LEICESTER AND SMALL-POX- 1902-04
by J.T. BIGGS J.P.
[Source] CHAPTER 80. LEICESTER AND SMALL-POX- 1902-04.
ON the issue of this (Dr Millard's) report (see chapter 79), I published an article, a revised and abridged copy of which follows :—
WHY THE EPIDEMIC LASTED SO LONG.
DR. MILLARD'S OPINIONS.
LAW AND AUTHORITY.
ERRORS OF DIAGNOSIS.
THE WORKHOUSE OUTBREAK.
VACCINATION AND REVACCINATION OF CONTACTS.
THE UNVACCINATED.
FATALITY ATTRIBUTED OFFICIALLY TO THE UNVACCINATED.
VACCINATION AND REVACCINATION.
THE REVACCINATED.
THE FATAL CASES.
TRAMPS.
A "CLOUDBURST SCARE."
INJURIOUS EFFECTS OF VACCINATION.
A COMPARISON OF FATALITIES.
COST OF THE EPIDEMIC.
"ADVANCE" LEICESTER!THE long drawn-out visitation of small-pox at Leicester has now ended. Commencing with some vaccinated cases at the close of 1902, what may be called the first outbreak continued until the end of 1903, during which period there were 394 cases and 21 deaths, being a fatality percentage of slightly over 5.3. After a short interregnum, the hospital being empty for a few days, the second outbreak started, continuing until August, 1904. During the second outbreak, 321 cases occurred, with only four deaths, giving the probably unequalled low fatality-rate of only just over 1.2 per cent. Taking the two outbreaks together, there were in all 715 cases, with 25 deaths, giving a fatality percentage of only 3.5. It is doubtful whether any authentic records of small-pox supply such extremely low death-rates, or indeed any comparable with these.
WHY THE EPIDEMIC LASTED SO LONG.
The outburst might have been limited to the first few cases, and I attribute the prolonged continuance of the epidemic—the longest in duration for nearly forty years —to several main causes. These are (1) errors of diagnosis, (2) delays in notification, and (3) failure to recognise cases on the part of medical men. The existence of a number of mild, unsuspected cases, coupled with some degree of carelessness displayed by many of the inhabitants, have also been contributing factors, and lastly, but by no means least, the undue—in some cases almost illegal—pressure, direct and indirect, amounting to disregard of personal liberty, by which, vaccination and revaccination were forced upon many of the unfortunate contacts. To this I refer hereafter.
Dr. Millard, in his valuable, instructive, and exhaustive treatise, exhibits characteristic courage and originality. His medical friends are at once puzzled and nonplussed by his outspoken convictions as the result of his experience—an experience which runs counter to so many long-cherished beliefs. While disagreeing with some of his conclusions, I have the greatest admiration for the painstaking candour and transparent honesty manifested in the expression of his opinions, which have brought down so many medical fulminations upon his devoted head.
The Doctor's history of vaccination law is lamentably incomplete. Only three out of six Acts of Parliament are quoted, and, strange to say, one of those omitted is the principal Act of 1867, which is practically the basis of our vaccination laws. Then Dr. J. C. McVail is actually cited as ''one of the highest authorities on small-pox." If Dr. Millard will read Dr. McVail's misleading, unfair, one-sided, and prejudiced references to Leicester in his "Vaccination Vindicated," he will hesitate to accept him as a reliable authority. Mr. Alfred Milnes's able papers, "McVail Unveiled"—in earlier volumes of the "Vaccination Inquirer"—have irretrievably shattered Dr. McVail's claim to be regarded on this question as one's guide, philosopher, and friend."
The outbreak of 1902-03 started with the disease being imported by a tramp in the workhouse, and it appeared almost concurrently in the town. Early in the outbreak a medical attendant erroneously diagnosed a case of small-pox as chicken-pox. How fatally these errors operate may be gathered from the fact that between 40 and 50 cases, and some deaths, are known to have occurred from this case. Three other errors led to nearly 70 cases. One of the vital omissions from the Medical Officer of Health's report is the absence of a tabulated list of these errors of diagnosis, with their mortiferous consequences. Very many were reported to the Sanitary Committee, and if all had been recorded, they would account for a large proportion of the total number of cases. Considering the enormous number of contacts, it is marvellously surprising that the epidemic did not swell to undue proportions. Once more, there has been none of the predicted decimation of Leicester's population, and, as the Medical Officer of Health himself says of Dr. McVail and other medical prophets of evil to unvaccinated Leicester, "the prophecies remain unfulfilled." Although he unhesitatingly affirms that the "gigantic experiment ... is not yet completed, and therefore is not yet conclusive," he is compelled to admit "that it has been successful beyond all expectation." Seeing that the "Leicester Method" has stood the test of about thirty years (1904), and Jenner's "method" was rewarded by Parliament after doubtful and disputed experiments of a few years only, one would like to know when the " conclusive" period is likely to arrive. An impartial judge could readily furnish an answer.
