VACCINATION 29 Its utility to the in dividual. assumption that this contagious skin disease imported from the tropics is a thing that Europe must reckon with for an indefinite time. On the other hand, the teaching of epidemiology is that a foreign pestilence never stays unless it finds quarters suited to its existence, and that it may even take its departure capriciously, as in the case of the plague, after it has had a certain career, or on being displaced by some congener such as typhus. A r accination is considered to have turned smallpox in great part aside from the early years of life and thrown it more than ever upon the later nges, while measles and other maladies proper to childhood have at the same time increased. 1 Thus far as regards the utility of vaccination to the state ; we have now to consider its utility to the individual. Do the vacci nated escape in an epidemic ? or, if they do not escape an attack of smallpox, do they escape death from it ? In answer to the first question, apart from the familiar negative experience of everyone, we have the statistics of smallpox hospitals, which relate to the poorer class and probably do full justice to the fact of non-vaccina tion, inasmuch as the unvaccinated residue is mostly to be found in those slums and tenements of the poor where smallpox (now ns always) is apt to linger. At the Eastern Metropolitan Hospital (Homerton) from its opening early in 1871 to the end of 1878 there were 6533 admissions for smallpox, of which 4283 had vaccination marks, 793 had no marks although vaccinated, and 1477 were un vaccinated, giving a proportion of 29 unvaccinated. In the epidemic hospitals of Liverpool, Glasgow, and Dublin the proportion was 0"25 during the same period. For some of the German states the proportion of unvaccinated cases comes out a good deal less than one-fourth ; thus, in Bavaria in 1871 of 30,742 cases 29,429 were in vaccinated persons, or 95 7 per cent., and 1313 in the un vaccinated, or 4 3 per cent. 2 In some of the small local outbreaks of recent years the victims have been nearly all vaccinated (e.g., at Bromley in 1881, a total of 43 cases, including sixteen confluent, all vaccinated). 3 In the army and navy, where vaccination and re-vaccination are absolutely without exception, the proportion is accordingly 0. It would thus appear that the rather excessive pro portion of cases among the small residue of unvaccinated in the civil population must have other associated circumstances besides non-vaccination ; and these are not far to seek. The next question is the death-rate among the vaccinated and unvaccinated respectively. The total death-rate from smallpox in modern times is almost the same as it was in the 18th century ; large aggregates collected by Jurin and others in pre-vaccination times show a mortality of 1S 8 per cent, and corresponding aggregates in English and American hospitals, mostly since 1870, show a mortality of 18 5 per cent. It has, however, to be borne in mind that the division into discrete, confluent, and malignant smallpox is an old one ; that a mild type was quite common in the 17th and 18th centuries, and was now and then characteristic of whole epidemics, just as in the case of scarlatina ; and that the vaccinated are at present liable to be attacked by the confluent and malignant disease as well as by the discrete. But are the vaccinated liable co the fatal forms of smallpox, in the same proportion as the un vaccinated ? It is only since 1879 that the registrar-general s tables for England and Wales have attempted to supply data bearing on this ; and it will be seen from the following abstracts (Tables IV.- VII.) that the data are still far from being sufficient : Table IV. Deaths from Smallpox, shoiving the Numbers of the Unvaccinatcd. Year. Total Deaths. Unvac cinated. Vacci nated. Xot stated. Year. Total Deaths. Unvac cinated. Vacci nated. Nut stated. 1879 536 231 117 188 1882 1317 325 176 816 1880 648 282 121 245 1883 957 162 78 717 1881 3098 1068 652 1378 1884 2234 595 493 1140 Table ( V. Same for the Provinces (Metropolitan Deaths deducted}. c K u >H Total Deaths in Provinces. Unvac cinated. Vacci nated. Not stated. >* Total Deaths in Provinces. Unvac cinated. Vacci nated. Not stated. 1879 86 20 9 57 1882 887 143 06 678 1880 171 43 14 114 IS 83 821 111 35 675 1881 731 133 90 508 1884 1336 282 239 815 Table VI. Deaths from Smallpox in Infants under One Year. Year. Total Deaths. Unvac- cinated. Vacci nated. Not stated. Year. Total Deatlis. Unvac- Vacci- cinated. nated. Not stated. 1881 319 144 14 161 1883 126 32 I 1 93 1882 129 43 2 84 1884 2i>4 118 i 7 129 1 See Farr, Ueg. Gen. Report for 1867, p. 213: "To operate on mortality, pro tection against every one of the fatal zymotic diseases is required ; otherwise the suppression of one disease-element OJMMIS the way to another" (p. 219). Ilo quotes Watt (1813) to show that the decrease of smallpox mortality among infants in Glasgow from 1783 to 1812 was balanced by a great increase in the infantine deaths from mea.sles. See also Guy, Journ. Statist. Soc., 1882, p. 430. - Majer, Vierteljahrsclirift fii r gericht. Med., xxii. 355. 