over six times tlie "unvaccinated enumerated," were left
out of the calculation altogether. For these and other reasons, il is impossible
that the population could have been vaccinated to the extent that was claimed ;
and, therefore, the calculations that are based on this estimate are
misleading.
It has been shown that the unvaccinated may be exposed to small-pox without
taking the infection, and also that the most recent and efficient vaccination of
individuals will not prevent the complaint, and considering that such a large
proportion of sufferers are among the vaccinated, who, in most instances, start
and spread the epidemic, the statement so often promulgated that an
unvaccinated individual is a source of infection and a danger to
the community, is
erroneous. It has also been pointed out, that even if vaccination was a complete
protection against smallpox, this would be no argument for legislation ; for,
in the words of Dr. J. H. Bridges, " non-vaccinated people are not a source of
injury to their neighbours; for their neighbours can get themselves
vaccinated."1 It follows, therefore, that the law which was first passed on the
assumption that the unvaccinated are a danger to society—even if there were no
other evidence against vaccination—should be immediately abrogated.2
1 Positivist Review, vol. iv., p. 226. (November, 1896.)
2 If vaccination mitigates small-pox, as maintained by some, it is no
argument for compulsion. The medical officer of health to the City of
Birmingham (Report for 1893, p. 45) alleges that one of the causes of the
rapid spread of small-pox in the recent epidemic was due to "the mildness
and modification of the attacks in vaccinated persons, making it most
difficult in some cases to decide the nature of the illness, and causing it to
be mistaken for chicken-pox and other trivial affections, and arousing no
suspicion of its being small-pox until severer iorms of the disease subse
quently appeared in the same family."
CHAPTER VI.
THE MITIGATION THEORY.
When it was discovered, in the epidemic of 1817-19, that small-pox attacked such
a large number of the vaccinated, the theory of mitigation was promulgated. iMom
the cases detailed in the last chapter, it does not appear that small-pox was
very conspicuously mitigated by vaccination in the early years, nor does there
appear to have been any relation between the severity of the attack and the
length of time which hud elapsed since the operation. It will be profitable to
proceed to enquire whether the later experience shows results more favourable to
the mitigation theory. Dr. George Gregory has indicated the measure of the
modifying powers, which, in his opinion, may be attributed to vaccination. "
Vaccination," he says, " does not appear to lessen the violence, or shorten the
duration, of the first or eruptive stage of fever, which is generally as severe,
and even sometimes severer and longer in its duration than that of the casual
confluent small-pox. It does not appear in like manner to influence the </iiantity
of eruption upon the skin, so much, at least, as has been generally imagined. It
is true, that, in many cases of small-pox, subsequent to vaccination, the erup-lion
has been very scanty ; but, in a large number also, I have seen it very copious,
more particularly about the
face, breast, and upper extremities, and occasionally fully equal, in point of
quantity, to what is seen in the worst kinds of confluent or coherent natural
small-pox."1 The great power of vaccination, he thought, consisted in modifying
the progress of inflammation in the variolous eruption on the skin and in the
throat; but he added : " It is curious to observe that it does not always affect
the course of the disease, when the variolous poison fixes itself on other
parts, more particularly on the brain. It is, in this manner, that small-pox,
after vaccination, occasionally proves fatal."2 In a foot-note on p. 331, he
explains that "the eruption on the skin and throat is only one of the effects of
the poison. Another, at least equally important, both with reference to
pathology and practice, is that which is excited upon the brain and nervous
system ; the chief evidences of which are delirium, inflamed eyes, stupor or
restlessness, and disposition to erysipelas and gangrene."
There are several ways of testing the mitigation question, one of which would be
to compare the case-mortality or fatality of small-pox before and after the
introduction of vaccination. In the Appendix will be found a table taken from
Dr. Creighton's " History of Epidemics." It consists of censuses of small-pox
epidemics during the years 1721-30, the fatality ranging from 9/1 to 36-4 per
cent, there being in all 13,192 cases, with 2,264 deaths, or an average fatality
of 17*2 per cent.
The principal objection that has been raised to these
1 " Medico-Chirurgical Transactions," vol. xii., pp. 328, 329. (1S23.)
. 2/^., pp. 330, 331. , , ,„,
., ,. ,
jurin's statistics. iSi
statistics is, that in the censuses of small-pox epidemics passing under the
name of Jurin, which largely dominate the figures in Dr. Creighton's list,
Jurin is said to have " not knowingly set down any deaths under two years old as
due to small-pox, . . . and that some of his correspondents, in furnishing him
with statistics, followed the same rule."1
The ostensible grounds for this assertion are :—
1. That the Aynho census, to which I have referred
in a previous chapter (pp. 43, 44), contains no cases
under two years of age.
The Aynho census, a copy of which is to be found in the archives of the Royal
Society, was made by the rector of the parish, and the cases are given in the
order of time, just as they occurred over a period of some fifteen months, three
in one family, two in another, and so on. There is no suggestion of infants
being excluded, and the fact that there were only three aged two years, and four
aged three years, out of a total of 132, makes the absence of cases in infants
not only credible, but probable. The epidemic was mainly among young people and
adults, and was quite intelligible for a country place where epidemics took
place infrequently.
2. The other ground of objection is founded on an
argument used by Jurin in his letter to Dr. Cotes-
worth.2 " It is notorious, that great numbers, especially
'Article on "Small-pox and Vaccination," by John C. M'Vail, M.D., in Stevenson
and Murphy's " Treatise on Hygiene and Public Health," vol. ii., p. 399.
London. 1893.
" A Letter to the learned Caleb Cotesworth, M.D., p. 11. James Jurin, M.D.,
Secretary to the Royal Society. London. 1723.
of young children, die of other diseases, without ever having the small-pox,"
etc.
The statement that a number of young children died of other diseases, without
ever having the small-pox, has no reference to the censuses which were taken to
show the fatality-rate of natural small-pox as contrasted with the inoculated.
It was part of an argument to show that the real hazard of dying of small-pox in
London was greater than the Bills of Mortality showed, inasmuch as the excessive
London infantile mortality cut off an immense number from other causes (such as
convulsions, infantile diarrhoea, etc.) before small-pox could attack them. But
Jurin admits (p. 12) that in all probability some infants, " very young
children, or at most not above one or two years," went through the small-pox,
which is sufficient evidence that he had no intention of counting them out, or
ignoring them, in the percentages of fatalities to attacks. His argument, such
as it was, applied only to London, but there were no statistics for London in
the censuses, which are all from the provinces, many of them made by Nettleton
of Halifax, and none of them made, nor even controlled, by Jurin himself.
The incidence of small-pox in the eighteenth century, as pointed out in a former
chapter, was almost entirely on the young ; for instance, at Chester,1 in 1774,
of 1,385 cases, 202 died, or a fatality of 146 per cent., the ages at death
being as follows (p. 150; Tables II. and IV.):—
1 " Philosophical Transactions," vol. Ixviii., p. 151. (Dr. Haygarth's
Observations on the Population and Diseases of Chester in the year 1774.)
OPINION OF THE ROYAL COMMISSION. 183
Under 1 month........................... ... ... o
Between 1 and 3 months ... ........................ 3
„ 3 and 6 „ ......................... 4
., 6 and 12 „ .......................... 44
„ 1 and 2 years ............... ... 38
„ 2 and 3 „ ......................... 42
„ 3 and 5 ,.................................... 49
„ 5 and 10 „ ... ... ... 22
Over 10 years .............. ... ... ... o
TotaJ ........................ 202
The contention, therefore, that the last century fatality of 17 or 18 per cent,
is lower than it should be, because of the deliberate omission of young children
from the censuses, is groundless, and ought never to have been raised.1
Let us now see what is the fatality of small-pox since ;i large proportion of
the cases have been vaccinated. Dr. Collins and Mr. Picton2 quote the experience
of the Metropolitan Asylums Board's Hospitals, where, from 1870 to 1894, 60,855
cases were treated, with a fatality of 167 per cent., and among 50,668 of these
admissions, the vaccinated were 41,061, or 81 per cent.