This is one of the most astounding and serious features of the epidemic. We are informed the "tramp sickened" on 16th December, but unfortunately was not removed to hospital till 22nd December. Meanwhile, the disease not being recognised as small-pox, "no precautions were taken." The patient was in close contact with sixty other inmates, six of whom contracted the disease. In all, twenty-two of the inmates were attacked—fifteen adults and seven children. As there were about 1,100 persons in the institution, it is a mercy it spread no farther. But what were the medical authorities about to allow a case of small-pox to exist for a week without discovery, notwithstanding the fact that there is, or should be, a daily inspection of these people? Where was the astute, capable, experienced, and energetic Medical Officer of the institution? Our Medical Officer of Health considers that "the fact that the outbreak was cut short and prevented from spreading farther . . . certainly reflects credit on the authorities for the energetic steps they took to stamp it out." Opinions differ on this point. Had a poor layman been in fault, no doubt he would duly have appeared before the Magistrates to answer for his shortcomings.
VACCINATION AND REVACCINATION OF CONTACTS.
The measures adopted for controlling the disease are tabulated thus :—(1) compulsory notification, (2) hospital isolation, (3) surveillance of contacts, (4) vaccination of contacts, (5) disinfection, (6) other measures. It is the fashion for those who belittle Leicester to claim that but for vaccination the town would suffer severely from small-pox. This view is effectually dissipated by our Medical Officer of Health. Although vaccination and revaccination were run for all they were worth, and a considerable number, amounting to 73 per cent, of the persons in invaded houses, were vaccinated, the Medical Officer of Health considers the result as a "mere drop in the bucket." He says, "the extent to which it was resorted to ... was altogether too small to have any appreciable effect upon the course of the outbreak." Nevertheless, by dint of creating terror in the minds of the unfortunate contacts, fear of losing employment, grief-stricken with the calamity which had befallen them, subject to daily persistent attacks on their inbred aversion to the Jennerian rite, many reluctantly yielded against their conviction. To such an extraordinary extent was this pressure exercised that it provoked indignant remonstrance both inside and outside the Sanitary Committee. In one instance a poor widow submitted, and was disabled from work for no less than nine weeks. She lost several pounds in this way, and only received a mere pittance of a few shillings as "contact" pay. In another case a man's wife was taken to hospital, and although he was daily importuned, and had a family of six unvaccinated children, he refused to allow the operation to be performed, and all escaped. This should appear in the next report, but how many important facts of a like nature are omitted we do not know.
Dr. Millard comes to the conclusion arrived at by Dr. Coupland, who investigated the outbreak of 1892-94 for the Royal Commission, "that the part played by unvaccinated persons in determining small-pox incidence has been over-rated." Certainly when we know that out of about 80,000 unvaccinated persons in Leicester, only 198 out of a total of 394 cases caught the disease, with the thousands of opportunities for contact, the result is surprising to those who are so strongly prejudiced as to believe that small-pox must of necessity "spread like wild-fire amongst the unvaccinated." This untenable theory has been many times exploded by the experience of Leicester, but no doubt, like the fiction of the French and German armies and others of a like kind, it will be resurrected many times yet to come. The low death-rate among the unvaccinated, taking the figures of the report as they stand, and assuming they are correct, is noteworthy. Official records show that in the eighteenth century, before vaccination, and with the prevalence of small-pox increased, and its fatality increased by variolous inoculation, insanitary conditions, lack of hospital accommodation, indifferent medical treatment, and doubtful nursing, the fatality was about 16.5 per cent. In the nineteenth century, with cessation of variolous inoculation, vaccination penally enforced, improved sanitary conditions, palatial hospitals, advanced medical science, rational and educated nursing, this fatality rose to 16.9 per cent.
