LESSONS OF THE SMALL-POX EPIDEMIC AT LEICESTER—1892-94
[Extract: CHAPTER 78. LESSONS OF THE SMALL-POX EPIDEMIC AT LEICESTER—1892-94]
AT the conclusion of the above small-pox epidemic, I published an article in the "Leicester Daily Post," 19th June, 1894. This has been revised and considerably abridged :—
THREE OBJECTIONS.
MEDICAL OPINIONS ON LEICESTER.
DEATH-RATIOS OF THE "PROTECTED" AND "UNPROTECTED."
DIFFUSION OF SMALL-POX
TREATMENT OF THE SMALL-POX PATIENTS.
OUR HOSPITAL STAFF.
OUR "UNPROTECTED" (?) CHILDREN.
STATEMENTS DAMAGING TO LEICESTER
THE BEST-VACCINATED COMMUNITIES
STAGGERING AND MORTAL BLOW
ONE MORE COMPARISON.
AN ANNUAL SAVING OF 1,356 LIVES.THE Medical Officer's annual report upon the Health of Leicester for 1893 has been looked for with more than usual interest and expectancy on account of the smallpox epidemic which existed with greater or less severity throughout the year. Now the report is issued, we are able to gauge, compare, and analyse the effects of the outbreak which has attracted so much attention. Throughout the report Dr. Priestley, oblivious of logic and sequence, loses no opportunity of exalting Jenner's prescription to the skies, and gratuitously affirms at page 137 that his "own faith as to the efficacy of vaccination and re-vaccination is well known now. Suffice it, therefore, to add that such faith has not been shaken, but, on the contrary, strengthened, by what I have seen in dealing with Leicester's small-pox epidemic, not only whilst treating the patients in hospital, but also in dealing with the cases generally in the town (quarantines and others)." One might almost doubt whether a faith, regarded by its devotees as so impregnable, required so many affirmations of belief as the report contains, but certainly the Medical Officer of Health ought to be gratified by the reception his report has received from the medical world. After the many rude shocks to which the theory of vaccination has been subjected of late, this report is regarded as a veritable ark of salvation. Wherever Convenient, the Medical Officer has throughout his report followed what is becoming more and more the formula of the medical profession. "Vaccinated " and " unvaccinated " have now been supereded by the terms "protected" and "unprotected"; therefore, I shall be held blameless for following professional leading on this point. I fully agree with the advocacy of sanitary measures contained in the report, but, having been a careful eye-witness of the outbreak, my figures and conclusions will be utterly opposed to those of Dr. Priestley.
The Medical Officer assumes that there have been a greater number of vaccinations performed in the last few years than are shown in the official returns. He bases this upon the percentage of vaccinated children found at the Board School, Newfoundpool, and upon the supposition that the medical men or the parents do not now trouble to send in the certificates when the operation is performed. In making this assumption he loses sight of
In the first place, to say the medical men or the parents do not send in their certificates is to affirm that they neglect their duty. Secondly, the vaccination officer's income depends upon his fees, and he would take care no vaccinations were omitted from the registers. And thirdly, the school at Newfoundpool was until recently outside the borough, and in the Blaby Union ; therefore the percentage of vaccinations would be much higher than in the town. The signal success which for upwards of twenty years (since the small-pox epidemic of 1871-73) has rewarded the efforts of the Sanitary Committee at Leicester, and enabled them, without recourse to vaccination, to keep the town free from the ravages of small-pox, has naturally provoked the widespread criticism of those who advocate vaccination as the only prophylactic against small-pox. Our escape from "decimation" has hitherto been attributed to our good fortune, coupled with the absence of epidemic conditions. Adverse criticism has focussed itself on the prophecy of Approaching doom, when real epidemic conditions prevailed amongst the "combustible" and " unprotected material" which has been for so many years augmenting at Leicester.
MEDICAL OPINIONS ON LEICESTER.
