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9df5804c-3ca8-4ce8-aa78-9b63716620c0 | It seems to us scarcely possible to deny that, speaking generally of the British Isles, a more vaccinated population has exhibited a diminished mortality from small-pox. It was not, of course, to be expected that this should be seen year by year, or that the correspondence should be exact, even assuming vaccination to be the principal cause of this diminished mortality. We have already pointed out that small-pox tends at times to become epidemic, i.e., to spread more readily than at other times. The occurrence of the conditions, whatever they may be, which cause the disease to be thus epidemic have, of course, no relation to the state of the population as regards vaccination, even conceding to the full that it has a protective effect. The only result of widespread vaccination, in a case where small-pox became epidemic, could be to render the extent of the epidemic more limited, and its fatality less than it would otherwise be. |
9e1c6495-8815-486f-a886-6acd13f7f0ab | All that we should anticipate then would be a general correspondence over a long series of years between a vaccinated condition of the people and a diminished mortality from small-pox. In considering whether vaccination has been the principal cause of the decline, we must inquire whether the other causes suggested by those who deny the efficacy of vaccination will satisfactorily account for it. It is said that the decline has, in the main, been due to changes in the general conditions of life in the different parts of 1OO the United Kingdom, apart from the spread of the practice of vaccination ; amongst other things, to improvement of sanitary conditions. |
27a84162-2395-45ba-83ae-b90fd1c35f1d | It is beyond doubt than an infectious disease like small-pox is, other things being equal, more likely to spread in towns than in country districts, and more likely to spread in crowded town districts than in others not so densely populated; so that we should expect a lessened proportion of over-crowded dwellings, by diminishing the opportunities for contagion, to check the prevalence of the disease and consequently to render its mortality less. On the other hand it is certain that, during the period of the decline, there has been in England and Wales and in Scotland, though not in Ireland, a large increase of the population; so that the density of the population in two out of these parts of the United Kingdom, taking each of them as a whole, has been increasing. And it is equally certain, and probably far more important, that in all of them, during the period of the decline, there has been a continually growing proportion of the population living in the towns, and particularly in the larger towns. |
e7f3c456-8e4c-4f06-bd8a-7930c84d09fc | This growth of the proportion of the population living in towns has been a condition tending to an increased prevalence of, and mortality from, small-pox. There has also been, during the period of the decline, another change in the conditions of life, affecting all three countries, which would seem, at all events on a priori grounds, to have largely tended to an increased prevalence of small-pox; namely, the enormous and continued extension of movement among the population, and of communication with other countries, following the increasing facilities for such movement and communication. We have already pointed out that on a priori grounds it is 101 reasonable to think that improved sanitary conditions would tend to diminish the fatality of, and so to a corresponding extent the mortality from, small-pox. And there can be no doubt that the period with which we are dealing has been characterised by an improvement of this description. There has been better drainage, a supply of purer water, and in other respects more wholesome conditions have prevailed. |
bd3a32e9-029d-4719-b3a8-cbfec87c1bb0 | We have seen, then, that if some changes have occurred tending to diminish mortality from Small-Pox, other changes have been simultaneously in progress tending in the contrary direction. We do not think it possible to strike the balance between the two, and assert that it would tell in favour of a smaller mortality. In saying this, we do not mean to indicate an opinion that sanitary improvements have been without an effect on Small-Pox mortality, but only that, when all the changes which have occurred are considered, it cannot be asserted that they afford an adequate explanation of the diminished mortality from Small-Pox. If, however, improved sanitary conditions were the cause of the mortality from Small-Pox becoming less, we should expect to see that they had exercised a similar influence over almost all other diseases. Why should they not produce the same effect in the case of Measles, Scarlet Fever, Whooping Cough, and, indeed, any disease spread by contagion or infection, and from which recovery was possible ? |
24864d51-41e0-439f-bd35-b7338b8457ff | Why should they not lead to these diseases also prevailing less, and to those attacked by them being better able to combat the disease ? We have had put before us no satisfactory answer to these questions. It has, indeed, been urged that whilst the diseases we have just mentioned almost exclusively affect children, SmallPox largely attacks adults. We cannot feel that this circumstance is of much weight. It must be remembered that in former days Small-Pox was more fatal to children than to any other class. But apart from this, we fail to see why improved sanitary 102 conditions should enable children (and as we have said it is amongst them that the diminution of Small-Pox mortality has been greatest) to escape attacks of Small-Pox and overcome the disease rather than to escape from and overcome any of the other diseases to which we have referred. In the case of Measles, there has not been during the period in question any diminution in the mortality corresponding with that displayed in the case of Small-Pox. |
c8414b45-b2b5-4b1b-8023-7587d8a7dae5 | The following table shows the mortality from Measles in England and Wales during each of the years 1838-1842 and 1847-1894. The figures for the years 1843-1846 are not available:— Year. Deaths from Measles to every 100,000 living. Year. Deaths from Measles to every 100,000 living. 1838 43 1867 30 1839 71 1868 53 1840 59 1869 46 1870 34 1841 43 1842 54 1871 41 1843 1872 37 1844 Causes of death not abstracted by Registrar-General. 1873 32 1845 1874 52 1846 1875 26 1847 51 1876 41 1848 40 1877 37 1849 31 1878 31 1850 40 |
c00fb4c4-2bc3-4497-863d-80b13d5351f7 | 1879 36 1880 48 1851 52 1852 32 1881 28 1853 27 1882 48 1854 50 1883 35 1855 39 1884 42 1856 37 1885 53 1857 31 1886 43 1858 48 1887 59 1859 49 1888 35 1860 48 1889 52 1890 44 1861 45 1862 48 1891 44 1863 55 1892 46 1864 40 1893 37 1865 41 1894 39 1866 51 103 We find, indeed, as regards England and Wales, that though the death-rate from Measles was higher in the three years 1838, 1839, and 1840, |
8abb0861-ca20-4b16-82f7-2079270ff75b | than it has been in any three consecutive years since, there has been no material decline in that death-rate during the years 1838-94. The following table shows the mortality from Scarlet Fever and from Diphtheria in England and Wales during each of the years 1838-1842 and 1847-1894. We are unable, for the earlier years included in the table, to separate those causes of death:— Year. Deaths from Scarlet Fever to every 100,000 living Deaths from Diphtheria to every 100,000 living Year. Deaths from Scarlet Fever to every 100,000 living Deaths from Diphtheria to every 100,000 living 1838 38 1867 57 12 1839 67 1868 100 14 1840 126 1869 124 12 1841 89 1870 145 12 1842 79 1871 82 11 1843 Causes of death |
975324d7-1245-4b58-aecc-3b2b50d4aa87 | not abstracted by Register-General 1872 52 9 1844 1873 56 11 1845 1874 105 15 1846 1875 85 14 1847 86 1876 69 13 1848 118 1877 59 11 1849 75 1878 75 14 1850 75 1879 69 12 1851 76 1880 68 11 1852 104 1881 55 12 1853 85 1882 52 15 1854 100 1883 47 16 1884 40 19 1855 89 2 1885 23 16 1856 71 3 1886 22 15 1857 65 8 1887 28 16 1858 121 34 1888 23 17 1859 98 52 |
1bf6d22f-c712-48ab-bc3c-febe32500d56 | 1889 24 19 1860 49 26 1890 24 18 1861 45 23 1891 17 17 1862 73 24 1892 19 22 1863 148 32 1893 24 32 1864 142 26 1894 17 29 1865 84 20 1866 55 14 104 We do not think it necessary to burden our report with similar details in reference to the mortality from Whooping Cough during the period under discussion. It will be sufficient to say that there has been no decline in the mortality from that disease corresponding with the decline in Small-Pox mortality. Great stress has been laid on the fact that the records of the Registrar-General show that the mortality returned under the head " fevers " has very largely diminished. |
350a3e6d-ed82-4b03-bb35-de1188ac0779 | But it is notorious that in comparatively recent years the nomenclature and classification of diseases where fever is present have undergone great changes, owing to improved diagnosis. In the case of many such diseases where the cause of death was formerly returned merely as " fever," it is now attributed to some other disease separately specified. The apparent diminution is therefore not entirely a real one. Changes in nomenclature and classification, however, cannot wholly explain the diminution in the number of deaths returned as due to fever, though they prevent exact quantitative comparison such as can be made in the case of diseases like Small-pox, Measles, &c. The mortality from fevers has undoubtedly decreased largely. In considering the relation of this decrease to improved sanitary conditions, it is important to advert to the nature of these sanitary improvements. |
f0a14c3e-ae4e-4e6c-9140-24647b272e99 | They may be broadly classed as follows :—(a) Drainage, including in the term the removal of moisture from damp and swampy places, and the adequately rapid and effectual removal of the excreta of the bowels and the kidneys. (b) Ventilation of dwellings or the rapid and effective renewal of the air surrounding the inhabitants. (c) Lighting of dwellings. The means taken to secure this also entail greater ventilation; the two go together, but besides this the effect of light on organisms or microbes, to which contagia seem analogous, would lead one to suppose that increased light, at least sunlight, tended to destroy contagia. (d) A supply of pure water for drinking purposes. (e) Personal cleanliness. This, apart from its influence on general health, would have a tendency to render an individual less likely to receive contagion, 105 and less likely to convey it to another. |
