THE GREAT PER-CENTAGE  SCARECROW OR THE HIGHER DEATH RATE OF THE UNVACCINATED ANALYSED AND DISPOSED OF IN THE REPORT OF DR LEANDER JOSEPH KELLER
Head Physician of the Imperial Austrian State-Railway Company

Translated from the German by MRS HUME-ROTHERY

1876.

"I have much pleasure in acknowledging myself indebted for this valuable Report of an eminent Austrian medical authority, to the kindness of Count Adolph Zedtwitz, of Baden in Austria, who forwarded it to me with other interesting papers a few days since, specially directing my attention to the important facts therein elicited by analysis of the ages of the victims of small-pox.
M. C. H. R.

REPORT

On Small-pox Cases among the Employees of the Imperial Austrian State-Railway Company, for the year 1873.

BY DR. LEANDER JOSEPH KELLER,

Head-Physician of the Imperial Austrian Stats-Railways.

BY MRS HUME-ROTHERY

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"IN the Viennese General Medical News last year, I have already laid before the public the results of experience in respect to small-pox on the railway lines and in the works of the Imperial Austrian State Railway Company during the year 1872. Although the num­ber of cases we had to report upon during that year was but com­paratively small, (573 in all,) my report nevertheless attracted considerable attention, the more so, because it was grounded on the reports of the surgeons employed both on the lines and in the works in different provinces of the empire, and because it precisely recor­ded not merely the age of the patients, but also the facts of their vaccination, non-vaccination, re-vaccination, of their having pre­viously had small-pox, or remaining doubtful in respect of vaccination. I am now induced to present a further report on the results of the small-pox cases of 1873, on account of the much greater amount of materials for observation offered by these. And having given the results of the year 1873, I shall then give a general report on the results of the cases of both years taken together.

I would first observe that the number of small-pox cases especially in the work-depots of the Banat of Hungary and at Brandeisl, in Bohemia, was very much greater in 1873, and that the death-percentage was also much higher than in the preceding year, but that nevertheless those results to which I drew attention in my last year's report remain similar, and are even brought out more clearly and distinctly than before.

The Imperial Austrian State-Railway Company employs con­stantly about 37,000 officials, servants and workmen, who with the addition of wives, children, pensioners, &c., represent altogether a population of 55,000 to 60,000. This population is divided among 195 railroad-stations and 11 principal work-depots, to which last appertain 92 villages with collieries, colonies and lands. On the railway lines 68 medical men are employed and 12 upon the works in the mountains, the workshops, the forests and domains. The duty of all these medical men is to attend the employees of the Company and their families in all cases of illness. They keep exact records of all cases, and at the end of each month and each year, send in to the Directors of the Company a full statistical report of the same, and are all under the special oversight of the Head Physician.

From the reports of these medical men it appears that in the year 1873 there were (under their care) 2,054 cases of small-pox. Of these 1,669 recovered ; 385 died. The cure-percentage was therefore 81.26 ; the death-percentage 18.74. Among these cases were:

The age of all the patients is precisely recorded in a separate table A.*

 [* This table as well as two others, giving in detail the cases of smallpox in the years 1872 and 1873, massed together, and names of all the localities in different parts of the Austrian Empire where the cases occurred, I have thought it needless in reprint, as the (rest unreadable)]

When we consider the death-percentages of the different age-periods, we arrive at almost precisely the same result as that already obtained in the year 1872, that, namely, the greatest mortality ob­tains in the first two years of life, that this mortality gradually diminishes in the following periods, reaches its minimum between 15 and 20, and then again gradually, and in advancing age rapidly, increases.

Just such are the proportional death-rates affecting mankind in general.