FATALITY ATTRIBUTED OFFICIALLY TO THE UNVACCINATED.
It is the fashion now to give very high unvaccinated fatality-rates, much above those of the eighteenth century, before vaccination was known. No one can explain how this comes about. The following table is compiled from the official publications in each instance ;—
Middlesbrough, 1897-98 (Dr. Dingle) - - - 47.4
London, 1901 (M.A.B. Interim Report) - - 50.5
Leicester, 1892-94 (Dr. Priestley) - - - 12.4
Leicester, 1903 (Dr. Millard) - 8.1
Leicester, 1904 (Dr. Millard] - 1.6The epidemic produced many instances where vaccinated contacts caught the disease and the unvaccinated escaped. All these should have been carefully tabulated in the report. It is also a significant fact that although smallpox has been and is frequently introduced into Leicester by vaccinated persons from well-vaccinated districts, there is no authenticated record, so far as I know, where an unvaccinated Leicester person has conveyed the disease elsewhere. It is manifest from the above table that there is some considerable element of error requiring correction, otherwise, with our better conditions of life, the unvaccinated fatality would not be enormously higher, but less than in the eighteenth century. The low fatality rates of the Leicester figures conclusively prove this.
VACCINATION AND REVACCINATION.
At no period since the great epidemic of 1872 in Leicester have vaccination and revaccination been urged with such unceasing effort upon the population, or enforced by such unvarying persistency upon contacts, as during the recent outbreak, and at no period have we suffered from so prolonged an epidemic. The Medical Officer of Health has adopted a new term in connection with this subject. When before the Royal Commission, I referred to the variety of qualifying terms used in regard to vaccination. Dr. Millard's faith is limited to "recent successful vaccination" as the true and only reliable antidote to small-pox. In the past, before Dr. Millard's time, vaccination alone, of whatever kind, was all-sufficient. Then "good," "proper," "successful," "efficient," and other similar terms were used to designate genuine vaccination of the real stamp. When Dr. Gayton was before the Royal Commission, he declared that his tables proved that this multifarious vaccination did not protect for any given length of time, as infants and children died of small-pox soon after vaccination, as well as adults, on whom the operation had been performed for a longer period.
During the Leicester epidemic, thirty of the cases were vaccinated during the incubation period, and eleven cases occurred, all of whom had been revaccinated. One of these was a medical man, who visited the hospital with many others, at the invitation of the Sanitary Committee and the Medical Officer of Health, for the purpose of acquiring some useful knowledge of small-pox. It is most amusing to read the table of revaccinated. First of all, some doubt is thrown upon the cases, as they are "stated" to have been revaccinated. Then most of them did not "take," or the protection had lapsed through effluxion of time. If they did not "take," the patient must have been immune. But it is certain that if they had all escaped, their escape would have been attributed to revaccination, at whatever date and under whatever circumstances performed. How often have we been assured that protection lasts in some degree through life, and that revaccination makes it doubly secure? There is nothing in the whole realm of history or science that has changed so frequently and illogically as this shibboleth of so-called protection by vaccination and revaccination.
Of the twenty-one fatal cases, four were vaccinated in infancy—one having three marks and three having four marks—and three were vaccinated during the incubation period. Two are classed as uncertain, three were infants of three weeks, five months, and thirteen months respectively. Of the remaining ten cases, one was a tramp, and another suffered from other complications. They are thus classified by the Medical Officer of Health:—
Cases Deaths. Fatality.
Vaccinated - 194 4 2.06
Unvaccinated - - - 198 16 8.08
Uncertain - - - - 2 1 —
Total - 394 21 5.33It will be seen that certain deductions must be made before an accurate classification is secured, but taking the figures as they stand, how is it that Leicester yields so low a fatality for both vaccinated and unvaccinated? Is it the improved stamina of the people, due to better sanitation and less vaccination? The following is not a very robust confession of faith by the Medical Officer of Health
"Although there is reason to think that the protection conferred by revaccination (performed after a person has grown up) usually lasts somewhat longer than that conferred by infantile vaccination, it is quite certain that the protection is not permanent, and cannot be trusted to last a lifetime."
