w m% L I B RA FlY OF THE U N IVERSITY or ILLI NOIS SMALL-POI AND VACCINATION. A LETTER TO THE Right Hon. LYON PLAYFAIR, C.B, M.P., F.R.S., 4'c., 4-c.; WITH REFERENCE TO MR. HOPWOOD'S ilOTION FOR THE REPEAL OF THE COMPULSORY CLAUSES OF THE YACCINATION ACTS. WILLIAM B. CARPENTER, C.B., M.D., F.R.S., Sfc, Sfc, Corresponding Member of the Institute of France. LONDON: HARRISON AND SONS, ST. MARTIN'S LANE, /-T 1883. SMALL-POX AND VACCINATION. Dear Dr. Playfair, Before the House of Commons is moved to repeal the compulsory clauses of the Vaccination Acts, I desire to call your attention, and that of other Members of the Legislature, to what appear to me the very cogent reasons against this measure, drawn from facts which cannot be contested. I take as my basis Mr. P. A. Taylor's own Table^^ of the mean annual death-rate from Small-pox per 1,000,000 Hving in England and Wales, from 1 838 to 1879 ; substituting for the rate 344 given by him as that of the last period (which is really that for measles) the true small -pox death-rate now admitted by him to be no more than 82.t With this I combine a similar Table for Scotland, commencing with the date at which the Registration-system was intro- duced ; and across each column I have drawn a hne, showing when Vaccination was made compulsory : — England and Wales. Scotland. 1838—42 571 1843—46 No returns. 1847—49 803 1850—54 279 1855—59 199 1855—59 298 1860—64 190 1860—64 392 1865—69 147 1865—69 47 1870—74 4.33 1870- 74 375 1875—79 82 1875—79 10 Now, although, by Mr. Taylor's own showing, the Small-pox death-rate had progressively come down in England and Wales from 571 in 1838-42 to 147 (or scarcely more than one-fourth) in 1865-69, * Nineteenth Century for May, 1882, p. 794. t See my letter in the Echo of May 31, 1882, and bis reply thereto in the Echo of June 2. he sees no evidence that Vaccination had anything to do with this decline. Such evidence is furnished, however, by the marked irregularity in the rate of that reduction ; by far the greatest fall occurring in the periods which followed the two principal legisla- tive measures for the promotion of Vaccination. Previously to 1840, the Vaccination of the great bulk of the population depended upon the gratui- tous action of the Medical profession ; and in many country localities it was altogether neglected. The consequence of this was, that severe epidemics of Small-pox were not unfrequent ; but as there was no general system of Registration until 1838, the actual mortality could not be determined. It was in 1840 that provision was first made for Vaccination out of the Public purse ; and it is only by separating the years of Mr. Taylor's first quinquennial period, that tlie immediate efi:ect of that measure is made apparent. ,^ Small-pox J ^'^^- Death-rate. Averages. 1838 1,064 1839 589 1840 663 _ 772 Public Vaccination. 1841 400 1842 168 284 Admitting the death-iate of 1838 to have been exceptionally high, I do not think it fair to take the short three years' average, 772, as representing the Small-pox death-rate previously to the introduction of Public Vaccination ; but accept Mr. P. A. Taylor's own average, 571, of the entire quinquennial period. So, again, as the death-rate of 1842 was exception- ally low, I do not claim the whole of the sudden reduction of the two years' average to 284 as the result of that measure. But it is clear that it was followed by a sudden and marked reduction, and that this reduction was continuously maintained ; the death-rate being little more than one-half m the B 2 period 1847-49, and less than one-half in the next quinquennium. — It was in 1854 tiiat Vaccination was made comjjulsory in England and Wales ; and another sudden reduction took place in the next quinquennial period, followed by a further con' tinuoiis reduction in the two succeeding periods, bringing the death-rate down in the years 1865-61) to little more than one-fourth of what it had been in 1838-42. These facts are made conspicuous by the follow- ing graphic arrangement : — Death- rate. 1838-42. 1847-49. 1850-54. 1855-59. 