Popular Science Monthly/Volume 59/October 1901/The Late Epidemic of Smallpox in the United States
|THE LATE EPIDEMIC OF SMALLPOX IN THE UNITED STATES.|
RUSH MEDICAL COLLEGE.
THE adaptability of man to his environment is one of many generous provisions for his welfare. But it is a provision with conditions. The adaptation once secure, even a temporary failure of complete adjustment to the environment may be perilous.
The commercial travelers of all countries are accounted, on the whole, as of a healthy class; they breathe all airs, they drink all waters, they consume all foods with impunity. They are rarely adjusted to a single environment for any length of time. The farmer, on the other hand, long habituated to his narrow circle of surroundings, would often become seriously ill if for a time he should leave his farm and village to breathe the air and drink the water and consume the food that are familiars of the traveling salesman who would sell a lightning-rod for the protection of the farmhouse.
This adaptability extends to a surprising degree. toward the limit of endurance of toxic agencies. The farmer whose case has been supposed may year after year drink with impunity the water from a well contaminated with germs that would promptly induce typhoid fever in one wholly unaccustomed to a daily dosage of the poison. But the same farmer may lose his immunity if for any length of time he removes to another residence and afterward, returning to his own place, makes use of the contaminated water to which he was once habituated.
The greatest peril from loss of adaptation to environment lies in the changes wrought by the sudden removal of a man from his country home, or even from a less salubrious city residence, to a situation where men are massed together in considerable number. Here a new and complex problem is presented. If every man of those thus suddenly congregated had recently surrendered his adaptation to a special environment, the chances of thus begetting disease are enormously multiplied. Such a condition is presented in prisons, hospitals, great fairs (such as those at Nijni-Novgorod, Chicago and Paris), and especially in the camps of soldiers. The camp as a focus of disease is more potent than all others; for one reason, among others, that even though previously subjected to selection by physical examination, and supposedly under the direction of sanitarians, the recruits are not free to select for themselves their sleeping places, food and clothing, but are at many points under subjection. Not only are they densely massed together, but they are not adapted to the new environment, even after they become veterans, who may be classed as respects immunity with the commercial traveler and the 'globe-trotter.'
War and pestilence are twin brothers, but they do not always work side by side. Often pestilence follows war; more rarely they reap their dreadful harvest on the same day. The word 'pestilence' should be understood to include not merely the grave plagues that have decimated the human race, but the less severe epidemics of disease which have spread over large areas of space and affected to a less extent great numbers of the human family. Even thus, however, in comparison, the deadliness of war is far surpassed by its grim camp-follower. Where the one slays its thousands, the other destroys its ten thousands.
In this country, the epidemic visitations following war have been both mitigated and severe. We fought Great Britain in the Revolution, and soon after were afflicted with maladies some of which had not before tormented our people. Soon after 1780 the daily papers of Boston, New York and Philadelphia were filled with advertisements of remedies for the itch, a malady which had never before so multiplied on our soil, water being abundant, soap cheap and the habits of our forefathers cleanly. The War of 1812 was chiefly naval and its aftermath of disease insignificant, for the reason that of all afloat the American war vessel has ever been the most scrupulously clean. But the Mexican War was followed by an epidemic of cholera of severe grade; and the late Civil War was the precursor of a succession of typho-malarial fevers that were previously almost unknown save in certain special localities and to physicians there resident. In a similar way the plague followed the Saracen armies under Mahomet in 622; syphilis spread through Europe after the campaign of the dissolute Frenchmen who followed to Italy the standard of Charles VIII.; and the English paid a price for the crushing of the last of the Plantagenets on Bosworth field in the epidemic of 'sweating sickness' that ensued.