During this period the figures have varied considerably. In the year 1896, the
fatality was 4-oi per cent.; whereas, from December 1, 1870, to February 3,
1 The Royal Commission say (section 53)—" It has been urged that the deaths of
those dying under two years of age were excluded from Jurin's ■,l:ilistics, and
that this must have led to the omission of many deaths, as l he mortality in
that class was high. The evidence relied on to show that nises under two years
of age were excluded certainly cannot be regarded icv establishing it."
'' Royal Commission on Vaccination, Dissentient Commissioners' Statement,
section 97.
1871, it was as high as 2O'8i per cent. This high fatality in the earlier years
may in part be due to the limited accommodation at the hospitals, when the
tendency would be to admit the more serious cases. In this epidemic (1870-72),
however, the fatality was high, for the Lancet of July 15, 1871 (vol. ii., p.
94), estimated the fatality of small-pox at 17-5 per cent. ; and hence, the
large proportion of vaccinated casesx does not appear to have diminished the
severity of the disease, as compared with the last century.
The other method of testing the question is to compare the fatality in the two
classes. Dr. Davies, the medical officer of health for Bristol, in the Bristol
Mercury of April 2, 1896, states the case thus: "The unvaccinated die at the
rate of thirty or forty deaths per hundred cases, the vaccinated at something
less than five per hundred cases." This agrees approximately with Mr. Ernest
Hart's figures2 in his summary of different towns during recent epidemics. The
claim is that vaccination mitigates small-pox in the bodies of those who have
taken the disease, and this is practically the whole case for the observance of
the operation ; and the evidence is chiefly to be derived from the reports of
medical officers of health and others in official position, from which the
following have been taken :—
1 In the epidemic of 1870-72, a total of 14,808 cases of small-pox were
admitted into the hospitals of the Metropolitan Asylums Board. Of these,
11,174, or 75-5 per cent., were in vaccinated persons.
2 British Medical Journal, March 2, 1895, vol. i., p. 487.
FATALITY STATISTICS. 185
Unvaccinated Fatalities—/Sj6-g6.
Report of Hospital or Medical y
c n»ith<i Fatality
Officer of Health. Vearf"
<-ase!" '«aths. per cent.
Ilighgate. ............. 1836-51 2,654
996 37-5
Ilighgate1 ... ... 1871 74
49 66'2
Dublin (Hardwickel Feb. 1871 to^ , „,
Hospital)2 .............. ) March 1872 J 7° 55
7 ^
llomertoij ....... 1871-77 1,243 570 45-9
Hampstead .......... 1876-78 847 397 46^9
Dublin (Cork Street) ... 1876-80 448 288 643
Kulham ... ... ... 1877-79 374
176 47'i
Deptford ...................... 1878-79 258
i2i 469
Sheffield ... ' ... 1887-88 1,173
392 33'4
Uirmingham ............... 1893-94 329 107
32-5
(Iloucester ... ... 1895-96 781
317 4C6
Hence, in these instances, the proportion of deaths to iittacks among the
unvaccinated is stated to have ranged from 78 to 32 per cent. Most of these
figures are, however, impossible, for the simple reason, that in the last
century, as already shown, before the introduction of vaccination, the average
fatality of small-pox was only about 17 or 18 per cent.
In making a critical examination of the fatality •statistics in the two classes,
it is obvious that their accuracy would depend on whether the statement us to
vaccination could be absolutely relied upon ; and secondly, on whether the two
classes were perfectly comparable in every respect; and to do this il is
necessary to say a word or two about the different types of small-pox, and also
the method of I'lassification.
Hritish Mfi/ifitt /onrnat, February 10, 1872, vol. i., p. 171. 'I'M., p. <>Sj,
June 22, 1872. These figures include four doubtful cases. I!',
A prominent feature in medical and official publications advocating
vaccination1 has been to paint the horrors of small-pox in its natural state in
the most vivid colours. I have already dwelt on the fact that, in the last
century, the average fatality of small-pox was only about 17 or 18 per cent, of
those attacked, and in many epidemics the proportion was much less. Different
forms of small-pox have been distinguished from the time of Rhases,2 and it may
be said that Sydenham's main success in his treatment of the disease was due to
the fact that he recognised a discrete and confluent variety, in the former of
which the patient, if left alone to Nature, invariably recovered.
The following quotations from Sydenham bear on this point:—" As it is palpable
to all the world, how-fatal that disease (small-pox) proves to many of all ages,
so it is most clear to me, from all the observations that I can possibly make,
that if no mischief be done, either by physician or nurse, it is the most slight
and safe of all other diseases." 3
Sydenham observes that in 1669 small-pox "appeared
1 See Mr. Ernest Hart's "Truth about Vaccination," pp. 2-8 (1880), and also
"Facts concerning Vaccination for Heads of Families," a tract "revised" by the
Local Government Board, and "issued with their sanction," in which it states (p.
4)—"The disease (small-pox) used to rage unchecked, killing a very large
proportion of those whom it attacked, and maiming, blinding, and disfiguring
those whose lives it spared."
3"A Treatise on the Small-pox and Measles." Translation from the original Arabic
by Dr. W. A. Greenhill, and printed for the Sydenham Society, 1848, pp. 71-73.
3 Letter to Mr. Robert Boyle, dated Pall Mall, April 2, 1688. The Works of
Thomas Sydenham, M.D. Translation from the Latin Edition of Dr. Greenhill, with
a life of the author, by R. G. Latham, M.D. Printed for the Sydenham Society,
1848, vol. i., pp. lxxii., lxxiii.
• vdkniiam's classification of small-pox. 187
111 -,omc few places, but in a mild and manageable lorm." '
" Now, the confluent small-pox is as much worse than I In: distinct, as the
plague is worse than the confluent."-
" As for the distinct sort, even if it can be seen beforehand, bed is so much
out of the question, that injunctions against it are superfluous. The scanty
number of the exanthemata makes matters safe either way." :i
" With few pustules, and those of the distinct sort, I In: treatment is
immaterial ; provided there is no gross <Tmr. The disease is a slight one. The
ignorance of 1 he physician, who aims at nothing so much as the promotion of
heat, can alone make it dangerous. I hingerous, too, it has been made ; since in
such cases 1 he doctor, though unconsciously, helps the disease."4
In referring to the treatment of small-pox, "all this applies to the confluent
small-pox only. With the distinct sort, they have nothing to do. Those who boast
about curing cases where the rash has been icanty, deceive themselves and
others. If they really wish to test their skill, let them take a confluent case
in a young subject who has drunk hard ; and not so far blunder as to fancy that,
in their easier practice, they have saved the lives of patients whom it would
have been a hard matter to have killed.""'
Other authorities testify to the mildness of some Inrms of the disease. Thus
Wagstaffc, in a letter to Dr.
1 "Medical Observations." Printed for the Sydenham Society, 1848, Mil. i., p.
160.
" Letter to Dr. Cole. JbiU., vol. ii., p. 58.
;l I It iit., p. 65. 4 Ibid., p. 71. "' Ibid., p.
79.
Freind, observes—"There is scarcely, I believe, so great a difference between
any two distempers in the world, as between the best and worst sort of
small-pox, in respect to the danger which attends them. ... So true is that
common observation, that there is one sort in which a nurse cannot kill, and
another which even a physician can never cure."1 Sir Richard Blackmore, in his
remarks on the treatment of small-pox, says :—" In the most favourable sort of
the distinct small-pox, which are few in number and mild in quality, Nature
herself, as I have before observed, is able to cure the distemper, and needs
not call the physician in aid."2 Isaac Massey, the apothecary to Christ's
Hospital, thus gives his experience:—"Here in the natural stnall-pox, hut one in
forty-nine died, and, I can assure the reader, that upon a strict review of
thirty years' business, and more, not one in forty small-pox patients of the
younger life have died, i.e., about five, and under eighteen."3 Mr. John Mudge,
a surgeon, of Plymouth, writing in 1777, says— "There is not perhaps a disease
to which the human race is exposed, that differs more from itself at different
times than the natural small-pox. We sometimes see this disorder so mild and
benign, as scarcely to expose the patient to more danger than a common cold ;
and at others, exasperated by a degree of malignity and
1A Letter to Dr. Freind showing the danger and uncertainty of inoculating the
Small-pox, pp. 9, 10. \V. Wagstaffe, M.D., F.R.S. London. 1722.