When, therefore, what appeared to be a persistent and continuous outbreak of small-pox occurred in Leicester in 1892, it was universally hailed with grim satisfaction by medical prophets, both at Leicester and elsewhere, as likely to fulfil their prognostications, which have been given forth with a fervency worthy of a nobler cause. . . . Letters appeared in "The Times " and other papers, significantly illustrating the attitude of the medical mind towards the great services Leicester has rendered to mankind by proving on a large scale the superior efficacy of sanitary measures properly applied to the treatment of small-pox, as compared with the alleged "protection" afforded by vaccination. The "Lancet," of 20th January, 1894, also adversely commented on Leicester. . . .
After some reference to the Royal Commission, my article continued :—
In 1871-73 our population of Leicester was what the medical men would call a well-vaccinated and well-protected population. Notwithstanding this, the small-pox epidemic of those years was terribly fatal. There were thousands of small-pox cases and 360 deaths, while the small-pox death-rate for the year of the highest prevalence (1872) was 3,523 per million. The condition of our population is now reversed. If there is any such Community in the country, we are pre-eminently an "unprotected" population. Yet during the years 1892-94 ,we have only had 362 cases and 21 deaths, or a death-rate of only 89 per million in 1893, the year of highest prevalence. If our small-pox death-rate for 1893 had been equal to that of 1872, we should have had 650 deaths, instead of the insignificant 15 which actually occurred in that year. Our small-pox death-rate was only 89 per million in 1893, with little vaccination ; while it was 3,523 per million in 1872, with vaccination in full swing. Small-pox was therefore nearly forty times more fatal in our "protected" population of 1872 than it was in our "unprotected " population in 1892. If our opponents claim that sanitary conditions account for this enormous difference, we reply so much the worse for vaccination, the necessity for which would be entirely destroyed by such an admission.
DEATH-RATIOS OF THE "PROTECTED" AND "UNPROTECTED."
It is well known that Jenner obtained £30,000 on the promise or guarantee that vaccination would protect from small-pox for life. Very few medical men believe in life protection now, and they fix the duration of "protection" according to fancy, from a few weeks to five, ten, or in some instances fifteen years. No tangible proofs are adduced, but the Local Government Board, probably acting upon what it assumes to be the consensus of medical opinion, has issued a memorandum fixing the limit at about ten years.* Let us see how this medically and officially recognised limit applies to Leicester. The population of Leicester is estimated by the Registrar-General to be 184,547 for 1893. The births during the ten years 1884-93 have been 50,370, and the primary vaccinations only 6,289. Whatever the deaths under ten may have been, it will be fair to both sides to allow the influx of population to make up the losses by death of both the vaccinated and unvaccinated. This would leave our "unprotected" child population under ten over 44,000, and the "protected" would be rather more than 6,000, or about one-seventh of the "unprotected." To measure accurately the amount of protection existing in our population it will be necessary to add to the primarily vaccinated or once "protected" the revaccinated, or "doubly protected," during the same period. At the time of the outbreak medical men freely circulated the report
* I do not profess to adopt this method of calculation as my own, but rather to illustrate the dilemma into which an incautious use of figures sometimes lands the medical profession. It has been suggested that the figures representing vaccination should be raised on account of the extension of the Borough. I may point out that this would in no way affect the calculation. It would mean a readjustment, leaving the proportions practically altered.