Our late war with Spain was followed by an epidemic disorder which spread extensively throughout the United States, and which has attracted but little attention from our public economists, for the reason that it has been suggested to few to see the results in a comprehensive survey of the broad area involved in the extension of the disease. The malady spread from the eastern and southern borders of the United States to the Middle West, and thence in regular progression to the Pacific Slope, including in its progress not merely the States where there are efficient health boards, possessing ample powers and trained officials, operating with modern methods, such as New York, Pennsylvania, Ohio and Illinois; but also the as yet partially settled districts of the further West as far as Idaho, Oregon and California. The sweep of the malady has included individuals of the white race, the Indians and the negroes, the well-to-do and the poor, the filthy and the cleanly, people of all sorts and conditions. If the results had been in any considerable proportion grave, the entire country would have been alarmed, and the attention of all classes concentrated with a profound interest upon the earliest invasion and progress of the disease in the several localities where it spread. But, fortunately, the results were mild, so mild, indeed, that the nature of the epidemic, certainly at first, was misunderstood in almost all the places where its victims were discovered. Medical men, well trained in their profession, in many cases could not recognize the nature of the malady by reason of the special features it now for the first time presented. Some physicians, even after demonstration by experts of the character of the symptoms before their eyes, refused to accept the inevitable conclusions. Though obviously a contagious disease and one spreading in epidemic form in an astonishingly large number of villages and towns. East and West, the victims of the disease, because of the very general misapprehension respecting its nature, were permitted free access to those not affected. In many such centers of population, persons betraying all the external evidences of the disease attended churches, schools and theaters; delivered milk, groceries and other provisions at the houses of their customers; officiated in public stations; and even slept in beds occupied by other non-infected members of the same family. A study of the special character of this epidemic possesses interest, because, as a matter of fact, the malady was smallpox.
The history of smallpox in classical career has been studied with a patient faithfulness and with an attention to every detail that is set forth fully in most of the text-books. Few trained physicians are ignorant of the essential facts thus collated. In the late epidemic visiting this country, confusion in many cases arose from the total failure of the symptoms of the disease to correspond with the classical types previously portrayed in the books and encountered in practice. Almost all the histories of smallpox in the past have been descriptive of epidemics that spread among a people either previously unprotected from the disease by modern methods, or through the medium of individuals not so protected. It might, however, have been expected that an epidemic of disease occurring during the last century and another at the beginning of the present, operating on a different soil and under different conditions, would exhibit differences in type.
That smallpox may be so modified as to be stripped of every one of its formidable features has long been known. The so-called variola sine variolis (smallpox without pocks) is not a fiction of the schools, but a fact of experience. In these instances, after a day or two in which there may be slight sensations of chilliness and possibly moderate fever, the disease actually not preventing the patient from attending to his or her usual vocation, the end is reached, and without the occurrence of eruptive symptoms. These cases are sufficiently common, and the proof of the reality of the variolous process in one class, where the patient afterward is not capable of receiving disease in an epidemic, is substantiated by the proofs furnished by another class of cases, in which, for example, a pregnant woman, having suffered no more than in the instance cited, later brings into the world a child covered with unmistakable symptoms of the disease.
From the extreme of benignancy illustrated in such a group of cases to another in which symptoms are exhibited of a severity just short of the pronounced features of classical smallpox, there is every gradation and not a few excursions to the one side or the other of oddity and apparent caprice. In the late epidemic, physicians were often at sea respecting the nature of the disease, because, perhaps, after a regular onset of classical and threatening symptoms, there followed an almost absurd abortion of the morbid process, which in twenty-four hours or more lost every menacing feature; or the eruptive phenomena failed to develop the characteristic fluting or puckering of the vesico-pustules known technically as 'umbilication'; or the peculiar odor of the disease was lacking; or the mouth failed to exhibit symptoms; or the progression of the eruptive phenomena from point to point of the body-surface was not according to rule.
The question of the influence of vaccination upon the victims of the epidemic and others aroused special interest. It was claimed in many of the localities where the disease prevailed that the vaccinated and unvaccinated suffered alike; and hence that vaccination did not protect. It was further claimed that in some cases vaccination had been effective in those who were convalescent from the new disease. And thus blunders innumerable complicated the question, the answer to which was of the highest moment to the welfare of the commonwealth. The disease was variously called 'Cuban itch,' 'Porto Eico scratches,' 'Cuban measles,' 'chicken-pox,' 'Porto Rican chicken-pox,' 'Spanish measels,' etc. These popular names constituted the jargon of the ignorant. There are no maladies in Cuba, Porto Rico or Spain recognized by any such terms or others like them.
Greed is among the most potent of human motives, and it must be admitted that in the presence of the late epidemic, among those who were ignorant of its nature, there were to be found others who preferred to close their eyes to the facts. Merchants did not care to suffer the paralysis of their local trade which usually is wrought by the panic that flees before a pestilence. Editors of papers in the smaller towns were unwilling to spread the news to their immediate rivals in the adjacent county that their readers were victims of a disease which should be fought by quarantine. School boards did not care to dislocate the machinery of their system. Manufacturers pleaded for the families likely to be ruined if their works were shut down. In the minds of many there were a shame and a disgrace associated with the fact that they were singled out for the explosions of the pest; and there was some reason for this. Hence, in a considerable proportion of cases, the officers of local government, the large employers of labor, school superintendents and others refused to accept the facts, basing their belief on the evident mildness of the malady, and often upon the remarkable result that after a fortnight or more of the prevalence of the disease in their community there had been either no fatal results or so few that in several hundreds of cases the disproportionate mortality was so small as to disprove the accusation that smallpox was prevalent.
