• •■»■.•; •• .♦■%|'..i».' -..-•■■■. *^"»W'» ^.•.■♦- ■'«[(l»'" lit •v-f.:-. ^*: •<^i# V.' ■^' lv% • _ I i L I B RARY OF THE U N 1 VERSITY or ILLl NOIS t^ ^^^^^^ .5.=.**«^^ THE INFLUENCE OF YACCINATION ^cjc, ^t^, Hiitr #rcupati0ii MORTALITY IK SMALLPOX. ROBERT GRIEVE, M.D. MEDICAL SUPERINTENDENT OF THE HAMPSTEAD HOSPITAL. {Read be/ore the EpldenwJoiilcdl Societi/, lOth April, K72.) LONDON : J. & A. CHUECIIILL, NEW BURLINGTON STREET. MDCCCLXXII. THE INFLUENCE OF VACCINATION AGE, SEX, AND OCCUPATION ON THE MORTALITY IN SMALL POX. EOBEET GEIEVE, M.D., Medical Superintendent of ^lie Hampstead Hospital. (Read BEroRB the Epidemological Society, 10th April, 1872.) In Marcli, 1871, I brouglit under the notice of tliis Society an analysis of 800 cases of small-pox treated in the Hampstead Hospital during the existing epidemic. In the present paper I purpose giving, in a more detailed form, the statistics of a larger number, and from these figures endeavour to show the influence exercised by vaccination, age, sex, and occupation on the rate of mortality in small-pox. I confine myself to personal experience, trusting that a contribution towards the history of the present fatal outbreak by one who has had very great opportunities of observing it, may possess interest. Vaccination. — To show that the mortality amongst patients suffering from small -pox, and who have been previously vacci- nated, is very much less than it is amongst those who are not so protected, is, at the present day, but repeating a truism ; still, additional figures can do no harm, so I give them. Of 6,221 patients admitted, 1,248 were without marks of vaccination, and of these 638, or 51'12 per cent., died ; whilst among the 4,973 who showed proofs of being vaccinated, in only 567 instances did the disease prove fatal, giving a percentage of mortality of 11 "40. From these numbers it is seen, that although the number of patients received into the Hospital of the vaccinated class ex- ceeded the number in the unvaccinated, a fact of which the anti- vaccination League has made vigorous use, the larger number of deaths occurred amongst the unvaccinated. The general percentage of mortality is 19"36, which is above the average of late epidemics. This has been ascribed by Mr. Marson, who has noticed the same circumstance at the Small-pox Hospital, and whose lengthened experience entitles him to speak on this point with authority, not only to the form of the disease generally being more severe, but also to the large proportion of cases of the malignant and hjemorrhagic type which have come imder treatment. This great prevalence of haemorrhagic small-pox is characteristic of the present outbreak, and seems to depend upon a peculiar development of the epi- demic influence. It is possible for individuals to be vaccinated, and yet not to obtain all the protection they might do, as the vaccination may be ineSiciently performed. It may be inefiicient either in quality or quantity. As to quality, where there are different observers with possibly different standards, it is very difficult to reduce the results to figures ; so, while believing firmly that the character of the vaccine pock exercises an immense influence over its protec- tive power, I am unable to bring statistics to confirm my belief. With quantity we have not the sam.e difficulty ; there are the marks, and they have but to be looked for and counted. In the 3,555 cases in which the number of marks was noted, and in which the results are given in full in Table I, it is found that the percentage of mortality in those showing oue mark is 17'o9, showing two 12-17, showing three 10'58, showing four 8'38, showing five and more 6"43 — a scale in which the mortality is in inverse ratio to the number of mai'ks seen. The practical deduction to be made from these numbers is that the larger number of places in which we vaccinate tbe more protection is given. To obtain even a fair average of protection, at least three marks are required, but something is gained by exceeding that number. An interesting study in connection with the influence of cow- pox over small-pox is to watch the diseases when concurrent. A considerable number of children have come