that the inhabitants were flocking by thousands to be vaccinated and revaccinated. An attempt was made on their part to ascertain the exact number, but the inquiry was not sufficiently encouraging, and the figures were not published until the Medical Officer of Health's report appeared. Probably a liberal estimate would be to add one-half the number of the once "protected"—namely, just over 3,000. But to make assurance doubly sure, we will allow nearly another 1,000, making up the total number of "protected" and "doubly protected" to 10,000, out of a population of 184,547. Now, what follows? Taking the Medical Officer of Health's figures, and adding eleven other cases taken note of for the Royal Commission, and four in 1894, we have had from the beginning of the outbreak in 1892 to its close early in 1894, a total of 362 cases, which I distribute as follows:—"Unprotected," 154 (including one doubtful); "protected," 177 (including one doubtful); "doubly protected," 31; many of the two latter classes, as well as the former, being very severe cases. The attack rate in the "unprotected" population was less than 1 per 1,000, while in the "protected" and "doubly protected " classes combined it was nearly 21 per 1,000, being nearly twenty-four times greater than in the "unprotected" class. The deaths all told were 21, of whom one was vaccinated, one revaccinated, and the others are said to have been unvaccinated. Dividing these into three classes—the "unprotected," "protected," and "doubly protected "—we find the respective death-rates to be 109 per million living in the "unprotected," 159 per million in the "protected," and 270 per million in the "doubly protected" class. Whatever comfort the pro-vaccinator may derive from these figures will not be augmented by the knowledge that the outbreak began with vaccinated cases and ended with vaccinated cases, the risks all through being from the vaccinated to the unvaccinated. When we consider the elements which combined for the
in Leicester, we may well be amazed at the result. At the beginning of the outbreak came the error in diagnosis by the Medical Officer of Health at the Hospital, led to 13 of the scarlet fever cases there becoming infected with small-pox. Of these 13 cases, four died. This disaster led to the distribution of 145 scarlet fever patients to their homes all over the town. All of these had been exposed to the contagion of small-pox. In addition to the fatal possibilities of dissemination of small-pox by this means, the lack of accurate knowledge on the part of many of the medical men accentuated the danger. In one instance a doctor was attending several members of a family (some suffering from confluent small-pox) for nearly three weeks, before he was aware of the nature of the disease. In another instance two doctors were attending two patients for scarlet fever in the same room for nearly a fortnight, both of which cases proved to be small-pox. The Medical Officer of Health himself says that amongst the conditions causing the spread of the epidemic were many errors of diagnosis on the part of medical men. When it is borne in mind that these gentlemen were moving about amongst their patients and the population all the time, there need be no wonder at the continued diffusion of the disease through the town. Then we had no less than twelve importations of the disease by tramps and others from well-vaccinated districts around us, coupled with inadequate resources at the Hospital. Our Sanitary Committee was divided in its counsels, and its policy was dominated by a majority of medical men and their adherents, the former of whom were, to put it mildly, prepared to allow the wreck of the "Leicester method." There had been none too much loyalty in the administration of the Leicester system on the part of those who should have given it hearty support. Our difficulties have been well-nigh insuperable. Notwithstanding this, no fewer than 44,000 of our unvaccinated child-population under 10 have passed through the fiery ordeal unscathed.
After alluding to the "marks" theory, the death-rate of the revaccinated, and the errors of diagnosis, which are referred to elsewhere, I dealt with the
TREATMENT OF THE SMALL-POX PATIENTS.
It has been alleged that our unvaccinated cases suffered terribly, and a lurid picture has been presented of "revolting" cases resembling the "black" small-pox of earlier days. The present outbreak has undoubtedly presented features of great malignity, but to allege that only the unvaccinated suffered from this severe type of the disease is grossly untrue. Very many of the vaccinated and revaccinated cases were fearfully severe, not a vestige of natural features remaining, the "effluvia" being particularly offensive, while if ever a case of "black" small-pox occurred it was the vaccinated (probably revaccinated) laundress of the hospital staff who died. When I saw her a few hours before death, I observed to the nurse that she looked more like a negress than anything else. The severity of other well-vaccinated cases may be gathered from the fact that the Medical Officer, on account of the excessive scabbing and excoriation of the skin, ordered the total destruction of the clothing of the patients rather than incur the risk of infection from disinfected clothing being reworn. I shall be entering upon what