And yet smallpox indeed it was; mitigated, it is true, but still capable of awaking to a frightful activity in a favorable field and at an opportune moment. For it is among the facts established by a bitter experience that the mildest and most modified type of the disease, varioloid, for example, of insignificant features, may be the source of one of those epidemics of smallpox which rival in their mortality the most direful of the scourges that have afflicted the race.
Why was the late epidemic the mildest in its type and consequences of any of the same nature that have preceded it? Why were its features so masked that even physicians of experience failed to recognize them? Why was the resulting mortality so slight that the malady awakened little dread in the communities which it invaded, the people, made familiar by contact with its manifestations, failing to exhibit the horror which has usually been excited by its presence?
The answer is inwrought with the solution of some of the tremendous problems of the future of the human race. If devastating plagues cannot be wholly obliterated, can they be so modified by scientific methods that they are gradually converted into trifling ailments, productive of minimized danger and followed by trifling sequels? The culture-tubes and culture-plates of our bacteriological laboratories have spelled out the answer in sterilized media. The potency of almost all germs may be first gradually weakened and later annihilated by cultivation in special soils. Fraenkel has demonstrated that an enduring decrease, even a complete and irrevocable loss of virulence, has been produced by artificial cultivation of most of the different species of pathogenic bacteria, among which may be cited as conspicuous examples the germs of swine-erysipelas, of symptomatic anthrax and of pneumonia. Thus a minute organism, descended from a death-dealing source, may become in the culture-tubes of the experimenter as harmless as those found in an ordinary infusion of hay, such as the bacillus subtilis. Even thus the wild boar is proven the ancestor of the domestic hog, and the wild-cat the remote progenitor of the Angora kitten.
Even scarlet fever, under the impulse of some such causes as those under discussion, has evolved a 'new type,' which has been set forth by a competent health officer. Dr. William Robertson, of Leith. He reports that compulsory notification has not only lowered the mortality of scarlet fever, but actually modified its type, so much so that it is now difficult to tell when one has or has not to deal with the suspected disorder. On every side one hears it repeated that epidemics are now characterized by a want of symptoms and signs. The bright red rash is seldom seen, and when there is a rash it disappears before the arrival of the medical attendant. If one looks for throat-signs, they, too, may have been transitory. The symptoms of onset are so slight that even an anxious parent takes no notice of a passing indisposition.
These are the evidences, oftentimes somewhat vague, but again both significant and unmistakable, that the dream of the scientist is to have its realization in the future. Few believe that the great pests of the human family will be suddenly jugulated or annihilated. The gradual extinction of each by modification, by attenuation of virus, and by elimination of grave symptoms, is the aim of scientific medicine, and its disciples can thank God and take courage for the fruits of their labor, realized each year in larger measure and with fuller promise.
The germ of all epidemics of smallpox is one, but the soils on which it has grown are many. The culture-tubes and culture-plates on which it has been propagated until it has lost much of its potency and even many of its features are the bodies of the men and women of the last quarter of the nineteenth and the early part of the twentieth centuries.
The late epidemic of smallpox in the United States was the legitimate fruit of the Spanish-American War, and the popular terms by which it was designated among the common people, like almost all folk-words, contained a kernel of truth. Cuba and Porto Rico, before our armies descended upon their shores, were like the Philippine Islands, very abiding-places and citadels of smallpox. Our returning troops brought back with them the effective elements which lighted up the late epidemic in the United States. But the germ-carriers in this instance were our own previously vaccinated soldiers. The germ was attenuated in its potency at the outset. When it gathered to itself the added power by which it was enabled to spread from community to community, its extension was not through a population virgin of protection by previous vaccination, but for the most part constituted either of the vaccinated or of the children of the vaccinated.
