THE SMALL-POX EPIDEMIC, 1880-82.*

FOR several months prior to the close of the year 1879, the United States had been practically free from small-pox. From May to December inclusive, of that year, there were only five places in which cases of the disease had been reported. In New York there was one death during the week ended May 31; seven between June 7 and 21; six during August, and one in the week ended November 15. During the intervening periods up to October 4, there was no death reported from the disease in any part of the United States. In October, the contagion was brought into San Antonio from Mexico, and seven deaths (all Mexicans) occurred in that month, and four more in November. During December there were cases (nine deaths reported) in Philadelphia, Washington and Chicago, making a total of thirty-five deaths during the eight months, out of an aggregate of 504,595 deaths from all causes. So that it may be said that, during the year 1879, the small-pox contagion did not exist in the United States as a factor of the public health question. On the other hand, consular and other reports to the National Board of Health, the pages of medical and sanitary journals, and other mediums of information, show a widespread and increasing prevalence of the disease in Europe, Africa, South America and Canada, during the period above specified. A total of about 2,500 deaths were thus reported between May and December, 1879, and the following places were infected during this period:

London, Liverpool, Edinburg, Newcastle-on-Tyne and Dublin, in the British Islands.

Antwerp, Barcelona, Breslau, Brussels, Bucharest, Buda Pesth, Copenhagen, Dantzic, Dresden, Lisbon, Malaga, Naples, Paris, Rotterdam, Stockholm, Trieste, Turin, Venice, Vienna and Warsaw, on the Continent.

Algiers, Tangiers and Tripoli, in Africa.

Bahia, Callao, Iquique, Panama, Para, Pernambuco and Rio de Janeiro, in South America.

Havana and Santa Cruz, in the West Indies.
Matamoras and Tampico, in Mexico.

Montreal and St. John's, in Canada.

*The term "epidemic" is herein used in its popular and conventional sense-not as implying that a disease which only spreads through its own contagion, as does small-pox, can ever be strictly or accurately called an epidemic disease; but simply that, during the period treated of, there was an unusual prevalence and a rapid spread of small-pox, two conditions prominently characteristic of epidemics.

Delays, arising from various causes elsewhere explained, have afforded an opportunity of including in this report all the cases reported in the State during 1883; so that the period actually covered is from the date of the first case in Illinois, November, 1879, up to December 31, 1883.

ITS INCEPTION AND PROGRESS IN ILLINOIS.

The solitary death from small-pox in Illinois, in 1879, was due to an immigrant, who arrived in Chicago, in the eruptive stage of the disease, about the last of November of that year.* From this introduction there resulted cases in January, February and March, 1880, but without any other death; and the contagion was believed to have been substantially eradicated, when several arrivals of infected immigrants, in April, caused a new outbreak, which was still further added to, from the same source, during May and June, and again in October and November. With the revival of immigration in the spring of 1831, the disease, which had been kept under control during the winter months of 1880-81, rapidly increased in Chicago, and occasional cases began to appear at other points in the State. In July and August, .881, however, only four new outbreaks occurred in the State at large, and, in September, three; but in October a heavy immigration movement began; the disease rapidly increased in Chicago, and five new points were infected in the State during the month, twelve more in November, and twenty-eight in December.

During the year there were 79 different outbreaks reported, outside of Chicago, causing an aggregate of 774 cases, with 170 deaths; and in all but six of these outbreaks the origin was directly traced either to newly-arrived immigrants or to intercourse with places previously infected by immigrants.

At the November, 1851, meeting of the BOARD, the situation was fully discussed. The necessity for aiding local health authorities, in very many localities, by instruction, advice and information concerning their duties, powers and responsibilities; the want of familiarity, on the part of many of these authorities, with the proper method of dealing with an outbreak so as to secure its prompt suppression; their failure or inability, of themselves, to cooperate with each other in adjoining infected or threatened localities; the evidence of the existence of a very large percentage of unvaccinated, or imperfectly vaccinated, among the population, both of adults and of school children; the dangers existing and threatened, through the unprecedented influx of immigrants arriving in the State without any previous sanitary supervision; and other important features of the situation, were duly considered.

As a result of these deliberations it was decided that such a sanitary emergency existed as justified the exercise of all the powers and resources at the command of the BOARD. An order was adopted looking to securing the vaccination or revaccination of all public scholars prior to the beginning of the new school year, January 1, 1882; local health authorities were repeatedly advised of their powers, duties and responsibilities, and of their relations to each other and to the STATE BOARD; circular letters urging vaccination and revaccination of all employes, and others under control, were addressed to railroad and steamboat managers and superintendents, manufacturers, mill-owners, iron-masters, quarry-workers, and employers generally, and to the officers of all public institutions; the

*See Chicago, in "Details of Local Outbreaks." Also, "Immigrant-Introduction of Small-Pox."

