THE INDIAN MEDICAL GAZETTE. SMALL-POX AND VACCINATION IN BIIURTPOOR. By Robert
Surgeon
Harvey, M.B., &c., Eajpootana Political Agency.
(Continued from page 258, The State of
Bhurtpoor,
the first cases
in common with, the surrounding small-pox for nearly four years,
were
data to go upon, epidemic. Some of
no
in famine-stricken
the disease had
and
refugees from appeared in Agra a
before these some
Bikanir and
were
doubts
as
to its introduction
by special contagion,
and
suggests the possibility of the sudden vivification of dormant germs under some unknown circumstances favourable to their
development. I was absent on tour when the first cases occurred, and was unable to trace them with certainty on my return ; but howsoever originated, the disease appeared about the end of November or beginning of December, and once established, spread with great rapidity to every quarter of the city. The first death was registered on the 14th of December, and for the next two months the disease raged with great violence, carrying off many victims. The space at my disposal being limited, I shall confine myself to a detail of the leading features of the epidemic, and the results deduced from the observed cases. One of the first points which struck me was the entire similarity of the cases, in type, symptoms, and results to those which I had seen in Dudley during the English epidemic of 1863-64. There were no signs of that peculiar virulence, which, according to Copland, Marson, and most modern writers, characterizes the invasion of small-pox in the dark skinned races; and after a few days' observation it was evident that the number of comparatively slight cases (variola discretaj was far more than in ordinary epidemics in England, or in the experience of the small-pox hospital of London for a long series of years, thus reducing the total mortality much below the English average. The following table shews the relative proportion of the different forms of small-pox in 728 cases in unvaccinated children in Bhurtpoor, and in the small-pox hospital for fifteen years Small-pox
Shuetpoob. 1863-69.
Smail-pox
Hospital, 1836-51.
greatest, and the death-rate highest. Let one melancholy example illustrate this. In a small enclosure, close to an open sewer near the Beonarain Gate, and inhabited by four Mussulmans, were fourteen unvaccinated children. All of them caught the disease in its confluent or semi-confluent form, and eight died, two of those who recovered being permanently blind. A3 a rule, however, the form of the disease was the discrete and mild; the initiatory fever being moderate ; the eruption appearing, maturating and desiccating in due course; the secondary fever being slight; and the convalescence uninterrupted and without distressing sequelae. Some very severe Cftses recovered, amongst them several in which it would hardly have been possible to touch any portion of healthy skin. In a few instances petechial and haemorrhagic symptoms were present, and almost all died. Three cases were noted as corymbose, the pocks gathered here and there in confluent patches, Avhile the rest of the body was sparsely sprinkled. This form of the disease is described by Marson as peculiarly fatal, but two of them recovered. In the third the patches were diffused and flat, the pustules not filling properly, each patch being surrounded by a broad livid areola of an erisipelatous character; with great nervous depression, and much irritation and swelling of the throat. There were two groups of pustules, one, two inches in diameter, on the right side of the forehead, and another a little larger in front of the left thigh, the remainder of the surface being pretty thickly studded with distinct and well developed pocks. Fever persisted throughout, and the patient died on the eighth day. Three cases of cancrinn oris (all fatal), two of diffuse inflammation of joints (both fatal), several of troublesome boils and of abeesses in the scalp and cellular tissue generally, and many of partial and complete blindness, came under my notice as sequelae of the disease.