b7737a92-9ea5-42ac-81be-00e477594262 | (f) The increased general recognition, during the last 10 or 20 years especially, of contagion as the source of certain diseases, and increased knowledge of the means of avoiding its spread, may be recognised as a sanitary improvement of no slight value. It is obvious that these sanitary changes are not calculated to effect even all zymotic diseases in the same manner and to the same extent. The chief fevers are (1) Malarial Fevers, (2) Typhus, (3) Typhoid. There is much uncertainty concerning the fever classed as " simple continued," nor does this appear ever to have contributed largely to the returns. Now, Malarial Fevers are directly dependent on the development of the contagia in swamps and marshes; when these are adequately drained the fevers disappear. |
0ae7a1bd-518c-429e-bcee-1b53eb61ebd0 | Typhus Fever, which seems to have furnished the largest share of "fevers" in the last and in the beginning of this century, is found to prevail in connection with overcrowding in dark ill-ventilated dwellings, combined with deficient nutrition. When these conditions cease, the fever disappears, and Typhus has thus become almost unknown in this country at the present day. Typhoid Fever is directly dependent on the contagia furnished by the excreta of one case being introduced into the alimentary canal. Where, by means of adequate drainage and personal cleanliness, this is prevented, the disease is prevented also. In the case of each of these fevers, then, there are special circumstances developing the disease which sanitary improvements tend directly to remove. There is no like feature in the case of Small-Pox. It resembles Measles in this, that the spread of it is not connected with any particular sanitary fault, as distinguished from those general conditions which tend to the spread of infectious disease. |
201949d2-52dd-459f-bdb2-2d7815eea70a | There is no evidence in the history of Small-Pox, either before or during the nineteenth century, to connect outbreaks of that disease in a special way either with imperfect removal of excreta, or with lack of air and light, or with deficient food, or with lack of personal cleanliness. Moreover, the general tendency of sanitation to lower the prevalence and the fatality of the disease is largely neutralised both in the case of Small-Pox and Measles by the greater facility 106 of intercourse. |
5f577e60-1f21-4d69-a7a2-41a920de6363 | Whilst, then, there is ample reason to regard the decrease in the case of Typhus and Typhoid Fever (and it may, perhaps, be said of fever generally) as the result of improved sanitary conditions, since each of these is specially dependent on conditions which sanitary improvements have removed, there is no adequate reason to attribute the decrease of Small-Pox in the nineteenth century to a similar cause, though we fully recognise that sanitary improvements have had an effect in reducing the mortality from Small-Pox as from the other diseases to which we have just been referring. This view is strongly confirmed by the fact that, in spite of sanitary improvements, the mortality from Measles and Whooping Cough has remained undiminished, and the diminution in the mortality from Scarlet Fever has only been apparent in comparatively recent years. It has been maintained that the decline in Small-Pox mortality is largely due to more frequent and systematic attempts to isolate those suffering from Small-Pox. |
0ba46c79-e803-422f-afaf-eecabedf9522 | We think an answer to this contention is to be found in the fact that, as we shall presently show, it is only in quite recent years that there has been any systematic practice of isolating Small-Pox patients, and that it has been confined even then to a very limited number of localities. The fact to which we are about to call attention in greater detail than hitherto, that the decline in the deaths from Small-Pox is found almost exclusively among those of tender years, appears also to militate against the contention. The risk of contagion is not confined to children. Adults also are subject to it. If a better system of isolation had been a main cause of the reduced mortality, we should have expected to see it operate in the case of adults as well as of children. |
b04cb5d1-7d42-4e53-a74a-e18e77f11205 | At the same time we are far from thinking, as will appear when we come to deal with that subject, that the efforts at isolation which have characterised recent years have been without a beneficial effect on Small-Pox mortality. A study of the age incidence of Small-Pox mortality is very 107 instructive. In connexion with this point it is necessary to bear in mind that experience has led to the conclusion that whatever be the protective effect of vaccination it is not absolutely permanent; the most convinced advocates of the practice admit that after the lapse of nine or ten years from the date of the operation, its protective effect against an attack of Small-Pox rapidly diminishes, and that it is only during this period that its power in that respect is very great, though it is maintained that, so far as regards its power to modify the character of the disease and render it less fatal, its effect remains in full force for a longer period and never altogether ceases. |
2c017d85-15e4-4d94-9970-59cf6d2c173e | The experience upon which this view is founded is derived almost exclusively from the case of infantile vaccination. It has been supposed by some that the transitory character of the protection results from changes connected with the growth from infancy to adult years. Whether this be so or not, we have no means of determining. No doubt when Jenner drew the attention of the public to the value of vaccination, he believed that a single successful inoculation of vaccine matter secured absolute immunity for the future from an attack of Small-Pox. It is certain that in this he was mistaken. It may well be doubted whether the anticipation was a reasonable one. No such immunity is secured by an attack of Small-Pox, though there are few who would maintain the proposition that it is without protective influence against another attack. A priori there would seem to be no sound ground for expecting that vaccinia would afford more potent protection than Small-Pox itself. |
f229f792-d5bb-439e-9de3-03119307ce1d | The extent of the protection afforded (assuming that there is some protective influence) could only be determined by experience. It soon became apparent that Jenner had, in the first instance, over-rated the effect of vaccination. That he should thus have over-estimated it is not to be wondered at, when the tendency to be unduly sanguine, which besets the discoverer of any new prophylactic, and, indeed, every discoverer, is borne in mind. The fact has been already noted that in the eighteenth 108 century (and there is no satisfactory evidence that there was a difference in this respect in earlier centuries) Small-Pox was fatal chiefly to children ; indeed, in particular local epidemics of which we have records, the mortality was confined entirely, or almost entirely, to that class of the population. Adults were at that time very largely protected by a previous attack of Small-Pox. Children were then the only class, for the most part, unprotected. |
09505625-682a-4edc-a81b-eea9748c512d | During the present century this cause of protection has largely diminished ; it is now only a very small section of the community which enjoys protection thus acquired. If, then, vaccination be most potent in its effect during the first few years after the inoculation of the vaccine matter, we should expect to find the conditions which formerly existed reversed—children would be the best, adults the worst protected class. Applying ourselves now to the statistics on this head, we find a remarkable change in the age incidence of Small-Pox mortality. The following table exhibits the change which has taken place in this respect. For the years 1848-54 cases of Chicken-Pox are unavoidably included, there being no means of distinguishing them. This, of course, tends to increase unduly the share of mortality borne by the earlier age periods, but the information which we possess with reference to Chicken-Pox mortality since mortality from that disease has been separately recorded, enables us to say that the error thus introduced cannot seriously affect the comparison. |
28d197dd-ef78-4135-9442-28b615abe4fb | From 1855 onwards Chicken-Pox has been uniformly excluded, so that from that date there is nothing to affect it. England and Wales: Deaths from Small-Pox at certain age periods to 1,000 deaths from Small-Pox at all ages. - Under 1. 1-5 5-10 10-15 15-25 25-45 45 and upwards. |
c8a8ac92-1bb3-4b1c-913c-b1a5567c044e | 1848-54 251 426 130 33 75 67 18 1855-59 231 328 144 37 117 112 31 1860-64 237 313 108 42 123 133 44 1865-69 231 314 103 33 126 145 48 1870-74 143 169 140 58 200 224 66 1875-79 112 129 113 72 218 266 90 1880-84 113 122 98 68 216 286 97 1885-89 112 81 54 51 229 344 129 1890-94 166 117 52 26 131 338 172 109 The first point calling for notice is that in the period 1855-59, as compared with the earlier period, |
aaf5c149-706f-487d-ae16-0c4f77a6bd8d | there was a considerable diminution in the share of Small-Pox mortality borne by those between one and five years of age. In the earlier period it was 426, in the latter 328. As regards those under one year of age, the share fell from 251 to 231. It must, of course, be remembered that whatever the prevalence of vaccination amongst children the age period under one year will always contain a considerable unvaccinated class. We are naturally led to inquire whether there is anything in the history of vaccination to account for the remarkable change we have adverted to. In the year 1853 vaccination was made compulsory, and though no sufficient means were provided for rendering the law effectual, it cannot be doubted that it was calculated to increase vaccination in the subsequent years. The next marked change is seen in the quinquennium 1870-74. |