is considered as a sacred domain in speaking of the treatment of the patients at the Leicester Fever Hospital. In my opinion it was open to criticism on account of the liberal use of alcohol, and in the omission of other remedies known to be beneficial, but not recognised in the pharmacopoeia of the faculty. I believe most of the lives of the children might have been saved by the adoption of these remedies. How long the public will submit to this medical perversity it is not for me to say. The statement of the Medical Officer at page 70, that "The treatment (medical and otherwise) was the same in all," seems to show inadequate adaptation to the circumstances of the cases. Why in such a variety of conditions and physical constitutions was the treatment the "same in all?" Champagne and brandy might be moderately administered to old "topers" like the tramps, or even to strong adults, without much harm, but would it not be calculated to unduly raise the temperature of the children, increase their fever and delirium, and minimise their chances of recovery? It must not be assumed that I am opposed to the use of alcohol where it is necessary, but the following medical testimony is valuable and significant, showing without its use a saving of nearly 50 per cent, in the mortality. Dr. John Moir, L.R.C.P., Edin., Medical Superintendent of West Haiti Infectious Diseases Hospital, writes:—
"That in the outbreak of the disease, 1884-85, two thousand odd cases were treated by me in the usual routine method, with the use of alcohol when the heart's action seemed to indicate it, but with no reduction whatever in the ordinary mortality of disease, as I find on consulting my notebook of the cases, the average mortality of the 2,148 attended by me in the West Ham Guardians' Hospital, in addition, to that of nearly 700 cases treated by me elsewhere was 17 per cent. In the hospital ships at Long Reach, Deptford, Dr. Birdwood, the Medical Superintendent, in 1886-87, treated the cases under his care there without alcohol, with the surprising result that the mortality was only 6 per cent. The results obtained by Dr. Birdwood determined me to treat my small-pox cases since 1886 without alcohol, with the result that the average mortality in the last 500 cases treated by me has diminished from 17 per cent, to 11 per cent., and in the last 200 cases has been only 8 per cent. So many apparently hopeless cases have I now seen recover without the use of alcohol, which, in my former experience did not recover with its use, that I do not regret the substitution of safer remedies, and I should be afraid again to treat small-pox cases with alcohol, fearing that the mortality might again rise, and that my treatment was responsible for that rise, and consequent loss of life. This record may encourage other observers to adopt the non-alcoholic, treatment, and will most assuredly confirm them by their own experience of its trustworthiness and superior efficacy."
A result like this would have saved at least seven out of the fourteen children. Here we may have an explanation of the high temperature, delirious lever, and lengthened suffering which the Medical Officer affirms distinguished the unvaccinated children.
The cost of the outbreak and quarantine has been included in another chapter, so is omitted here.
Much has been written about the "protection" afforded to the hospital staff at Leicester by revaccination, and the dreadful punishment of the six refractory members of the staff who wickedly refused revaccination when generously offered by the Medical Officer. This subject well illustrates the spirit in which the Medical Officer approaches the question. At page 109 of the Health Report for 1893, speaking of the hospital staff, he says :—
"The remaining six had only been vaccinated in infancy, and were not, therefore, efficiently protected."
This is all very well until we remember that in the self-same report the doctor claims that many cases escaped because they had only been vaccinated in infancy. To consider these six unfortunate individuals seriatim, we find one side holds good until the other is told. At page 109 of his report the doctor says:—
"The only one 'inefficiently' protected to escape was the matron, who, of course, was not much exposed to the contagion, taking no part in the actual nursing of small-pox cases, and only entering the wards occasionally."
This is entirely opposed to the facts of the case. I have myself walked many times all through the wards with the matron, and she has freely gone in and out, assisting with patients all the time. The next is Nurse W., who, the doctor observes, is "said to have been revaccinated ten years ago." He is "unable to ascertain whether or not her revaccination was efficiently done, the medical man who is stated to have performed it having died."
Seeing that the doctor obtained much of his information by hearsay, it is strange that he should seem to cast doubt upon the statement of the nurse herself, as she is one of the most reliable of our hospital staff. Notice also the delightfully vague manner in which the case is described, so as to save revaccination from reproach if it should appear that she was, after all, revaccinated. The doctor says she "suffered from a doubtful attack of modified small-pox, half a dozen spots in all, and these aborted."