I saw
no case
of variola sine variolis.
second attacks, but three of these doubtful. Five were distinctly pitted, in two instances deeply, and the history of the previous attack was clear and distinct. The ages of the five were 5, 8, 16, 23, and 25. In all the disease was distinct aad much modified. They all recovered. The disease resembled post vaccinal small-pox (varioloid) in
Eight
cases were
reported
as
were
strong
% 33 2 ? ? ? -
PBBSOIT3.
a
every respect and in all the cases, and there was no secondary fever in any one of them. Four were known to have been exposed to infection, and the cases at 23 and 25 years of
in
UNVACCIIfATED
epidemic.
mild as it was, it still in particular instances virulence of great power. It raged with special fury in the dirtiest and most squalid parts of the city. There the cases were most numerous, the proportion of confluent cases
shewed
full month noted; but its almost simultaneous appearance throughout the North-West Provinces and Bajpootana causes
Marwar,
of the
Comparatively
Vol. IV. J
when the present outbreak began. Having I shall not speculate on the origin of the
and the total results, therefore, (a mortality of 18-55^ compared with 37'53 per cent.) prove the comparative mild-
ness
had been free from
districts,
1870.
reported, as
to the Eastern
[Januaey 1,
age were in women, who had nursed children
XI
suffering
from,
small-pox. S "
P4
g-8 a
s. a
cu
W
Confluent
26-24
13-33
1,833
69-25
Semi.Confluent
23-02
2-33
614
23-13
45'74
1-81
Distinct Total
100-00 17-52
...
202 18-55
7-6:
2,654 100-00
50-98 35-31 8-30 3
1-92 *30 37-53
It shews too, that in assuming the average English death-rate the death-rate of Bhurtpoor, the deduced results differ fi oiu one per cent., a circumthose obtained resistration
as
by
by only
which goes to prove at once the accuracy of the returns, and the similar fatality of the different forms of small-pox in England and in India. The actual Bhurtpoor death-rate is calculated on the total cases and deaths reported at the Kotwalli, not on my observed cases ; the final results of which, for
stance
already given, are not considered trustworthy. I have said that I believe almost all cases and deaths to have been duly reasons
It was useless to recommend treatment which would not, and could not, have been carried out. As a rule, the patient was shut up in a dark close room, made closer by the fumes of a pan of constantly burning charcoal; spices and warm condiments
freely given to bring out the eruption, and when desiccacommenced, ghee was applied over the pustules. For the rest, prayers to Situla, charms and spells, and the protective influence of bunches of neem leaves hung over the door, were trusted to, to bring the patient round. All I could do was to recommend freeer ventilation, and the employment of cooling drinks, while I utilized the charcoal pan in producing sulphurous acid. This seemed useful, especially in allaying the great and irritation of skin when the scabbing process had itching begun, and it was largely adopted and greatly praised by many were
tion
natives whose children I had not seen, but who had heard of the plan from others. In one or two cases I gave the acid internally, but without much evident effect. The total number of reported cases was 2,162, and of deaths 401.
These
were
reported
every
morning by
the jemadars of
January 1,
SMALL-POX & VACCINATION IN BHURTPOOE.?BY E. HARVEY.
1870.]
mohullas, and were checked by the sweepers' reports ; while I personally went over the lists of one or two mohullas daily, and seldom lighted on an unreported case. Those seen and noted by myself were 802, a number sufficiently large to work upon in deducing the general averages of the whole. Of the 802, 684, or 85*29 per cent., were five years of age or under, and of the remainder only 18 cases, or 2*24 per cent., were over ten; a terrible testimony to the violence of preceding epidemics, and to the almost universal protection of all but the An almost identical provery youngest by previous small-pox. 84*20 of the 1,830 fatal cases where in noted was Agra, portion were under five years, and only 2*18 over ten. Sixty-two childunder one year; 94, or 11-73 per ren, or 7-74 of the whole, were cent., between one and two ; 136, or 16*96 per cent., between two and three ; 169, or 21*07 per cent., between three and four ; 129, or 16*08 per cent., between four and five ; while 94, or 11*73 per cent., had completed five years. This bears out Watson's state* that " infants are little susceptible to the operation of ment,
contagions," but that after the very earliest periods of life" they become more liable than in mature age to infectious disThe diminution in number after four years is probably eases. owing to a part, though but a small part, of the children over that age having gone through small-pox during the epidemic of "
1864-65. The 802 cases occurred in 550 houses, there more cases
in each of 133 houses.
close to infected
places,
but I cannot
Many others
give
being were
two
or
noted as
the exact numbers.