as patients into the Hospital suffering from both vaccinia and variola, and my ex- perience is, that if the cow-pock reach the eighth day before ^tf»< UIUC . \ / the small-pox eruption makes its appearance, the latter disease is modified. As tlie result of the investigations I have been able to make into the question of the period of incubation of small- pox, I have come to the conclusion that in the great majority of cases the small-pox eruption shows itself on the fourteenth day after the reception into the system of the variolous influence ; vaccination during the first three or four days of the period of incubation will accordingly be useful — a strong reason for vac- cinating persons in a house where small-pox has already shown itself. Of small-pox after re- vaccination I have not seen much, owing, I believe, to the rarity of its occurrence. Out of the 6,221 cases above mentioned, in only three could any satis- factory proof of previous re- vaccination be discovered. A good many of the patients said, on their admission, that they had been re- vaccinated ; but, on pressing the inquiries, it was found that while the operation had been performed no after efiects were produced, and that thereupon the doctor had assured them, that as they were not susceptible to the vaccination there was no fear of their taking small-pox. Their presence in the Hospital was sufiicient proof of the fallibihty of this doctrine, one which is inculcated even yet by many members of the profession. Our nurses and servants in constant and close attendance on small-pox, when protected by re- vaccination, do not take the disease ; and in this respect the experience at the Hampstead Hospital coincides with that at the older Institution at Highgate. I wish it were possible to bring home to the minds and belief of the general public my conviction regarding re-vaccination, namely, tliat it is a sure protection against small-pox. To ensure this protection, re-vaccination producing some local efiect must have been performed after the individual had reached 15 years of age. Cases of variola subsequent to re- vaccination are merely the exception that prove the rule ; they are more uncommon than second small-pox, and differ also in this way, that whereas the latter are frequently severe, and sometimes fatal, the former are very mild indeed. Age. — The extremes are alike unfavourable in small-pox, as will be seen by a reference to Table II, in which the percentages of mortality are highest at the beginning and end. Taking the unvaccinated class, amongst whom age is the chief modifying influence, we find the period of minimum mortality to be be- tween the 10th and 20th years of age. Under 5 as many as 70'87 per cent, die, this diminishes to 35'03 per cent, between 10 and 20, and increases gradually to 100 per cent, over 60, but the number in the last category is so small as to possess little value. Amongst the vaccinated the period of n 'nimum mortality is also between 10 and 20, after 20 tbe increase is proportionally greater than in the unvaccinated, showing that the protective power of vaccination becomes lessened by the efflux of time. Unvaccinated infants under one year of age rarely recovered. It is worthy of note that cases of small-pox of the hasmorrhagic type, unfortunately in this epidemic so common in adults, were very seldom found amongst the children. Sex. — !More males than females were treated, the active work of men bringing them in more frequent contact with the con- tagion : the numbei's were 3,377 males and 2,844 females, of the former 680, or 2013 per cent, died ; of the latter 525, or 18-49 per cent., a higher rate amongst males than females. This is the case both iu the vaccinated and unvaccinated classes ; but, taking age in conjunction with sex, we find that the lower rate of females is limited to adult life. Separating the patients under 20 from those over that age, the statistics are as follows : — Males under 20 — Vaccinated admitted 1,210, died 87 = 7-8 per cent. Unvaccinated „ 491 „ 251 = 51-12 „ Females under 20 — Vaccinated admitted 1,103, died 79 = 7'16 per cent. Unvaccinated „ 410 „ 225 = 54-87 „ Males over 20 — Vaccinated admitted 1,506, died 