In respect to the death-rate of vaccinated and unvaccinated the examination of the different life-periods yields very important results. If we compare the death-rate of vaccinated and unvaccinated of all ages in the year 1873, we find that the unvaccinated show a death-rate higher by 8.45 per cent, than the vaccinated. This result is not only similar to that of the year 1872, but it is also quite a usual one, which is brought to light and must naturally be brought to light by nearly every statistical report of small-pox cases; and it is precisely this result upon which the friends of vaccination rely when they assert that from this constantly higher death-rate of the un­vaccinated, the conclusion is inevitable, that if vaccination does not prevent small-pox, it nevertheless ensures a milder course of the malady.

A single glance at the table is, however, sufficient to convince us that this conclusion is entirely false; and that vaccination has, in no case, any share in the lower small-pox death-rate of the vaccinated. For we must at once note, that the cause of the higher death-rate among the unvaccinated is to be found solely in the greater number of cases which occur in the first two years of life, in which a higher rate of mortality universally prevails. If, namely, we leave the first two years of life entirely out of the calculation, we find that in the re­maining life-periods the death-rate of the vaccinated (of 1,257 there died 173) is 13.76, while the death-rate of the unvaccinated (of 365 there died 48) is only 13.15 per cent., so that in all the later life-periods the mortality of vaccinated and unvaccinated is almost equal, and even proves most favourable to the unvaccinated.

It must now be supposed that the mortality of the unvaccinated in the first two years of life which raises the death-rate of all the unvaccinated 8.45 above that of the vaccinated, must be greater than thaLof the vaccinated in these first two years of life.

But this is not so.   On the contrary, the death-rate is for the:

Unvaccinated in the first year of life .........    46.24 %

"                             second                                  38.10%

While the death-rate is for the:

Vaccinated in the first year of life ............       60.46%

"       "                   second        "       ............      54.05%

From this it may be clearly seen that, though the death-rate of the unvaccinated is actually less than that of the vaccinated during the first two years of life, nevertheless the death-rate of the unvacci­nated of all ages is and must be raised, because the number of unvaccinated cases in these two years is great; but the number is great only because at that age there are far more unvaccinated than vacci­nated children on the railway lines and in the work-depots. Were the contrary the case, and were all the children actually vaccinated in the first three months of life, then naturally a great many more vaccinated children would be attacked, and as the death-rate in these first two years of life is considerable, the mortality of the vac­cinated would then be much higher than that of the unvaccinated; without our being entitled to lay the blame upon vaccination. What is here said of the results of the year 1873, will be shown as clearly from the combined tables of 1872 and 1873, so I will only observe now, that statistical tables of small-pox cases in which age (and the normal death-rate) is left out of sight, are quite worthless as regards a de­cision on the question what influence vaccination may have exercised; even if they have been quite correctly and conscientiously drawn up, which unfortunately is very seldom the case.

In respect to the Re-vaccinated, and to those who had previ­ously had small-pox, the table shows a death-rate of 15.22 per cent, among the former and 18-18 per cent, among" the latter, from which we naturally conclude that neither re-vaccination nor a previous attack of small-pox affords any protection from small-pox *; and that the death-rate in both categories is comparatively low, only because no children in the first years of life are to be found among them. The most favourable death-rate appears in the case of those returned as "doubtful" in respect of vaccination, 14.06 per cent, namely.

[*On the contrary the death-rate in both classes is considerably higher than that of the unvaccinated, when the two first years of life are excluded, 13.15% namely.  And such exclusion is absolutely necessary before rational comparison can be instituted.]

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If we now examine the small-pox cases of the years 1872 and 1873 taken together, under the same points of view which have been already brought forward, the same results manifest themselves to which I have drawn attention in considering the cases of the two years separately; only the results are brought out more clearly and more strongly established by the amount of the material and the larger numbers dealt with, as compared with the separate years.

In the two years 2,627 cases of small-pox were treated. Of these 2,158 or 82.16 per cent, recovered, while 469 or 17.85% died.