c7ffc2e7-4fca-4b31-9d23-d4bd4cd26fd7 | The proportion of Small-Pox mortality borne by those under one year of age decreased from 231 to 143, and of those between one and five years of age from 314 to 169. We have already called attention to the fact that in 1867 power was given to the Guardians to appoint Vaccination Officers, and that advantage was taken of this from time to time by different Unions, though a large number remained without such officers until after 1871, when their appointment was made compulsory. There can be no doubt that the effect of this legislation was to cause an increasing extension of the practice of vaccination in 1868 and subsequent years, and very largely to increase the amount of vaccination in and subsequently to the year 1871. The effect of this would be at once felt in the earliest age-periods, and at a period correspondingly later in the succeeding age periods. |
94252baf-2222-4a92-87ed-86996bc11479 | We have already pointed out the marked change in the incidence below five years of age in the quinquennim 1870-74, and it will be seen that in subsequent quinquennia there was a diminished incidence in the age-periods 5-10 and 10-15, and later still in the period 15-25. During the last quinquennium there 110 has been some increase in the incidence of the disease in the first two life-periods. This has been coincident with some diminution in the practice of vaccination. The following table shows the death-rates in England and Wales from Small-Pox per million living during the seven years from 1848-54, and for each decennium since that period. It is to be remembered that, as already stated, the deaths for the years from 1848-54 include those from Chicken-Pox as well as SmallPox:— - Under 5. 5-10. 10-15. |
dc123a60-151a-4f32-a5e8-3402f2b4ed64 | 15-25 25-45. 45 and upwards. 1848-54 1,514 323 91 110 69 24 1855-64 788.8 209.5 68.7 118.9 87.8 36.2 1865-74 782.5 333.2 142.3 267.2 220.7 87.5 1875-84 127.8 62.9 46.4 82.4 76.6 33.9 1885-94 50.2 14.9 1l.l 24.0 31.6 19.0 It is right to observe that there must have been among those whose age exceeded 10 a certain number who had been revaccinated. |
376bca12-ae49-4728-8bb2-8251ae0af345 | The effect of this operation would be to restore protection, if protection there be, and to place the re-vaccinated in a somewhat similar relation to those of the same age who had been once vaccinated, as vaccinated children bear to unvaccinated. It is not possible to ascertain the number of re-vaccinated persons in the class over 10 years of age in the two epochs respectively. But it seems clear that the mass of the people were not at either epoch re-vaccinated, and we do not think that the number of the re-vaccinated was sufficiently large to affect materially the value of any inferences to be drawn from the contrast to which we have directed attention. |
67e8a21c-002a-4287-abce-b39d6015e8b4 | We may observe, however, that in discussing the effect of vaccination the question of re-vaccination will have to be considered, and that any phenomena exhibited by the class of re-vaccinated persons, when compared with those of a similar age who have only been vaccinated in infancy, have a similar relevancy to the contrast afforded in the case of vaccinated and unvaccinated persons of a similar age. 111 In London there had been a considerable falling off in the amount of vaccination for some years prior to 1892. In 1883 the per centage of births left unaccounted for (including, as before, the postponed cases) was 6.5. It was not materially different in the following year. In 1885 it had increased to 7 per cent.; in 1886 to 7.8; in 1887 to 9 per cent.; in 1888 to 10.3 per cent.; in 1889 to 11.6 per cent. |
23c0fec4-c851-4b43-86d2-e2c8a990dbc0 | ; in 1890 to 13.9 per cent,; and in 1891 to 16.4 per cent. Taking these years together, the per centage left unaccounted for is 9.9. The per centages we have given are derived, of course, from a very large number of births, so that the increase in the number appearing thus to be left unvaccinated is very considerable. Thus in the year 1883 the number unaccounted for was 7,816, whilst in 1891 it was 19,806. There seems to be no doubt, therefore, that, so far as regards the class under 10 years old, London compared unfavourably as regards the amount of vaccination both with Warrington and Sheffield. |
8c10bb60-3c56-40fb-87d7-c36ca2d4cb7b | It has been suggested that Small-Pox is specially amenable to improved sanitary conditions, and that this appears from the influence which they have in diminishing the proportion in which those under five years of age die of Small-Pox in healthy districts as compared with towns, where the sanitary conditions are inferior. In proof of this reliance is placed on a comparison of two tables of mortality, showing of what diseases and at what ages a million live-born children might be expected to die, which appeared in a supplement to the 35th annual report of the Registrar-General, the one derived from a Liverpool life-table and the other from a life-table for certain selected "healthy districts" in different parts of England and Wales. The tables were, in the main, based on the experience of the years 1861-1870, and, of course, assume that the conditions which then obtained would remain unchanged. |
0a500fed-9c21-4b78-af1e-40af68be40f1 | It is quite true that it appears from these tables that whilst in Liverpool the per centage of deaths from Small-Pox expected under five years of age was 63.5, in "healthy districts" it was only 25.5. But in order to judge whether this difference (so far as it really represents a different 112 incidence of fatal Small-Pox on the ages under and over five) can be attributed to the superior sanitary conditions of what are termed the " healthy districts," it is necessary to define what is meant by sanitary conditions, and also to see how the case stands with regard to other diseases. A supply of pure water, good drainage, sufficient light and air and cleanliness, these and the like are usually regarded as the elements which render one area superior to another in its sanitary condition. Different areas may be better or worse in these respects or some of them, and this superiority may largely influence zymotic disease. |
981fb8b1-1e8d-46aa-af78-67cb137e846c | But in relation to diseases of this class, there are other respects in which a great town differs from rural districts. In the former, a large population is collected in close proximity, whilst in rural districts the population is scattered over a wide area, and the people collected in close proximity are comparatively few in number. The necessary effect of this, as we shall presently show, is that the cases of zymotic disease would be more numerous in the former area than in the latter districts, and that, as regards certain zymotic diseases, a larger proportion of the deaths would occur under five years of age. In the outbreak of Small-Pox in London in 1892-3, of the vaccinated under 10—110 were attacked, none of whom died. Of the unvaccinated of a similar age, 228 were attacked, of whom 61 died, or 26.7 per cent. |
291cfd53-d275-497f-8440-e6cbb2b42fe2 | Of the vaccinated over 10 years of age, 1,643 were attacked, of whom 39 died, or 2.3 per cent. Whilst of 181 unvaccinated of a similar age who were attacked, 38 died, or 20.9 per cent. Mr. Marson's observations, made during 32 years in respect of 19,467 cases at the Small-Pox Hospital, showed a fatality among the unvaccinated of 36.5 per cent., whilst the highest death-rate amongst those having vaccination marks, viz., those having one vaccination cicatrix only, was 12.8 per cent. We shall have to revert to his figures presently, when considering the 113 question whether various degrees of vaccination differ in their protective effect. Dr. Gayton furnished us with the results of an examination of 10,403 cases at the Homerton Hospital between tne years 1873 and 1884. |
13bc89c6-c313-480e-83c4-479829d69bec | The deaths amongst the vaccinated (in which class are included those said to be vaccinated, but who had no marks) were 869 out of 8,234, or 10.5 per cent.; the deaths amongst the unvaccinated 43.4 per cent., the numbers being 938 out of 2,169. So far, we have made no discrimination as regards the age of the persons attacked. Out of the total number of 1,807 deaths, 700, i.e., 38 per cent., were under 10 years of age. The fatality of the vaccinated under 10 was 10.4, being 137 out of 1,306. The deaths among the unvaccinated of a similar age were 563 out of 1,187,or a fatality of 47.3 per cent. |
4f86c1b8-f34a-4d9b-874d-bbe1b9e85734 | If the cases of children under one year of age be excluded, the figures are as follows :—In the vaccinated class, 1,286 cases with 130 deaths, or a fatality of 10.1 per cent. ; in the unvaccinated class, 1,032 cases with 465 deaths, or a fatality of 45 per cent. Over the age of 10, the fatality of the vaccinated was 10.5, being 732 out of 6,928. The death-rate of the unvaccinated of a similar age was 38.1, being 375 out of 982. Mr. Sweeting put before us statistics relating to 2,584 cases at Fulham Hospital between the years 1880 and 1885. Of these 428 died, or 16.5 per cent. The deaths among the vaccinated (in which class are included, as with Dr. |
bf2eb45d-3ed7-4a52-8924-0c0e3366091e | Gayton's tables, those said to be vaccinated, but who bore no marks) were 263 out of 2,226, or 11.4 per cent. The deaths amongst the unvaccinated were 165 out of 358, or 46 per cent. Discriminating again with reference to the age of the persons attacked. Of 202 under 10 years of age in the vaccinated class 16 died, or 7.9 per cent. Of 168 of a similar age in the unvaccinated class 78 died, or 46 per cent. The fatality of the vaccinated over 10 years of age was 12.2, being 114 247 out of 2,024. Of the unvaccinated of a similar age, 87 out of 190, or 45.7 per cent., died. |
61f30761-89d4-4345-8463-85a69ad3d025 | It has been urged against these statistics that, even though every effort were made to classify the cases correctly, the classification was still open to error, inasmuch as persons might be brought to the hospital with the eruption of confluent Small-Pox upon them, which would prevent the marks even of efficient vaccination being visible. It is true that this might be so in some cases, but both Dr. Gayton and Mr. Sweeting assert that it could have happened very rarely. We do not think that it could make such a difference as to modify substantially the contrast exhibited in the fatality amongst the vaccinated and unvaccinated classes. Inasmuch as the vaccinated class includes, both in the case of Dr. Gayton's and Mr. Sweeting's tables, a considerable number who, though said to be vaccinated, showed no marks, it may be interesting to observe what was the fatality in that class when dealt with separately. |
