Chapter IV: Smallpox (4)

At Newcastle, Lettsom’s design had at least a trial, under the influence of his friend Dr John Clark[952]. The Dispensary, founded in 1777, was designed from the outset to undertake gratuitous inoculations; but it was not until 13 April, 1786, that it got to work. The “liberality of the public” enabled the managers in that year to offer premiums to parents, to cover the expense of having their children sick from inoculation--five shillings for one child, seven shillings for two, nine shillings for three, and ten shillings for four or more of a family. On the first occasion, 208 children were inoculated, and all recovered. From 1786 to 1801, the cases numbered 3268. It was the aim of Dr Clark to get the operation done in infancy; accordingly in the space of four and a half years (1786-1790), of 1056 inoculations 460 were on infants under one year, 270 from one to two, 122 from two to three, 69 from three to four, 62 from four to five, 66 from five to ten, and 7 from ten to fifteen. This was perhaps the most systematic attempt at infant inoculation from year to year. The other dispensaries at which inoculation was steadily offered to the children of the poor were at Whitehaven (1079 inoculations from 1783 to 1796), at Bath, and at Chester.

Before the society was started at Chester for the purpose, the inoculations were some fifteen or twenty in a year, and these, we may suppose, in the richer families. The society got to work in 1779, but its operations were stopped in 1780 by a singular cause--the general diffusion of smallpox in the town by a regiment of soldiers. The whole inoculations of poor children from the spring of 1780 until September, 1782, were 213, besides which 203 were done in private practice. The year 1781 was tolerably free from epidemic smallpox (8 deaths), but in January, 1782, a very mortal kind prevailed in several parts of the town.

At Liverpool the first gratuitous general inoculation was in the autumn of 1781, to the number of about 517. “The affluent,” says Currie, “being alarmed at the advertisement for this purpose, presented their children also in great numbers, and 161 passed through the disease.” There was a second gratuitous inoculation in the spring of 1782 (to which some of the above numbers may have belonged), and it was intended to continue the same at regular intervals; but there is no record of more than those two[953].

Although Dimsdale opposed “general” inoculations in the large towns, for the reasons mentioned, he was in favour of inoculating together all the susceptible subjects in a smaller place or country district; and that kind of general inoculation was not unfrequently undertaken, sometimes hurriedly at the beginning of an epidemic, at other times after an epidemic had been running its course for months, and here or there, it would seem, during a free interval and by way of general precaution.

Dimsdale himself, with the help of Ingenhousz, carried out on one occasion, in Berkhamstead and three or four other villages of Hertfordshire, a general inoculation to the number, he guesses, of some six hundred persons of all ages, including some quite old persons. In 1765 or 1766 Daniel Sutton at Maldon, Essex, inoculated in one morning 417 of all ages, who were said to be all those in the town that had not had smallpox in the natural way. Some hundreds were also inoculated by him at one time in Maidstone.

In the small Gloucestershire town of Painswick in 1786, a very violent and fatal smallpox broke out during a time of typhus and intermittent fever. In consequence of the epidemic, one surgeon inoculated 738 persons from the 26th of May to the end of June[954]. In another Gloucestershire parish, Dursley, a single surgeon in the spring of 1797 inoculated 1475 persons of all ages, “from a fortnight to seventy years.” But in certain villages near Leeds in 1786-7 a general inoculation, organised by a zealous clergyman and paid for by a nobleman, mustered only eighty. About the same time, during an epidemic of malignant smallpox at Luton, Bedfordshire, 1215 were inoculated, and thereafter about 700 more; the average number annually attacked by smallpox during a period of nine years had been about twenty-five[955].

Inoculation was tried first in Scotland in 1726 by Maitland, during a visit to his native Aberdeenshire, but was not persevered with owing to one or two fatalities among the half-dozen cases. About 1733 it was begun at Dumfries by Gilchrist, who practised it during the next thirty years upon 560 persons, most of them, doubtless, paying patients. The returns made to Professor Monro, of Edinburgh, showed in the chief medical practices 5554 inoculations down to 1765; of which 703 were in Edinburgh and Leith, 950 in Glasgow, 208 in Stirling, 260 in Irvine, 157 in Aberdeen, 310 in Banff, 243 in Thurso, and 560 in Dumfries as above[956]. Seventy-two deaths are put down to the practice. When the Statistical Account of the 938 parishes was compiled in the last decade of the century, a few of the parish ministers made reference to inoculation.

Thus, in Applecross, Ross-shire, and three neighbouring parishes, an
uneducated man is said to have inoculated 700 after a very fatal
epidemic in 1789; it happened, however, that the pestilence
reappeared, whereupon inoculation was “generally adopted[957].”
Applecross may have been populous then; now there is not a smoke to be
seen in it for miles. Again, the practice is said to have become
“universal” in Skye from about 1780[958]. In Durness parish, which the
tourist may now traverse for thirteen miles to Cape Wrath without
seeing anyone but a shepherd, inoculation was rendered “general” about
1780 by the benevolence of a gentleman belonging to the parish[959].
From October, 1796, to July, 1797, a surgeon of Thurso inoculated 645
in that town and in country parishes of Caithness during a very severe
epidemic[960]. In the parish of Jedburgh the cost of an inoculation
was defrayed by the heritors, in that of Kirkwall by the kirk session,
in another by the commissioners of annexed estates, in Earlstown,
Berwickshire (on 70 children) by the chief proprietor. The ministers
who mention it at all were mostly strong advocates of it, but they
usually imply that the common people were (or had been) apathetic or
prejudiced. It was sometimes recommended from the pulpit, and actually
done by the ministers; it was even recommended that students of
divinity should be instructed in the art. Statements that it had
become “general” or “universal” are made for several parishes, mostly
in the Highlands or Islands. The very full and trustworthy account of
the parish of Banff says that “inoculation is by no means become
general among the lower ranks[961];” which is perhaps about the truth
for the country at large.