3 Nioolson, iM/icet, 27th August 1881. . Table ( VII.), Same for the Provinces (Metro2iolitan Deaths deducted). cs V >- Total Deatlis in Provinces. Unvac cinated. Vacci nated. Not stated. iJ a I* Total Deatlis in Provinces. Unvac- cinated. Vacci nated. Not stated. 1881 66 13 1 52 1883 108 21 1 86 1882 90 20 1 69 1884 146 56 . 85 These figures may be made to prove anything, according to the bias of the individual ; the column of " not stated " commands the situation. The official figures 4 for Bavaria in 1871 are more pre cise : among the 29,429 cases of smallpox in vaccinated persons there were 3994 deaths, while among the 1313 unvaccinatcd cases there were 790 deaths ; of the latter no fewer than 743 deaths were of infants in their first year. The mortality among both the vacci nated and the un vaccinated is always excessive for infancy. Feeble health, as well as non-vaccination, is a factor in the very excessive smallpox mortality at that tender age. The returns from special smallpox hospitals make out a very small death-rate (6 per cent.) among the vaccinated and a very large death-rate (40 to 60 per cent.) among the unvaccinated. The result is doubtful qua vaccination, for the reason that in pre-vacci- uation times the death-rate (18 - 8 per cent.) was almost the same as it is now in the vaccinated and unvaccinated together (18 5). At the Homerton Hospital from 1871 to 1878 there were admitted 793 cases in which "vaccination is stated to have been performed, but without any evidence of its performance " ; the deaths in that important contingent were 216, or 27 2 per cent., but they are not permitted to swell the mortality among the " vaccinated." 5 Again, the explanatory remarks of the medical officer for Birkenhead in 1877 reveal to us the rather surprising fact that his column of "unvaccinated" contained, not only cases that were admittedly not vaccinated, but also those that were "without the faintest mark " ; of the 72 cases in that column no fewer than 53 died. His column of "unknown" contained 80 per cent, of patients who protested that they had been vaccinated (28 deaths in 220 cases or 12 7 per cent.). Those who passed muster as veritably vaccinated were 233, of whom 12 died (5 1 per cent.). With reference to this question of the marks, it has to be said that cowpox scars may be temporary, that their "goodness "or " badness " depends chiefly on the texture of the individual s skin and the thickness or thinness of the original crust, and that the aspect of the scar, or even its total absence some yeai s or even months after, may be altogether misleading as to the size and correctness in other respects of the vaccine vesicle, and of the degree of constitutional disturbance that attended it. This was candidly recognized by Ceely, 6 and will not be seriously disputed by anyone who knows something of cowpox nnd of how it has been mitigated, and of the various ways in which the tissues of individuals may react to an inoculated infection. In confluent cases the marks on the arm would be less easily seen. The following statistical table (VIII.) shows death from smallpox to be comparatively rare where the marks are many and "good." Table VIII., showing the Number and Kind of Arm Marks in 370 Fatal Cases of Smallpox at Homerton Hospital, 1871-80 (Gayton). Admissions. Deaths. Mortality per cent. Vaccinal Marks. ; Under 10 Over 10 Under 10 Over 10 Under 10 Over 10 Years. Years. Years. : Years. Years. Years. 4 good 56 247
4 ) 3 good 44 388
12 r 2 j 41 5 8 1 19 1 43 422 1 20 j- 2-4 4 1 4 imperfect 01 317 3 17 3 imperfect .... 107 545 3 43
3
2 imperfect .... 1 imperfect .... 1-1-2 13S 930 S20 17 18 92 129 [12, 12-6 The practice of re-vaccination was first recommended in England Re-vac- by G. Gregory, and in Germany for the army by Heim (1829). It dilation, has been more or less the law in Prussia since 1835 : 7 " re-vaccina tion of school pupils at the age of twelve is an integral part of the vaccination law." Notwithstanding the fact that Prussia was the best re-vaccinated country in Europe, its mortality from smallpox in the epidemic of 1871 was higher (69,839) than in any other northern state. The efficacy of re- vaccination is sometimes sought to be proved by the immunity of nurses in smallpox hospitals. The experiment of not re-vaccinating the nurses was tried at the small pox hospital of the South Dublin Union in 1871-72 ; 29 out of the 36 attendants had not been re-vaccinated, and these all escaped smallpox as well as the other seven. 8 But nurses are not rarely chosen from among those who have had smallpox, and cases of smallpox in re-vaccinated nurses are not unknown. 9 The evidence as to re-vaccination on a large scale comes from the army. Accord ing to a competent statistician (A. Vogt), the death-rate from small-
- Major, op. cit. 5 Parliamentary Return, 24th February 1880.
6 Trans. 1 rnv. Med. and Surg. Assor., viii., 1840. 7 Horn s Medicinal- Vesen in I rrussen, ed. Eulenborg, Berlin, 1873-74, pp. 100 and 215. 8 Mrtl. Press and Circ., 27th March 1872.
9 Sweeting, Hep. Fvlham JIosp., 1881.