1860-64.1865-69. I 1870-74.1875-79. (300 500 400 300 200 • -- 100 fuiuctl Now that this second reduction in the EngHsh death-rate was not due either to any mitigation in the type of the disease, or to a general improvement in the health of the population, is shown by the fact that the Small-pox death-rate in Scotland, where Vaccination was not then compulsory, was fifty per cent, higher than that of England for the years 1855-59, and more than a hundred per cent, for the years 1860-64. — Compulsory Vaccination being then introduced into Scotland, and being accepted by its population generally without resistance, the Scotch mortality immediately underwent a most extraordinary diminution ; the mean for the ensuing five years falling from 392 to 47, a reduction of no less than eighty-eight per cent. So far, then, everything tells in favour of the effect of Vaccination in preventing Small-pox ; since it can scarcely be contended that three such successive reductions in the death-rate, following directly upon three legislative measures, and not only maintaining themselves, but steadily increasing, can be fortuitous. But, it is affirmed, the whole case for Vaccination breaks down under the severe Epidemic visitation of Small-pox which commenced in 1871, carrying up the mean death-rate for the quinquennnium 1870-74 to 433 in England, and 375 in Scotland. It is impossible for Mr. Taylor to controvert the fact, that this Epidemic originated in the importa- tion"'', at the end of 1870, of a type of Small-pox which had not prevailed in this country during the present century, but was often mentioned in the Medical history of the preceding 200 years as the " malignant ; " bearing the same relation in severity to the '* confluent," that the confluent bears to the " mild " or " discrete." Not five per cent, of those * It seems now clear that this " malignant " type of Small- pox had made its appearance in Brittany in 1867, and gradually found its way to Paris in the two succeeding years. attached hy it recover ; and death usually takes place witliiu four or five days — often before any eruption appears. It is the frequent occurrence of this form among the ?/7ivaccinated since 1870, which has raised the total proportion of deaths in that class in the Small-pox Hospitals of London to forty-Jive per cent, of the cases ; a proportion which (having been never even apprpached in any modern Small- pox epidemic) Mr. Taylor and his supporters have treated as ''incredible," but which the returns published by the Metropolitan Asylums Board unequivocally prove ; while even higher rates have been show^n in North America, as, for instance, above 50 per cent, in Boston, 54 per cent, in Montreal, and above 64 per cent, {nearly two-thirds of the un vac- cinated cases) in Philadelphia (see pp. il, 12). It is urged, however, by Mr. P. A. Taylor, that if this Epidemic is really of a more malignant cha- I'acter than has been known since the introduction of Vaccination, this only shows the fallacy of the ex- pectation expressed by Jenner and his followers as to the mitigation of Small-pox, if not its entire extinction. But no one has ever (that I know of) anticipated any such effect upon the ^t7^ vaccinated ; just as well might it be expected that Pasteur's " vaccination " of one flock of sheep would protect from the deadly charhon another flo(;k turned into a poisoned pasture. That the vaccinated have thus been almost entirely exempt from the " malignant " type of Small-pox, is shown by the fact that the proportion of deaths to cases among them in this epidemic has been but little above the average. I shall notygo again over the proof of this which I formerly gave f' but shall support my case for the protective influence of Vaccination, by the figures given by the llegistrar-Generalt in regard to the renewed outbreak of Small-pox in the Metropolis in 1S81. Of the 2,375 recorded deaths, 962 occurred * Nineteenth Centiiri/ for April, 1882. t Annual Sunimary for 1881> p. vi. among the certified imvaccinated, and 524 among the certi^ed vaccinated, 885 being reported as "doubt- ful/' It is quite obvious that even if the un vac- cinated residuum be admitted to constitute 15 per cent, of the MetropoHtan population, the advantage is enormously on the side of the vaccinated ; for (putting aside the " doubtful " cases) if the vaccinated portion of the population of London had died at the same rate as the un vaccina ted, their mortality would have been 5,451, or more than ten times as great as it actually was. This comparative exemption of the vaccinated is attributed by Mr. Taylor and his party to the different Sanitary conditions of the two populations ; but what evidence is there of this ? Doubtless some of the large areas which were almost entirely un- visited by this peculiarly localized epidemic, con- tained a population on the whole more favourably circumstanced in this respect than that of the North- east and South Districts, in which 68 per cent, of the total Small-pox mortality occurred.'"' But what about the nearly two million vaccinated subjects inhabiting the latter, who, according to Mr. Taylor, had no protection whatever, and were exposed, equally with the unvaccinated, to