At the end of an epidemic at Leeds, in 1781, which had attacked 462 and killed 130 during six months, “in the next six months there were inoculated 385, of whom four died” (two by contagious smallpox). A second general inoculation was carried out in Leeds sometime previous to 1788. Lucas, writing in that year, says: “The result of two general inoculations in Leeds has been that the smallpox has since been less frequent and less fatal[962].” This will be a convenient opportunity of considering the gross effects of inoculation upon the prevalence of smallpox.

The first and most obvious consideration is that it usually came too late. “Most born in London,” said Lettsom quite correctly, “have smallpox before they are seven”--i.e. before the age for admission to the inoculation hospital. He might have added that, if they had run the gauntlet of smallpox in London until they were seven, they were little likely to take it at all. The inoculations in London were therefore done upon a very select class (they were, in fact, a very small number), who may be assumed to have escaped the perils of smallpox in London in their childhood, or to have come to London (as many did) from country places where smallpox broke out as an epidemic only at long intervals. In other large towns as well as the capital the inoculated must have been a residual class. At Leeds, with a population of 17,117, “the number of those who were still uninfected was found on a survey to be 700” at the end of an epidemic, of whom 385 were inoculated. If a general inoculation had been tried at Chester after the epidemic of 1774, there would have been only 1060, in a population of 14,713, to try it on. How many of these, above the age of childhood, were constitutionally proof against smallpox? The case of Ware, in Hertfordshire, after the epidemic in the summer of 1777, is so related by Lettsom as to bring out the ambiguity of much that was claimed for inoculation. “After about eighty had been carried off by it, a general inoculation was proposed, to prevent those who had not yet been attacked, and whose number was still considerable, from sharing the same fate. The alarm which had been excited induced most of the survivors to adopt this proposition, after which not one died, and the infection was wholly eradicated.” Eighty deaths in one epidemic is a large mortality for such a place as Ware in any circumstances; the smallpox for once had done its worst. But, says Lettsom, there were a few families of those hitherto untouched by the epidemic who did not submit to inoculation. Not one of them caught the disease--from their inoculated neighbours (Lettsom is arguing that there was no danger in that way), nor, of course, from the epidemic contagion. It cannot but appear strange to us that the natural cessation or exhaustion of an epidemic should not have been thought of. Dr Currie, of Liverpool, records that in the first general inoculation there in 1781 there were 417 inoculated gratuitously and about 100 more in private practice, and that “about three or four thousand liable to the disease were scattered in the same manner [as the inoculated], not one of whom caught the infection.” For a few weeks there was not a case of smallpox known in Liverpool, so that no matter could be got for inoculation. He adds, in the most ingenuous manner: “An important particular has been recalled to my mind by Mr Park; that previous to this first general inoculation, which extinguished the smallpox in so extraordinary a way, the disease raged in town with much violence and was very fatal[963].”

The general inoculations were often carried out in so haphazard a manner as to make them valueless for a scientific as well as for a practical purpose. A Bath surgeon of long experience wrote in 1800: “Whenever the inoculating rage once takes place whole parishes are doomed, without the least attention to age, sex, or temperament--no previous preparation, no after treatment or concern.... Are not scores and hundreds seized upon at once, for the incisions, scratchings, puncturings and threadings, without even a possibility of their being properly attended to? and whether they may or may not receive the infection is just as little known or cared about[964].” It must have been equally little known or cared about whether they had had smallpox in the natural way before. What Dimsdale found to obtain at St Petersburg would have been the rule elsewhere: “The general method was to search for marks, and, if none were found, it was concluded the party had not had the disease[965].”

Thus in any attempt to estimate the gross advantages of inoculation in the 18th century we are met on every hand by sources of fallacy. Whatever its theoretical correctness, it does not follow that the inoculation of smallpox was a practical success to the extent of its trial; and even its theoretical correctness will be thought by some, and was so thought at the time, to have gone by the board when the artificial disease was brought down to a pustule at the point of puncture, with or without a few bastard pocks on the skin near. I have found two instances in the 18th century history in which there are data for a rough practical judgment, although not for a precise statistical one. The first is the town of Blandford, in Dorset; the other is the Foundling Hospital in London.

During the smallpox year 1766, smallpox of a very malignant type broke
out at Blandford in the first week of April[966]. It was estimated
that 700 persons in the town (population 2110 in 1773) had not had the
natural smallpox, and a general inoculation was resolved upon on the
13th April. “A perfect rage for inoculation,” says Dr Pulteney[967],
“seized the whole town,” and in the week following the 16th April some
300 were inoculated, the total rising to 384 before the panic ceased;
of these, 150 were paid for by the parish. There were thirteen deaths
among the inoculated, but most of these confluent or haemorrhagic
cases, seem to have been due to the epidemic contagious smallpox,
which had been peculiarly fatal, with haemorrhagic symptoms, to the
few that were seized before the inoculation began, and continued to be
fatal to many. The mortality from smallpox for the year in the parish
register was 44, and from all causes 104, or more than twice the
normal[967]. The last epidemic of smallpox in Blandford had been in
1753, when 40 died of it, the deaths from all causes being 96. In that
year also there had been a general inoculation to the number of 309.
The parish register gives the deaths in an earlier epidemic, in 1741,
which was a year of great distress and typhus fever all over England:
76 deaths are ascribed to smallpox (102 to all causes), which is a
larger total from smallpox than in either of the subsequent occasions
when general inoculations were tried. Comparing these three epidemics
in a Table, with the associated circumstances, we get the following:

_Statistics of Blandford in three Smallpox Years (Population in 1773,
2110)._

| | | | Annual Averages of
Year of |Deaths| Deaths |Inoculations| eight previous years
Epidemic| from | from | |-----------------------
| all |Smallpox| | | |
|causes| | |Marriages|Births|Deaths
--------|------|--------|------------|---------|------|------
1741 | 102 | 76 | --- | 24·87 |63·37 | 49·25
1753 | 96 | 40 | 309 | 19·37 |50·62 | 49·62
1766 | 104 | 44 | 384 | 20·62 |54·12 | 49·12

It will be seen that the higher mortality from smallpox in 1741 was
associated with other things besides the absence of inoculation. The
annual average of deaths for eight years preceding each of the three
epidemics is almost the same. But the marriages and births for eight
years preceding 1741 were much in excess of those in the periods
preceding the other two epidemic years. In the former there was a much
larger susceptible population of children, upon which the smallpox
mainly fell; and that alone would account for more deaths from
smallpox in the epidemic of 1741. But the year 1741 was peculiar in
another way; it was the worst year of typhus fever and general
distress in the whole of the 18th century, and in the circumstances
the deaths from smallpox would have been unusually numerous for the
cases. Another epidemic of smallpox without inoculation, in 1731,
showed how mild smallpox could be. At a time when sixty families had
the disease among them, a fire broke out on 4 June, and burned down
the town. It is said that 150 ill of smallpox were removed to gardens,
hedgerows and the arches of bridges, and that only one of the whole
number died[968]. This is usually cited to show the benefits of fresh
air; but if it be true, it shows more than that.

The Foundling Hospital may seem to offer all the conditions for a fair trial of the question. It had been a standing rule of the Governors, since the opening of the charity in 1749, that all children received into it should be inoculated. Sir William Watson, who states the fact, adds that he himself was “in a situation of superintending every year the inoculation of some hundreds.” Still, the rule may not have been uniformly carried out; and even in this community of children, it was not always possible to learn on their admission whether they had had smallpox before in the natural way[969].

The lists of the inoculated are longer in the later periods than in
the earlier: thus, from March, 1759 to May, 1766, the annual average
is something under a hundred, the inmates having been 312 in 1763; but
from May, 1766 to July, 1769, the annual average is some two hundred
and fifty, the inmates in 1768 having been 438. Sir William Watson, in
his essay upon the inoculations at the Foundling, breathes no hint
that such a thing as natural smallpox ever happened there[970]; but in
another context he does casually mention that there was an epidemic of
sixty cases, with four deaths, in the end of 1762, and another
epidemic in the following summer, of “many” cases, nineteen of which,
with eleven fatalities, occurred in children who had lately been
through the measles and were weakened in consequence[971]. Another
epidemic, as I find by the apothecary’s book of weekly admissions to
the infirmary, happened in the winter of 1765-66, twenty-six names
being entered as admitted for “natural smallpox.” After that date all
the great epidemics appear to have been of measles, whooping-cough,
influenza or scarlatina; but almost every year smaller groups of
“natural smallpox” occur, of which the following have been collected
from the available records:

_Foundling Hospital, London._

Natural
Year Smallpox

1766 8
1767 2
1768 8
1769 7
1770 1
1771 2
1772 3
1773 1
1774 4
1775 3
1783 1
1784 0
1785 8 (or 16?)
1786 0
1787 5
1788 4

The occurrence of one or more cases seems to have been the signal for
a general inoculation; or, again, it may be that the few cases of
natural smallpox in the infirmary at one time had followed a general
inoculation. Thus, in June-July, 1767, one case is entered on the
second day from the inoculation (of a large number), and another on
the fourth day. Again, in Nov.-Dec., 1768, one of the four cases of
natural smallpox is marked “soon after his inoculation.”

The received cases in which inoculation failed to save individuals from the natural smallpox are few. Besides those already given for the first period of the practice, and the case from Heberden, there are six fully detailed by Kite of Gravesend, in two groups of three each, all in the spring of 1790[972]. Apart from exact records, there are various testimonies more or less trustworthy. The Marquis of Hertford is said to have told Dr Jenner that his father, having been inoculated by Caesar Hawkins, the serjeant surgeon, and thereafter attended by him during a tour abroad, caught smallpox at Rheims and died[973]. Bromfeild, surgeon to Queen Charlotte, is said to have “abandoned the practice of inoculation in consequence of its failure[974].” Jenner and his friends made a collection of cases in which inoculation had failed, to the number of “more than one thousand, and fortunately seventeen of them in families of the nobility[975].” A Bath surgeon said he had heard of “innumerable” cases of attacks of natural smallpox long after inoculation, and had himself professionally seen “not a few[976].” A surgeon of Frampton on Severn knew of four cases, out of five inoculated together in 1784, that took smallpox afterwards in the natural way, of whom one died[977]. In an epidemic of smallpox at Enmore Green, a suburb of Shaftesbury, in 1808, a surgeon from Shaston found that “nearly twenty” of the victims had been inoculated “by the late Mr John White” about ten years before, and were supposed to have had it “very fine[978].” Dr John Forbes learned that some nineteen cases of natural smallpox in and around Chichester in 1821-22 were of inoculated persons[979]. It would be incorrect to say that such cases could be multiplied indefinitely; on the contrary, they are hard to find. Whether that shows that inoculation was on the whole a success, to the extent that it was tried, or that its failures are in part unrecorded, I am not competent to decide. But it cannot be doubted that the usual estimates of the saving of life by inoculation were extravagant and fallacious. La Condamine, a mathematician, counted up the saving to the slave-owner in an ideal plantation of three hundred negroes[980]. Watson, with the epidemics in the Foundling fresh in his memory, estimated that inoculation might have saved 23,000 out of the 23,308 who had died of smallpox in London in ten years, 1758-68[981]. Haygarth[982] reckoned that 351 might have been saved by inoculation of the 378 children who died of smallpox at Chester from 1772 to 1777. Woodville, who wrote the history of inoculation down to the advent of Sutton, declared in 1796 that the art of inoculation, originally a fortuitous discovery, “is capable of saving more lives than the whole _materia medica_[983].” Arnot, the historian of Edinburgh (1779), asserted inoculation to be “a remedy so compleat that we hesitate not in the least to pronounce those parents, who will not inoculate their children for the smallpox, accessory to their death[984].” The College of Physicians, in a formal minute of 1754, pronounced it “highly salutary to the human race.”