-"A Treatise upon the Small-pox," p. 42. Sir Richard Blackmore, M.D.,
F.R.C.T. London. 1723.
'"Remarks on Dr. Jurin's Last Yearly Account of the Success of Inoculation," p.
7. Isaac Massey. London. 1727.
CONFIRMED BY JENNER. 189
virulence, little, or perhaps not at all, inferior to the plague itself."1
The matter has also been alluded to by jenner. ()f course Jenner never dreamt in
the first ardour of his discovery, that the advocacy of vaccination would be
reduced to a mere plea for mitigation, and thus we obtain the following
interesting confirmation of the painstaking and carefully recorded experience of
Sydenham. " There are certainly more forms than one," he says, "without
considering the common variation between the confluent and distinct, in which
the small-pox appears in what is called the natural way.— .About seven years ago
a species of small-pox spread through many of the towns and villages of this
part of Gloucestershire: it was of so mild a nature, that a latal instance was
scarcely ever heard of, and consequently so little dreaded by the lower orders
of the community, that they scrupled not to hold the same intercourse with each
other as if no infectious disease had been present among them. I never saw nor
heard • if an instance of its being confluent."-
More recently also we have the corroboration of Mr. Marson, who says—"The
death-rate from distinct small-pox among the unvaccinated is only four per
c:i:iit., and even those four per cent, die of convulsions, <>r some other
disease to which children are liable."3
' " A Dissertation on the Inoculated Small-pox," pp. I, 2. John Mud^c,
Surgeon. London. 1777.
'"An Inquiry into the Causes and Effects of the }^arioltc Vaccina-" I
'\,\. Edward Jenner, M.I)., K.R.S. London. 1798.
'1,1. 4,,;i6, Report from the Select Comn.ittee on the Vaccination \ 1
(1S07). 1871.
And Dr. William Gayton,1 medical superintendent of the North-Western Fever
Hospital, has admitted that discrete small-pox is a comparatively mild disease
even in the unvaccinated.
Another variety of small-pox, viz., malignant or hajmorrhagic, is of a different
type. Regarding this, Dr. MacCombie2 states (i) That it is by no means rare ;
(2) that the majority of attacks occur in vaccinated persons ; and (3) that
recovery does not take place. This last statement accords with the experience of
Dr. Gayton, who informed the Royal Commission (O. 1,818), that malignant or
haemorrhagic small-pox was almost uniformly fatal whether the person had been
vaccinated or not. The following table, compiled from the hospital reports by
Mr. Wheeler,3 demonstrates this point conclusively :—
Malig nant Small-pox.
Vaccinated. Unvaccinated.
Years. Attack. Dea.h, ^W Attacks. DJh, FataH*
Homerton ... 1871-77 163 139
853 153 153 1000
Hampstead... 1S76-78 127 105
827 127 115 go'6
Fulham ... 1877-79 26 l8 (9
- 44 39 88'6
Deptford ... 1879 2I
2I 1000 jo 10 1000
DlSf°lk}l8768° '63 "3 6</3 '°3 93 9O-3 Total
... 500 396 79'2 437 410 938
1 Q. 1,816, Second Report, Royal Commission on Vaccination. '' Allbutt's
"System of Medicine," vol. ii., pp. 203, 204. London. 1S97..
3Third Report, Royal Commission on Vaccination, Appendix, p. 206 Table Q.).
VARIETIES OF SMALL-POX. 191
As vaccination apparently has no influence on this Conn of the disease, Dr.
Grieve, medical superintendent of the Hampstead Small-pox Hospital, was probably
correct when he stated that it was " but too common in people who had lived in
defiance of all sanitary laws, or who by intemperance have debilitated their
constitutions."1
Another particularly fatal, but rare variety, termed corymbose small-pox, has
been observed. This was described by Mr. Marson 2 as presenting" two or
three-patches or clusters about the size of the palm of a hand, upon which the
eruption is as thickly set as it possibly can be, while the skin around for some
distance is almost, if not entirely free. Mr. Marson gives the figures for 104
cases of this variety, which came under his observation : 29 were unvaccinated,
of these 13 or 44'8 per cent, died ; and 74 were vaccinated, of which 32 or 43'2
per cent. died. Thus, the fatality in the two classes of this variety of the
disease, is practically identical.
The only remaining type of the disease for us to consider is the confluent, and
from the above it will be evident that the huge difference in the rates of the
vaccinated and unvaccinated must take place in cases of this description. In
this variety of the disease, the pustules coalesce, so as to render the features
hardly recognisable, and it can easily be understood that marks of vaccination
may be and are readily obscured, so that
1 "An Analysis of 800 cases of Small-pox." The Lancet, March 18, 1S71, vol. i.,
p. 371.
2Article on "Small-pox," by Mr. J. F. Marson. Reynolds'" System c>[ Medicine,"
vol. i., p. 438. London. 1866.
it is impossible to determine from an examination of the arm whether they exist
or not.
This difficulty has been recognised by the leading authorities. Thus, Dr.
Gregory says—" Great difficulties were necessarily experienced in determining
who had been really vaccinated, of those who assumed to have undergone that
process. The cicatrix was our chief guide, but this often failed us, from the
swollen and pock-covered condition of the arm at the time of the patient's
admission."1 Dr. James B. Russell remarks— " Sometimes persons were said to be
vaccinated, but no marks could be seen, very frequently because of the abundance
of the eruption. In some of those cases which recovered, an inspection before
dismissal discovered vaccine marks, sometimes ' very good.' Those who died, or
who were not so examined, are placed in a separate column as ' said to be
vaccinated, but V.M. not visible.' I do not observe in the reports on smallpox,
as observed in London and Dublin, any allusion to this difficulty. Even the best
vaccine mark is readily obscured, or even hidden, by a copious eruption, and
unless such special means, as I have described, are adopted, it is impossible
accurately to ascertain the facts of small-pox in the vaccinated."2
Not only may the scars be obscured by eruption, but there is no doubt also that
they may wear out. Dr. George Gregory says—" The absence of a cicatrix is not
decisive against either the present or prior existence of vaccine energy in the
system, because in many cases,
1 " Medico Chirurgical Transactions," vol. xxii., p. 97. 1S39.
2 Glasgow Medical Journal, vol. v., p. 6 (November, 1872).
CLASSIFICATION OF SMALL-POX PATIENTS. 193
the specific inflammation is moderate, and the resulting ■.car wears out in the
progress of life, as other scars do which are not the result of a specific
poison."1 In his " Observations on the Variola Vaccines'' Mr. Robert Ceely, of
Aylesbury, says—" Inspection of many scars, caused by this lymph, shows that in
a few months little is to be learned in many subjects, with thin skins, of the
degree to which the vaccine influence has been exerted on them."2
A Committee appointed by the Epidemiological Society (Epidem. Soc. Trans., vol.
v., p. 153, 1885-86) recognised that " not every cicatrix which is once Ibveated
will always retain its condition of foveation, and, further, that not every
cicatrix will permanently exist." Dr. Savill in his report on the Warrington
outbreak has also called attention to the fact that vaccination scars tend to
become obliterated with age, and to alter in character with time.3
Let us now see what has been the practice with regard to the classification of
small - pox patients. Mr. Francis Vachcr, Medical Officer of Health for
Birkenhead, candidly observes—" The mere assertions of patients or their
friends, that they were vaccinated, counted for nothing, as about 80 per cent,
of the patients entered in the third column of the table ('unknown') were
reported as having been vaccinated in infancy."4 Mr. Marson informs
us—"Patients were
1 London Medical Gazette, vol. xxv., pp. 289, 290 (November 15, 1839).
'-'"Transactions of the Provincial Medical and Surgical Association/' vol.
viii., p. 416, foot-note. 1840.