the infection *? There is a more cogent way, however, of testing Mr. Taylor's doctrine. If Vaccination affords no pro- tection, the ages at which the vaccinated and the un- vaccinated respectively die should correspond ; but the exact reverse of this is shown to be the fact by the Registrar- General's latest figures, as by all previous comparisons. Of the 962 deaths among the unvac- cinated, three-fourths (speaking roughly) occurred under the age of 20, the disease showing the same fatality among the young at present, that it used to do in pre-vaccination times : but of the 524 deaths among the vaccinated, three-fourths occurred above the age of 20, — that is to sa}^, among adidts, who * Registrar- General's Annual Summary for 1881, p. vii. 8 had outgrown their original protection, and had not (so far as was ascertained) renewed it by revaccina- tion. The proportion of children under 5 years old, vaccinated however indifferently, that died in the epidemic of 1881, was quite insignificant, bein^ only 5 "2 per cent, of the 524 deaths among the vaccinated ; whilst the proportion of deaths among t^?i vaccinated children under 5 years of age was 38*2 per cent, of the 962 deaths in that class. {Op, cit., p. vi). To the evidence of the protection afforded by re- vaccination which I have given elsewhere,'" I now add the following, the cogency of which can scarcely be over-estimated : — In Germany, vaccination is compulsory in children under a year old ; and every man on his entrance into the army is revaccinated. In France, on the other hand, vaccination is not compulsory, and revaccina- tion is not enforced on army-recruits. During the Franco-German War of 1870-71, the total number of deaths from Small-pox in the German army was 263, while in the French army it was 23,469, or very nearly ninety times as great. Of the 263 Small-pox deaths among the half-million or more of men brought into the field on the German side, it may be safely said that as many would have suffered in this Epidemic if they had been all "protected" by a previous attack of Small-pox ; and no one now claims for vaccination a greater power than this. What reason is there to doubt that the adoption of com- pulsory revaccination in the French army would have saved a large proportion of the 23,469 who died of Small-^ox, as well as an enormous amount of sickness ? The testimony as to the protective power exerted by revaccination upon nurses and hospital-attendants during the recent severe epidemics in the United States and Canada, is fully confirmatory of that of our own Small-pox Hospital superintendents. * Nineteenth Century for April, 1882. The control which Vaccination has exerted, and is exerting, over the ravages of this deadly pest, is farther shown by the fact that even during the worst period of its epidemic spread, the mean rate of Small-pox mortality was only a little more than three-fourths that of the period 1838-42, the later being 433, and the earlier 571 ; whilst upon its general subsidence, the death-rate of England and Wales fell during the next quinquennium to 82, — a figure far lower than it had ever previously approached. The reduction was still more remarkable in Scotland ; for the Small-pox death-rate of the epidemic years (which was somewhat lower than that of the years 1860-4 immediately preceding the introduction of compulsory vaccination) dropped suddenly from 375 to 10, and has for the last five years averaged only 4 per million."^ Now it is very easy to treat this extraordinary fall as an effect of the previous epidemic prevalence of Small-pox, which gave it to the great bulk of the subjects susceptible of the disease. But this theory fails in two particulars. In the first place, it is totally unsanctioned by experience, the amount of reduction being altogether unprecedented, as Mr. Taylor's own Table shows ; and, in the second place, it does not accord with the fact that, though the disease is still present among us in undiminished malignity (as is proved by the occurrence of local outbreaks in the Metropolis and elsewhere through the whole series of years since 1874), it attacked scarcely any of the four millions of infants born and vaccinated in England and Wales during the years 1875-9, or of the 800,000 born and vaccinated in * In drawing attention to the fact that the total number of Smcill-jtox deaths in all Scotland in 1878 was onlj four, the Registrar- General for that kingdom remarks — " This is a most satisfactory circumstance, for which we have no doubt, in a great measure, to thank our excellent Vaccination Act, and the common sense of our people, which does not dispose