Unvaccinated but yet 'children of the vaccinated'—is any degree of immunity conferred by inheritance? However difficult of exact demonstration, the affirmative must be accepted not merely as a logical sequence of the experiments in the laboratory to which reference has been made, but by certain clinical phenomena of striking importance. For example, it is well known that among some of the immigrants touching our shores for the first time, who come from countries where the mosquito is not found, notably from English homes, the ravages produced in midsummer, when women and children especially are lodged in cheap boarding-houses, with windows unprotected by screens, the results of the attacks of the American insect upon their exposed skins are of a grade of severity unparalleled among natives of our soil. Generations of Americans have succeeded in establishing a partial immunity by the mere succession of these accidents in a long series of summers; so that while they may, and actually do, suffer from mosquito bites, the effects are far milder and without any proportion to those experienced by the immigrant. A striking illustration of this fact is recorded in the history of the Revolutionary War, when in the midst of their first summer on this soil the mercenary troops from Hesse-Darmstadt and Hesse-Cassel were so savagely attacked on their march from Trenton that whole platoons of troops were unable to distinguish objects through their swollen eye-lids, and were thus rendered wholly unfit for duty. Looking at the obverse of this proposition, every student of public hygiene is aware of the fact that truly formidable ravages of smallpox occur in epidemics attacking virgin populations, as, for example, islanders long unvisited by Europeans, where neither the individuals themselves nor their ancestors for generations have enjoyed the immunizing protection of vaccination. In these cases it is often not merely a decimation which results, but it may be a destruction of more than half of the entire population. In a few isolated instances almost every individual of a tribe or village has been cut off. Not the sins alone of the fathers but some of their safeguards are visited upon the children. The clean living that drove away leprosy from English soil and that so widely substituted the gout for the 'King's evil,' has tinctured the blood of the children of the men who fought at Naseby and learned a lesson in humanity from Howard.
It will be seen that the whole question pivots upon vaccination. It is necessary to look critically upon this means of securing immunity, for the procedure is again under the searchlight.
All said and done, vaccination is an invaluable means of securing immunity against smallpox, but it is not a perfect means. What artificial conquests of man are rounded to the perfection-point? Every one knows that the finest double-screw steel vessel that steams across the Atlantic can be crushed by a single blow of the arm of the sea if the gale be sufficiently furious and the billows sufficiently huge. As it is necessary to admit that even one attack of smallpox does not confer absolute immunity against a second, seeing that some men have had two and even more of such attacks in a lifetime, equally must it be admitted that vaccinated persons, and even many times revaccinated persons, have had attacks of smallpox. In ordinary seasons when smallpox is not prevalent a larger protection is conferred by vaccination than that conferred by the lightning-rod upon the dweller beneath the roof above which it rises. But in seasons of epidemic influence, even though the epidemic be as mild as that which furnishes the theme of this paper, such an influence is appreciable and in many cases highly effective. At these times those who previously were incapable of being vaccinated (even the vaccini culturists occasionally find heifers which cannot be made to serve as vaccinifers) are inoculated with ease; at such times also vaccination can be made effective even after the onset of unmistakable symptoms of smallpox; at such times also even those who have had smallpox can be vaccinated, and that after the recent establishment of convalescence. The ardent advocates of the position that the mild epidemic through which this country has just passed was not one of smallpox pointed with what seemed to them convincing force to the fact that they had successfully vaccinated the victims of the disease immediately after recovery. But the argument was without force. The skin of a person convalescent from smallpox is in an exceedingly irritable state and readily is excited to the production of local symptoms at the point where the needle of the vaccinator has been at play. It has to be borne in mind that the actual introduction of a disease by inoculation is a far more rigid test than mere exposure to a volatile poison, the kind of exposure through which, as a rule, smallpox is acquired. What physician, for example, would dare to inoculate a patient with the virus of smallpox after the most classically perfect vaccination? He would be held criminally liable for the result if, as might happen, in this way he should disseminate the disease throughout the community in which he lived.
But the spurious results cited of vaccination of convalescents from modified smallpox prove nothing. Even highly typical results would not disprove the fact of a previous attack of modified or unmodified smallpox. It has been shown that both the vaccination process and the variolous process may pursue their career at one and the same time in the same body. But Dr. Mosely, of Kentucky, put the question to a decisive test last year when he vaccinated three negroes, each convalescent from smallpox, immediately on his release from quarantine. Each subsequently exhibited classical results of successful vaccination in due time and course.
Respecting the enormous value of vaccination to the human race, it would seem scarcely necessary to appeal to statistics at this late hour of the scientific day. But surely so long as we have the poor with us, we shall have with them a class of men whose minds are so curiously constituted that they will select for study the nether side of the social fabric, the weakness of the best of governments, and the minor defects in the character of the world's heroes.