6b78b370-6d63-41f4-99c6-1373464483d2 | It contained in all probability a certain proportion of unvaccinated persons. The fatality in this doubtful class in Dr. Gayton's table was 27.1 per cent., being 352 out of 1,295. Eliminating these cases from the total number hitherto treated as vaccinated, the result shown is a fatality of 7.4 per cent., being 517 out of 6,939. Dealing with Mr. Sweeting's statistics in the same manner, we find the fatality in the doubtful class to be 33 per cent., being 88 out of 266, whilst in the vaccinated class, eliminating these doubtful cases, it is 175 out of 1,960, or 8.9 per cent. |
1f883a3f-6369-422b-8d73-18d2dbe9f20d | It will thus be seen that there is a somewhat striking correspondence in the death-rate shown by this doubtful class in the two cases, and that in each case that death-rate was considerably higher than the fatality in the vaccinated, but considerably lower than that in the unvaccinated class. We proceed to consider the explanations of the contrast 115 between the fatality of Small-Pox in the case of the vaccinated and the unvaccinated, which have been suggested by those who deny that it is due to vaccination. It has been said, and this is the main argument employed, that the unvaccinated are mostly to be found in the poorer and more neglected classes of the population, who would on that account be constitutionally weaker, and less able to resist an attack of Small-Pox, and to escape a fatal result. Speaking generally, this may be to some extent true, though it is not so at all times and in all places. |
d6781912-6ec3-46ed-b8e7-acc3bffdd9d5 | There are facts stated in the reports we have so often quoted, especially those relating to Warrington, Dewsbury, Leicester, and Sheffield, and in the evidence with reference to the last-named town, which seem to show that the explanation suggested cannot be the correct one. In the report on the Warrington epidemic, as we shall see immediately, it is expressly stated that the vaccinated ana unvaccinated were of the same class, and lived in the same houses and in the same manner. Moreover, the persons admitted into the Homerton and Fulham Hospitals were for the most part, whether vaccinated or unvaccinated, of the pauper class, or of the class immediately above it. It is not conceivable that in this section of the population the presence of vaccination or its absence should indicate so marked a difference of constitutional strength as to account for the difference of Small-Pox fatality which we are now considering. |
2237e75e-933c-4080-9689-841c37c80aee | It is further to be observed that, taking the statistics of the six towns, in the case of the vaccinated aged 1.10 the fatality was 2.8 per cent., in the case of the unvaccinated of a similar age it was 30.3 per cent., whereas in the case of those over 10 years the fatality in the case of the vaccinated was 5.4 per cent., in the case of the unvaccinated 34.3. It will be seen, therefore, that the disparity in the death-rate of those classed as vaccinated and unvaccinated was greater nearer the date of vaccination than it was at a later period. The same phenomenon is observable in the hospital statistics. We do not think it possible, then, to accept the suggestion that there were more of the poor in the unvaccinated than in the vaccinated class as a sufficient explanation of the contrast we have been 116 sidering. |
5e62469f-673b-44b1-a453-d9337d33428d | The difference of fatality in the two classes is, in our opinion, far too great to be thus accounted for, and the suggested explanation does not explain all the phenomena. We should think it much more reasonable to conclude that the remarkable difference of fatality was due to vaccination, even if it were only in that respect that the two classes differed in their relation to Small-pox. But this is not the case. There are other points of distinction between the two classes. We are about to discuss the differences they exhibit both in liability to be attacked by SmallPox and in the type of the disease from which they suffer. And the bearing of these facts upon the question whether the smaller fatality in the vaccinated class is due to vaccination, which is obviously important, will afterwards be considered. |
d99617eb-21fb-4311-a2fa-2a0157857286 | Another explanation given of the greater fatality which characterises the unvaccinated class has been that, inasmuch as the unvaccinated class includes those whose vaccination has been postponed for medical reasons, there would be amongst its number a larger proportion of children of delicate constitution who would on that account be more likely to succumb to an illness. With reference to this argument, it is to be observed in the first place that the number of those whose vaccination is postponed for medical reasons is but small, and in the next place that the postponement by no means necessarily shows that the child is of a delicate constitution. It often results from the presence of some ailment to which young children are subject, and which affects the strong no less than the weak. But besides this it must be remembered that those whose vaccination is postponed are frequently vaccinated at a later period, and thus pass from the class of the unvaccinated to that of the vaccinated. |
fecb9c4b-483b-4ae1-848b-f7d20491f182 | Giving due weight to these considerations, we find it impossible to believe that the cause suggested can account to any material extent for the difference to which we have been adverting between the fatality among chijdren under 10, observed in the classes of vaccinated and unvaccinated. It must always be borne in mind that the difference is not a narrow one, it is not measured by a 117 small per centage. A broad margin might be allowed for error without the force of the argument derived from the contrast being seriously diminished. The next point for consideration is the question whether the evidence shows that vaccination has a protective effect against an attack of Small-Pox. We have lately been considering whether it affords any protection against death from the disease in persons attacked by it. The question with which we have now to deal obviously presents greater difficulty in arriving at accurate results. The liability to attack depends on contact with or proximity to sources of infection. |
efb1d1bd-9ecd-48d6-8580-ab2fe5c52304 | When an epidemic of Small-Pox visits a town, the liability to infection of the inhabitants of different parts of the town may differ widely. Those who are residing in a house where a person is suffering from Small-Pox are subject to a risk which does not attach to persons living in a house not so invaded. On the other hand, persons moving about the town, or congregating for purposes of business or pleasure may come in contact with sources of contagion, so that the risk of contagion is, of course, not confined to those who are living in a house where Small-Pox is present, though it may be greater in the case of this class than of the rest of the community. These considerations appear to have been kept in view by the medical men who have dealt with the matter in their reports on the local epidemics to which we have so often referred. In his report upon the outbreaks in London during 1892 and 1893 Dr. |
38d5d9e2-acd1-42d3-af37-f71c03b6e1f1 | Luff has not entered into the question of the rate of attack among the unvaccinated as compared with the vaccinated. His report, nevertheless, affords some data for such a comparison. Of a total number of 2,353 cases as to which he obtained information there were 409 unvaccinated persons, or 17.3 per cent. It is not likely that the percentage of unvaccinated persons, whether in London or in the districts specially effected, was as great as this. Dealing with the age period 0—10, there were 358 attacks. 118 Of the persons thus attacked, 228 were unvaccinated, or a percentage of 63.7. It is not open to doubt that this was greatly in excess of the percentage of unvaccinated persons under 10 years of age in London or in any part of it. Turning now to the statistics of Small-Pox in London hospitals supplied by Dr. Gayton and Mr. |
96186354-0300-47b9-a3fe-877a1f6ce13d | Sweeting, we find that the percentage of unvaccinated persons treated in the Homerton Hospital was 20.8; the numbers being 2,169, out of 10,403. Of children under 10 years of age the number of unvaccinated admitted was 1,187, out of 2493, or 47.6 percent. At the Fulham Hospital 358 was the number of admissions of unvaccinated persons, out of a total of 2,584, the percentage being 13.8. Out of the total number of 370 children under 10 years of age admitted to the hospital 168, or 45.4 per cent., were-unvaccinated. It will be remembered that all those who were said to be vaccinated, even if they showed no marks of it, were excluded from the unvaccinated class. |
48589c97-9324-4636-a843-95f65226ad36 | When these figures are examined they show a proportion of unvaccinated persons, especially children, admitted to the hospital which it is impossible to believe corresponded with the proportion of unvaccinated persons existing in the population of London or of any district of it. It has been suggested that the inmates of these hospitals were drawn from the poorer class of the population, and that in that class there would be a larger proportion of unvaccinated persons than in the population at large. This, probably, is so to some extent. But it seems to us quite inadequate as an explanation of the very large proportion of unvaccinated children admitted to the hospitals. When the returns of vaccination in London are examined it will be seen that the children not finally 119 accounted for between the years 1872 to 1884 had only ranged from 9.3 of the births in 1874 to 5.7 in 1881, the average for those 13 years being but 7.4. |
