222 



NA TURE 



[January 6, 1898 



It is certainly not going beyond the facts of the case to 

 state that the above-mentioned characteristics of this 

 epidemic must in great measure be attributed to the large 

 number of unvaccinated children who were in attendance 

 at school, and who were thus not only extremely suscep- 

 tible to the attacks of small-pox, but were in a position 

 to disseminate the disease, though in a milder form, 

 amongst those who had been vaccinated. That is, the 

 neglect to have the children vaccinated left them in a 

 condition in which they would readily take small-pox 

 just at the time when their surroundings were of such a 

 nature that everything was favourable to their taking the 

 disease from one another, and in turn passing it on to 

 those with whom they daily came in contact ; with the 

 result, as Ur. Coupland points out, that one in twenty of 

 the whole population of Gloucester were struck down 

 with small-pox. Indeed, he goes so far as to say that, 

 " viewing the subject with as impartial a mind as I can, 

 the conviction is forced upon me that Gloucester would 

 not have suffered as it did had its child population been 

 vaccinated." It was this want of vaccination, and the 

 impossibility of maintaining effective isolation of the 

 attacked, that allowed of the abnormally rapid spread 

 of the disease after it has once obtained a firm hold in 

 the city. 



If there was one more important feature than the 

 rapidity of the outbreak, it was that the epidemic faded 

 away — for that is the only term that can be applied — so 

 abruptly. Numerous explanations have been put for- 

 ward to account for this, but the only factor that appears 

 to have had any real determining influence in bringing 

 about this abrupt cessation of the disease, was the 

 universal adoption of re-vaccination after small-pox had 

 already obtained its firm foothold in the city. 



That Dr. Coupland is not going beyond his brief when 

 he holds that this high child mortality was due to the 

 unvaccinated condition of many of the children, is evi- 

 dent from certain statistics which he gives concerning 

 3546 cases. Of these only 85, or 2"5 per cent., were in 

 vaccinated children below the age of ten years ; and 

 amongst these 85 cases there was only a single death. 



These were all cases recorded in papers and reports 

 which had come directly under Dr. Coupland's per- 

 sonal observation during his investigations into the 

 outbreaks of small-pox in Dewsbury, Manchester, 

 Oldham, Leeds, Halifax, Bradford and Leicester. 

 In the Dewsbury, Leicester, and Gloucester outbreaks 

 the number of children that had not been vaccinated 

 was very high indeed. Now, taking Dewsbury, where 

 the proportion was lowest, the number of deaths to 

 attacks was as one to nine ; in Leicester, as one to 

 seventeen ; and in Gloucester — where the proportion of 

 unvaccinated was highest of all — the proportion of deaths 

 to attacks was as one to four and a half, although the 

 attacks in Gloucester were nearly 2000 (1979), in 

 Leicester 357, and in Dewsbury 1039. 



Comparing these three outbreaks, and bearing in mind 

 the proportion of unvaccinated as above, we find that 

 the proportion of the whole number attacked under ten 

 years was in Dewsbury 217 per cent., in Leicester 30'5 

 per cent., and in Gloucester 35'6 per cent. ; the fatality 

 of this class in the three cases being Dewsbury 25*4 per 

 cent., Leicester 137 per cent., and Gloucester 39*6 per 

 cent. 



As affording evidence of the disproportionate in- 

 cidence of the disease upon young children, to which 

 reference has already been made, it may be stated 

 that 706 of the whole number attacked, or 357 per 

 cent., were under ten years of age ; whilst of the 

 434 fatal cases 280, or 64'5 per cent., occurred in 

 this age period. Of these 706 only 26 had been vac- 

 cinated before the epidemic broke out, whilst of the re- 

 mainder, 80 were undergoing vaccination when attacked 

 with small-pox, the operation having been performed 



NO. 1471. VOL. 57] 



within fourteen days of the onset of the disease. It will 

 thus be seen that only 4 per cent, of those attacked at 

 this age period had been vaccinated, although a much 

 larger proportion of vaccinated had been exposed to 

 infection. It is found that of those exposed to in- 

 fection, in households invaded by small-pox, of the vac- 

 cinated class 3386, and of the unvaccinated class 1475, 

 there were attacked with small-pox— of the vaccinated 

 class 1028, or 30*3 percent. ; whilst of the unvaccinated 

 class 689, or 46'6 per cent., became infected. 