:> Final Report, Royal Commission on Vaccination, Appendix v., p. 42 4 "Notes on
the Small-pox Epidemic at Birkenhead in 1877," p. 9.
never entered in the register as vaccinated, unless the account of the
vaccination was a tolerably clear one."1 And Dr. William Gayton, in the Homerton
Report for 1875, observes (p. 58)—"I have always classed as ' vaccinated' those
upon whom any mark supposed to result from vaccination has existed, and as '
unvac-cinated' when no scar presumably arising from the effects of vaccine lymph
could be discovered. Individuals are constantly seen who state that they have
been vaccinated, but upon whom no cicatrices of any description can be traced.
In a prognostic and statistic point of view it is better, and, I think,
necessary, to class them as unvaccinated."
The fallacies of this method of classification have been pointed out by Dr.
Rirdwood and Dr. Ricketts.
Dr. Birdwood, with an experience of twelve thousand cases of small-pox, stated,
before the Royal Commission, that in his opinion the evidence of primary
vaccination, collected in small-pox hospitals, should not be relied on.
Because—
"(1) On the outbreak of an epidemic there is necessarily much administrative
confusion, and many untrained observers. The early observations are incomplete
and faulty.
"(2) In the worst instances the eruption may be sufficient to, and does obscure
the scars.
" (3) The statement of parents as to primary vaccination, and of adult patients
as to re-vaccination, should be accepted even when scars are not seen.
1 " Medico-Chirurgical Transactions," vol. xxxvi., p. 374. 1853.
2 Sixth Report, Royal Commission on Vaccination. Q. 31,221.
DRS. UIRDWOOD AND RICKETTS' EVIDENCE. 195
"(4) Scars produced in infancy grow with the growth of the body ; as was pointed
out, I understand, by Sir James l'aget.
"(5) In such statistics insufficient allowance is made for other circumstances,
such as occupation, intemperance, and the existence of other diseases. An
altogether different death-rate might be anticipated if small-pox broke out in a
public school, or in the infirm and aged wards of a workhouse. A typhoid fever
patient, or an ill-fed baby, catching discrete small-pox and dying, would be
counted a death from small-pox, obviously neither vaccination nor its neglect
having anything to do with it.
"(6) The accurate observation and record of clinical details is one of the most
difficult duties required of medical men employed in hospitals for infectious
disease."
Dr. Ricketts says—"In some of the earlier statistics on vaccination only two
classes of cases were considered, viz., those vaccinated and those unvaccinated
; apparently the only evidence as to vaccination that was accepted being the
presence or absence of scars. An absolute reliance, however, ought not to be
placed on this evidence. There is no doubt that cases occur in which vaccination
has been successfully performed, although cicatrices are not present when the
attack of small-pox supervenes. There is a small class, too, but naturally a
very fatal class, in which the rash is too abundant over the upper part of the
arm for an assertion to be made that scars are absent." On Table
1 Report of the Metropolitan Asylums Board for 1893, p. 136.
H, pp. 144, 145, he gives twenty-six cases, with thirteen deaths, in which the
absence of scars could not be asserted because of the abundant eruption ; and in
twenty-five of these, the patient was stated to have been vaccinated.
Let us see how Dr. Ricketts' figures work out. On Table 11.c, pp. 185-188 of the
same report, there arc forty-two vaccinated deaths, and forty-four in which
there is "no evidence" as to cicatrices. On p. 138, he describes an
age-distribution he has made of the " no evidence" cases. He puts it in the form
of a diagram, and on comparing it with similar diagrams for the vaccinated and
for cases in which the vaccination cicatrix was " absent," he finds that the
diagram corresponds much more nearly with the former than the latter. There were
ninety-four deaths in which the vaccination cicatrix was " absent," but it will
be noticed that forty-four of these are in the first three years of life, in
which there are no cases or deaths in the other two classes. In all fairness
these should be therefore struck off; we then get fifty deaths in this class,
and if we add the " no evidence" deaths to the vaccinated (I am aware that I am
slightly overstating the case), we have eighty-six vaccinated deaths, and fifty
in which the cicatrix was " absent." Thus, over three years of age, there are,
if we include the " no evidence " cases with the vaccinated, 6y2 per cent, of
the deaths vaccinated.
But there are further allowances to be made, for on p. 134, Dr. Ricketts says of
his class, in which the vaccination cicatrix was " absent," that he is not able
to describe these cases as all " admittedly unvac-
SOURCES OF FALLACY. 197
cinated." Another source of fallacy is pointed out in the British Medical
Journal of October 23, 1880 (vol. ii., p. 672). The editor says—" It is probable
that a larger proportion of unvaccinatcd persons is to be found among the
ignorant, dirty, and wretched inhabitants of the slums of London, and very few
indeed among the educated and better fed members of society," And Dr. Gayton
admitted before the Royal Commission (Q. 1,843) tnat this would be likely to
operate detrimentally by way of raising the unvaccinated mortality. This
applies to all places vaccinated up to the usual average. When allowance is made
for these fallacies, it will be found that the proportion of deaths vaccinated
will not be very largely different from that of the vaccinated population, which
in London, from the amount of default that has taken place in recent years,
would not be very high.
It is only fair to mention that other reports agree in not assigning such a
large proportion of deaths to the unvaccinated. In the Glasgow Medical Journal
of November, 1872 (vol. v., p. 12), Dr. Russell classifies his cases according
to the eruption. He found that in discrete cases the fatality in both classes
was nil, and in confluent small-pox the fatality of the vaccinated exceeded
that of the unvaccinated. Thus, among seventy-one vaccinated confluent cases
there were forty-nine deaths, or a fatality of 6g per cent., and of one hundred
and sixteen unvaccinated confluent cases, sixty-four, or 55^2 per cent., died.
But the most striking figures come from Prussia, and they show that up to ten
years of age there is practically no difference in the fatality in
the two
classes. The following table gives the figures for Berlin ' in the 1871-72
epidemic:—
Vaccinated. Unvaccinnted.
Age. Cases. Deaths. "^ ^Ca^ Dea.hT^f
o- j 259 136 52-5 977 570 58-3
2- 5 J>244 437 35'' ',359 564 41 "5
6-10 737 163 22T 251 77 307
If the difference between 52 and 58 per cent, is all the mitigation that can be
fairly claimed on behalf of vaccination within a year of the operation, even the
most enthusiastic champions of vaccination will ;:gree that we must look to
other and more scientific methods for the extirpation of small-pox.
To recapitulate the facts briefly :—Figures have been put forward showing an
enormous difference in the rates of the vaccinated and unvaccinated. It has been
shown that these are open to suspicion, because the rates in the unvaccinated
considerably exceed those of the last century before vaccination was discovered.
When we come to analyse them, we find that the disparity obtains principally in
cases of confluent smallpox, in which, according to the leading authorities,
the vaccination marks are readily obscured ; and when it is remembered that it
has been the practice to classify the cases according to marks, whether
discernible or not, it is evident that the results have been largely fallacious.
Other sources of fallacy are the different conditions under which the two
classes labour, and also the age. Of course, when the different ages are
separated as
1 " Beitrage zur Beurtheilung des Nutzens der Schutzpockenimpfung," p. 168.
Berlin. 1888.
INVESTIGATION BY THE REGISTRAR-GENERAL. 199
in the reports of the Metropolitan Asylums Board, this objection would not hold,
but in the majority of instances, all ages are taken together, or separated only
into those under and over ten ; and considering that the unvaccinated more
largely consist of young infants, who normally have a high small-pox fatality,
this method naturally raises the rates for this class.
The Government returns of small-pox deaths would appear to be one way of
settling the question, but here we are met with the difficulty that in
death-certificates of cases of small-pox, medical men in a large proportion of
instances make no statement about the vaccination, although they have been
repeatedly urged to do so by the Registrar-General, and also by the medical
press. In England and Wales, in 1892-95, there were 2,931 deaths from small-pox,
of which 391, or 13-3 per cent., are reported in the vaccinated ; 596, or 2O'3
per cent., in the unvaccinated; whereas, in (,944, or 66'3 per cent, of the
whole, there is no statement as to whether the patient was vaccinated or not.
The following from the British Medical Journal of March 17, 1877 (vol. i., p.
330), appears to throw some light on the matter :—" It may not be generally
known that the Registrar-General, during the epidemic of smallpox in London in
1871-72, attempted to obtain more complete information as to the vaccination of
persons dying of small-pox than was furnished in medical certificates. Then, as
now, no information as to vaccination was given in a large proportion of
medical certificates.