I
where every member of a family, previseized by the disease, and in fact very was ously unprotected, few escaped it who did not submit to vaccination in the course could cite many
cases
of the
epidemic. worthy of remark that the Mussulmans, who form 21 of the population of the city, furnished 30 per cent, of
It is cent, cases.
per the
This is due in part to their distrust of our motives in and in part to their living chiefly in the worst
vaccinating,!
parts of the town. Brahmuns and Banians together give 27 per cent., of the Hindu population. As a class, they are more pre-
20th and succeed-
Week.
ing.
Bhurtpoor.
30 41 43
Agra.
45 60 137
145
181
Ninety-three and a half per cent, of the total mortality in Bhurtpoor thus took place in the first nine weeks of the epidemic, and the disease had finally disappeared after seventeen weeks; whereas in Agra only 25-43 per cent, of the deaths were within nine weeks, the total number was spread over 39, and 22 weeks had elapsed before 93 per cent, had been registered. This contrast is great, and the peculiar distribution of the cases in Bhurtpoor is as striking as it is unusual. Dr. Bedford, in a most exhaustive paper on vaccination and inoculation in India,* and the commission appointed by Government in 1850 to inquire into the same subject, have shewn, that beginning in December or January, small-pox goes on spreading and extending till March or April, gradually dying out as the hot season draws near, and finally disappearing on the commencement of the rains ; and Dr. J. MacPherson,f besides confirming this, proves that in epidemic years it appears earlier and continues its ravages longer than usual, so that a severe outbreak may be expected when cases begin to be met with early in the cold weather. In the North-West Provinces, from what I can learn, the same geneThe following monthly summary shews ral rule holds good. that in Agra as in Bhurtpoor the height of the disease was reached in January, but the decline is more gradual in Agra; and the epidemic beginning earlier is spread over a much a longer period. It finally, I believe, died out for want of fresh victims, after having attacked, (supposing the ratio of cases to deaths to have been the same as in Bhurtpoor), 9,898 persons, and occasioned an amount of suffering and death which it is painful to think of, and still more painful to know, was almost entirely avoidable:? Months.
vaccination than any other, and it has always been difficult to get them to submit their children to the operation. They furnished 46 per cent, of the cases among the Hindus, and it is among them that any unregistered cases occurred.
judiced against
\
Bhurtpoor.,
I have said that once established the disease spread over the with great rapidity. Coming into a population ready to receive it, its accession was far too sudden and to
34
Agra
ly
admit of its
suburbs alone. At first their efforts seemed to have little effect. Fresh cases were reported in ever increasing numbers, and for several 'weeks it seemed that the constant multiplication and concentration of the poison was increasing their severity. The following table shews, however, that their exertions were not in vain, and that the mortality culminating in. the fifth week, then took a downward turn, and after four weeks more almost
entirely ceased ; the brunt of the epidemic being borne by two months, although cases were spread over four. For the sake of comparison, I place side by side of the Bhurtpoor figures, the returns of deaths in the city and suburbs of Agra :?
*
Principles and Practice of Physic, 3rd Edition, Vol. Ii(
p, 712. t It is a common belief among uneducated Mahommedans that a Prophet With milk instead of blood in his veins is speedily to appear to restore the reign of the faithful; and that the English Government has instituted who is instantly to be made away with. vaccination to discover this
child,
liisum lc neatis, umici?