eaef7a97-599f-4bde-b127-574450abf612 | Our attention has been called to the fact that the proportion of vaccinated patients admitted to the Highgate Small-Pox Hospital has often been as high as 94 or 95 per cent. And it has been suggested that this indicates an attack-rate in London in the class of vaccinated persons quite as high as that prevailing in the case of the unvaccinated. The experience at the Highgate Hospital certainly differs greatly from that of either Homerton or Fulham. The test was a larger one in point of number at the two latter hospitals than at the former. Moreover, the fact mentioned in the preceding paragraph must be borne in mind In London the absence of vaccination is to found chiefly in the poorer classes of the population. The inmates of the Highgate Hospital belonged in part to a more prosperous class. In that class the cases of non-vaccination would be very rare. Moreover, those who were admitted by contract with the Guardians of different Unions came from areas outside London. |
58352d23-de21-4b92-ab54-282f4ac1e8d0 | It will not do, therefore, to estimate what was the proportion of vaccinated and unvaccinated persons in the population of London when considering whether the unvaccinated contributed more than their share of the Inmates of the Highgate Hospital. We think, taking it all together, that the evidence bearing upon the question whether the vaccinated are less liable to be attacked by Small-Pox than the unvaccinated, points to two conclusions; first, that there is, taking all ages together, less liability to attack among the vaccinated than among the unvaccinated, and next, that the advantage in this respect enjoyed by vaccinated children under 10 years of age is greatly in excess of that enjoyed at a more advanced period of life. It is alleged that vaccination not only diminishes the risk of attack by small-pox and the fatality of that disease, but that it 120 renders the type of the disease in the vaccinated less severe than it would have been had they remained unvaccinated. |
46b1fa16-e82c-4ad7-9af9-8cddba07f336 | Small-pox differs greatly in the degree of its severity. It may be an illness of a very serious character, entailing grave after consequences, or it may be a comparatively trifling ailment. The most severe forms of the disease have been termed malignant or haemorrhagic. Next in severity comes the confluent type, which is also of a very serious character. The mildest species of the disease has been termed varioloid, or sometimes simply "mild." Between the confluent and the mild or varioloid come in order of severity the coherant and the discrete types. |
cf230dea-b33c-468a-ba9d-6da6c8e5fe87 | Quite apart from the danger of a fatal termination to the illness, it is obviously a matter of great importance to those who suffer from the disease that its type should in their case be of a mild rather than of a severe character, not merely because the illness is in the one case trifling and in the other painful and prolonged, but because evil consequences such as pitting of the countenance often follows in the one case which in the other are absent. It is important, then, to test the validity of the assertion that vaccination has this beneficent influence, and that for two reasons. If it can be established it would show, first, that vaccination carries with it this distinct advantage independently of the others we have been considering; and next, it would add support to the view that vaccination has an influence upon the disease of small-pox, a point which has been contested. Let us inquire, then, what light the evidence throws upon the claims thus advanced in favour of vaccination. |
382e129e-6ed9-423a-967e-69e391412c65 | He divides the cases into "very mild," "discrete," " "severe discrete," "confluent," and "haemorrhagic." The cases in the latter class are very few in number, and it will be more convenient to class them with the confluent cases. The number of cases in which the type of disease was discriminated was 2,353, of whom 1,944 were vaccinated or doubtful and 409 unvaccinated. 121 Of the 1,944 vaccinated cases— 108, or 5.6 per cent., were very mild. 1,622 „ 83.4 „ „ discrete. 32 „ 1.6 ,, „ severe discrete. 182 „ 9.4 „ „ confluent. Of the 409 unvaccinated cases— 2, or 0.5 per cent., were very mild. 142 „ 34.7 „ „ discrete. 64 „ 15.6 „ „ severe discrete. |
96e6af7d-b00e-49cd-8624-1a4926ccf568 | 201 ,, 49.1 ,, ,, confluent. Separating now children under 10 years of age:— Of the 130 vaccinated cases— 30, or 23.1 per cent., were very mild. 83 ,, 63.8 „ „ discrete. 4 ,, 3.1 „ „ severe discrete. 13 ,, 10.0 „ ,, confluent. Of the 228 unvaccinated cases— 1, or 0.4 per cent., was very mild. 84 „ 36.8 „ were discrete. 45 „ 19'.7 ,, ,,severe discrete. 98 „ 43.0 „ „ confluent. In London, a classification of the types of disease renders comparison less easy. If, however, the severer class be composed of the severe discrete and the confluent, the milder class as before consisting of the mild and discrete, the result is as follows:— Milder. Severer. |
7979ae89-6a41-48eb-bce6-cf6d58829adf | London Vaccinated 89.0 11.0 Unvaccinated 35.2 64.8 If the proportion which the mild bear to the severe cases in those under 10 years of age be examined, it will be seen that in the vaccinated class the ratio of the milder type is much greater 122 than at all ages; indeed, the proportion of severer cases is in all the towns quite insignificant. Before passing to another branch of the subject it will be well to take account of the bearing upon one another of the facts relating to the fatality, the attack-rate, and the type of the disease of Small-Pox, which we have been considering. Between the facts with which we have been concerned when investigating the fatality of Small-Pox, and those which have engaged our attention when considering the type of the disease, the connexion is obvious and intimate. |
4fef8f14-43ac-4212-8f77-fd8ee3697829 | In each of these cases we have had to deal with the same classes of vaccinated and unvaccinated persons—indeed, we may say with the very same persons—we have already pointed out that it is more than improbable that on a division of the persons who suffered from Small-Pox, into two such classes the fatality should be so strangely different, unless there were something in the condition of the one class which differentiated it from the other, and rendered those within it less liable to suffer fatally from the disease. What is to be said when it is found that, apart from the fatality of the disease, its type in the two classes also differs, and perhaps even more widely than its fatality does, and that the milder type distinguishes the same class which exhibits the smaller fatality ? |
babdb55f-67d9-4e20-b753-ae52b413a7fe | That this should be a mere chance coincidence is incredible when it is observed that the phenomenon is uniform not only in the case of epidemics in five different towns, but in the case of the same epidemic in different parts of the same town. The facts surely afford strong corroboration of two propositions; first, that a classification was, on the whole, accurately made in these cases of persons whose condition in relation to Small-Pox differed from one another ; and, secondly, that this difference of condition was due to vaccination. We cannot but lay stress on the force of the facts relating to the fatality, the attack-rate, and the type of the disease, in the vaccinated and unvaccinated classes, when considered in 123 tion with one another. |
e54de0dc-2cbc-4334-8016-fbcecb0b65f9 | So far as can be ascertained, there was nothing materially to distinguish the two classes, except that the one contained, with some possible exceptions, unvaccinated persons only, whilst the other consisted, certainly for the most part, of vaccinated persons; unless it be, as suggested, that the unvaccinated class comprised a larger proportion of weakly persons. We have already expressed our opinion that this suggested distinction is not an adequate explanation of the very different fatality in the two classes if that phenomenon stood alone. It appears to us in no way to account for the difference in the attack-rate and type of the disease which equally distinguishes these same classes. Though a stronger constitution may enable a patient better to battle against the disease, and so avoid a fatal result, than a weaker one, we are not aware of any evidence that strength of constitution would determine the type of the disease. |
f3164b4f-1951-4be0-9424-e07a5f0d17a0 | We believe that confluent cases are frequently found in those whose constitution is strong, and mild cases in those who are not of robust health. Nor, again, is there any ground for asserting that if both came equally within the reach of contagion a person of good physique would escape its influence, while another less robust would be attacked by the disease. And yet the distinction between the vaccinated and unvaccinated is as marked, or even more marked, when the attack-rate and type of disease are studied than when the fatality of the disease is in question. In dealing with the comparison between the attack-rate and fatality of the classes of vaccinated and unvaccinated persons, no distinction has hitherto been drawn in respect of the quality or character of the vaccination. Many (though not a large number proportionately) have been included in the vaccinated classes whose arms bore no marks of vaccination. In the case of some of these the operation of vaccination may have been performed without success. |
b6e4a10f-098f-4898-adc9-4ac8d82a3d61 | If vaccinia did not result from the operation, it could, of course, have no more effect than if it had never been performed. Amongst those whose bodies showed by the marks they bore that vaccination had undoubtedly been successful, the 124 number of cicatrices varied from one to four and upwards. The cicatrices differed also in size. They have also been distinguished according as they exhibited, or did not exhibit, foveation. The question whether the protection afforded by vaccination differs in proportion as it has been, more or less thorough has been made the subject of investigation. Dr. Gayton, in his analysis of the cases of the Homerton Hospital already referred to, furnishes the following particulars:— Of 592 persons with 1 good mark, 22 died, or 4.1 per cent. |