Even as late as the month of April in the first year of the new century one of the largest and most widely read of the daily papers of the country published over the name of a well-known anti-vaccinationist a statement apparently made in good faith to the effect that vaccination counted more victims than smallpox, and that the practice was a relic of barbarism, asking that a halt be called upon the passage of compulsory laws looking to the protection of the people by any such measures. These singular protests against the operation of the most beneficent of life-saving devices will probably be repeated so long as there is a law on any statute book. Their starveling and distorted figures, garnered from the refuse heaps of mortality, must ever and again furnish forth the tables on which these purblind reasoners rely. They close their eyes to the latest signal victory of science in this field. The Island of Porto Rico, according to the report of Surgeon-General Hoff, in the year 1896 harbored no fewer than three thousand cases of smallpox. Imagine a State of the Union of similar size exposed to such an extent to the ravages of the disease! After the establishment, however, of a government vaccine-farm, "eight hundred thousand natives were vaccinated, at a cost of about four cents for each individual, with the result that by October, 1899, no case of smallpox was known either to the military or civil authorities anywhere in the island." This was a fine illustration of the carrying of 'the white man's burden.' Porto Rico bombarded us with a filth-germ and in revenge we made her clean!
In the year 1867 vaccination was made compulsory for school children in the city of Chicago, and for twenty years after there was practical immunity from smallpox for this important class of the population; while the police of the same city, exposed to every form of infectious disease in their surveillance of its several districts, since vaccination was made compulsory also for them, have never developed a case of the disease.
Dr. Buchanan, medical officer of the local government board (England), in 1881 prepared a table of comparative smallpox death rates among Londoners, vaccinated and unvaccinated respectively, for the fifty-two weeks ending May 29, 1881, calculating that the vaccinated persons of all ages living in London, in the twelve months concerned, were 3,620,000, and the unvaccinated of all ages 190,000 in number. This table reads:
|Death rate of people
of subjoined ages
|Per million of each age
of the vaccinated
|Per million of each age|
of the unvaccinated
|Under twenty years||61||4,520|
|Under five years||401||5,950|
Statistics of this sort might be piled mountains high; but they mean nothing and they count for nothing with the prejudiced. It is well to remember at times that any agency and influence operating at any one moment upon large masses of human beings of both sexes and of all ages has to bear its percentage of damage and death. The killed on the day of the passing of the funeral cortege of Queen Victoria, the fatality attending ocean and railway travel, even the victims of the awful fire-tragedies lately occurring in Paris and New York, which shocked every reader of the public press, have not deterred men and women of ordinary common sense from going to fairs, sleeping in hotels, or crossing the continent by rail or the ocean steamer. Vaccination of every member of any community, including men, women and, in particular, infants will, without any question, be followed by untoward results in a proportion of cases. The mere statistics of common accidents and ordinary disease account for a large part of the list in the relatively slender catalogue of vaccination accidents. Men, women and children perish annually from the stings of bees, from the bites of flies, from the prick of a pin, and from the accidental impaction of a bit of food in the larynx. Lately a physician reported a disease not due to vaccination. An infant was brought by appointment to his office in order to be inoculated, but the physician chanced to be called away from the city, and the date of the trifling operation was postponed for a week. In that week the child developed symptoms of syphilis, which would probably have been laid to the account of the vaccination if the latter had been performed.
It has been said that if the modern tourist could be transported to the streets of London in the eighteenth century, before the general adoption of the practice of vaccination, he would be immensely astonished, not so much by the quaintness of the dress and the speech of the people, by the aspect of their shops, and by the odd-looking vehicles on their streets, as by the extraordinary number of pock-marked faces he would encounter on every hand. Even as early as the year 1778, the officers of foreign troops on American soil wrote back to their countrymen in the old world that the American women were surpassingly beautiful and were very ’seldom pock-marked.' Macaulay, describing the distress in London in 1694, wrote as follows: "That disease over which science has since achieved a succession of glorious and beneficent victories was then the most terrible of all the ministers of death. The havoc of the plague had been more rapid; but the plague had visited our shores only once or twice within living memory, and the smallpox was always present, filling the churchyards with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maid objects of horror to the lover."
At last our English brethren have learned the lesson and learned it well. They have had bitter experience of the devastation which smallpox is capable of working among their kindred, whether in the hovel or in the palace. They have mourned the loss of a gracious sovereign smitten with the pestilence on the very throne of their kingdom. While we may not wish to follow them in all matters, they have set us a worthy example in the patience with which they have buttressed their bulwarks of immunity. The germs of this pestilence are powerless against the army of their humble villagers and peasantry, ranks upon ranks of whom bear upon the arms of each no fewer than four, and often as many as six and eight, simultaneously produced scars of successful inoculation of cow-pox. Vaccination should be the seal on the passport of entrance to the public schools, to the voters' booth, to the box of the juryman, and to every position of duty, privilege, profit or honor in the gift of either the State or the Nation.