If we examine the mortality of these small-pox patients as a whole, with reference to the varying scale of ages, we find pre­cisely such a decreasing and then again increasing death-rate as corresponds with the general mortality of the human race. But we find just the same series of variations, if we examine separately the mortality of the vaccinated, and of the unvaccinated in the various life-periods. The following percentages result:

We see in these tables that the death-rate, from the first year of life in which it is very high, falls gradually, till between the 15th and 20th years of life it reaches its minimum, equally with the vaccinated as with the unvaccinated, and from this point rises again with ad­vancing years. The arithmetical sequence of death-percentages is only a little disturbed among the vaccinated between the 4th and 5th, among the unvaccinated between the l0th and 15th years of life; and on a larger number of cases would undoubtedly right itself.

If we now compare the death-rate of the vaccinated and the unvaccinated in the different life-periods, we find that the cases of the unvaccinated between the l0th and 40thyear, in which compara­tively very few cases occurred, yield a somewhat higher death-rate, whereas in all the other periods, and especially in the first years of life, they shew a much lighter death-rate than the vaccinated. Notwithstanding these, for the unvaccinated, very favourable pro­portions, the total death-rate of all the life-periods shows 23-20 per cent, for the unvaccinated, and only 15-61 for the vaccinated. For here arise precisely the same circumstances as we observed in our previous examination of the cases of the year 1873.

This raising of the death-rate of the unvaccinated is referable solely to the cases in the two first years of life. If namely we exclude (from the total mortality, vaccinated 1659 died 259—15.61 per cent.; unvaccinated 793 died 184—23.20 per cent. Table C.) the two first years of life, the death-rate of the vaccinated (of 1570 died 210) amounts to 13.37 Per cent.; that of the unvaccinated (of 515 died 66) to 12.82 per cent., so that from the second year of life onwards the death-rate of the unvaccinated is more favourable than that of the vaccinated.

Further these two first years of life which so raise the death-rate to the disadvantage of the unvaccinated, exhibit nevertheless, the startling fact, that the mortality among the vaccinated for these two years amounted to 55.06 per cent; among the unvaccinated only to 42-44 per cent., clearly proving, that not vaccination, but simply the greater number of unvaccinated cases in the first two years of life, which according to natural law yield a higher death-rate than the later life-periods, is cause of the difference of death-rate as against the unvaccinated.

Among the re-vaccinated (76 in number) the death-rate amounts to 15.79 per cent., which considering the circumstance that among them were no children under four years of age, may be considered a markedly unfavourable one; and sufficiently shows what value may be ascribed to re-vaccination.

The number of those who had previously undergone an attack of small-pox was very small (13,) and the death-rate is still more unfavourable (23.08 per cent.) principally because several of these cases occurred in advanced years; still, as among these patients who had previously had small-pox three cases arose between 5 and 10 years of age, it is clear that a previous attack of small-pox cannot long protect, and that any so-called immunity, if it exist is of very short duration.

Those returned as " doubtful" in respect of vaccination, of whom there were altogether 86, show a mortality of 12.79 per cent, which, considering that neither in the three first years, nor yet in an advanced period, of life did any of them occur, cannot be regarded as specially favourable, as it has already been shown that the death-rate among the unvaccinated, excluding the first two years of life, only amounts to 12.82 per cent.

If we now summarize the results of these statistics we arrive at the following conclusions :—

1.    Vaccinated and unvaccinated, re-vaccinated, and those who had previously suffered from small-pox were alike attacked; the overwhelming majority of the cases were vaccinated, doubtless because, there are, except in the first two years  of life, many more vaccinated than unvaccinated persons.

2.    In the first two years of life many more unvaccinated than vaccinated children were attacked by small-pox, because at that age there are *many more unvaccinated than vaccinated children.

[* In Austria and in the class under consideration, of course to be understood.—Trans.]

3.    The death-rate in the first two years of life is in all cases the highest, the death-rate in very advanced age alone excepted ; still it was  lower among the unvaccinated than among the vaccinated children of this period of life.

4.    If we set aside these two first years of life the death-rate is nearly equal for vaccinated and unvaccinated, but still somewhat less favourable to the vaccinated.