d28b95a4-898e-413a-8b61-baeb3b2eda38 | „ 649 „ 2 „ marks, 22 „ 3.3 „ ,, 518 ,, ,, ,, 3 ,, ,, 12 2.3 ,, „ 389 „ „ 4 or more good marks, 6 died, or 1.5 per cent. The following table gives the results derived from Mr. Sweeting's observations at the Fulham Hospital, divided according to the age periods 0 to 10, and over 10 years of age:— - One Mark. Two Marks. Three Marks. Four & over Four Marks. Cases. Deaths. Death Rate. Cases. Deaths. Death Rate. Cases. Deaths. Death Rate. Cases. Deaths. Death Rate. |
e110fc83-fae4-4f7c-bc7e-4571f72b6e0c | 0—10 21 1 4.76 29 1 3.45 37 0 0 53 0 0 Over 10 years of age 384 41 10.68 509 46 9.04 459 37 8.06 396 19 4.80 At all ages 405 42 10.37 538 47 8.73 496 37 7.45 449 19 4.23 With regard to the area of the marks, Mr. Sweeting gives the following information:— 125 - More than ½ square inch Total Area. Less than ½ square inch total Area. Cases. Deaths. Death Rate. Cases. Deaths. Death Rate. 0—10 0 0 — 11 0 0 Over 10 years of age 60 3 5 per cent. 240 40 16.6 percent. Dr. |
3e63bfa0-5f04-4f4d-8cdb-49a4c76a258a | Thorne Thome handed us a table founded (a) on information given in the 36th volume of the Medico-Chirurgical Society's Transactions by Mr. Marson, as the result of his observations made during the years 1836 to 1851 on 3,094 cases of post-vaccinal Small-Pox, and (b) on data derived from Mr. Marson's evidence before the Vaccination Committee of 1871, based on a further experience of 10,661 such cases, and covering the years 1852 to 1867. Percentage of Deaths Percentage of Deaths in each Class respec- in each Class respecCases of Small-Pox classified according to tively ; Uncorrected, tively; Corrected. the Vaccination Marks borne by each Patient respectively. 1836-51. 1852-67. 1836-51. 1852-67. 1. |
6593bc88-ef26-471c-a32b-39ea484df083 | Stated to have been vaccinated, but having no cicatrix .25-5 40. 3 21.7 39. 4 2. Having one vaccine cicatrix 9. 2 14. 8 7. 6 13. 8 3. Having two vaccine cicatrices 6. 0 8. 7 4..3 7.7 4. Having three vaccine cicatrices 3. 6 3. 7 1.8 3. 0 5. Having four or more vaccine cicatrices 1.1 1. 9 0.7 0. 9 Unvaccinated 37.5 35.7 35.5 34.9 Taken together, the number of cases, classified according to the marks found on the patients, is very considerable; it exceeds 20,000. Apart from Mr. |
c8a45e56-2706-46ee-addb-b8399a7298a3 | Marson's cases the number is 6,839. Dealing with this number, they being all cases in which the observations were made in very recent years, and dividing into classes according to the number of marks, we obtain the following result:— 126 1 mark, 1,357 cases with 85 deaths, or 6.2 per cent. 2 marks, 1,971 „ 115 „ 5.8 „ 3 ,, 1, 997 ,, 75 ,, 3.7 ,, 4 ,, 1,514 ,, 34 ,, 2.2 ,, Dr. Gayton, in his evidence, stated that, in the analyses which he gave of the cases at the Homerton hospital, when he found one good mark and some imperfect marks, he ignored the imperfect marks and only recorded the good one. |
a30b2b2b-b5a6-4299-b8b1-9d7e521e315b | As the basis of his calculations was not precisely the same as that adopted in the other cases, it may be well to see how the figures would stand if Dr. Gayton's cases be eliminated. We should then have 4,754 cases, distributed as follows:— 1 mark, 828 cases, with 63 deaths, or 7.6 per cent. 2 marks, 1,322 „ 93 „ 7.0 „ 3 ,, 1.479 ,, 63 ,, 4.2 ,, 4 ,, 1,125 „ 28 „ 2.4 „ We think it is of importance to ascertain the effect of combining in this way the information obtained from different observers. The greater the number of cases in which the comparison can be made, the less opportunity is there for the undue influence of any accidental circumstance, and consequently the higher is the value of the result. |
d4cd93e8-8f02-4161-954f-d88a127ff87a | Upon the whole, then, the evidence appears to point to the conclusion that the greater the number of marks the greater is the protection in relation to Small-Pox enjoyed by the vaccinated person. This further indication also seems to be afforded, that whilst the distinction in this respect between those with one and those with two marks is not very great, there is a very marked contrast between those with four or even with three marks as Compared with those with either one or two. The subject of re-vaccination, to which we have already alluded, is obviously one of great importance. If vaccination 127 exercises a protective influence which diminishes in its effect after the lapse of some years, it is of moment to ascertain whether that influence can be restored by a repetition of the vaccine operation. |
6f79a295-8f9e-4160-88b1-c6627178f5b1 | Moreover, if it should be found that re-vaccinated persons are more favourably situated with reference to an attack of Small-Pox than unvaccinated persons or than persons vaccinated only in infancy, this would obviously have a direct bearing on the disputed question whether vaccination has a protective influence. Unfortunately, it is not possible to obtain any statistics shewing the amount of re-vaccination in this country generally. It is certain that it varies greatly in different towns, and the amount is probably not anywhere large, in proportion to the number of the population who have passed the age of childhood. The proportion of re-vaccinated persons to the population almost certainly increases in any town immediately after it has been visited by an epidemic of Small-Pox. A panic then arises which leads many people to resort to vaccination. In speaking of re-vaccination it is necessary to distinguish between cases in which the operation has been performed without result and cases of successful re-vaccination. |
c889eb4b-a3d7-49ca-8ae4-f396f0507fe1 | It is only when the vaccine virus has induced vaccinia that a person can properly be called re-vaccinated. The term is, however, often applied where the attempt to re-vaccinate has failed. In that case the subject of the operation has acquired no more protection by the process than if re-vaccination had never been attempted. No doubt the want of success shews, if the operation has been thoroughly performed, that the person is at the time insusceptible to the virus, and, it may be, to the virus of Small-Pox also. But this condition of insusceptibility is not necessarily permanent, and it is impossible to predicate how long it may last. Moreover, experience shows that where re-vaccination has led to no result, a repetition of the process after a lapse of a few days only may produce the normal features of successful re-vaccination. |
e83e0552-8152-4ed3-ae34-784d338d1377 | A single unsuccessful attempt at re-vaccination cannot therefore be 128 regarded as an indication of insusceptibility unless of the most transient nature. Where re-vaccination is not successful, this may be due on the one hand to insusceptibility produced by the previous vaccination, or, on the other hand, to impotency of the operation caused by the imperfection of the lymph used or by want of skill on the part of the operator. Where re-vaccination, unsuccessful at the first attempt, is successful when the operation is repeated after a short interval, there is strong reason for thinking that the want of success was due to the latter and not to the former cause. If a re-vaccination is unsuccessful it ought not from that fact to be taken for granted that immunity is certain, but the operation should be repeated once or even twice, as in the case of failure of primary vaccination in infants. In London Dr. |
0781ee62-c9ad-4d62-8227-0fe08de36cf1 | Luff reported the number of attacks of revaccinated persons to have been 108, with four deaths, showing a fatality of 3.7. The fatality shown amongst vaccinated persons above the age of 10 in the same epidemic was 4.2. The fatality amongst the unvaccinated of a similar age was 20.9. The character of the disease in the re-vaccinated class was reported to be mild in 101 cases and severe in seven. Dr. Gayton gives the following facts as regards Small-Pox among the hospital staff at the Homerton Small-Pox Hospital. From 1 st February, 1871, the date when the hospital opened for the reception of patients, to the end of 1877, 366 persons had been employed in the hospital. All of these were re-vaccinated on commencing duty, with the exception of an assistant nurse, who was not brought under Dr. |
2e98e65f-1d9d-44a9-90e5-8069d2f51b01 | Gayton's notice for some reason until after she had been in the wards. This woman in a fortnight was down with the Small-Pox, and passed through a severe attack, but recovered. Dr. Gayton was unable to give the exact number employed in the years subsequent to 1877, but he thought it might be fairly estimated that an equal number were engaged 129 in the work. There was only one person attacked among these, she had not been re-vaccinated. A third case occurred, in which a nurse engaged in the hospital was attacked. She was sent into a ward on 27th February, 1880, after being re-vaccinated. On 3rd March, the operation, being evidently a failure, was repeated. On 7th March, however, she presented symptoms of Small-Pox. |
a43cb4c3-ed27-4d69-bcc6-b9f1a8b9e3bc | In the Small-Pox Ship-Hospitals of the Asylums Board during the 12 years, 1884-95, among the attendants (doctors, nurses and servants), varying in numbers from below 50 during the year to a little over 300, cases of Small-Pox have occurred in three years only, in 1884, in 1892, and in 1893 ; in all the other years there were no cases at all. In 1884, with 283 attendants employed, there were four cases; in 1892, two cases among 138 attendants ; in 1893, six cases among 320 attendants. It is a striking fact that in all these years there should have been so few attacks of the disease amongst so many persons who were in a remarkable way exposed to contagion, for the exposure to contagion in a ShipHospital is very great. |
bad555d4-068d-42d1-bc4c-0cdaa344550c | It is to be observed that in one of these cases the disease appeared within three days of her entering the Hospital; in another nine days, in four others ten days, and in four others twelve to fifteen days after they joined the staff. None of the recorded cases appear to have been re-vaccinated successfully prior to the period of incubation of the Small-Pox, though the operation was in all cases attempted shortly after joining. Mr. Sweeting gives the following statistics on the same point with reference to the Western Hospital, formerly the Fulham Hospital:—The total staff, during the time the Hospital has been in use, is stated by him to 'have been 362, of whom one half, roughly speaking, were habitually employed in the wards. Of the 362, 48 had had Small-Pox before they came into the Hospital. Of 314 persons who had never had the Small-Pox, seven contracted the disease. |