Despite all those academic pronouncements, inoculation was somehow not a practical success. It cannot be maintained that it failed because the people were averse to it; for it continued to be in popular request far into the 19th century, until it was at length suppressed by statute. For the present we may return to the proper subject of epidemic smallpox, premising, on the ground of what has been said, that inoculation made but little difference to the epidemiological history.

The Epidemiology continued from 1721.

The ordinary course of smallpox in Britain was little touched by inoculation. The inoculators were like the fly upon the wheel, with the important difference that they did indeed raise the dust. The writers who kept up the old Hippocratic or Sydenhamian habit of recording the prevalent maladies of successive seasons, such as Huxham, Hillary[985], and Barker, of Coleshill, while they dealt with epidemics impartially and comprehensively, were as if by a common instinct adverse to the fuss made about inoculation. Says Barker, in an essay against inoculation during the Suttonian enthusiasm, “It is undoubtedly a great error that the smallpox is now considered the only bugbear in the whole list of diseases, which, if people can get but over, they think they are safe.” This hits fairly enough the disproportionate share given to inoculation in the medical writings of the time, while it is made more pointed by the author’s suggestions for a scientific study of the conditions of smallpox itself[986]. It is still possible, with much trouble, to bring together the data for a scientific handling of the disease in the 18th century, thanks most of all to the exact school of observers or statisticians which began with Percival, of Manchester, and was continued to the end of the century by Haygarth, Heysham, Ferriar, Aikin and others. The best of the original English inoculators, Nettleton of Halifax, has also left a large number of interesting statistics relating to epidemics in Yorkshire and other northern counties in the years 1721-23; also, upon his suggestion, the figures were procured from many more smallpox epidemics in other parts of England down to 1727. It will be convenient to resume the history with these, as they come next in order after the London epidemic of 1720, at which point the interlude of inoculation came in. The following is a complete table of the figures collected from various sources: it will be observed that most parts of England are represented, the fullest representation being of the northern counties.

_Censuses of Smallpox Epidemics in England, 1721-30._

Percentage
Locality of the Deaths of
Epidemic Period Authority Cases Fatalities

Halifax[987] winter of 1721 Nettleton, 276 43 15·9
to April 1722 _Phil. Trans._
XXXII. 51
Rochdale[988] " " 177 38 21·4
Leeds[989] " " 792 189 23·8
Halifax parish 1722 _Ibid._ p. 221 297 59 19·9
towards Bradford
Halifax parish, " " 268 28 10·4
another part
Bradford " " 129 36 27·9
Wakefield " " 418 57 13·6
Ashton under Lyne[990] " " 279 56 20·0
Macclesfield " " 302 37 12·2
Stockport " " 287 73 25·4
Hatherfield " " 180 20 11·1
Chichester[991] 1722 Whitaker, 994 168 16·9
(to 15 Oct.) _Ibid._ p. 223
Haverfordwest 1722 Perrot Williams, 227 52 22·9
_Ibid._
Barstand, Ripponden, " Nettleton, in 230 38 16·5
Sorby, and part of Jurin’s _Acct._
Halifax parish for 1723, p. 7
4 miles from the
town
Bolton 1723? Jurin’s _Acct._ 406 89 21·6
for 1723, p. 8
Ware " " 612 72 11·7
Salisbury " " 1244 165 13·2
Rumsey, Hants " " 913 143 15·6
Havant " " 264 61 23·1
Bedford " " 786 147 18·4
Shaftesbury 1724? _Ibid._ for 660 100 15·1
1724, p. 12
Dedham, near " " 339 106 31·3
Colchester
Plymouth " " 188 32 17·2
Aynho, near 27 Sept. 1723 Rev. Mr Wasse, 133 25 18·8
Banbury to 29 Dec. 1724 rector, _Ibid._
for 1725, p. 55
Stratford on Avon " Dr Letherland, 562 89 15·8
_Ibid._
Bolton le Moors " Dr Dixon, _Ibid._ 341 64 18·8
Cobham " Sir Hans Sloane, 105 20 19·0
_Ibid._
Dover 29 Sept. 1725 Dr Lynch of 503 61 12·1
to 25 Dec. 1726 Canterbury, in
Jurin’s _Acct._
for 1726, p. 17
Deal 25 Dec. 1725 " 362 33 9·1
to 29 Nov. 1726
Kemsey, " Dr Beard, in 73 15 20·5
near Jurin, _Ibid._
Worcester
Uxbridge[992] 1727 Dr Thorold, in 140 51 36·4
Scheuchzer’s
_Acct._ for
1727 and 1728
Hastings 1729-30 Dr Frewen, 705 97 13·7
_Phil. Trans._
XXXVII. 108

The years 1722 and 1723, to which most of these epidemics belong, were one of the greater smallpox periods in England. In Short’s abstracts of the parish registers those years stand out very prominently by reason of the excess of deaths over births in a large proportion of country parishes (see above, p. 66); and, according to Wintringham’s annals, it was not fever that made them fatal years, but smallpox, along with autumnal dysenteries and diarrhoeas. Of one epidemic centre in the winter of 1721-22, which is not in the table, the district of Hertford, we obtain a glimpse from Maitland, who repaired thither from London to practise inoculation.