It has already been indicated that amongst the un- 

 vaccinated at Gloucester the type of the disease was 

 much more severe than in the vaccinated class. For 

 purposes of comparison it may be shown that in 

 Gloucester, where, as we have already seen, the number 

 of unvaccinated children was very high — much higher 

 than in Dewsbury or Leicester — the type of the disease 

 over all was much more severe than at either Dewsbury 

 or Leicester, and still more so than in many of the other 

 recent outbreaks. Taking the severe type as including 

 malignant and confluent cases, and the milder type as 

 including coherent, discrete and mild cases, we find that in 

 Dewsbury 265 per cent, of all attacks were of a more 

 severe type, in Leicester 26*8 per cent., and in Gloucester 

 43" I per cent. ; whilst the mild type accounted for 27*5 

 per cent, in Dewsbury, 35*5 in Leicester, and only 25*5 

 in Gloucester. 



If we now take out Dr. Coupland's figures as regards 

 attacks of small-pox affecting vaccinated and unvaccin- 

 ated patients, we find that in Dewsbury 64*3 per cent, of 

 the whole number, with a mortality of 27 per cent., vvere 

 vaccinated; in Leicester 55-8 per cent., with a mortality of 

 I per cent. ; in Gloucester 6 1*2 per cent., with a mortality 

 of 9"8 per cent. These figures compare very favourably 

 with the cases of deaths in the unvaccinated class. There 

 were 357 percent, of the whole cases that had not been 

 vaccinated in the Dewsbury Union, and amongst these 

 there was a fatality of 25 per cent. ; in Leicester 44'3 per 

 cent, of the cases were unvaccinated, with a death-rate of 

 12 per cent; whilst in Gloucester 38*8 per cent, of the 

 cases had not been vaccinated, and amongst these there 

 was a death-rate of 40-8 per cent. It will thus be seen 

 that the lowest death-rate in the unvaccinated class (12 

 per cent, at Leicester) was considerably higher than the 

 highest death-rate in the vaccinated class (Gloucester, 

 9"8 per cent). It must be borne in mind, of course, that 

 even in the worst vaccinated districts the proportion of 

 unvaccinated to vaccinated persons is very much lower 

 than the proportion of vaccinated small-pox cases to 

 non-vaccinated cases, so that we not only have an enor- 

 mously greater mortality amongst those attacked, but the 

 percentage of attacks is also considerably higher. 



Any one who goes carefully and with unbiassed 

 mind into the statistics collected by Dr. Coupland must 

 inevitably come to the conclusion that, although the 

 disease was spread in schools owing to the simultaneous 

 infection of school children from cases unrecognised by, 

 or unknown to, the authorities until the area of infection 

 had been considerably widened ; although after the 

 sudden outbreak of small-pox it became, first, a difficult 

 — and eventually an impossible — task to isolate the 

 patients attacked, and to treat even a small proportion in 

 hospital ; and although insanitary surroundings and a 

 certain amount of overcrowding may have played some 

 part in spreading the disease, we must ultimately fall back 

 upon the neglect of a large number of parents to see to 

 the vaccination of their children for an adequate ex- 

 planation of the extent of the epidemic and the rapidity 

 of its extension. The utter futility of all ordinary 

 measures recommended for the limitation of the spread 

 of small-pox, apart from vaccination, is only too clearly 

 brought out. 



Hospital accommodation and isolation are usually in- 

 sisted upon, by those who do not believe in vaccination, 