I need only ask the question—What is a doubtful, modified, abortive attack? Another case was the poor laundry-woman, who was well-vaccinated, and probably revaccinated. I saw her a few hours before death, and she died a truly terrible example, notwithstanding her "protection." No. 4 is a stoker who was the victim of fear. When supplying the wards with coal, being afraid, he rushed in and out of the wards, but his "well-vaccinated" condition did not save him from a confluent attack of the disease he was supposed to be "protected" from. Of the two remaining members of the staff I need say but little. I saw them along with others, and there is more than one opinion as to their having suffered from small-pox at all. Is not this hospital start business a little overdone? However, to gratify the doctor, we will assume they suffered from small-pox. It is useless to say they were only semi-protected, because not all revaccinated. The law insists, under penalties upon the unbeliever, that " vaccination is a protection" from small-pox, and such " protection" they had all without exception received. We had at the beginning of the outbreak a total staff of twenty-eight, part well-vaccinated, and the other part revaccinated. Of these twenty-eight "protected" persons, five were attacked with small-pox, one, if not two of them, being revaccinated. One of the latter died, giving an attack rate of about 18 per cent, and a death-rate of the attacked of 20 per cent.
Comparisons with Leicester and other towns are made in another chapter.
OUR "UNPROTECTED" (?) CHILDREN.
I have reserved this most important part of the question until last. Speaking of children, the Medical Officer, at page 67 of the Health Report for 1893, says :— "Under ten years of age, Leicester is practically unvaccinated, and has suffered severely." Yet at page 99 he curiously observes :- "What would have happened had the small-pox 'caught on' amongst children of that age period it is serious to contemplate." He also predicts that in the future "Leicester will suffer severely." Have we not for many years been medically taught to believe that when infection came these children would "catch on" to decimation? Yet after this outbreak it is still to be in the future. What a commentary on medical prophecy! m
At page 116 the Medical Officer observes :— "This unvaccinated element under ten years of age is, in my opinion, Leicester's weak point."
At a meeting of the Town Council held in January, 1893, the chairman of the Sanitary Committee read a statement prepared by the Medical Officer, which also appears at page 316 of his report, to the effect that he is "able to make the significant statement that there has not been a single case of a vaccinated child under ten years of age treated for small-pox at the hospital during his whole of our epidemic." This has appeared all over the country, and the "Lancet," of 20th January, 1894, refers to it in the following terms:—"Whereas there was no instance of small-pox occurring in a vaccinated child under ten years of age," yet, on looking at the list, I find no fewer than five small-pox cases under ten years. Why was this misleading and untruthful statement made? If this is a measure of the general veracity of the report, it does not say much for its accuracy. As a sample of the alleged protection afforded until puberty by primary vaccination, I find there are sixty-three small-pox cases ranging from a few months old to twenty-one years, all of which were vaccinated.
STATEMENTS DAMAGING TO LEICESTER
have appeared all over the country to the effect that our child population has suffered terribly from the recent small-pox epidemic. But the very worst thing that can be said against us is, that fourteen children under ten years of age have died of small-pox during an epidemic spreading over nearly two years, and that all these children were unvaccinated. We do not shrink from the issue which this statement involves. On the contrary, we heartily welcome the opportunity of meeting it. Of itself, the bare statement that fourteen unvaccinated children have died of small-pox proves nothing for or against vaccination, and such a statement only becomes of value as a test when fair comparison is made with other epidemics at other times and places, otherwise it is valueless. In one respect it would have been singular, where nearly all the children are unvaccinated, for any others to die. It is also well known that in
THE BEST-VACCINATED COMMUNITIES
there is always a residue of children, amounting to at least 2 per cent, of the whole population, physically and medically unfit for the ordeal of vaccination. The high death-rate of this residue is always unfairly included in the death-rate of the unvaccinated, and raises the percentage of the unvaccinated death-rate out of equitable proportion. This residue furnished a large proportion of cases and deaths in the Sheffield epidemic of 1887-88. Although the population of Leicester would afford us about 4,000 such children, contributing a large quota to the recent outbreak, we do not wish to shield ourselves behind this zymotically susceptible army. It is obvious, however, that the wider the basis of the unvaccinated population the death-rate is proportionately lowered. This is not only what we should expect to find, but what we do actually find in Leicester.