“I own that it seem’d probable that the six persons in Mr Batt’s
family might have catched the smallpox of the girl that was
inoculated; but it is well-known that the smallpox were rife, not only
at Hertford but in several villages round it, many months before any
person was inoculated there: witness Mr Dobb’s house in Christ’s
Hospital buildings, where he himself died of the worst sort with
purples, and his children had it; some other families there, and
particularly Mr Moss’s, (where the above-named Elizabeth Harrison,
inoculated in Newgate, attended several persons under it to prove
whether she would catch the distemper by infection); both Latin
boarding-schools, Mr Stout’s and Mr Lloyd’s families, Mr John
Dimsdale’s coachman and his wife, and Mr Santoon’s maid-servant, who
was brought to the same house and died of the confluent kind of the
smallpox[993].”

Here we have the same indication of adults attacked as well as children, which we find in Dover’s practice in London in 1720 and in all the 17th century and early 18th century references to smallpox. The most detailed account is that given for the epidemic of 1724-25 at Plymouth by Huxham, who was not an inoculator but purely an epidemiologist and practitioner in the old manner.

The epidemic was a very severe one and of an anomalous type. Adults,
according to his particular references and his general statement, must
have been freely attacked. The major part of the adult cases, he says,
proved fatal, including one of an old gentlewoman of 72,--“a very
uncommon exit for a person of her years”! When the disease raged most
severely, some children had it very favourably and required no other
physic than to be purged at the end of the attack. The pustules were
apt to be small and to remain unfilled. In some there were miliary
vesicles, dark red or filled with limpid serum, in the interstices
between the smallpox pustules. Some had abundance of purple petechiae
among the pocks, the latter also being livid. Only one person survived
of all who had that haemorrhagic type. Swelling of the face and throat
was also seldom recovered from; in such cases that did well, the
maxillary and parotid glands would remain swollen for some time. “It
was a remarkable instance of the extraordinary virulence of these
smallpox that the women (tho’ they had had the smallpox before and
some very severely too) who constantly attended those ill of the
confluent kind, whether children or grown persons, had generally
several pustules broke out on their face, hands and breast.... I knew
one woman that had more than forty on one side of her face and breast,
the child she attended frequently leaning on those parts on that
side.”

Huxham appears to have adopted the whole Sydenhamian practice of
blooding, blistering, purging, and salivating. For the last he used
calomel: “Two adults and some children in the confluent sort never
salivated. Some very young children drivelled exceedingly through the
course of the distemper. A diarrhoea very seldom happened to
children[994].”

Corresponding very nearly in time to Huxham’s malignant and anomalous constitution of smallpox at Plymouth, and agreeing exactly with his generalities as to children and adults, there is an interesting table of the ages and fatalities of those who were attacked at Aynho, in Northamptonshire, six miles from Banbury. It was then a small market town, and its smallpox for some fifteen months of 1723-24, as recorded by the rector of the parish, may be taken as a fair instance of what happened at intervals (usually long ones) in the rural districts in the earlier years of the 18th century[995]:

above
Ages 0-1 -2 -3 -4 -5 -10 -15 -20 -25 -30 -40 -50 -60 -70 70 Total

Cases 0 0 3 4 6 15 33 14 16 9 12 10 4 4 2 132
Deaths 0 0 2 1 0 1 3 1 3 3 3 4 1 2 1 25

The small fatality of the disease between the ages of five years and twenty is according to the experience of all times. But the considerable proportion of attacks at the higher ages would hardly have been found anywhere in England, not even in a country parish, a generation or two later, although it is consistent with all that is known of smallpox in the 17th century and in the first years of the 18th[996].

Another glimpse of a prolonged smallpox epidemic of the same period in a town is given in Frewen’s census of Hastings, with a population of 1636 (males 782, females 854). The disease was prevalent for about a year and a half, and had ceased previous to 28 January, 1732[997]. The table accounts for the whole population:

The number of those that recovered of the smallpox
(including four that were inoculated) 608
Died of it 97
Escaped it 206
Died of other diseases since the smallpox raged there 50
The whole number of inhabitants in that town are 1636

Leaving out the fifty who died of other diseases as persons who may or may not have had smallpox, it appears that 725 of the inhabitants of Hastings had been through the smallpox in previous epidemics, that 705 were attacked in this epidemic, and that 206 had hitherto escaped, some of them to be attacked, doubtless, in the future. The proportion of attacks above the age of childhood in the epidemic of 1730-31 would have depended on the length of time since the last great epidemic; the interval was probably a long one, by the large number of susceptible persons in the town, just as at Boston, Massachusetts, in 1721 and 1752, and at Charleston, Carolina, in 1738[998]; and, as the fact is known for these places, so it is probable that the epidemic at Hastings had included many adolescents and adults.

On the other hand, where smallpox came in epidemics at short intervals, or where it was always present, the incidence, even in the first half of the 18th century, was much more exclusively upon childhood. Thus at Nottingham there was always some smallpox, with a great outburst perhaps once in five years. The year 1736 was one of those fatal periods of smallpox, the victims being “mostly children.” From the end of May to the beginning of September, great numbers were swept away; the burials in St Mary’s churchyard were 104 in May; the burials from all causes for the whole year exceeded the baptisms by 380; there had been no such mortality since thirty years. Such excessive incidence of smallpox upon the earliest years of life happened in places where the infant mortality was high from all causes. Nottingham was one of those places. Leaving out the great smallpox year, 1736, the other seven years of the period 1732-39 had a total of 2590 baptisms to 2226 burials, of which burials no fewer than 1072 were of “infants,” meaning probably children under five years, although the work of Harris on the Acute Diseases of Infants, which was current at that time, defines the infantine age as under four years[999].