" The Registrar-General, therefore, requested the local registrars, in cases
where the medical certificate was
silent on the point, to endeavour to ascertain from the informants of the deaths
(almost invariably relatives), and to insert in the Register, whether the
deceased had or had not been vaccinated.
"Information derived in this way certainly yielded results very similar to those
obtained by the anti-vaccinationists themselves; relatives almost invariably
asserted that the deceased had been vaccinated ; but, as inquiries of the
medical attendants in a large number of these ' not stated ' cases elicited the
fact that the deceased, the statements of relatives notwithstanding, bore no
marks of vaccination, registrars were subsequently instructed to insert in the
Register no facts as to vaccination unless certified under the hand of a
registered medical practitioner."
It need hardly be said that this inquiry of the Registrar-General is very
important. In these " not stated " deaths, the medical men presumably are unable
to decide the fact of vaccination. The difficulty no doubt is great, for as Dr.
Savill has pointed out in his report on the Warrington epidemic, " in nearly all
fatal cases the eruption is profuse and tends to hide the vaccination scars if
they exist."1 Dr. Birdwood, as I have shown, is also alive to the difficulty,
and recommends that the statements of parents as to primary vaccination should
be accepted. The relatives in the cases I am referring to almost invariably
asserted that the patients had been vaccinated, and thus I cannot help thinking
that the most important part of the case for vaccination has been given away,
for if in the recent
1 Final Report, Royal Commission on Vaccination, Appendix v., p. 34.
CLASSIFICATION BY MARKS. 2OI
epidemic (1892-95), we add the "not stated" cases to the vaccinated, nearly 80
per cent, of the total deaths from small-pox will be found in the vaccinated
class.
It seems a pity that the vaccinal condition of patients suffering from small-pox
has not more often been determined by reference to the vaccination register.
Dr. Birdwood informed the Royal Commission (O. 31,250-51) that the Metropolitan
Asylums Board used to forward a list of patients to the Local Government Board
for this purpose, but that he knew of no published results of their inquiries.
If the Local Government Board would undertake investigations of this nature,
they would doubtless receive the cordial co-operation of both parties in the
vaccination controversy, and the results would prove interesting, if not
instructive.
It has been urged that the protection afforded by vaccination is in proportion
to the number and the quality of the marks. In the first place, cicatrices
resulting from the same lymph of good quality vary considerably. They may be
smooth, striated, puckered, pitted, and so on; in fact, a French observer,
Decanteleu, has figured no less than seventy different varieties of scars.1 Dr.
Savill points out that " the foveation of vaccination scars does but follow the
same laws which govern other lesions involving only the superficial layers of
the skin;"2 and he figures the arm of a girl to show
1 Professor Crookshank's Evidence. Fourth Report, Royal Commission .hi
Vaccination. Q. 11,892.
"Final Report, Royal Commission on Vaccination, Appendix v., l>. 42.
the similarity of foveate texture in a scar resulting from a superficial burn on
the shoulder, and in some primary vaccination cicatrices. Thus, it would appear
that the texture of the vaccination cicatrix depends on the amount of the local
inflammation, on the method of performing the operation, on the age,
surroundings, and general health of the individual, and on other factors.
It is also worthy of notice that in classifying cases of small-pox according to
vaccination marks, different methods are adopted by different observers. Thus
Dr. Gayton informed the Royal Commission (Q. 1,700-06) that when he found one
good mark and three imperfect ones, he might class them as a case of two good
marks, or he would ignore the three imperfect marks, and class the case as one
of a single good mark. Of 10,403 cases of small-pox admitted to the hospitals of
the Metropolitan Asylums Board during 1870-84, Dr. Gayton1 classified 2,085, or
2O Per cent., as "vaccinated with good marks ;" whereas, at another hospital of
the same Board, during the years 1880-85, Dr. Sweeting2 placed only 39 out of
2,584, or i-5 per cent., in the category of " good vaccination." The Dissentient
Commissioners, Dr. Collins and Mr. Picton, observe (Section 129)—"It is evident
that such a difference indicates a wide margin for personal discrimination as to
what is and what is not 'good vaccination.'" It is, therefore, not altogether
surprising to learn, on the authority of Dr. M. D. Makuna, when medical
superintendent of the Fulham
' Second Report, Royal Commission on Vaccination, Appendix, p. 245. 2 Ibid.
Q. 3,689.
" GOOD " AND " BAD " MARKS. 2O3
Small-pox Hospital, that "what one will call an indifferent mark, another will
call fair, a third moderate, and a fourth bad, and so on, till the confusion is
worst confounded."1
The following testimonies appear to show that even " good vaccination " is far
from securing a perfect immunity against small-pox. Thus, Dr. J. J. Bigsby, in
an epidemic of small-pox at Newark, found that "some 1 >f the worst cases (of
small-pox) had remarkably good ■.cars."2 In the British Medical Journal of April
1, 1871, Ur. Atthill is reported to have stated that "he <lid not think that a
good mark insured protection more than an ill-defined one."s
Dr. B. Browning, medical officer of health to Rother-hithe, gives particulars of
469 cases of post-vaccinal small-pox, of which 100, or 2i"3 per cent., died.
"Many of these sufferers," he says, "showed good vaccine marks of the kind that
would be deemed worthy of an extra grant from the Government Inspector (at least
I used formerly to receive such ".rants for doing similar looking work), and yet
the)' look small-pox—some within six days, some within ,ix months, and some
within six years of their vaccination date."4 And lastly, I may quote the
valuable ustimony of Dr. John MacCombie, who, on June 12, 1 .S78, stated before
the Epidemiological Society that " the evidence afforded by the
cases admitted into
I Report of the Fulham Small-pox Hospital for the year 1878, pp. 11, 12.
" London Medical Gazette, Sept. 28, 1839, vol. xxv., p. 18.
II British Medical Journal, April I, 1871, vol. i., p. 352.
4 Transactions of the Society of Medical Officers of Health (Session 1SS1-82),
p. 29.
the Asylum Boards Hospitals goes to show that the good and bad marks are equally
protective against attacks of small-pox,"1 and he further remarks that "good
vaccination protects absolutely against no form of small-pox."2
In considering the theory that the protection is in proportion to the number of
marks, it may be mentioned that, if we are to be guided by jenner, "a single
cow-pox pustule is all that is necessary."3 But this, as well as other theories
promulgated by Jenner, has been discarded, and the orthodox number of marks at
the present time is four. It is not pretended that this theory has any
scientific basis, but it appears to rest mainly on certain figures compiled by
Mr. Marson,4 surgeon to the London Small-pox Hospital. The results he obtained
are given in the following tables :—
Cases. Deaths. »T
Unvaccinated ... ... 2,883 1,006 3489
Vaccinated (no scars) ... 259 102 39'38
Vaccinated (scars) ... 10,293 685 666
1 scar ............................... 2,584 357 1382
2 scars ... ... ... 3,138 242 771
3 scars ... ... ... 2 139 65 3'O4
4 scars ... ... ... 2,432 21 '86
1 Paper on "Comparison of Small-pox Statistics, Epidemics 1871 and 1876," by
John MacCombic, M.A., M.B., Medical Superintendent to the Deptford Small-pox
Hospital. Transactions of the Epidemiological Society (Sessions 1877-78 and
1878-79), vol. iv., part 2, p. 190.
''■Ibid., p. 192.
3 11 Further Observations on the Variolif VaccimE, or Cow-pox," p. 38,
London. 1799-
4 Pages 236, 237, Report from the Select Committee on the Vaccination
Act (1867). 1871.
MR. MARSON'S STATISTICS. 205
Indifferent scars. Good scars.
..... ■»• ^e., ^ath,"^? C^es. Death, W
1 1,530 328 21-44 1,054 29 275
.! 1,838 224 I2'I9 I,3OO 18 I 38
3 1,151 55 478 988 10 roi
4 1,179 2O '7° 1,253 1 08
I'olal ... 5,698 627 iroo 4,595 58 1 26
I" obtain the above figures, Mr. Marson deducted I' illis for
superadded disease, thus :—
Total Deaths Percentage of
(Uaths. .deducted, deaths deducted.