In this outbreak, as in many others, the poor tramp comes in for his share of blame. While having no special affection for the persons forming this class of the community, I must observe that there is one important fact respecting tramps which has hitherto been lost sight of or ignored. It is that they are the best revaccinated class in the whole population. Were a vaccinal census taken, it would be found that the great majority had not only been vaccinated, but also revaccinated again and again. Whether in vagrant wards or lodging-houses, with or without the bribery of tobacco or the "King's shilling," they usually freely submit to the operation, unless, as not infrequently happens, they have suffered ill effects from the operation. When "tramps" are again accused of introducing small-pox, let us remember that in spite of their vaccinal protection, doubled or trebled in many instances, it is their filthy habits which spread disease. Insanitary conditions are the cause.
In April occurred what the Medical Officer of Health describes as a "cloudburst." Out of 65 cases, only one could be traced, and out of 156 cases occurring in four weeks, 112 could not be traced. The sudden and untraceable nature of the outburst induced the Medical Officer of Health to say that the infection appeared to have "dropped from the clouds." Whether these 112 cases started "de novo" or through contact remains unascertained. These incidents prove how little is known and how much is conjectured respecting these outbreaks. This outburst was a scare useful to the medical men. It gave a combined fillip to vaccination and fees. On the Sanitary Committee determined efforts were made by medical members to create a "scare," to rush into extraordinary expenditure in the erection of additional buildings, and other panic-stricken measures. Fortunately for the ratepayers, these interesting and interested efforts were successfully resisted, and the town saved from an outlay which would have been trumpeted from "Land's End to John o' Groat's" as indicating a failure of the "Leicester Method." Nevertheless, there is no mistake about the widespread and serious nature of the attack. No fewer than 61 houses were infected at one time in 58 streets, covering an area of no less than two-thirds of the borough. Thirty-seven cases worked at 32 factories and shops, and a "number of unrecognised cases, of a highly infectious type, were going about spreading infection broadcast." Also other unrecognised cases played an important part in the spread of the disease. Such was the nature of the attack which has been successfully resisted, and for which, were it a well-vaccinated town, Leicester would be covered with laudation by all the medical journals in the kingdom.
INJURIOUS EFFECTS OF VACCINATION.
These are too often ignored. Our Medical Officer of Health treats them lightly, although in one case brought before the Sanitary Committee a person was disabled for nine weeks. Could we but follow up the history of all the cases vaccinated during this epidemic, we should hear a sorrowful story. The records of inoculable diseases contain a ghastly series of increased disease and death, while the general death-rate is declining. For a recent proof, we have only to turn to the Gore Farm Lower Hospital extension works. Dr. Stewart had under his care 587men, the majority of whom were vaccinated by himself. All the Local Government Board requirements and regulations as to precautions were carried out. Yet, in spite of pure lymph, expert operators, and "every precaution taken," no fewer than 166, or 28 per cent, of these strong, able-bodied navvies, were disabled for periods ranging from 51/2 to 35 days, and the whole were on compensatory sick-pay for an average of seven or eight days each. If this is the effect on such a body of workmen, what is it likely to be on our children?
A smallpox outbreak occurred in 1892-4, when Dr. Priestley was Medical Officer of Health. There were 362 cases with 21 deaths, or a fatality percentage of 5.8. Very much has been said about the low fatality (5.3) of the epidemic of 1903, but it was not appreciably less than that of 1892-4. I am sure Dr. Millard will not withhold his meed of praise to Dr. Priestley, and without wishing to detract from Dr. Millard's skill in handling the epidemic of 1903, I think, considering all the circumstances, Dr. Priestley's achievement was equal to, if indeed it does not exceed, that of Dr. Millard in obtaining a low fatality. The 1903 outbreak found the town better prepared than that of 1892-94. We had an increased sanitary staff of more experienced officers. Although not yet complete, we possess additional hospital accommodation, with up-to-date appliances, ampler means of isolation, better equipment, and a larger staff of nurses. Besides all this, we have a clever, fully-qualified bacterial expert Medical Officer resident at the hospital. In addition, we called in the aid of another medical man to assist at the hospital. Dr. Priestley coped with it all himself. In April, 1894, the "British Medical Journal" published an article containing a comparative table of small-pox cases and fatalities at various towns. All of these had sedulously obeyed the vaccination laws. On next page I give this table with Leicester (to a later date), and Middlesborough added.