The years of distress and typhus fever in England, Scotland, and Ireland from 1740 to 1742 were another great period of smallpox epidemics throughout the country. The mortality from that cause is known to have been excessive in Norwich, Blandford, Edinburgh and Kilmarnock, which may be taken as samples of a larger number of epidemics in the same years. The association of much smallpox of a fatal type with much typhus fever, which can be traced in the London bills from an early period, is at length seen to be the rule for the country at large. After 1740-42, the next instances of it were in 1756 and 1766: it is most definitely indicated again in 1798-1800, very clearly in 1817-19, and in 1837-39. In all the later instances smallpox was the peculiar scourge of the infants and children in times of distress, while the contagious fever was as distinctively fatal to the higher ages. There is some reason to think that the law of incidence was the same in populous cities in 1740-42.

Thus at Edinburgh there died in the two worst years of the distress (population in 1732 estimated at 32,000)[1000]:

_Edinburgh Mortalities._

1740 1741

Under two years 439 562
From two to five 198 269
From five to ten 53 93
Above ten 547 687
---- ----
1237 1611

Fever 161 304
Flux 3 36
Consumption 278 349
Aged 102 156
Suddenly 56 62
{Smallpox 274 206
{Measles 100 112
{Chincough 26 101
{Convulsions 22 16
{Teething 111 141
{Stillborn 29 50
Other diseases 77 78

More than half the deaths were under five years, and among those deaths it will be necessary to include most of the smallpox mortality. That disease in the two exceptional years made 17 per cent. of all deaths, or one in six. But in its somewhat steady prevalence among children in Edinburgh from year to year, smallpox accounted for one death in about ten, as in the following[1001]:

_Deaths by Smallpox and all causes in Edinburgh, including St Cuthbert’s parish, 1744-63._

All Dead of
Year Burials Smallpox

1744 1345 167
1745 1463 141
1746 1712 128
1747 1200 71
1748 1286 167
1749 1132 192
1750 1038 64
1751 1241 109
1752 1187 147
1753 1105 70
----- ----
12709 1256
or 1 in 9·6

1754 1215 104
1755 1187 89
1756 1316 126
1757 1267 113
1758 1001 52
1759 1136 232
1760 1123 66
1761 903 6
1762 1305 274
1763 1160 123
----- ----
11613 1185
or 1 in 9·8

As in other epidemics, it was not until its second year that the smallpox reached Norwich. The mortality had been enormous in 1741, owing to the distress and the fever, 1456 burials to 851 baptisms; but in 1742 the burials were 1953 (to 825 baptisms), the excess over the previous year being ascribed, in general terms, to the smallpox[1002]. It is probable that the enormous excess of burials over baptisms at Newcastle in 1741 was due in great part to the same disease among the children; but the statistics do not show it.

Northampton is an instance of a town with very moderate mortality for the 18th century; for that and other reasons its bills were used by Price as the basis of a table of the expectation of life. It had certainly shared in the fever epidemic of 1741 and 1742, for in the latter of those years the annual bill shows the very high fever-mortality of 37 in 130 deaths from all causes in All Saints’ parish, which had fully one-half of the population. But in that year there are no smallpox deaths recorded, and only nine in the next four years. The great periodic outburst of smallpox came in 1747[1003]:

_Smallpox in Northampton, 1747._

Percentage
Parish Cases Deaths of Fatalities

All Saints 485 76 15·6
St Sepulchre 175 21 12·0
St Giles 131 23 17·5
St Peter 30 6 20·0
----- ---- ------
821 126 15·3 or 1 in 6·5

Of the 76 deaths in All Saints’ parish only 58 were buried there. The deaths from all causes in that parish were 189, of which 103, or 54 per cent., were under five years of age, and 10 between five and ten years. Next year, when things had improved much, although the mortality was still high, All Saints’ parish had 119 burials, of which 47, or 40 per cent., were under five years, and 4 from five to ten, only three of the deaths being from smallpox. Only a few smallpox deaths appear in the bills of All Saints’ parish until 1756 and 1757, when an epidemic occurred, part of it in each year, which produced in that greatest of the four parishes 85 burials, or half as many again as in the epidemic of ten years before. It is singular that the deaths under and over five are in a very different ratio in the two successive years of the epidemic:

_All Saints’ Parish, Northampton._

1756 1757

All deaths 140 135
Smallpox deaths 31 54
All deaths under 2 54 24
" " 2-5 12 18
" " 5-10 7 21
" " 10-20 5 6
" " 20-30 13 18
" " 30-40 7 12
" " 40-50 4 5
" " above 50 38 31

This looks as if a good many more had died of smallpox at the higher ages in the second year of its prevalence than in the first; but the great difference between the deaths under two in 1756 and 1757 is explained chiefly by the article “convulsions,” which is 28 in the former year and only 10 in the latter.

In Boston, Lincolnshire, a town almost as healthy as Northampton, the intervals between epidemics of smallpox were almost as long, and the effect in raising the mortality for the year nearly the same. The population in the last year but one of the table was 3470. The deaths averaged 104 in a year, the smallpox deaths 9·45, or one in eleven[1004].