5.    If the mortality of the total unvaccinated cases is higher in proportion than that of the vaccinated, this is not to be ascribed to non-vaccination, but only to the great proportion of this large mortality occurring in the first years of childhood.

6.    The mortality in the different periods of life follows, both with vaccinated and unvaccinated, the ordinary law of mortality of the human race in these respective periods, and vaccination has no power to alter or affect this law of nature.

7.    Having due regard to all these facts it appears that vaccination is utterly worthless.

If we now only cursorily examine, with an unprejudiced eye, the important results which I have here collected from the practice of no less than 80 medical men employed on the railway lines and works, we must at once recognise what great weight attaches to the statement of age in all returns of small-pox cases, if we wish to draw any conclusion from such returns as to the value of vaccina­tion. It is inconceivable that at the present day reports of small­pox cases should be relied on, in which no mention is made of the age of the patients, and that from such reports the friends of vaccination would fain draw the conclusion that vaccination exercises some degree of protective power, because the mortality of the unvaccinated is, as a rule, greater than that of the vaccinated. That this is the case we see confirmed in the above reports; but often and often has it already been proven to pro-vaccinators that other considerations besides that already dwelt on of the tender age of the unvaccinated must here be taken into consideration, of which I will only mention one, viz.: That only the healthy children are vaccinated and the sickly ones, as a rule, are left unvaccinated.

What would be said if any one should bring forward the assertion that, because far fewer of school going children die than of those who do not go to school, therefore, not going to school is the cause of the greater mortality? Everyone who can see clearly, perceives the absurdity of the assertion, because it is just to the class who do not go to school that the younger and sicklier children belong. And yet pro-vaccinators set up precisely the same absurd assumption in relation to vaccinated and unvaccinated."

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Thus far, Dr. Keller. Few words can be needed to point the immense value of his conclusions in respect to those paper per­centages of death from small-pox among the unvaccinated, even when these are correctly and conscientiously obtained, which unfortunately is very seldom the case, which I have already elsewhere designated as "the last refuge for the destitute." No candid reader can, I think, peruse the foregoing pages, and dissent from the conclusion that this "last refuge" of pro-vaccinators is henceforward as un­tenable as their exploded dogma, that a person once vaccinated is thenceforward protected for life from small-pox infection. Attention has already on various occasions been directed in this country to the great preponderance of infant cases among the unvaccinated deaths, and of older and adult cases among the vaccinated deaths. This was notably the case in the Todmorden and also the Keighley epidemic, and will doubtless prove to be the case generally, if the statistics of small-pox are only analysed so as to develope the fact. In England, it is true, the law fixes the age for vaccination three months earlier than that (six months I believe) fixed in Austria; but it is also undoubtedly true that, owing to the unwillingness of many parents to vaccinate, and the negligence of others, a large number are not vaccinated till considerably later, to say nothing of the large number who, let the authorities reckon as they may, escape vaccination altogether, and the other large class of children set aside as unfit for vaccination; and reckoning all these, to be found chiefly among the poorest and most wretched of the population who are exposed far beyond any other class to the causes of small-pox, is there any doubt that ample and more than ample margin is afforded to account for a greater preponderance of unvaccinated death-rate than even pro-vaccination statistics allege, without reference of even a single case to the "utterly worthless" protective influence of vaccination? How hopelessly statistics, judiciously manipulated, may stultify the facts they profess to record, is startlingly evinced by Dr. Keller's analysis of the preponderance--working unvaccinated death--rate of infancy, which, as already shown, is actually lower than the vaccinated death-rate of the same life-period, though the number of cases at that early age when the normal death-rate of the human race is high, enables pro-vaccinators to dress up the percentage scarecrow, which bears about as much resemblance to truth as an actual scarecrow bears to the human form it parodies

MARY   C. HUME-ROTHERY, Merlon Lodge, Tivoli, Cheltenham, April 12th, 1876

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