Town Small-Pox Cases. Small-Pox Deaths. Fatality per cent, in cases. Birmingham 1,203 96 8.0 Leicester 366 21 5.7 Brighouse 134 15 11.2 Manchester 406 27 6.7 Salford 173 22 12.7 Glasgow 279 23 8.2 Liverpool 194 15 7.7 Halifax 513 44 8.5 Warrington 598 60 10.0 Aston Manor 113 6 5.3 St. Albans 58 6 10.4 Middlesbrough 1,411 202 14.3 Totals 5,448 537 Ave. 9.5 All the above are well-vaccinated towns, excepting Leicester, and, perhaps to a much less degree, Halifax, and both these are below the average fatality.
The three epidemics at Leicester give the following results :—
Cases. Deaths. Fatality.
1892-94 366 21 5.7
1902-03 394 21 5.3
1903-04 321 4 1.2Let any impartial mind examine the above tables, and say whether the protected towns show any advantage. The nearest approach to Leicester is the residential suburb of Birmingham, Aston Manor. But consider the enormous difference in the conditions of Leicester's crowded artisan factory population with that of Aston Manor. Where is the benefit of vaccinal protection? It is perfectly obvious that, whatever the amount of vaccination, no town can afford to ignore the measures implied by the "Leicester Method," introduced by Dr. Johnston in 1877, and now, with improvements, universally adopted. Indeed, more attention is now given to the sanitary precautions of isolation, etc., and no one would now dream of relying solely upon vaccination. Notwithstanding much that is said to the contrary, this is an absolute proof of belief in the influence of sanitation for controlling small-pox.
One of the bogies usually marshalled against the "Leicester Method" is that of cost. From past observation I have found that £10 per case is not an excessive expenditure during a small-pox outbreak. It, of course, depends to some extent upon the number of cases, but I have seen statistics where the cost has run up to £20 and £30 per case. Our Medical Officer of Health estimates the cost at £1 per week, and taking 41/2 weeks as the average duration, our cases have cost only £4 10s. each. This may or may not be strictly accurate, but what is more to the point is the fact that not a single extra farthing was added to the rates in consequence of the epidemic, and the hospital expenditure was normal. The estimates were prepared without any special provision for small-pox and the cost of special expenditure such as compensation to contacts for staying away from work, various contingencies, gratuities to the staff for extra work, etc , were covered by our normal hospital expenditure. The "Leicester Method" is not only effective, but inexpensive
In summarising the results of the epidemic we may adopt the Australian motto. We are able to take a broader view than the Medical Officer of Health, who, although he has shown a degree of courage and out-spoken heterodox conviction, is, in a measure bound by tradition. The advance he has made is shown by the limitations of his vaccine creed, now narrowed down to a very meagre base. A little more recognition of the unscientific character of all disease inoculations will remove the last shred of his faith in the "grotesque superstition."
Leicester's small-pox history, and her successful vindication of sanitation as a small-pox prophylactic, will bear the closest scrutiny. Each successive epidemic since vaccination has decreased, with a larger proportion of unvaccinated population, furnishes a still lower death-rate. Leicester's detractors, having failed in repeated attacks upon her ability to deal with small-pox when imported from well-vaccinated communities, have abandoned this cue, and an attempt is now being made to defame her good name by suggesting that syphilis and diarrhoea find their habitat among her population. The infantile syphilitic death-rate is much below that of England and Wales, and the diarrhoea death scourge, which in high vaccination times was the principal cause of over 240 deaths in the first year of life out of every 1,000 births, has now fallen to such an extent that the 240 is reduced to about 160 per 1,000. Let those who decry unvaccinated Leicester bring forward another town of equal size and similar conditions, well-vaccinated, with as little small-pox and zymotic disease, and as clean a bill of health for comparison, if they can! Notwithstanding Leicester's artisan population, its unfavourable geographical position in a water-logged valley, its death-rate, once 27 per 1,000 in vaccination times, is now only 14 per 1,000. This is considerably below that of England and Wales, which includes all the health-giving rural districts and sea-side holiday resorts. With such achievements Leicester may well be proud. When will her detractors have the common honesty to acknowledge her good works. If imitation is the sincerest form of flattery, their words do not accord with their action for the "Leicester Method" of dealing with small-pox now, with a greater or less degree of completeness, practised everywhere.