In this and the preceding table 9 deaths in the Bhurtpoor hospital are
city
wide-spread being stamped out by isolation of cases, which, within a fortnight or three weeks of the first outbreak, were numbered by hundieds. The only hope of checking it lay in vaccination, and this Avas pushed on vigourously, five men giving their wholo time to it, and vaccinating Jn the city and
9
The total mortality per 10,000
Bhurtpoor
and 128 in
miles of each
of population
accidental-
omitted.
was
65 in
The two cities are within
Agra.
thirty atmospheric
and How then is the difference in the course and severity of the epidemic to be accounted for ? I know of no cause, and can imagine none, except that vaccithe Jats of Bhurtpoor, and in great nation has been
other,
and their
general sanitary
conditions are almost identical.
accepted by rejected by the Mussulmans
of Agra. Dr. Christison, to whose kindness I am indebted for the above information and returns, and who was formerly Superintendent of Vaccination in the Circle, tells me that it was always difficult to vaccinate within the limits of the city, much more so than measure
of
Agra,
in the
villages around;
and I have heard the same statement
made by others. The early subsidence of the disease in Bhurtpoor was due to the absence of cases for the virus to act upon, but this absence was caused by vaccine protection', not by want of children.
Very
few
children
unprotected
over
*
six
children
months, and
escaped. In examining 732 up to five years of age, a few
Indian Annals of Medical Science, 2fo. I.
t Ibid, JSo. XY., page 84
THE INDIAN MEDICAL GAZETTE.
!0
weeks ago, I found that 221, or 3019 per cent., were marked with ; 476, or 65'03 per cent., had vaccine cicatrices; while or 4-78 per cent., were unprotected and had escaped : and all these had been infants in arms during the epidemic.
small-pox only 34,
The Bhurtpoor census of 1867 only discriminates between children and adults. It is, therefore, impossible to give correctly the population liable to small-pox. The following estimate must suffice:?In the census report for the North-West Provinces it appears that the relative proportion of children to
higher than in England; and as Bhurtpoor may purposes be regarded as part of the North-West, rule holds good within the limits of the State.
adults is much for all the
same
Now, to
practical
the
the number of children under five years of age, according English census of 1861, was 27,00,782, in a population of
2,00,66,224,
or
applied to small-pox of these, 8,283,
13*46 per cent.; a proportion which in a population of 61,448. As
Bhurtpoor gives 8,283
had been absent for four years, at least four-fifths it, and a considerable number of the remainder, who were for the most part in extreme infancy when the could not have had disease was last
prevalent, probably escaped. I shall, however, doubt, exclude the whole of these, or 1,656. From the remaining 6,627 I deduct 1,844, the number of children, five years old and under, (calculated from 802 cases, at 85-29 per cent.) who contracted small-pox, and 369, (4-78 per cent.) the estimated number of those who, though unvaccinated, escaped the disease. This leaves 4,414, which I believe to represent the number of cases saved from small-pox by vaccination. I cannot the see that this number is exaggerated, or detect a flaw in process by which the conclusion is arrived at. A large margin for possible error has been left, in each term of the calculation, and the number might plausibly have been put higher. If the figures are correct or nearly correct, they carry the simple corrollary that an incredible amount of suffering, and some 800 lives have been saved by vaccination in Bhurtpoor alone. The course of the epidemic indicates that though not at once stamped out its violence was speedily controlled, and after a short struggle strangled, by vaccination. Before concluding this part of the subject I will give one instance where On the the stamping out protess was effectual and complete. 7th of January a fatal case of confluent small-pox took place in a small village in the angle between the Deeg and Circular Iloads. This was the first case. The same day all the other unprotected children, 32 in number, were vaccinated by Mohammed Buksh, one of my best operators. On the 13th I accompanied him to inspect the cases. Three of them, having been incubating the disease at the time of the operation, were found to have s uallpox. All the others presented excellent vesicles, except one child, in whom they had been rubbed and broken. A week later I revisited the village and found a case of confluent small-pox in a child that had been brought from a distance on the eighth, the day after the vaccinations had been performed, but this was the only case. The three former cases in which small-pox (unmodified) and vaccinia had progressed together were convalescent, to
and
avoid all
none
of the other children had been seized. No cases afterI think most persons will acknowledge that
wards occurred.
but for vaccination few of these 29 children would have escaped small pox, and four or five of them would probably have died.