Unvaccinated ... ',043 yj 35
Vaccinated (scars)... 790 105 133
Indifferent scars. Good scars.
„„ „ Total Deaths Pefr^enSge Total Deaths
Pefr?n'?,g<;
Sc™- deaths. deducted, fj^ deaths, deducted. °<J^
1 353 25 7-1 34 5
147
2 252 28 hi 24 6 25'o
3 65 10 15-4 14 4
286
4 37 17 45 9 'I i° 909
Total ... 707 80 113 83 25 30'y
This shows that he deducted a larger proportion of deaths for the vaccinated
than for the unvaccinated, lor good scars than for indifferent scars, a larger
proportion for two scars than one scar, for three scars than two scars, and for
four scars than three scars, I he climax being reached with four good scars, in
which class, with eleven deaths altogether, he deducted Irn before making his
calculations, and these, forsooth, •ire the figures on which the notorious marks
theory l<ii|;dy depends !
Mr. P. M. Davidson, the medical officer of health to Congleton, has drawn
attention to the strange conclusions to which we should be driven were we to
accept some of the figures in Dr. Barry's Sheffield Report. Table cxiv. (p. 212)
shows the fatality and type of disease with one, two, three, and four or more
scars in cases treated at the Borough Hospital, Winter Street.
Under 20 years of ace. Above 20 years of age.
C^ion.tO Cases. Death,. £»g C^T^hs. »
No visible primary \
cicatrix, or 1 cica-r 22 o 00 73 13 178
trix only ... ...I
2 primary cicatrices 94 3 32 165 21
127
3 primary cicatrices 187 3 1 6 185 18 97
4 or more primaryl
, .
. . I 67 O
O-O 32 2 6 2
cicatrices ... ___ 1
With regard to the type of disease under twenty years of age, there was one
confluent case, and that had four marks. The only conclusion to be deduced from
these figures is, that under twenty years of age, no visible mark, or one mark
only, secures the greatest immunity from death and severe disease; whereas when
a person reaches the age of twenty and upwards, one-mark cases have the greatest
fatality, the fatality gradually diminishing with two, three, and four marks,
and thus twenty years must elapse before the influence of plurality of marks
comes into play. Dr. Barry surely did not intend us to believe that this was the
case, but it is unquestionably what his figures tend to show. Again in Table
CXV. (p. 214), Dr. Barry gives statistics for the Ecclesall Bierlow Union
Workhouse Hospital at all ages, as follows :—
mr. Davidson's cases. 207
Scars. Attacks. Deaths. Fatality
per cent.
1 or 2 14 7 500
3 or more 118 2 17
These percentages are seriously set forth to show the alarming difference in
fatality between one or two and three or more marks, Dr. Barry and those who
supplied him with the statistics apparently forgetting that the fatality he
gives for one or two marks is nearly three times the average fatality of the
unvaccinated in the Last century, and even much larger than the figures lie
himself gives for his own unvaccinated class, and if they show anything at all
they show that the one-mark vaccination which was fashionable during the first
half of the century was provocative of a fatal issue if attacked, and that most
of the private vaccination at the present time is in the same plight, and that
Mr. Krnest Hart is giving the best of advice when he says— " Better by far let
such applicants (for one or two small insertions) depart with their children
unvaccinated than place them in a state of false security."1
Mr. P. M. Davidson, besides criticising Dr. Barry's figures, has given us the
result of his own painstaking and valuable experience of a small outbreak he had
to deal with at Congleton, and the following has been extracted from a table he
gives of these cases, on l>. 27 of his report.2
1 AUbuH's " System of Medicine," vol. ii., p. 676. London. 1897. 1 Special
Report on the Recent Outbreak of Small-pox in Congleton.
Xo. Name.
Age. Results of
vaccination. Character
of small-pox.
1 George T. - 18 Five deeply pitted scars, one and one-
Semi-confluent, severe, numerous pits.
third square inch in
area.
j
2 Henry B. - 43 One superficial scar, one-third square
Discrete, very mild, no pitting; worked
inch in area. throughout
illness.
3 George W. - 26 Three scars (one deeply pitted, two
Semi-confluent, very few pits.
pitted), one and one-quarter square inch in area.
4 Emma B. - 40 Two superficial scars, two-thirds square
Discrete, very mild, no pitting; had only
inch in area. about twenty spots
; never in bed.
5 Annie S. - - 25 Four scars (two pitted, two
superficial), Discrete, very mild, no pitting.
one-half square inch in area.
6 Randel B. - 32 Four scars (three deeply pitted, one
Confluent, severe, pitted deeply, exten-
pitted), two-thirds square inch in area. sively, and permanently ; face
completely covered.
7 Harry B. - - 26 I Eight scars (two pitted, six
superficial), Confluent, pitted considerably.
one square inch in area. j
8 John P. - - 19 I Two deeply pitted scars,
one-third Confluent, extensively and permanently
j square inch in area. pitted.
9 Daniel C. - 27 Three scars (one pitted, two
superficial), Discrete, very mild, no pitting.
one-fifth square inch in area. I
10 James C. - - 20 Four scars (two deeply pitted,
one Discrete, some pitting.
pitted, one superficial), three-quarters square inch in area.
j 11 John C. - - 19 Four scars (two deeply pitted, one
pit- J Confluent, seveie, much pitted.
ted, one superficial), one square inch in area.
12 William T. - 25 Four pitted scars, one-third
square Discrete, a few slight pits.
inch in area. 1
13 Thomas S. - 55 Three scars (one deeply pitted, one
Semi-confluent, slightly pitted.
pitted, one superficial), one-third square inch in area.
14 Annie P. - - 18 Threescars(onedeeply pitted,two
super- Discrete, very mild, two or three pits.
; ficial), four-fifths square inch in area.
15 Mrs. C. - - 43 Two deeply pitted scars, three-quarters
Discrete, severe, slightly pitted.
square inch in area.
16 Margaret T. -| 40 I Four deeply pitted scars, three-quarters
Confluent, haemorrhagic, pitted exten-
| ' : square inch in
area. sively ; the most severe
case.
j 17 Sarah A. - - 27 One deeply pitted scar, one-third
square Discrete, very mild, no pitting; mildest !
inch in area. of all except Cases
2 and 4.
1______________________________________________
Thus five of the cases (Nos. 6, 7, 8, 11, and 16) were confluent, three
semi-confluent (Nos. 1, 3, and 13), and nine discrete (Nos. 2, 4, 5, 9, lo, 12,
14, 15, and 17). All the confluent cases, except No. 7, had well-pitted
vaccination scars. One of them (No. 7) had eight scars, three (Nos. 6, 11, and
16) had four scars, and the remaining one (No. 8) two scars ; the average number
of scars being four and one half, and the average superficial area three
quarters of a square inch.
Of the three semi-confluent cases, No. 1 had five scars, and this was the most
severe ; and the remaining two (Nos. 3 and 13) had three scars each ; the
average number of scars being three and two thirds, and the average superficial
area one square inch.
Of the nine discrete cases, three (Nos. 5, 10, and 12) had four scars, two (Nos.
9 and 14) three scars, two (Nos. 4 and 15) two scars, and the remaining two
(Nos. 2 and 17) one scar each ; the average number of scars being two and two
thirds, and the average superficial area one half of a square inch. The
following table gives a summary :—
Average number Average superficial area,
of scars. in square inches.
5 confluent cases ... ... 4^ ... f
3 semi-confluent cases ... 3| ... I
9 discrete cases ... ... 2-| ... \
Mr. Davidson adds (p. 15)—"Comment on this is superfluous, and I leave it to
anyone caring to consider the matter to judge for himself what he is to expect
from scars and superficial areas in this part of the country. If they teach
anything, it is that the more you have of them, and the larger and deeper they
are, the more severe will be your small-pox."