8fa3f963-7aba-4fa3-881f-3985a3d377f1 | Two of these seven had not been revaccinated on entering the Hospital, owing to some oversight. 1 130 Two were unsuccessfully re-vaccinated, one of these being a case of second Small-Pox; another was not re-vaccinated early enough, as the operation was not performed until the fifth day; and in the other two cases there is no record of any result. These occurred in his predecessor's time. The total staff employed in ambulance duty was 42. Of this number only one took the Small-Pox. He was not re-vaccinated, his arrival not having been reported. He contracted the disease thirteen days after he arrived on duty. Mr. Marson, surgeon to the Highgate Small-pox Hospital, giving evidence before the Select Committee, stated that during the preceding 35 years no nurse or servant at the hospital had been attacked with Small-Pox. |
27952749-028c-49b2-85d6-cff7884bb8f9 | Since then, up to the present time, one case only, that of a gardener, has occurred, so that there is now a record of nearly sixty years with one case only. Of the 137 nurses and attendants who have been taken on since May, 1883, 30 had had Small-Pox previous to their entering the service. (Some of these were patients in the hospital, engaged as nurses or ward maids after their recovery.) All the others were re-vaccinated upon entering the service, with the exception of the one case, the gardener who took the disease. Typhoid Fever cannot fairly be compared with Small-Pox, since the mode of contagion is different. Nor are there records available as to the hospital staff specially in care of Typhoid Fever or of Diphtheria patients as there are in the case of Small-Pox. |
55b9bd48-9e10-46b5-af69-fbf7da69b345 | But if the cases of ordinary contagious diseases, such as Scarlet Fever and Diphtheria, be taken together, and even if Typhoid Fever be included, a striking contrast is afforded by the returns of the Metropolitan Asylums Board between the attendants in the hospitals treating these diseases, and those in the Small-Pox and Ship-Hospitals mentioned above. This is shown in the following table:— 131 Year. Metropolitan Asylums Board's Fever Hospitals. Metropolitan Asylums Board's Small-Pox Hospital-Ships. Number of attendants employed either temporarily or otherwise in the course of the year. Of whom, there contracted Scarlet-Fever, Diptheria or Typhoid during the year. Number. Proportion. Number of attendants employed either temporarily or otherwise in the course of the year. Of whom, there contracted Small-Pox during the year. Number. Proportion. 1884 283 4 1.4 per cent. |
37957449-f593-40d8-a592-9c45a1baa290 | 1885 Figures not available. 240 0 0 „ 1886 110 0 0 „ 1887 1,103 37 3.4 per cent. 55 0 0 „ 1888 Figures not available. 35 — 46 0 0 ,, 1889 42 — 53 0 0 „ 1890 1,312 53 4.0 per cent. |
0673d8b5-3aae-48d9-9cf7-37b0d60514b5 | 64 0 0 „ 1891 1,160 68 5.9 „ 64 0 0 „ 1892 1,652 121 7.3 „ 138 2 1.4 „ 1893 2,175 121 5.6 „ 320 6 1.9 „ 1894 2,182 111 5.1 ,, 289 0 0 „ 1895 2,514 116 4.6 „ 274 0 „ Making every allowance on the one hand for the mixed character of the cases in the Fever Hospitals, and on the other hand for doubts about the re-vaccination of some of the staff at the ship-hospital, it is clear that Small-Pox stands apart from all the other contagious diseases in relation to attacks among the staff. We have further evidence with regard to the postal service. |
300ce14f-0b96-486f-ab65-0d76b0530495 | Sir Charles Dilke, speaking in June 1883, made the following statement about those employed in that service in London:— " In the case of persons permanently employed in the postal service in London, averaging 10,504, who are required to undergo vaccination on admission, unless it has been performed within seven years, there has not been a single death from Small-Pox between 1870 and 1880, which period included the Small-Pox epidemic, and there have been only 10 slight cases of the disease. In the telegraphic department where there is not so complete an enforcement of vaccination there have been only 12 cases in a staff averaging 1,500 men." |
ecabad55-635d-402d-825c-5e8232f2497d | When it is remembered how many of the persons so employed become subject in a degree exceeding 132 that of the population at large to the risk of contagion, and that the period referred to included that of the epidemic in London of 1870.2, when there were so many attacks of and deaths from Small-Pox, the statement is certainly noteworthy. We have not been able to obtain information bringing the statistics given above down to the present date. We have been furnished, however, with the following particulars:— Year. General Post Office Number of established officers employed. Number of cases of Small-Pox. Number of deaths from Small-Pox. 1891 47,264 None. None. 1892 54,198 2 None. 1893 58,311 4 None. |
02a00bf8-f7bb-42d7-8bd5-7176a3571b7d | 1894 60,490 11 1 It is noteworthy that, in the year 1892, 12 officers were absent from duty on account of the presence of small-pox in their houses ; in 1893, 44 ; and in 1894 as many as 53. It should be mentioned that a study of the facts observed by the medical men who have investigated recent epidemics tends to the conclusion that the re-vaccination induced by the existence of an epidemic of Small-Pox has played no small part in checking the spread of the disease and narrowing its limits. It seems to have been a very important factor in controlling the epidemic. |
28151e49-0e9f-4fd2-b38f-c9836b128f91 | Summing up, then, the evidence on the subject of re-vaccination so far as regards this country, we find that particular classes within the community amongst whom re-vaccination has prevailed to an exceptional degree have exhibited a position of quite exceptional advantage in relation to Small-Pox, although these classes have in many cases been subject to exceptional risk of contagion. We find, further, taking the evidence as a whole, that in the population at large re-vaccinated persons seem to be 133 in a position much more advantageous not only than the unvaccinated, but than adults who have only been vaccinated in infancy. There is another conclusion suggested by the evidence to which we ought to advert, for it is of importance. Where re-vaccinated persons were attacked by or died from Small-Pox, the re-vaccination had for the most part been performed a considerable number of years before the attack. |
0f908ef1-ef1c-4bf4-88b8-e886343ea597 | There were very few cases where a short period only had elapsed between the re-vaccination and the attack of Small-Pox. This seems to show that it is of importance in the case of any persons specially exposed to the risk of contagion that they should be re-vaccinated, and that in the case even of those who have been twice vaccinated with success, if a long interval since the last operation has elapsed, the operation should be repeated for a third, and even for a forth time. Much criticism has been applied to the writings of Jenner, and of other early advocates of the practice of vaccination, and strenuous efforts have been made to shew that their observations cannot always be relied on, and that their reasoning was at times unsound. This appears to us, even if it were established, to be of little importance as a guide to the conclusion which ought to be arrived at on the question whether vaccination affords any protection against Small-Pox. |
73ece8f3-418e-481f-85a8-680198991f1d | We have now in our possession the experience of more than half a century, during which facts relating to the effect of vaccination upon Small-Pox have been carefully recorded. If a study of this experience taught us that vaccination had not exercised any beneficial influence as a protection against Small-Pox, that the ravages of the disease were as great in the case of the vaccinated as of the un-vaccinated, and that no difference could be observed in the manner in which it treated the two classes, we could have no faith in vaccination as a prophylactic, however apparently accurate the observations of Jenner and his associates, or however apparently conclusive their 134 reasoning. |
aaac73b3-0c6d-403a-b86f-4c1b27899db5 | If, on the other hand, the reasonable conclusion, from an experience of more than half a century of the practice of vaccination, be that the vaccinated show less liability to attack by the disease of Small-Pox, or when attacked, suffer less fatally or severely, these facts cannot be displaced by showing Jenner and his associates erred in some respects both in their observations and in the conclusions they founded upon them. It would, in our opinion, in that case, have been proved that however mistaken they may have been in other respects, they were right at least on this cardinal point, that the vaccinated enjoyed a position in relation to Small-Pox superior to that of unvaccinated persons. |
b273a2f0-2209-44e6-b800-559b45c43369 | We think it would be as little reasonable to reject the conclusion to which the experience of vaccination led us, because Jenner and other early advocates of the practice made mistakes, as it would be to believe in its protective influence on account of the credit which seemed due to their judgement or observations, in spite of the lessons to the contrary taught by a lengthened experience of the practice. In saying this, we must not be supposed to admit that all the criticisms to which Jenner and his associates have been subjected are sound, or to give our adhesion to them; we have desired only to point out why it seems to us of comparatively little importance whether they be so or not, and to assign to them their true place among the considerations which ought to guide us in determining the question whether or no vaccination has a protective influence. We proceed, then, to sum up the evidence bearing upon the question whether vaccination has any, and, if so, what protective influence in relation to Small-Pox, and to state the conclusions at which we have arrived. |