(To
be
continued.)
[Januaky 1,
1870.
Surgeon
Harvey, M.B., &c., Eajpootana Political Agency.
(Continued from page 258, The State of
Bhurtpoor,
the first cases
in common with, the surrounding small-pox for nearly four years,
were
data to go upon, epidemic. Some of
no
in famine-stricken
the disease had
and
refugees from appeared in Agra a
before these some
Bikanir and
were
doubts
as
to its introduction
by special contagion,
and
suggests the possibility of the sudden vivification of dormant germs under some unknown circumstances favourable to their
development. I was absent on tour when the first cases occurred, and was unable to trace them with certainty on my return ; but howsoever originated, the disease appeared about the end of November or beginning of December, and once established, spread with great rapidity to every quarter of the city. The first death was registered on the 14th of December, and for the next two months the disease raged with great violence, carrying off many victims. The space at my disposal being limited, I shall confine myself to a detail of the leading features of the epidemic, and the results deduced from the observed cases. One of the first points which struck me was the entire similarity of the cases, in type, symptoms, and results to those which I had seen in Dudley during the English epidemic of 1863-64. There were no signs of that peculiar virulence, which, according to Copland, Marson, and most modern writers, characterizes the invasion of small-pox in the dark skinned races; and after a few days' observation it was evident that the number of comparatively slight cases (variola discretaj was far more than in ordinary epidemics in England, or in the experience of the small-pox hospital of London for a long series of years, thus reducing the total mortality much below the English average. The following table shews the relative proportion of the different forms of small-pox in 728 cases in unvaccinated children in Bhurtpoor, and in the small-pox hospital for fifteen years Small-pox
Shuetpoob. 1863-69.
Smail-pox
Hospital, 1836-51.
greatest, and the death-rate highest. Let one melancholy example illustrate this. In a small enclosure, close to an open sewer near the Beonarain Gate, and inhabited by four Mussulmans, were fourteen unvaccinated children. All of them caught the disease in its confluent or semi-confluent form, and eight died, two of those who recovered being permanently blind. A3 a rule, however, the form of the disease was the discrete and mild; the initiatory fever being moderate ; the eruption appearing, maturating and desiccating in due course; the secondary fever being slight; and the convalescence uninterrupted and without distressing sequelae. Some very severe Cftses recovered, amongst them several in which it would hardly have been possible to touch any portion of healthy skin. In a few instances petechial and haemorrhagic symptoms were present, and almost all died. Three cases were noted as corymbose, the pocks gathered here and there in confluent patches, Avhile the rest of the body was sparsely sprinkled. This form of the disease is described by Marson as peculiarly fatal, but two of them recovered. In the third the patches were diffused and flat, the pustules not filling properly, each patch being surrounded by a broad livid areola of an erisipelatous character; with great nervous depression, and much irritation and swelling of the throat. There were two groups of pustules, one, two inches in diameter, on the right side of the forehead, and another a little larger in front of the left thigh, the remainder of the surface being pretty thickly studded with distinct and well developed pocks. Fever persisted throughout, and the patient died on the eighth day. Three cases of cancrinn oris (all fatal), two of diffuse inflammation of joints (both fatal), several of troublesome boils and of abeesses in the scalp and cellular tissue generally, and many of partial and complete blindness, came under my notice as sequelae of the disease.
I saw
no case
of variola sine variolis.
second attacks, but three of these doubtful. Five were distinctly pitted, in two instances deeply, and the history of the previous attack was clear and distinct. The ages of the five were 5, 8, 16, 23, and 25. In all the disease was distinct aad much modified. They all recovered. The disease resembled post vaccinal small-pox (varioloid) in
Eight
cases were
reported
as
were
strong
% 33 2 ? ? ? -
PBBSOIT3.
a
every respect and in all the cases, and there was no secondary fever in any one of them. Four were known to have been exposed to infection, and the cases at 23 and 25 years of
in
UNVACCIIfATED
epidemic.