them to receive without qualification the statements of the Anti- vaccina^tors." 10 Scotland during the same period. And this con- dition of thinofs has continued, as recrards the Pro- vinces and Scotland, to the present time ; the only considerable exception to it being furnished by the outbreak of 1881 in London and the surrounding counties. But this outbreak, as already shown, was almost exclusively confined (1) to the known unvaccinated, (2) to those (ranked '' doubtful ") whose arms showed no sign of vaccination, and (3) to vaccinated adults who had not renewed the pro- tection i.hey had outlived. I feel fully justified, therefore, in re-affirming the protective power of Vaccination, as eminently shown in the control it has here exerted over this most deadly Epidemic ; more especially since Legislative provision was made, by the compulsory appointment of Vac- cination officers, for the more thorough enforcement, in the country generally, of the Law which it is now proposed to repeal. Of that enforcement, the locali- ties in which it has been resisted are receiving the benefit ; just as unvaccinated families who are living in parts of London not visited by Small-pox, are en- joying the practical immunity conferred by the " pro- tection " of the great bulk of their inhabitants. Of what would be the consequence of the aboli- tion of Compulsory Vaccination among ourselves, we may judge from the recent experience of the United States, where the system had never been adopted either by the Federal or the State Governments. The malignant type of Small-pox poison carried across the Atlsintic in 1871, was extensively diffused over the American continent in succeeding years, causing severe epidemics in most of its great cities. During a visit which I paid in the latter half of last year to the United States and Canada, I made a special point of gaining all the information I could from the most authentic sources in regard to this Epidemic ; and I everywhere received the same testimony to its extreme severity among the un- vaccmated population. Owing to the former absence 11 of any public provision for Vaccination in the United States, the proportion of unvaccinated was there much greater than in this country ; and no inconsiderable number of persons among the upper classes were destitute of its protection. The disease prevailed epidemically in Boston (N.E.) in 1873 ; and the number of deaths out of a population of 265,000 was 1,045 in thirteen months, or at the rate of 965 for twelve months. This was a far heavier mortality in proportion to the population, than even that of London in 1871 ; for the Metropolitan population, being then 12*3 times that of Boston, its pro-ratd mortality would have been 11,869, or almost exactly fifty per cent, more than the actual mortality of London in that year, which was 7,912. Now, it cannot be said that the general sanitary condition of Boston is worse than that of London ; but we are expressly told that " the disease in its most malignant and contagious form ivas present in every 'part of the city.'''''' The total number of cases was 3,187, and the number of deaths 1,045, being thus at the high rate of nearly one-third of the whole number attacked ; mainly owing to the terrible proportion of deaths to cases — considerably over 50 per cent. — among the im vaccinated. In Philadelphia (in which city the labouring population is remarkably well housed, " tenement- dwelling" being almost unknown), the number of cases of Small-pox in the twelve months' epidemic of 1871-2 was 2,337 ; nearly equalling the total number of cases (2,517) of this disease during the previous thirty years, t The total of deaths from Smalhpox during the previous thirty years had been only 429, or at the rate of 17 to 100 cases ; but in the Epidemic of 1871-2 the total number of deaths was 743, raising the death-rate of those attacked to 32*15, or nearly double the previous average. That * North American Bevieiu, April, 1882, p. 370. t I take these figures from the Report of the Board of Health of the City of Philadelphia for the year 1872. 