41310917-b0ce-45dd-bc1d-ac439b4d54a4 | We find that the period which immediately followed the introduction of the practice of vaccination was characterised in all countries in which the practice prevailed by a marked though irregular diminution of Small-Pox mortality, and that this diminution of mortality, when compared with the century 135 preceding vaccination, has continued in those countries down to the present time. We think this statement of the case is accurate, notwithstanding that the present century has witnessed epidemics of considerable severity, even in countries where vaccination has largely prevailed. There has always been in those countries a class, more or less numerous, of unvaccinated persons who would, of course, be no less subject to the disease than if their neighbours, like themselves, had remained unvaccinated. |
5423aeee-6e7c-48af-855c-b96753d04eb9 | Moreover, if it be true that experience has taught that the protective effect of vaccination diminishes in force, or for some purposes may even disappear, after the lapse of, say, ten years from the date of the operation, there will be many of the vaccinated class liable to be attacked, and to suffer more or less from the disease, even conceding the protective effect of vaccination. We cannot think, therefore, that the fact that epidemics have from time to time occurred, and that deaths from SmallPox continue, ought reasonably to be accepted as a proof that Small-Pox is uninfluenced by vaccination. In referring to the experience of the period which followed the introduction of vaccination, we are, of course, speaking generally. We have already considered the extent to which causes other than vaccination may have contributed to the diminished mortality from Small-Pox. We observe next that there has been in the United Kingdom a remarkable change in the age-incidence of Small-Pox. |
5f150924-8534-42ec-972f-af3665a57cd7 | The change does not appear to have been confined to this country, but we limit our remarks to it, because we have not as precise information on the point in the case of other countries. This change in the age-incidence appears, on the whole to have become increasingly marked as the infantile population came to be more completely vaccinated. On the other hand, we have seen that where vaccination has been neglected or practically abandoned, a Small-Pox epidemic has been characterised by a very large mortality among children, when compared with the mortality exhibited in a well-vaccinated place visited by an epidemic of the 136 same disease. This affords support to the view that vaccination is of protective value against a fatal result in the case of persons attacked by Small-Pox, and that its protective power is greatest during the early years after vaccination has been performed. We are unable to see that any satisfactory explanation has been given of the phenomenon now under consideration except that just indicated. |
290130da-c4bd-4ac6-85e8-0040898492d8 | We are indeed quite unable to appreciate the bearing of some of the circumstances which have been put forward as explaining it. As to others, such as improved sanitation, we have already pointed out that they do not really afford any explanation of the phenomenon when viewed, as it must be, in connection with the age-incidence and mortality found to prevail in the case of other diseases. There is further strong evidence that where attacks of SmallPox occur the fatality is far less in the case of the vaccinated than of the unvaccinated, and that this difference is much more marked in the first 10 years of life than at a later period. We have given full effect to all the considerations which have been urged with the view of showing that the division into vaccinated and unvaccinated cannot be relied on as accurate. |
bf9bef09-e9ad-450f-aedf-d9cfdc8ec837 | We quite admit that absolute accuracy may not have been obtained in any of the instances in which this discrimination has taken place, but looking at the matter fairly as a whole, we cannot but believe that the division may for all practical purposes be regarded as substantially accurate. Indeed, for the most part it would seem to err, if at all, in representing the vaccinated class as comparing less favourably than it really ought with the unvaccinated, for all cases of doubtful or alleged vaccination have been included in the vaccinated class, and whatever errors there may have been in erroneously placing vaccinated cases in the unvaccinated class, we think that they are counterbalanced by errors in the opposite direction. |
ae6c6f33-e646-4bdb-ba43-84e010bc0c1b | We think the improbability extreme, indeed it seems to us to reach the point of incredibility, that the fatality in classes of persons discriminated on different occasions by so many different observers, only on the ground that vaccination was 137 believed to be present in the one and absent in the other, should always show so very wide a divergence, unless there were some real difference in the liability to a fatal attack of those included in the one class as compared with those comprised in the other. We can see nothing to differentiate them in this respect, save that the one class possessed, while the other did not, the protection of vaccination, unless it be the circumstance suggested that the unvaccinated were drawn from a more neglected, and therefore from a less robust portion of the population. We have already given our reasons for thinking this explanation quite insufficient to account for the phenomenon. |
cb4e616d-e94b-4c4e-96d4-ef3f0f65b0b0 | We notice further that the same classes of vaccinated and unvaccinated persons, which display when attacked by Small-Pox so marked a contrast in the fatality of the disease, manifest a contrast no less marked in the type of the disease from which they suffer, viewed in relation to its severity or mildness. Here again, unless vaccination be regarded as the determining cause of the difference, it would remain to us, after considering all the explanations which have been vouchsafed, an unsolved mystery. The next point forced on our attention is the greater liability to attack, which the evidence shows to exist in the case of the unvaccinated than of the vaccinated. We are, of course, again confronted by the possibility of error in the classification, but the same test was applied in dividing into the two classes those who inhabited the invaded houses as in making a similar division in the case of the individuals attacked. |
74db704a-c307-43e2-b282-62ccf37b524f | It is possible, too, that the inhabitants of the invaded houses included in the two classes were not all equally within the reach of contagion, but any error in this respect is just as likely to have affected the vaccinated as the unvaccinated class. When the numbers dealt with are considered, and it is remembered that the classification was made in different towns, and always with the same result, we do not think this source of possible error can be regarded as serious. 138 When we find again that, both as regards the type of the disease and the attack rate, the contrast is specially noticeable in those under 10 years of age, and that the explanations proposed are even less deserving of weight when applied to these phenomena than when regarded as a reason for the difference in the fatality of the disease in the two classes, the conclusion that vaccination exercises an influence in relation to Small-Pox, specially potent during the early years after the operation, to which, as we have already indicated, other considerations point, receives strong confirmation. |
b41d0101-2f6a-41f0-9a62-b3e485910bbe | We see no reason for hesitating to adopt the conclusions to which we should otherwise be led, or to doubt the accuracy of the facts to which we have been adverting, on account of the objection, even if it be well founded in fact, that the fatality among the unvaccinated at the present day exceeds that experienced before the era of vaccination. We have already pointed out that in the statistics of modern times, with which we have been dealing, the fatality among the unvaccinated varied greatly, and it is by no means established that there were not as great variations in the pre-vaccination days. We have still to notice two other groups of facts bearing upon the question. We have shown that there is evidence that where vaccination has been most thorough, the protection appears to have been greatest. |
ee26f50e-f469-4651-81f9-81b8090d88da | It may be that on this point the force of the evidence is less than on some of those just alluded to; nevertheless, it cannot be left out of sight, or regarded as of no importance, when we are seeking an answer to the question whether vaccination has a protective influence, or is altogether ineffectual. The fact that the re-vaccination of adults appears to place them in so favourable a condition, as compared with the unvaccinated—and that, too, even when they are subjected to specially grave risk of contagion, and we take this to be established as a fact—affords further confirmation of the conclusions 139 suggested by the evidence which we have already passed under review. We have hitherto, save for a cursory reference to the bearing of some of the facts upon one another, treated the various tests which have been applied to ascertain whether vaccination has a protective effect separately and independently. |
81aab719-7a50-4ce8-ae0c-5fcdeb24d6cf | We have found that in each case the result of the test has been to suggest an affirmative answer to the question. In order to estimate the value of the evidence aright, it is necessary to consider in conjunction all the tests which have been adopted, and the results which they exhibit. They are, it is true, independent of one another, and have been separately applied in a number of cases. But the greater the number of tests employed, and the greater the number of cases to which they are applied, the more certain is it that the play of chance, or the influence of other causes, will be excluded, and the more safely may the conclusions to which they lead be acted upon. The cumulative force of a number of independent pieces of evidence, all pointing in the same direction, is very great indeed. Even if a more or less plausible answer could be suggested in the case of each one of them standing alone, the cumulative force of the testimony might still be irresistible. |
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