mild as it was, it still in particular instances virulence of great power. It raged with special fury in the dirtiest and most squalid parts of the city. There the cases were most numerous, the proportion of confluent cases
shewed
full month noted; but its almost simultaneous appearance throughout the North-West Provinces and Bajpootana causes
Marwar,
of the
Comparatively
Vol. IV. J
when the present outbreak began. Having I shall not speculate on the origin of the
and the total results, therefore, (a mortality of 18-55^ compared with 37'53 per cent.) prove the comparative mild-
ness
had been free from
districts,
1870.
reported, as
to the Eastern
[Januaey 1,
age were in women, who had nursed children
XI
suffering
from,
small-pox. S "
P4
g-8 a
s. a
cu
W
Confluent
26-24
13-33
1,833
69-25
Semi.Confluent
23-02
2-33
614
23-13
45'74
1-81
Distinct Total
100-00 17-52
...
202 18-55
7-6:
2,654 100-00
50-98 35-31 8-30 3
1-92 *30 37-53
It shews too, that in assuming the average English death-rate the death-rate of Bhurtpoor, the deduced results differ fi oiu one per cent., a circumthose obtained resistration
as
by
by only
which goes to prove at once the accuracy of the returns, and the similar fatality of the different forms of small-pox in England and in India. The actual Bhurtpoor death-rate is calculated on the total cases and deaths reported at the Kotwalli, not on my observed cases ; the final results of which, for
stance
already given, are not considered trustworthy. I have said that I believe almost all cases and deaths to have been duly reasons
It was useless to recommend treatment which would not, and could not, have been carried out. As a rule, the patient was shut up in a dark close room, made closer by the fumes of a pan of constantly burning charcoal; spices and warm condiments
freely given to bring out the eruption, and when desiccacommenced, ghee was applied over the pustules. For the rest, prayers to Situla, charms and spells, and the protective influence of bunches of neem leaves hung over the door, were trusted to, to bring the patient round. All I could do was to recommend freeer ventilation, and the employment of cooling drinks, while I utilized the charcoal pan in producing sulphurous acid. This seemed useful, especially in allaying the great and irritation of skin when the scabbing process had itching begun, and it was largely adopted and greatly praised by many were
tion
natives whose children I had not seen, but who had heard of the plan from others. In one or two cases I gave the acid internally, but without much evident effect. The total number of reported cases was 2,162, and of deaths 401.
These
were
reported
every
morning by
the jemadars of
January 1,
SMALL-POX & VACCINATION IN BHURTPOOE.?BY E. HARVEY.
1870.]
mohullas, and were checked by the sweepers' reports ; while I personally went over the lists of one or two mohullas daily, and seldom lighted on an unreported case. Those seen and noted by myself were 802, a number sufficiently large to work upon in deducing the general averages of the whole. Of the 802, 684, or 85*29 per cent., were five years of age or under, and of the remainder only 18 cases, or 2*24 per cent., were over ten; a terrible testimony to the violence of preceding epidemics, and to the almost universal protection of all but the An almost identical provery youngest by previous small-pox. 84*20 of the 1,830 fatal cases where in noted was Agra, portion were under five years, and only 2*18 over ten. Sixty-two childunder one year; 94, or 11-73 per ren, or 7-74 of the whole, were cent., between one and two ; 136, or 16*96 per cent., between two and three ; 169, or 21*07 per cent., between three and four ; 129, or 16*08 per cent., between four and five ; while 94, or 11*73 per cent., had completed five years. This bears out Watson's state* that " infants are little susceptible to the operation of ment,
contagions," but that after the very earliest periods of life" they become more liable than in mature age to infectious disThe diminution in number after four years is probably eases. owing to a part, though but a small part, of the children over that age having gone through small-pox during the epidemic of "
1864-65. The 802 cases occurred in 550 houses, there more cases
in each of 133 houses.
close to infected
places,
but I cannot
Many others
give
being were
two
or
noted as
the exact numbers.