248 = 16-46 per cent. Unvaccinated „ 170 „ 94 = 55-29 „ Females over 20 — Vaccinated admitted 1,154, died 153 = 13-85 per cent. Unvaccinated ,, 177 „ 68 = 38-41 „ What makes the adult male more liable to death when attacked by small-pox than the female ? Primd facie one would suppose that the female, from her more delicate organisation, would stand tlie worst chance, bnt fignres show tliat the reverse is the truth. This eifect must be produced by something which lowers the vital powers of men — most pro- bably the mode of life. It may be that the extra wear and tear undergone by them in the capacity of bread-winners may have something to do with it? but I am inclined to ascribe it to the greater prevalence of dissi- pated and irregular habits amongst men than women. Nothing unfits one to cope with small- pox, and other diseases as well, more than previous dissipation. The likelihood of an imperfectly vac- cinated hard drinker recovering from an attack of this disease is, I believe, small. Occupation, like sex, influences the mortality both directly and indirectly : directly, by increasing the number of deaths in the sufferers from the malady ; and indirectly, by certain callings bringing those following them in more than average contact with the infectious cause. Table III, which is a classified list of all occupations, of which We have had more than 10 representatives as patients, exemplifies both influences. The occupations placed in it above the dotted line have amongst the vaccinated a percentage of mortahty higher than the average, and those under it, less. By a reference to that table, it will be seen that sedentary employ- ments, contrary to what might have been expected, compare favourably with the others. The greatest mortality occurs in the occupations in which admittedly dissipated habits prevail, or in which the persons employed are exposed to a continuous high temperature. Perhaps the latter chcumstance induces the former. Amongst men may be instanced cabmen and black- smiths, and amongst the women laundresses and cooks, as classes whose occupations have increased the mortality in small-pox. This increase is owing to the large number of hemorrhagic cases developed under these conditions. In connection with the question of the influence of occupation and habits of life on the mortality of small-pox, much valuable information might be ob- tained from statistics collected in manufacturing districts compared with others from purely agricultural ones during the same epidemic. Table I. — Analysis of 3,555 Cases in ivhich the number of MarJcs was noted, with Sex and Age. Without Marks. Males. Females. Total. Age. Ad- mitted. Died. Per centage. Ad- mitted. Died. Per centage. Ad- mitted. Died. Per- centage. Under 5 Between 5 and 10 10 and 20 ..... . 20 and 30 30 and 40 40 and 50 50 and 60 Over 60 85 100 79 55 31 8 2 1 60 51 28 31 20 3 2 70 58 51- 35 -44 56-36 64-51 38- 100- 85 67 56 43 23 4 5 63 37 21 23 12 3 3 74-11 55-22 37-5 53-48 52-17 75- 60- 170 167 135 98 54 12 7 123 88 49 54 32 6 5 72-35 52 -69 36-25 55-10 59-25 50- 71-42 Total 361 195 54-02 283 162 57-10 644 357 55 -43 With One Maek. Under 5 . . . , Between 5 and 10 . . . 10 and 20 . . . 20 and 30 . . , 30 and 40 . . . 40 and 50 . . . 50 and 60 . . . Over 60 Total 22 107 87 40 12 3 3 20 7 2 1 1 20 18 •18 7 -47 22 -98 17 ■5 16 -66 33 3 33 3 10 16 73 103 29 12 5 2 30- 25 13 19 20 25 20 50 15 38 180 190 69 24 26-6 279 15 -77 250 48 19-2 529 92 17-39 w iTH Two Marks. Under 5 5 2 40- 4 2 50- 9 4 44-4 Between 5 and 10 24 2 [ 8-33 25 2 8- 49 4 8-16 10 and 20 210 11 5-23 175 8 4-57 385 19 4-93 20 and 30 245 44 1 17 -95 167 26 15-56 412 70 19-39 30 and 40 91 22 24 15 65 9 13-84 156 31 19-87 40 and 50 27 4 14-81 14 5 35-71 41 9 21-95 50 and 60 10 2 20- 6 1 16-66 16 3 18-75 Over 60 4 2 50- 3 1 33-3 7 3 42-85 Total 616 89 14-44 459 54 11-76 1075 143 13-29 With Three Marks Males. Females. Total. Age. Ad- mitted. Died. Per centage. Ad- mitted. Died. Per centage. Ad- mitted. Died. Per centage. Under 5 5 2 40- 6 1 16-6 11 3 27-27 Between 5 and 10 25 1 4- 21 — — 46 1 2-17 10 and 20 157 10 6-36 124 2 1-53 281 12 4-27 20 and 30 130 17 13 07 98 13 13-26 2-28 30 13-15 30 and 40 38 12 31-57 33 4 13-12 71 16 22-53 40 and 50 19 6 31-57 11 3 27 '27 30 9 30- 50 and 60 2 — — 1 — — 3 — — Over 60 1 — — — — 1 — — Total 377 48 12-73 294 23 7-85 671 71 10-58 With Four Marks. Under 5 Between 5 and 10 10 and 20 20 and 30 30 and 40 ..... . 