_Smallpox in Boston, Lincolnshire, 1749-68._

Died by
Year Baptised Buried Smallpox

1749 68 120 48
1750 80 93 --
1751 55 59 --
1752 88 85 --
1753 79 73 --
1754 88 111 1
1755 74 102 19
1756 66 110 34
1757 93 86 4
1758 83 88 4
1759 102 91 --
1760 106 84 2
1761 80 94 --
1762 95 134 3
1763 92 206 69
1764 130 102 5
1765 112 113 --
1766 144 117 --
1767 129 95 --
1768 131 117 --

This was a favourable instance of urban smallpox in the 18th century, Boston having “no circumstances of narrow streets, crowded houses, manufactories or want of medical assistance.” We may compare with it an industrial town only a little larger, the weaving town of Kilmarnock, Ayrshire, the smallpox epidemics of which came as follows[1005]:

_Smallpox in Kilmarnock, 1728-63._

Died by
Year Baptised Buried Smallpox

1728 111 162 66
1729 -- -- --
1730 -- -- --
1731 -- -- --
1732 -- -- --
1733 -- -- 45
1734 -- -- --
1735 -- -- --
1736 135 147 66
1737 -- -- --
1738 -- -- --
1739 -- -- --
1740 95 164 66
1741 -- -- --
1742 -- -- --
1743 -- -- --
1744 -- -- --
1745 116 102 74
1746 -- -- 8
1747 -- -- --
1748 -- -- 2
1749 134 149 79
1750 -- -- 5
1751 -- -- 1
1752 -- -- --
1753 -- -- 1
1754 146 203 95
1755 -- -- --
1756 -- -- --
1757 125 132 37
1758 -- -- 9
1759 -- -- --
1760 -- -- --
1761 -- -- --
1762 132 173 66
1763 -- -- 2

Although Kilmarnock had an average annual excess of baptisms over burials (134 to 107), which was more than that of Boston, its smallpox mortality was higher than that of the Lincolnshire market town. On an annual average, one death in eleven from all causes was by smallpox at Boston, one in six at Kilmarnock. In the former the epidemics came at intervals of about five years, in the latter at intervals of three or four. The oftener the epidemic came, the earlier in life it attacked children; and in all subsequent experience it has been found that smallpox is far more mortal to the ages below five than to the ages from five to ten or fifteen. More generally, the conditions were worse for young children in a weaving town than in a market town of nearly the same size. In the populous weaving parish of Dunse, 130 children are said to have died of smallpox in 1733, during a space of three months[1006].

The ages at which deaths from smallpox occurred in Kilmarnock from 1728 to 1763 are strikingly different from those already given for the small market town or village of Aynho, near Banbury, in 1723-24; at the latter the greater part of the fatalities, although not of the attacks, happened to persons between twenty and fifty; at the former nine-tenths of the deaths were of infants and young children, as in the following:

_Ages at Death from Smallpox, Kilmarnock, 1728-63._

Deaths
at all Under One to Two to Three to Four to Five to Above Age not
ages One Two Three Four Five Six Six stated

622 118 146 136 101 62 23 27 9

This almost exclusive incidence of fatal smallpox upon infants and young children in a weaving town during the middle third of the 18th century we shall find abundantly confirmed for English manufacturing and other populous towns in the last third of the 18th century, and thereafter until the middle of the 19th century. On the other hand, the less populous towns and the country districts continued in the 18th century to furnish a fair share of adult cases, for the reason that epidemics came to them at longer intervals, wherein many had passed from infancy to childhood, and even from childhood to youth or maturity, without once encountering the risk of epidemic contagion.

Of such less populous places we have an instance in Blandford, Dorset. Particulars of its smallpox have been given in connexion with general inoculations; here let us note that in this typical market town of 2110 inhabitants (in 1773), the known epidemics were in 1731, 1741, 1753 and 1766--at intervals of ten or a dozen years. In the villages the intervals were longer. Haygarth gives the instance of three parishes in Kent with only ten deaths from smallpox in twenty years, and of Seaford, in Sussex, with one death “eleven years ago[1007].” An authentic instance is the parish of Ackworth, Yorkshire, whose register of burials contains only one smallpox death in the ten years 1747-57, while there are thirteen such deaths in it in the next ten-years period, clearly the effects of an epidemic, perhaps in 1766[1008]. This parish, judged by the excess of births, was not so healthy as many[1009], while its mortality by “fevers” was considerable. The following somewhat general statements are made for the parish of Kirkmaiden, Wigtonshire[1010]:

1717. “Nearly thirty-seven died of the smallpox.”
1721. Forty-eight died, “mostly of fevers.”
1725. Forty-three died, “mostly of the smallpox.”

By means of this law of periodic return, at short intervals in the populous industrial towns, at longer intervals in the market towns, and at very long intervals in the villages, we may realize in a measure what smallpox was at its worst. It was the great infective scourge of infancy and childhood, admitting but few or feeble rivals or competitors, as we shall see in the historical accounts of measles, whooping-cough and scarlatina. The table of epidemics from 1721 to 1727, given at p. 518, is of a kind that might have been furnished by any series of years in the 18th century; they were so much of a commonplace that hardly anyone thought of chronicling them unless for a special statistical purpose, such as the inoculation controversy. Thus, the Salisbury epidemic of 1723, with 1244 cases and 165 deaths, must have been only one of a series at intervals, which may or may not have become more frequent, or of different age-incidence, or of more fatal type, as the century proceeded. We have a glimpse of one of them in 1752-3. Lord Folkestone having given a hundred pounds to the poor of Salisbury, it was ordered on 15 December, 1752, “that five shillings be given to every inhabitant who hath had the smallpox in the natural way since 1 September, or that shall have it hereafter.” The epidemic went on for months; it was not until the end of 1753 that the mayor advertised the city free of smallpox. In September of that year ten guineas were voted to Mr Hall, the apothecary, for his trouble during the smallpox, and a like sum to Mr Dennis, the surgeon[1011].