For the ten years ended 1872, the number of primary vaccinations which were performed in Leicester amounted to an annual average of 84.3 per cent, to the total births. Yet during the epidemic of 1871-73 there died of small-pox in Leicester and its hospital, which was hastily erected on Freake's Ground, no fewer than 193 children under ten, nearly all of whom were vaccinated. This is a small-pox death-rate of 6,699 per million living under ten, and a small-pox death-rate of 1,964 per million on the total population. For the ten years ended 1893, the number of primary vaccinations which were performed in Leicester, including its greatly enlarged area, amounted to an annual average of 12.9 per cent, to the total births yet only fourteen children under ten have died during the outbreak of 1893-94, or a small-pox death-rate of only 301 per million living under ten, and a death-rate of only 76 per million on the total population. The
given to the vaccination delusion by these figures is more graphically depicted in the following table :—
1871-73. 1892-94.
Estimated total population - 98,251 184,517
Percentage of primary vaccinations
to births for ten years, ending
with the middle of the year of each period - 84.3 12.9
Number of small-pox deaths under ten years daring each period - 193 14
Small-pox death-rate of children under ten per million living at that age 6,699 301
Small-pox death-rate of children under ten per million total population 1,964 76Thus we see that during a comparatively "unprotected" period Leicester's small-pox death-rate amongst children under ten was 6,398 less per million living at that age than it was when we were supposed to be fully "protected"; and it was 1,888 less per million when the deaths under ten are calculated on the total population. In other words, with about seven times more vaccination of children under ten, we had a small-pox death-rate nearly twenty-four times more fatal than in the less "protected" period. Had the same small-pox death-rate prevailed amongst the children under ten in 1892-94 as prevailed in 1871-73, there would have died not the fourteen who actually succumbed, but no fewer than 362. Even with this high number, we should have only been equal, and no worse than in 1871-73, with all our " protection " existing in those years.
In 1871-1873, with nearly all our children vaccinated, the 193 small-pox deaths under ten raised the general death-rate nearly two per 1,000 living, while the fourteen small-pox deaths under ten for 1891-94 make but a trifling fractional difference. In 1872, with full vaccination, Leicester's death-rate was nearly five per 1,000 above that of England and Wales. In 1893, practically without vaccination, Leicester's death-rate was about the same as that of England and Wales, but was also two per 1,000 lower than the average of the thirty-three great towns, equivalent to a saving in favour of Leicester of nearly 400 lives per annum. Again, compare the low fatality of our present unvaccinating period with the high fatality of our highest vaccination period, and we are effecting an annual saving of 1,356 lives, nearly all those of children, which vaccination used to boast it saved. We can well afford to concede all the saving that vaccination claims (even the lives of the fourteen children already referred to), while we show
AN ANNUAL SAVING OF 1,356 LIVES.
In the preface to his annual report for 1893, our Medical Officer of Health says :—"Small-pox, by the methods you have adopted, has been prevented from running riot throughout the town, thereby upsetting all the prophecies which have again and again been made. I need only mention such towns as Birmingham, Warrington, Bradford, Walsall, Oldham, and the way they have suffered during the past year from the ravages of small-pox, to give you an idea of the results you in Leicester have achieved—results of which I, as your Medical Officer of Health, am, justly I think, proud." With this I cordially agree. The "British Medical Journal" is so elated with what it is pleased to regard as the Medical Officer of Health's report in favour of vaccination, that it says, page 1,091, 19th May, 1893:—"We most earnestly hope that the attention of the Royal Commission on Vaccination will be directed to Dr. Priestley's admirable and very important contribution to the literature of the day on these matters." I also agree with this, as an opportunity would then be afforded of presenting the "other side."
Leicester has once more emerged in triumph from the severest ordeal she has yet been called upon to encounter since the "Leicester system" was adopted, and the "Lancet" and the "British Medical Journal" both know that her victory, and her vindication of the "Leicester system" under almost insuperable difficulties, has sounded the death-knell of the much-vaunted, but now discredited, practice of vaccination.