40 and 50 50 and 60 Over 60 3 13 72 67 13 9 3 4 10 3 1 5-5 14-92 23-07 33-3 3 18 68 47 11 3 4 1 5 1 3 5-5 7-35 212 27-27 6 31 140 114 24 12 7 1 9 11 6 1 3-22 6-42 9-64 25- 14-28 Total 180 18 10- 154 10 6-49 334 28 8-38 With Five or More Marks. Under 5 Between 5 and 10 10 and 20 20 and 30 30 and 40 40 and 50 50 and 60 Over 60 2 8 27 42 11 2 1 1 1 50- 3-70 2-38 1 17 43 42 6 1 1 5 2 2 5-88 11-62 4-76 33-3 3 25 70 84 17 3 1 1 6 3 2 33-3 4- 8-57 3-57 11-76 Total 92 3 3-26 110 10 9-09 212 13 6 13 10 Table II. — General Summary at Different Ages. Males. Without Marks. With Marks. Total. Age. Ad- mitted. Died. Per- centage. Ad- mitted. Died. Per- centage. Ad- mitted. Died. Per- centage. Under 5 165 117 70-90 44 16 36-36 209 133 63 75 Between 5 and 10 188 87 46-27 169 12 7-10 357 99 27-74 10 and 20 138 47 34 05 997 59 5-90 1135 106 9-42 20 and 30 96 51 53-12 1015 142 13-99 1111 193 17-37 30 and 40 54 30 55 -55 332 69 20-78 386 99 25-67 40 and 50 16 9 56-25 120 28 23-3 136 37 27-94 50 and 60 2 2 100- 28 5 17-85 30 7 23-3 Above 60 2 2 100- 11 4 36-36 13 6 46-15 Total 661 345 52-19 2716 335 12-33 3377 680 20-13 Females. Under 5 144 102 70-83 39 9 23-07 183 111 60-10 Between 5 and 10 150 81 54- 170 12 7-05 320 93 29-06 10 and 20 116 42 36-20 894 58 6-48 1010 100 9-9 20 and 30 120 41 34-16 791 82 10-36 911 123 13-50 30 and 40 36 17 47-2 245 43 17-95 281 60 21-35 40 and 50 15 6 40- 76 22 28-94 91 28 30-76 50 and 60 6 4 66-6 32 4 12-5 38 8 21-05 Above 60 — — — 10 2 20- 10 2 20- Total 587 293 49-74 2257 232 10-27 2844 525 18-49 Total of Both Sexes Under 5 309 219 70-87 83 25 30-12 392 244 62-24 Between 5 and 10 338 168 49-73 339 24 7-08 677 192 28-36 10 and 20 254 89 35-03 1891 117 6-18 2145 206 9-60 20 and 30 216 92 42 -59 1806 224 12 -40 2022 316 15-63 30 and 40 90 47 52-2 577 112 19-41 667 159 23-83 40 and 50 31 15 48-38 196 50 25-51 227 65 28-63 50 and 60 8 6 75- 60 9 15- 68 15 22-05 Above 60 2 2 100- 21 6 28-57 23 8 34-78 Total 1248 638 51-12 4973 567 11-40 6221 1205 19-36 11 Table III. — Occupations Classified. Occupations of Males over 20. Vaccinated. Unvacciuated. Trades. Admitted. Died. Percentage. Admitted. Died. Blacksiuitha 10 12 20 41 25 21 132 32 11 12 5 6 6 9 5 4 12 6 2 2 SO- SO- 30- 21-95 20- 19 04 18-93 18-75 18^18 16-6 2 2 1 3 12 2 2 2 Cabmen 1 Painters 1 Grrooms Barmen, &c 1 Butcliers liabourers 7 1 Drapers and Hosiers, &c.. . . Jewellers 1 1 Greneral percentage of mortality in Vaccinated Males oyer 20 = 16 -46. Shoemakers Tinmen Carmen Tailors Clerks, &c Carpenters, &c. . . . Gasfitters, &c Costermongers, &c. Porters Coaclunen Salesmen 20 3 15- 3 14 2 14-29 3 21 3 14-28 5 15 2 13-3 3 23 3 13 -04 9 1 11-1 9 1 11-1 27 3 11-1 67 2 10-44 11 1 9-09 14 1 7-]4 Occupation of Females over 20. Vaccinated. Unvaccinated, Trades. Admitted. Died. Percentage. Admitted. Died. Domestic servants, including Cooks 1 181 . 27 72 39 5 10 21-60 18-51 13-8 18 1 6 11 Laundress Sempstress 5 G-eneral percentage of mortality in Vaccinated Females over 20 = 13-35. Charwomen I 20 I 2 1 10 I 4 I 2 I have tliiis endeavoured to briefly present to you some of the facts deduced from the analysis of over 6,000 cases of small-pox 12 treated during the present epidemic, one which for severity has not been surpassed since the practice of vaccination was generally iatroduced. In doing so I have without doubt but repeated what is to many of you an old story. But if, from the figures here ad- duced, the smallest iota of additional proof is furnished of the immense value of vaccination and revaccination as a protection against this most ten-ible disease, or if one of the many benefits to be derived from leading a temperate life is shown, I will think the time is not wasted which has been given to their collection and arranarement. llARr.lS(.>^ AM> ^UNS, PRINTERS IS OBDINABT Tj IIEK MAJESTf, ST. MAJlTl.v'S LA.SL. >?% X^\ ^J^L-^ - 1 :4r ■ 1 ■^-t-iwi«A t *^ ^m^p^ 1 4 ^"^*iK» . ^1 r i*^^^ ■■■#1? ^^ • •'J*. : i P^^Hp^hiHHb^^ ,- <3l^^ 'fXlt'.s :^^-- 'i;»:f ^''m