THK SHEFFIELD EXPERIENCE. 211
The best way to test the question is to compare the incidence of small-pox
following vaccination by public and private practitioners, for the public
vaccinators are bound by their regulations to work up to a certain standard. In
the Sheffield epidemic (1887-88J it was found that 358, or 70/4 per cent., of
the 451 vaccinated cases of small-pox under ten years of age had been
vaccinated by public vaccinators, who had only performed 63 per cent, of the
successful primary vaccinations for the ten-year period up to the epidemic;1
hence it follows that small-pox picked out the work of the public vaccinators,
whose skilful and successful performances had qualified each operator for a
Government grant. Again, Sheffield Park, North Sheffield, and West
Sheffield—the districts of the borough which were the most seriously afflicted
with small-pox—had the largest percentage of their successful primary
vaccinations, for the ten years previous to the epidemic, performed by public
vaccinators; whereas Ecclesall and Upper Hallam, with the smallest percentage,
came off the lightest of all the districts of Sheffield.
The large proportion of three or four-mark cases of small-pox in very
efficiently vaccinated towns, as in the case of Willenhall, strongly condemns
the theory. Of the 681 vaccinated persons attacked in which the number of scars
was known, 374, or 54P per cent., had four marks, and 536, or 787 per cent., had
three or four marks, while the one-mark cases only amounted to 24, or 3'5 per
cent, of the whole.
1 Report on an Epidemic of Small-pox at Sheffield (1887-88), pp. 185, 187 ;
Tables xcvii., xcix.
Before concluding the chapter, the opinion of Dr. George Gregory, the
distinguished predecessor of Mr. Marson at the London Small-pox Hospital, is
worth recording. In the twenty-fourth volume of the Mcdico-Chirurgical
Transactions (1841, pp. 23, 24), after detailing several cases, he says :—" It
follows, I think, from these cases, that the cicatrix cannot be relied on as
affording any certain test of the degree to which the constitution has imbibed
an anti-variolous influence."
Another authority (Dr. Fleetwood Churchill) observes :—" For some years I have
only made one (puncture), on account of the severe inflammation which sometimes
results from two or more, nor have I had any reason to suppose that my object
was not as completely attained."1
The more recent authorities also deprecate the " mark theory." Thus, Dr.
Birdwood observes that, in regard to primary vaccination, he advocates " the
production of one vaccine vesicle only;"2 and Dr. Ricketts writes— " Considering
that scars vary in size and in appearance in the course of years, and that
vaccinia must be regarded as a specific fever, it is not at first sight apparent
what the characteristics of the inoculation cicatrices have to do with the
amount of protection afforded. But, after all, it is a question of fact, which,
provided proper observations are made, ought to be, and can be settled in course
of time by such statistics."8
ll'The Diseases of Children," p. 821. Third edition. Kleetwood Churchill,
M.D. Dublin. 1870.
-Sixth Report, Royal Commission on Vaccination. (,). 31,22!. 3 Report of the
Metropolitan Asylums Board for 1893, p. 134.
DR. COUPLAND'S FIGURES. 213
Some observers, besides those already mentioned, obtained equivocal results. Dr.
Dalton1 gives the following experiences :—
Marks. Cases. Fatality per cent.
1 126 2'4
2 171 5"3
3 177 2-8
4 140 07
5 or more 93 2'2
Also Dr. Coupland,2 who gives the following for the Dewsbury epidemic:—
Ma'ks. Cases. Deaths.
Fatality per cent.
1 34 O OO
2 175
IO 57
3 210
o o'o
4 or more 42
1 2'4
There is thus very slender evidence to show that the protection depends upon the
number or character of marks, and the little that exists is mainly afforded by
the earlier statistics, such as Marson's, which it is obvious are inaccurately
founded.
From the foregoing facts it is evident that the mitigation attributed to
vaccination depends largely upon the elimination of cases from the vaccinated
lists, rather than to any real modification of the disease, and this is borne
out by the fact that the fatality of smallpox in 1871-72, when a large
proportion of the cases were admittedly vaccinated, was as great as the average
fatality of the last century.
1 " Small-pox in its Relation to Vaccination," p. 23. J. 11. C. Dalton,
M.A., M.D., B.C. (Reprinted from the Medical Chronicle, October, 1893.)
-Final Report, Royal Commission on Vaccination, Appendix iii., p. 11q.
CHAPTER VII.
RE-VACCINATION.
THE admission that re-vaccination is necessary, is a departure from the original
position taken up by the profession. It was not only Jenner who was so positive
about the lifelong protection afforded by vaccination, but his opinion has been
endorsed by the highest authorities at a later period. Sir John Simon says :— "
On the conclusion of this artificial disorder (vaccination), neither renewed
vaccination, nor inoculation with small-pox, nor the closest contact and
cohabitation with small-pox patients, will occasion him (the vaccinated person)
to betray any remnant of susceptibility to infection."1
When this theory, upon which all vaccination legislation was initiated and
justified, was discovered untenable, that of re-vaccination was introduced.
Instances of both mild and severe attacks of smallpox taking place at all
periods after re-vaccination are numerous. I propose to give a few of these. Mr.
Badcock, the celebrated small-pox cow-pox vaccin-ator, relates his own
personal experience: " Towards
1 " Papers relating to the History and Practice of Vaccination,'' p. xiv. 1857.
KAMA)RE OF TRIPLE VACCINATION. 21 5
the end of the year 1836, I suffered severely from a dangerous attack of
small-pox, which happened but ;i few months after re-vaccination."1 We also have
the experience of Mr. Justice Grantham :—"Pie impressed on the anti-vaccinators
the peril they were incurring to themselves and their neighbours by their
opposition to inoculation, and in support of his arguments as to the effect of
vaccination, stated that he, after having been twice inoculated, had an almost
miraculous recovery from an attack of small - pox, which, in its incipient
stages, was as bad as it could be."2
The following case shows the complete failure of three successful vaccinations
to prevent a severe attack of small-pox. It is recorded by Dr. T. C. Wallace in
the American Medical Times of March 1, 1862 (vol. iv., p. 122). The patient,
Charles Nichols, aged thirty-five, had an " extraordinarily severe" attack of
confluent small-pox, and Dr. Wallace observed that he had never seen anyone so
completely covered with pustules. The man had a large scar on the right arm,
resulting, he informed Dr. Wallace, from vaccination when a child, and a similar
one on the left arm, due to vaccination three years prior to attack. He was
again vaccinated on the 24th of December, 1861, the vesicle being " fully
formed, large, and well filled," the vaccination being accompanied by some
slight constitutional symptoms. He was attacked with small-pox
' "A Detail of Experiments confirming the power of Cow-pox, etc.," |i. 11.
John Badcock, Chemist. Brighton. 1845. * Sussex Daily News, April 9,
1896.
on the 8th of January, 1862, just fifteen days after the third
vaccination.
The British Medical Journal of December 7, 1872 (vol. ii., p. 643), reports a
meeting of the Medical Society of the College of Physicians in Ireland, when Dr.
Darby furnished statistics of small-pox cases treated in the Rathdown Union
Hospital ; thirteen of the cases were re-vaccinated, with one death. At the same
meeting, Dr. Grimshaw alluded to three re-vaccinated cases of small-pox admitted
to the Cork Street Hospital, one of which was fatal.
In a letter to the British Medical Journal of December 9, 1876 (vol. ii., p.
774), Mr. R. G. Kellett wrote that, during an epidemic at Bilston,
Staffordshire, in 1871-72, he re-vaccinated himself, his wife, and his two
servants. Although the vaccination took well in all, each in turn developed
small-pox, "certainly of a most abortive form, not more than a dozen spots or so
appearing on any of us, but still it was small-pox."
The same journal1 also reports some cases of smallpox, which came under the
observation of the Health Department of Brooklyn, the statistics being furnished
to the Brooklyn Eagle, by Dr. J. H. Raymond, the Health Commissioner. Among
these is that of a child, aged three, who died of small-pox notwithstanding that
she had been well vaccinated in infancy and once later.
In the Homerton Hospital Report for 1878 (pp. 23-25), Dr. Gayton gives six cases
of small-pox after re-vaccination, with the following particulars :—
1 British Medical Journal, May 20, 1882, vol. i., p. 749.
DR. GAYTON'S CASES. 217
1. "Kate King, aged twenty, admitted February 18,
1878, three imperfect marks; eruption very discrete;
was placed on 'Full Diet' February 22, 1878, and dis
charged March 14, 1878. The re-vaccination was
stated to have been performed five years ago, with
success. The patient did not remember upon which
arm it was done, therefore the cicatrices observed
may have been due to either the primary or the
secondary operation, as no others were visible."