I
where every member of a family, previseized by the disease, and in fact very was ously unprotected, few escaped it who did not submit to vaccination in the course could cite many
cases
of the
epidemic. worthy of remark that the Mussulmans, who form 21 of the population of the city, furnished 30 per cent, of
It is cent, cases.
per the
This is due in part to their distrust of our motives in and in part to their living chiefly in the worst
vaccinating,!
parts of the town. Brahmuns and Banians together give 27 per cent., of the Hindu population. As a class, they are more pre-
20th and succeed-
Week.
ing.
Bhurtpoor.
30 41 43
Agra.
45 60 137
145
181
Ninety-three and a half per cent, of the total mortality in Bhurtpoor thus took place in the first nine weeks of the epidemic, and the disease had finally disappeared after seventeen weeks; whereas in Agra only 25-43 per cent, of the deaths were within nine weeks, the total number was spread over 39, and 22 weeks had elapsed before 93 per cent, had been registered. This contrast is great, and the peculiar distribution of the cases in Bhurtpoor is as striking as it is unusual. Dr. Bedford, in a most exhaustive paper on vaccination and inoculation in India,* and the commission appointed by Government in 1850 to inquire into the same subject, have shewn, that beginning in December or January, small-pox goes on spreading and extending till March or April, gradually dying out as the hot season draws near, and finally disappearing on the commencement of the rains ; and Dr. J. MacPherson,f besides confirming this, proves that in epidemic years it appears earlier and continues its ravages longer than usual, so that a severe outbreak may be expected when cases begin to be met with early in the cold weather. In the North-West Provinces, from what I can learn, the same geneThe following monthly summary shews ral rule holds good. that in Agra as in Bhurtpoor the height of the disease was reached in January, but the decline is more gradual in Agra; and the epidemic beginning earlier is spread over a much a longer period. It finally, I believe, died out for want of fresh victims, after having attacked, (supposing the ratio of cases to deaths to have been the same as in Bhurtpoor), 9,898 persons, and occasioned an amount of suffering and death which it is painful to think of, and still more painful to know, was almost entirely avoidable:? Months.
vaccination than any other, and it has always been difficult to get them to submit their children to the operation. They furnished 46 per cent, of the cases among the Hindus, and it is among them that any unregistered cases occurred.
judiced against
\
Bhurtpoor.,
I have said that once established the disease spread over the with great rapidity. Coming into a population ready to receive it, its accession was far too sudden and to
34
Agra
ly
admit of its
suburbs alone. At first their efforts seemed to have little effect. Fresh cases were reported in ever increasing numbers, and for several 'weeks it seemed that the constant multiplication and concentration of the poison was increasing their severity. The following table shews, however, that their exertions were not in vain, and that the mortality culminating in. the fifth week, then took a downward turn, and after four weeks more almost
entirely ceased ; the brunt of the epidemic being borne by two months, although cases were spread over four. For the sake of comparison, I place side by side of the Bhurtpoor figures, the returns of deaths in the city and suburbs of Agra :?
*
Principles and Practice of Physic, 3rd Edition, Vol. Ii(
p, 712. t It is a common belief among uneducated Mahommedans that a Prophet With milk instead of blood in his veins is speedily to appear to restore the reign of the faithful; and that the English Government has instituted who is instantly to be made away with. vaccination to discover this
child,
liisum lc neatis, umici?