12 this excess was mainly due to the large proportion of deaths among the ?ni vaccinated (of whom a consider - 9,ble proportion were negroes), is shown by the fact that putting aside the 51 cases in which there was no evidence in regard to previous vaccination, the numbers and percentages of deaths among the two classes w^ere as follows : — • Admissions. Deaths. Per Cent. Vaccinated . . Unvaccinated 1,629 697 276 449 16-94 64-41 Thus while the proportion of deaths to cases among those who had been vaccinated, whether well or indifferently, scarcely exceeded one-sixth, the pro- portion among the unvaccinated was nearly two- thirds, or cdmostfour times as great. — Surely, in the face of such evidence, Mr. P. A. Taylor and his sup- porters will no longer contend that there is nothing peculiar about this Epidemic, or continue to treat as " incredible " the statistics of our own Metropolitan Small'pox Hospitals, which showed a percentage of deaths among the unvaccinated amounting to nearly 45 per cent. I further learned that this Epidemic had been particularly fatal among the coloured population of some of thei Southern States, where Vaccination, formerly enforced by most of the planters on their slaves (for the protciction of their *' property "), had been of late very much neglected. I was personally assured by a medical officer, who had been sent by the United States Government to ta.ke charge of a Small-pox Hospital in the South, that the negroes smitten with this malignant ''black-pox" often fell down by the road-side ; and that such was the prevalent terror at this deadly plague, that these poor wretches were left untended by their own people, whilst he himself could with difficulty induce 13 his hospital attendants to bring them in, so certain was their speedy death I In Canada, the severity of the Epidemic in different locaHties bore a most direct relation to the proportion of tr/ivaccinated. Quebec, where vacci- nation had been all but universal, was passed over very lightly, notwithstanding the continual fresh importation of the poison. Among the immigrants, the mitigative efficacy of previous vaccination was very marked. Thus of 131 cases admitted into hospital between May, 1874, and June, 1875, the superintendent reported that among 54 returned as vaccinated, only one died; while of 69 unvaccinated 37 died, and of the 32 who recovered most were disfigured. In Toronto and Three Rivers, where vaccination had been general, there was scarcely any Small-pox. But in Montreal, where the French Catholic population had, as a class, been prejudiced against vaccination by a medical man of their own nationality and religion, the epidemic broke out with great severity. The Municipal authorities endea- voured to check it by compulsory Vaccination ; but this was resisted even to the extent of public rioting. Having heard of this at the time from my brother, the late Dr. P. P. Carpenter, who spent the last twelve years of his life in Montreal, I made a point of enquiring, during my stay there in August last, as to what had been the subsequent course of affairs. I learned, on the very best authority, that the objec- tions of the French Catholics had been completely overcome ; — partly by the public exposure made by the Medical profession of the flagrant mis-statements by which they had been misled, — partly by the very decided testimony in favour of the protective influence of Vaccination, given by the Catholic Sisters who took charge of the nursing in one of the Small-pox Hospitals, — and partly by their recog- nition of the fact, that the Irish Catholic population of their own class, living under the same conditions with themselves, but for the most jpart vaccinated, 14 almost entirely escaped. Vaccination being now as well carried out in Montreal by its Officers ot Healtli, as in the other great cities of the Dominion, Small- pox has become almost entirely extinct. So sensible are the highly intelligent people r)f the United States of the value of Vaccinntion, that although they do not consider direct compulsion a proper subject for Federal or even for State legisla- tion, yet they are now generally adopting a method of indirect compulsion, which has long been in use in many Continental countries — namely, the vaccina- tion of the whole existing School-population by Public Vaccinators, and the refusal to admit any child into the Public Schools without a Vaccination certificate. Of an admirable result of the adoption of this system — showing itself in the remarkable immunity of the whole School-population of San Francisco from a recent outbreak of Small-pox which originated in the Chinese quarter, and rapidly spi'ead among the adult population through even the best parts of the town — I last year gave an account,'" drawn from the lieport of its Officers of Health. I shall now cite another case from a Circular addressed on the 20th September, 188'2, by the Secretary of the Board of Health for the State of Illinois, to County Superintendents, School Boards, and Teachers, with reference to the " School Vaccina- nation Order" of the State Board of Health, pro- mulgated in December, 1881. At the date of this Order more than tivo-thirds of the School-population of Illinois proved to have been unvaccinated ; but subsequently to January 1, 1882, no fewer than 1,300,000 vaccinations had been performed, making, with those of the previous nine months, a total of two millions. " Until these measures were fairly under way, there was a steady increase of Small-pox in the State ; but coincidently with their successful operation came the decHne of the disease, until now * Nineteenth Century for April, 1882, p. 544. 