official order of the BOARD, Concerning the Prevention of Small-Pox, originally issued in March, 1881, was revised, enlarged and distributed to all infected and threatened localities; editions of this order were also prepared in the German and in the Scandinavian languages; and, in addition to all this, persistent effort was made to secure the assistance of the National authority in establishing a system of sanitary surveillance of immigrant travel, with especial reference to the prevention of the introduction of small-pox into the United States from foreign countries.*

By the middle of January these various agencies, with the exception of the immigrant inspection, were fairly under way; but during that month there was a large increase in the number of new outbreaks reported, the great majority, however, being in the first part of the month, 39 out of the total being reported on or before the 16th. On the 24th of January-up to which time from January 1, 1881, there had been 133 outbreaks reported-the Secretary summed up the situation, as follows, in a letter to Dr. Stephen Smith, of the National Board of Health, in response to a request for such information:

"Since November, small-pox has been introduced. from Chicago, St. Louis, Kentucky, Iowa (Keokuk Medical College), and the Ohio and Mississippi rivers, into nearly one hundred different localities in this State. Outside of Chicago and Cook county, the disease has been confined to the first cases, except in four instances. Chicago and Cook county are practically the same, and in that territory it has not seemed desirable or necessary that the STATE BOARD should interfere. In the four instances outside of Cook county, where the disease has spread beyond the first cases, the result is as directly attributable to the failure to carry out the instructions of the STATE BOARD as its limitation-its practical 'stamping-out--in the remaining ninety-odd places is due to the observance and enforcement of these instructions and precautions. To-day, in a population of nearly three million souls (exclusive of Cook county), there are not, at the outside, five hundred cases of small-pox and varioloid. For three days we have had reports of no new points of infection, and have every reason to believe that, in the State at large, we have control of the disease.

* In June, 1881, the following circular-letter had been sent to various State and municipal Boards of Health, and to the National Board:

Dr.

ILLINOIS STATE BOARD OF HEALTH,
SPRINGFIELD, June 13, 1881.

You are respectfully invited (or a representative of your Board) to attend a conference of State and local boards of health, on June 29th, at the Grand Pacific hotel in Chicago. The question of concert of action between local and Sta e boards of health and the National Board of Health, will be considered, and a plan submitted to prevent the introduction of small-pox into this country, and to prevent the spread of the same.

It is unnecessary to say how much we are all interested in this subject.

The prevalence of small-pox at this time is a disgrace, and unless more energetic measures are taken, it will continue to increase so long as immigration is pouring into this country as at present.

For the report of the proceedings had at this Conference, see pp. 119-130, Fourth Annual Report, ILLINOIS STATE BOARD OF HEALTH.

"As a result of our School-Vaccination Order, the State Superintendent of Public Instruction agrees with me in the estimate that about 600,000 school, children have been efficiently vaccinatedmainly with bovine virus-by competent physicians, who have been obliged to certify to the result of their work, and not merely that they have performed the operation. This, in itself, constitutes a new departure in vaccination in this country, where the requirement (for school purposes) has usually been complied with in a careless and perfunctory manner. In only two instances, out of the 12,000 in the State, are schools now closed on account of the disease, although in very many instances they were closed on the first appearance of the contagion, but were immediately re-opened under advice from this office that an enforcement of vaccination was the best and only safeguard.

"The efforts of the BOARD have met with surprisingly little opposition. Where such existed, the appearance of the first case of smallpox soon converted opponents into staunch supporters. Of course, measures so radical and comprehensive have not been put into operation without an immense amount of work, and the employment of all possible resources.

"I send you copies of our orders, blanks, etc. Of Nos. 50 and 50 A (the School-Vaccination Order), 45,000 copies have been distributed; of No. 51 (the School-Vaccination Certificate), over 700,000; and of No. 53 (Concerning the Prevention of Small-Pox), over 75,000, in English, German and Scandinavian.

"Much of this work has been pioneer, and all of it educational. I doubt if the people of any other State of equal age are as well protected against small-pox as those of Illinois at the present time.

"Necessarily, our first efforts were largely tentative; we had to feel our way, to merely advise where we can now direct; to argue and warn, where we can now speak with the assurance which comes of success. The hardest part of our work is done. Our machinery is all in operation, and we are sanguine as to the result."

The confidence expressed in the foregoing letter proved wellfounded. Only seven more new outbreaks were reported during the rest of the month, making a total of 58 places infected during January. In February the number fell to 24; in March, to 21; in April, to 14; in May and June, to 8 and 7, respectively. In the latter month, the Immigrant-Inspection Service of the National Board of Health was organized, and thenceforward the most prolific and dangerous source of small-pox introduction and dissemination was practically cut off during the maintenance of this Service.

An occasional new outbreak continued to be reported at long intervals until the advent of cold weather, when there was again an increase in the number, attaining its maximum in February, 1883, when seven newly-infected places were reported, three of these by immigrants the Immigrant-Inspection Service having been discontinued at the close of December, 1882, on account of the failure of Congress to make the necessary appropriation for its further maintenance. (For the details of the operations of the Service, see section entitled "Immigrant-Inspection Service, National Board of Health.")