In this and the preceding table 9 deaths in the Bhurtpoor hospital are
city
wide-spread being stamped out by isolation of cases, which, within a fortnight or three weeks of the first outbreak, were numbered by hundieds. The only hope of checking it lay in vaccination, and this Avas pushed on vigourously, five men giving their wholo time to it, and vaccinating Jn the city and
9
The total mortality per 10,000
Bhurtpoor
and 128 in
miles of each
of population
accidental-
omitted.
was
65 in
The two cities are within
Agra.
thirty atmospheric
and How then is the difference in the course and severity of the epidemic to be accounted for ? I know of no cause, and can imagine none, except that vaccithe Jats of Bhurtpoor, and in great nation has been
other,
and their
general sanitary
conditions are almost identical.
accepted by rejected by the Mussulmans
of Agra. Dr. Christison, to whose kindness I am indebted for the above information and returns, and who was formerly Superintendent of Vaccination in the Circle, tells me that it was always difficult to vaccinate within the limits of the city, much more so than measure
of
Agra,
in the
villages around;
and I have heard the same statement
made by others. The early subsidence of the disease in Bhurtpoor was due to the absence of cases for the virus to act upon, but this absence was caused by vaccine protection', not by want of children.
Very
few
children
unprotected
over
*
six
children
months, and
escaped. In examining 732 up to five years of age, a few
Indian Annals of Medical Science, 2fo. I.
t Ibid, JSo. XY., page 84
THE INDIAN MEDICAL GAZETTE.
!0
weeks ago, I found that 221, or 3019 per cent., were marked with ; 476, or 65'03 per cent., had vaccine cicatrices; while or 4-78 per cent., were unprotected and had escaped : and all these had been infants in arms during the epidemic.
small-pox only 34,
The Bhurtpoor census of 1867 only discriminates between children and adults. It is, therefore, impossible to give correctly the population liable to small-pox. The following estimate must suffice:?In the census report for the North-West Provinces it appears that the relative proportion of children to
higher than in England; and as Bhurtpoor may purposes be regarded as part of the North-West, rule holds good within the limits of the State.
adults is much for all the
same
Now, to
practical
the
the number of children under five years of age, according English census of 1861, was 27,00,782, in a population of
2,00,66,224,
or
applied to small-pox of these, 8,283,
13*46 per cent.; a proportion which in a population of 61,448. As
Bhurtpoor gives 8,283
had been absent for four years, at least four-fifths it, and a considerable number of the remainder, who were for the most part in extreme infancy when the could not have had disease was last
prevalent, probably escaped. I shall, however, doubt, exclude the whole of these, or 1,656. From the remaining 6,627 I deduct 1,844, the number of children, five years old and under, (calculated from 802 cases, at 85-29 per cent.) who contracted small-pox, and 369, (4-78 per cent.) the estimated number of those who, though unvaccinated, escaped the disease. This leaves 4,414, which I believe to represent the number of cases saved from small-pox by vaccination. I cannot the see that this number is exaggerated, or detect a flaw in process by which the conclusion is arrived at. A large margin for possible error has been left, in each term of the calculation, and the number might plausibly have been put higher. If the figures are correct or nearly correct, they carry the simple corrollary that an incredible amount of suffering, and some 800 lives have been saved by vaccination in Bhurtpoor alone. The course of the epidemic indicates that though not at once stamped out its violence was speedily controlled, and after a short struggle strangled, by vaccination. Before concluding this part of the subject I will give one instance where On the the stamping out protess was effectual and complete. 7th of January a fatal case of confluent small-pox took place in a small village in the angle between the Deeg and Circular Iloads. This was the first case. The same day all the other unprotected children, 32 in number, were vaccinated by Mohammed Buksh, one of my best operators. On the 13th I accompanied him to inspect the cases. Three of them, having been incubating the disease at the time of the operation, were found to have s uallpox. All the others presented excellent vesicles, except one child, in whom they had been rubbed and broken. A week later I revisited the village and found a case of confluent small-pox in a child that had been brought from a distance on the eighth, the day after the vaccinations had been performed, but this was the only case. The three former cases in which small-pox (unmodified) and vaccinia had progressed together were convalescent, to
and
avoid all
none
of the other children had been seized. No cases afterI think most persons will acknowledge that
wards occurred.
but for vaccination few of these 29 children would have escaped small pox, and four or five of them would probably have died.
(To
be
continued.)
[Januaky 1,
1870.