2. "John Wist, aged twenty-seven, two good marks ;
admitted March 7, 1878, with discrete small - pox.
The patient reported that he had been vaccinated
three times in the course of his life; the first in
infancy, the operation succeeding; the second at the
time of joining the Metropolitan Police, at twenty-two
years of age, and that this took ' very slight;' the
third and last time, six months before becoming a
patient, by a medical man in Whitechapel, but without
effect. He was also positive that the two cicatrices
seen upon the left arm were the result of the primary
operation, as the sore left by the secondary one soon
healed up and left no marks."
3. " Samuel Fish, aged twenty-three, admitted March
21, 1878, three imperfect marks; eruption confluent,
general symptoms very severe. Discharged cured June
17, 1878. Was vaccinated in infancy, and again when
ten years old. The certificate of re-vaccination in this
case was produced, but it could not be satisfactorily
determined to which operation the cicatrices were to
l>e attributed."
4. "James Connelly, aged thirty-nine ; admitted
March 30, 1878, with five marks, three good and two
15
imperfect, the eruption being discrete. He was put on 'Full Diet' on April i,
and transferred April 13, 1878. The patient, an old soldier, stated that he was
re-vaccinated when in India about four years ago, and that the operation was
very successful. There were three well foveated cicatrices close together, the
extent of surface being about the size of a shilling."
5. " Ellen Clark, aged twenty-one, with one imperfect
mark, admitted April 10, 1878, with small-pox of the
haemorrhagic form, and died April 12, 1878, was said to
have been re-vaccinated, and arm to have been slightly
sore for three or four days, but no cicatrix, except the
one referred to, could be traced."
6. " E. Williams, aged three years, admitted April 25,
1878 ; eruption discrete. On April 27 had ordinary-
diet, and on May 18 discharged ; was stated by parents
to have been ' vaccinated when an infant,' one imperfect
mark being now visible as the result. Six weeks ago,
in consequence of small-pox having occurred in the
house, she was again vaccinated in four places, all of
which were attended, apparently, by some result. The
marks seen, reddish-brown in colour, were small in size,
and not indented."
In the Deptford Report for the period from April, 1878, to December, 1879, Dr.
John MacCombie details the following experience (pp. 7, 8) :—
1. "William W., cet. nineteen; admitted May 13,
1878. Three imperfect marks of primary vaccination ;
re-vaccinated cet. sixteen, two re-vaccination marks ;
discrete attack ; discharged June 10."
2. "Matilda B., cet. twenty; admitted May 31, 1878.
Two imperfect marks of primary vaccination ; re-
DR. MACCOMBIE'S CASES. 219
vaccinated cet. sixteen, three re-vaccination marks; discrete attack;
discharged June 20."
3. "Caroline P., cet. twenty-three; admitted July ir,
1878. Five imperfect marks of primary vaccination ;
re-vaccinated cet. ten and sixteen. She stated that she
had a ' sore arm' on both occasions, but there were no
re - vaccination marks ; discrete attack ; discharged
August 22."
4. "Emma S., at. twenty-one ; admitted July 25,
1878. Two good marks of primary vaccination; four
marks of re-vaccination performed at the age of nine
or ten ; discrete attack ; discharged August 31."
5. "Lucy H., cet. forty-two; admitted August 5, 1878.
Two imperfect marks of primary vaccination; re-
vaccinated cet. twelve ; one re - vaccination mark ;
discrete attack ; discharged August 22."
6. "Sarah H., cet. thirty-six; admitted August 13,
1878. Three imperfect marks of primary vaccination ;
three marks of re - vaccination performed at the age
of sixteen ; attack confluent ; discharged July 23,
1879."
7. "Fanny C, cet. thirty-three; admitted March 11,
1879. One imperfect mark of primary vaccination;
i'c -vaccinated at. twenty-one, on left arm in two places.
There were no re-vaccination marks, but patient stated
that her arm was sore, and that the medical man to
whom she showed it a week after the operation was
performed said 'it was doing all right.' She died of
Miick small-pox on March 14."
8. "Sarah P., <Bt. twenty-one; admitted April 18, 1879.
'>.iid to have been vaccinated in infancy, but there
h-itc no marks. Has three marks of re - vaccination
performed at the age of eighteen ; discrete attack ; discharged May
5."
9. "Fanny L., at. thirty-six; admitted October 13,
t 879. Three imperfect marks of primary vaccination ;
two marks of re-vaccination performed at the age ot
thirty-one; discrete attack; discharged November 8,
1879."
10. "James H., at. twenty-seven ; admitted Novem
ber 8, 1879. One good mark of primary vaccination ;
re-vaccinated <zt. fifteen. Stated that he had a ' sore
arm' after re-vaccination. No marks ; discrete attack ;
discharged December 12."
Elsewhere Dr. John MacCombie says—" For myself, I am inclined to believe that
small-pox after successful re-vaccination is not infrequent."1 Apparently an
extended experience has not modified his views, for quite recently he says —
"Some persons who have been successfully re-vaccinated do, however, contract
small-pox. Of such cases observed by me the time intervening between the
re-vaccination and the attack of small-pox varied from one to twenty-five years
; the average being ten years."2 And further on in the same work he makes
further admissions when he says " it is impossible in all cases to promise
immunity from attack or even from death after vaccination and re-vaccination."3
In the Homerton Hospital Report for 1881 (p. n), Dr. Collie gives details of
three cases after re-vaccination.
1 Transactions of the Epidemiological Society, vol. iv., part ii., p. 193.
Sessions 1877-78 and 1878-79.
-Allbutt's "System of Medicine," vol. ii., p. 207. London. 1897. 3 Ibid.,
p. 222.
DR. COLLIE'S CASES. 221
1. "Henry P., cst. nineteen, admitted November n.
Primary vaccination in infancy; re-vaccination six
years ago ; three marks on right arm, two on left, but
patient cannot differentiate them ; all imperfect. Trans
ferred to ' Atlas' December 7. Mild discrete attack.
(Admitted from City and sent in City ambulance.) "
2. " Emma P. (sister of above), <zt. twenty-two,
admitted November 26. Primary vaccination in in
fancy ; five, imperfect marks ; re-vaccination six years
ago; no marks, but said to have taken well; again
re - vaccinated on morning of November 5 (first
symptoms of small-pox on November 21), seems to
have taken well. Transferred to ' Atlas' December 7.
Mild discrete attack. (Admitted from City and sent in
City ambulance.)"
3. "Ada J., at. twelve, admitted December 12.
Primary vaccination in infancy; two imperfect and
doubtful marks; re-vaccination six months ago; patient
says it took well; one imperfect and doubtful mark.
Mild discrete attack. (Sent by Hampstead in Hamp-
stead ambulance.)"
These cases, together with those recorded by Dr. Gayton and Dr. MacCombie, have,
through the courtesy of the Clerk, Mr. Duncombe Mann, been copied verbatim from
the reports of the Metropolitan Asylums Board. I wish to commend them to those
who affirm that compulsory re - vaccination would effectually extinguish
small-pox.
The following cases of small - pox, within short periods of re-vaccination, are
given in the Sheffield Report.
!
/1 Vaccinated ; Three well-marked cicatrices, ; Alleged to have suffered
:
: ! in infancy- j
three-quarters square inch j fromsmall-poxin Dec-
139 Ecclesall - -65 iElizabeth A. H. 29 !
; in area. , ember, 1887; eruption
P^e-vaccinated j One cicatrix,one-sixth square I only on the right hand ;
1 i l'October,i887.j inch in
area. no spots anywhere else
(
: Vaccinated j Three good-class cicatrices, i Small-pox in February, in
infancy. I area over one square inch. 1888, very mild attack, j
Re-vaccinated! Two well-marked cicatrices, tenspots.didnotfeelill. Sept.,
1887. I one-third square inch in
j
; ;
area.
. j
I ;