15 it is practically at an end in Illinois," — but for a few small local outbreaks among unprotected persons, which showed that the poison had not lost its virulence : — " In Munroe county an outbreak was caused by an infected mattress thrown into the Mississippi River, which lodged in Staten Island. Some unvaccinated persons came in contact with the mattress, and a number of cases ensued. Thence it was carried into Randolph county, where it found a number of other unvaccinated individuals near Prairie du Rocher, ai)d caused an outbreak among them, with 3 deaths at date of last report. In Alexandra county, some 19 cases and 4 deaths have resulted from infection brought from the river ; all these were among unvaccinated persons." With this may be contrasted the following re- sults of the enforcement of the Vaccination Order upon the School-population of the State, '' demon- strative," as the Secretary justly remarks, '* of its wisdom and utility :" — " First. Among the tliousands of caf^es of Small-pox which have occurred in the State since the Order was issued, not one is reported of a Public Scholar who had been properly or recently vaccinated. Several cases, however, with a large pro- portion of deaths, have occurred among Scholars who either had not been vaccinated at all, or not since infancy. " Second. In no instance where the Order was thoroughly enforced has it been necessary to close the Public Schools, even when Small-pox existed in a community. On the other hand, ScJiools have been broken up and studies interrupted in a number of instances, where — as shown by the returns in this Office — the Order had been neglected." With reference to the statements sometimes met with, of serious results from Vaccination, the Secretary adds that : — " Having made it his personal duty to investigate every report of the kind which has come to his knowledge, the net result has been that not one such report has been substantiated. He has been wholly unable to find any evidence of a death caused by vaccination in this State, or even of permanent injury or serious illness, due to the operation alone." I have received from several other quarters the same testimony to the absence of injurious results, in an aggregate of recent vaccinations, now amount- ing to majiy millions^ that have been made under 16 public authority in tlio United States, with the pure heifer-]ymph obtained from the estabhshment of Dr. Martin of Koxbmy, Massachusetts ; and having myself visited it, I can testify to the conscientious care with whicli the purest lymph is there supplied. There have, on the other hand, been some most severe — even fatal — cases of purulent infection, which were traced to the employment (from motives of economy) of vaccine matter supplied from another source, which proved, on microscopic examination, to be charged with pus- corpuscles. — The moral of this is obvious. I now commend these recent experiences to the attentive consideration of those, with whom rests the grave responsibility of deciding whether, under the guidance of Mr. P. A. Taylor, and in opposition to the general voice of the Medical Profession, they will undo a system, under which the death-rate from Small-pox is shown by Mr. Taylor's own Table — still more by the corresponding Table for Scotland — to have undergone such an enormous reduction ; and which has restrained within narrow limits an Epidemic whose virulence among the unprotected populations of Borneo, the Gold Coast, and Mada- gascar (as attested by recent Consular reports) shows it to be no less deadly than that which ravaged most of the countries of Europe in 1614 even more destructivdy than the Plague. Although Mr. P. A. Taylor treated my former assertion of this virulence as invented on the part of the advocates of Vaccination, in order to cover its failure, I trust that the intelligence of your House will see that it is fully borne out by the additional facts I have now adduced from authoritative sources. I remain, Dear Dr. Playfair, Yours faithfully, WILLIAM B. CARPENTER London, April 23, 1883. fJABBlaON AND SONS, PBINTEBS IN OBDINABT TO HER MAJESTY, ST. MARTJN'S LAN2. ^<% «C ; w