The year 1753 was also the time of one of the periodical Blandford outbreaks. For a year or two before there had been much smallpox at Plymouth, the account of which by Huxham will serve as a sample of his numerous references to the disease there from the beginning of his annals in 1728.

In May, 1751, smallpox was brought in by Conway’s regiment; it spread
in July and August, becoming worse in type in the autumn as it became
more common. In January 1752 it was still prevalent, the pustules
often crude, crystalline, undigested to the end; sometimes very
confluent, small and sessile; sometimes black and bloody, attended now
and then with petechiae. In March the type grew more mild; in April
the malady was still up and down, some cases being of a bad sort. It
became more frequent again in June, and was epidemic all the summer,
the eruption often confluent, small, sometimes black, with
haemorrhages from the nose, especially in children. In August it was
epidemic everywhere, and more fatal, becoming milder in September and
October. In December, “the crusts of the black confluent kind many
times remained for at least thirty days after the eruption.” It
declined from January, 1753, and entirely ceased in May, having had a
prevalence of two years[1012].

Smallpox in London in the middle of the 18th century.

There is hardly any epidemic malady in London of which so few particular records remain as of smallpox, except in the bills of mortality. The monthly notes in the _Gentleman’s Magazine_ from 1751 to 1755 by Dr Fothergill, who practised at that time in White Hart Court, Lombard Street (having afterwards removed westward to Harpur Street, Red Lion Square), contain the following references to it:

1751, May. Smallpox uncommonly mild in general, few dying of it in
comparison of what happens in most years.

1751, December. Smallpox began to make their appearance more
frequently than they had done of late, and became epidemical in this
month. They were in general of a benign kind, tolerably distinct,
though often very numerous. Many had them so favourably as to require
very little medical assistance, and perhaps a greater number have got
through them safely than has of late years been known.

1752, January. A distinct benign kind of smallpox continued to be the
epidemic of this month.... A few confluent cases, but rarely.
February--Children and young persons, unless the constitution is very
unfavourable, get through it very well, and the height to which the
weekly bills are swelled ought to be considered in the present case as
an argument of the frequency, not fatality, of this distemper.

1752, April. Smallpox continued to be the principal epidemic, as in
the preceding months; during which time it attacked most of those who
had not hitherto had the distemper, and it is now spread into the
suburbs and the neighbouring villages, but still in a favourable way
in general. Some have the confluent, a few the bleeding kind, but
these are not very common.

1752, June. Smallpox still continues, not many escaping who have not
had it before.

1752, July. Smallpox inclined to become malignant, but the
constitution on the whole remarkably mild. Children from one to three
years old have, I believe, suffered more from the distemper during
this constitution than those of any other ages; at least it has so
fallen out under the writer’s observation.

1753, December. Smallpox of a bad type.

1754, August. Smallpox frequent in many parts of the City, and eastern
suburbs especially. In general the kind was mild, distinct and
favourable. Out of sixteen who had the disease in a certain district,
of different ages, one only died. In some it was very virulent, with
livid petechiae.

1754, December. Smallpox not unfrequent. Many had the worst kind seen
for years.

1755, January. Smallpox more favourable.

Fothergill, who pointed out the defects of the London bills of mortality and made a serious attempt to get them reformed[1013], was disposed to take their figures of smallpox deaths as on the whole trustworthy: “The smallpox, of all diseases mentioned in the weekly bills, is perhaps the only one of which we have any tolerably exact account, it being a disease which the most ignorant cannot easily mistake for another.” Reserving this opinion for some critical remarks in the sequel, we may now resume the London statistics from the year last given.

_Smallpox Mortality in London, 1721-60._

Deaths Deaths
from from
Year smallpox all causes

1721 2,375 26,142
1722 2,167 25,750
1723 3,271 29,197
1724 1,227 25,952
1725 3,188 25,523
1726 1,569 29,647
1727 2,379 28,418
1728 2,105 27,810
1729 2,849 29,722
1730 1,914 26,761
1731 2,640 25,262
1732 1,197 23,358
1733 1,370 29,233
1734 2,688 26,062
1735 1,594 23,538
1736 3,014 27,581
1737 2,084 27,823
1738 1,590 25,825
1739 1,690 25,432
1740 2,725 30,811
1741 1,977 32,169
1742 1,429 27,483
1743 2,029 25,200
1744 1,633 20,606
1745 1,206 21,296
1746 3,236 28,157
1747 1,380 25,494
1748 1,789 23,069
1749 2,625 25,516
1750 1,229 23,727
1751 998 21,028
1752 3,538 20,485
1753 774 19,276
1754 2,359 22,696
1755 1,988 21,917
1756 1,608 20,872
1757 3,296 21,313
1758 1,273 17,576
1759 2,596 19,604
1760 2,181 19,830

The year 1752, to which Fothergill refers most fully in the notes cited, had the highest total of deaths from smallpox in the period 1721-60, namely, 3538, and was exceeded by only two years in the latter part of the century, 1772, with 3992 deaths and 1796 with 3548. Fothergill says twice that the disease in 1752 was on the whole mild, but so universal that not many escaped it who had not had it before; and that children from one to three years suffered most from it. As the year was not an unhealthy one in general, this epidemic of smallpox may be chosen to show its effect upon the weekly mortalities, of children in particular.

_London Weekly Mortalities: Smallpox Epidemic of 1752._

Under Two Five Convulsions
Week All two to to Smallpox deaths
Ending deaths years five ten deaths