Chapter IV: Smallpox (6)

A complete survey of smallpox in its great period, the eighteenth century, in all places and continuously from year to year, is impossible even if it were to be desired. Had it not been for the exact diligence of a few, especially in the North of England, we should have been left in doubt on some of the main epidemiological generalities. A system of registration such as was applied for the first time in the epidemic of 1837-39 would have saved much research and would have made it possible to bring the facts within a smaller compass. By comparison and classification of many scattered particulars we may still acquire a tolerably clear notion of what smallpox was in the 18th century. It was chiefly a disease of infancy and early childhood. It was always present in one part or another of the capital and of the larger towns, rising at intervals to the height of a great and general epidemic[1070]. At its worst, as in Glasgow, it took about a third part of the lives under the age of five, and perhaps a sixth part of the lives at all ages. It came in epidemics at somewhat regular intervals in the smaller towns, and at longer intervals in the country parishes. The village epidemics were apt to be very searching when they did come. Haygarth gives the instance of Christleton, a small village two miles from Chester, in 1778: “The distemper began in March and continued till October. At the commencement of the epidemic, 107 poor children had never been exposed to the variolous infection; of these 100 had the distemper, probably all who were capable of receiving the smallpox.” In all places, with the possible exception of London where the risks from infantile diarrhoea and “convulsions” were peculiar, it cut off the infants and young children more than any other single disease, infectious or other; and indeed it had few rivals among infectious diseases until towards the close of the century, being for a time the grand epidemic scourge of the first years of life just as the plague was once the unique scourge of youth and mature age. It was more mortal in some seasons than in others, and at certain places. Towards the end of the 18th century, much more is heard of it in the northern industrial towns than in England south of the Trent. If the statistics of Boston, Lincolnshire, are at all representative, smallpox certainly declined much in market towns in the last twenty years of the century. It appears to have declined also in the capital during the same period. In the parishes of Scotland, by the almost unanimous testimony of the articles which refer to it in the ‘Statistical Account,’ it had become much less frequent and less dangerous for some years previous to the publication of that work (1792-98). In Glasgow, with the worst statistics of children’s deaths in the whole kingdom, the maximum had been reached, and passed, in the period between the close of the American war and the first years of the great war with France. As the French war proceeded, and vast sums of public money were poured out (the bill being left to Prince Posterity to pay), the effects of this abundance were seen in the remarkable decline, and almost total disappearance, of fevers all over England, Scotland and Ireland. Corresponding with the lull in fevers there was a lull in smallpox, not so marked as the former, but very significantly covering the same period and lasting until the great depression of trade in 1816 which followed the Peace. This will appear in continuing the chronology of epidemics; but before we come to that, it remains to make clear the scientific or pathological nature of a new kind of inoculation which became at this juncture the rival of the old. The extent to which each of the rival methods was practised will become a subject of inquiry after the epidemic of 1817-19 has been dealt with.

Cowpox.

Much has been said, in previous sections of this chapter, as to the efforts of inoculators to reduce the effects of inoculated virus “to as low a degree as we could wish.” What kind of matter do you use? one inoculator would ask of another. The comparative trials of Watson had shown that serous or watery matter from an unripe pustule of smallpox, preferably from the unripe pustule of a previous inoculation on the arm, was most “successful,” the success being measured by the slightness of the effect produced at the time. The comparative trials of Mudge had confirmed that, but had gone a little farther in showing that these slight effects of crude or unripe matter left the constitution still open to the same effects by the same means, or to more severe effects by more severe means. What kind of matter to use was, accordingly, still an open question, which offered some scope for originality and ingenuity. Among other sources of crude or watery matter with bland properties was the glassy or watery variety of eruption called swinepox, which, like its congener chickenpox, was peculiar to man; and among those who tried that source of non-purulent matter for inoculation was Jenner, of Berkeley. It was in 1789 that he inoculated his child, aged eighteen months, with matter from the so-called swinepox of man. There was still another pox bearing the name of a brute animal, which was, however, a true affection of brutes--the cowpox or pap-pox. A farmer at Yetminster, Dorset, named Benjamin Jesty, had used matter from that source for the inoculation of his wife and two young children in 1774, with the result that the arm of the former was much inflamed and had to be treated by a surgeon. There seemed to be no good reason for preferring matter of such dangerous tendency, and the experiment was not repeated. A few years after, an apothecary of Lyme, in Dorset, is said to have heard of another case of the domestic use of cowpox matter for inoculation by the mistress of a farm house, and to have pressed this fact upon the attention of Sir George Baker; who, although a supporter of the mild or Suttonian inoculations with crude lymph, and by his own avowal a friend of experiments, did not favour the trial of matter from the pap-pox of cows, probably for the reason that he should have been departing from the ground-principle of inoculating for the smallpox if he were to go outside the class of variolous disease for his matter. The true virtuoso, however, has no antecedent objection to experimenting with anything. Sometime after Jenner had used the swinepox matter, he began to talk among his medical neighbours of using cowpox matter. But it was known that cowpox matter had properties and effects of its own, and that it would be a radical innovation to use it, a departure _toto coelo_ from every modification hitherto tried in the inoculation procedure. Although it was also a pox by name, and although cowpox to the apprehension of a man of words or notions might seem to be in the same class as swinepox, glasspox, hornpox, waterpox or chickenpox, yet those who had ever seen it on the chapped hands of milkers would hardly admit that matter from such a source could serve for inoculation purposes unless upon wholly independent and original proof of efficacy. Jenner’s colleagues are reported to have denied that cowpoxed milkers escaped natural smallpox any more than their fellows[1071]. About the year 1794 Jenner began to press the subject upon the attention of his friends. His clerical neighbour, Worthington, mentioned it in one of his letters to Haygarth, of Chester, who replied, on 15 April, 1794:

“Your account of the cowpox is indeed very marvellous, being so
strange a history, and so contradictory to all past observations on
this subject, very clear and full evidence will be required to render
it credible. You say that this whole rare phenomenon is soon to be
published, but do not mention whether by yourself or some other
medical friend. In either case I trust that no reliance will be placed
upon vulgar stories. The author should admit nothing but what he has
proved by his own personal observation, both in the brute and human
species. It would be useless to specify the doubts that must be
satisfied upon this subject before rational belief can be obtained. If
a physician should adopt such a doctrine, and much more if he should
publish it upon inadequate evidence, his character would materially
suffer in the public opinion of his knowledge and discernment[1072].”

It is clear that Haygarth, who was well acquainted with epidemic smallpox and with inoculation, saw in this Gloucestershire idea something quite new as well as antecedently improbable. What the real novelty was will appear from the next historical reference to cowpox in an original work upon Morbid Poisons by Joseph Adams, a writer of the Hunterian school. All that Adams knew of the nature of cowpox previous to March, 1795, came from Cline, surgeon to St Thomas’s Hospital, who had been a fellow student of Jenner’s five and twenty years before, and kept up some correspondence with him. Adams is writing on the peculiar danger of ulceration and sloughing, or phagedaena, from transferring animal matters from one body to another, his last illustration having been the notorious phagedaenic ulceration of the gums, with rashes of the skin and constitutional effects so severe as to be fatal, which followed the transplantation of fresh teeth from one person to another in a number of cases about the year 1790 and led to the speedy abandonment of that unnatural practice[1073]. He proceeds to say, “Thus far we have only traced the poisonous effects of matter applied from one animal to another of the same class,” and then he brings in the illustration of cowpox to finish the chapter:

“The cowpox is a disease well known to the dairy-farmers in
Gloucestershire. The only appearance on the animal is a phagedaenic
ulcer on the teat, with apparent inflammation. When communicated to
the human subject, it produces, besides ulceration on the hand, a
considerable tumour of the arm, with symptomatic fever, both which
gradually subside. What is still more extraordinary, as far as facts
have been hitherto ascertained, the person who has been infected is
rendered insensible to the variolous poison[1074].”

Jenner’s own essay on the cowpox, when it appeared at length in 1798, confirmed these statements as to the phagedaenic or corroding ulcerous character of the milkers’ sores, in his brief accounts of several cases, of which it will suffice to mention these two: William Stinchcomb, farm servant, had his left hand severely affected with several corroding ulcers, and a tumour of considerable size appeared in the axilla of that side; his right hand had only one small sore. A poor girl, unnamed, “produced an ulceration on her lip by frequently holding her finger to her mouth to cool the raging of a cowpox sore by blowing upon it[1075].” Inquiries made by Dr George Pearson in various other dairy counties of England brought out the same character of cowpox in milkers: the painful sores might be as large as a sixpenny piece, and might last a month or two, causing the milker to give up his work[1076].

As to the pap-pox itself, or cowpox in the cow, the most circumstantial account was obtained, a few months after Jenner’s first essay, by interrogating a veterinary surgeon or cow-doctor, one Clayton, who attended at most of the farms within ten miles of Gloucester:

“That the chief diseases of the cow are the lough, swellings of the
udder, and cowpox; that the two former are the most common, the latter
being rarely seen except in spring and summer.

That cowpox begins with white specks upon the cow’s teats, which, in
process of time, ulcerate; and, if not stopped, extend over the whole
surface of the teats, giving the cow excruciating pain.

That, if this disease is suffered to continue for some time, it
degenerates into ulcers, exuding a malignant and highly corrosive
matter; but this generally arises from neglect in the incipient stage
of the disease, or from some other cause he cannot explain.

That this disease may arise from any cause irritating or excoriating
the teats; but that the teats are often chapped without the cowpox
succeeding. In chaps of the teats, they generally swell; but in the
cowpox, the teats seldom swell at all, but are gradually destroyed by
ulceration.

That this disease first breaks out upon one cow, and is communicated
by the milker to the whole herd; but if one person was confined to
strip the cow having this disease, it would go no farther.

That the cowpox is a local disease, and is invariably cured by local
remedies.

That he never knew this disease extend itself in the highest degree to
the udder, unless mortification had ensued; and that he can at all
times cure the cowpox in eight or nine days[1077].”

No account of cowpox in the cow has ever been given which differs materially from that of this experienced Gloucester cow-doctor in 1798[1078]. Cowpox is not only a local disease, but it is peculiar to certain individuals of the species, namely cows in milk; in them it occurs on the teats, so that it was correctly known in Norfolk by the name of pap-pox. The common observation has been that one cow starts it, and that an infection is rubbed into the teats of others by the fingers of the milkers. The cow which develops this ulceration of the paps is usually either a heifer in her first milk, from which the calf has been taken away, or a cow in milk which has been bought in a market, with the udder “overstocked” or left distended for appearance sake, but as yet with no blemish of the paps. The cause of cowpox is the rough handling of a highly sensitive part, which was originally adapted only for the lips and tongue of the calf. Ceely, a correct observer in the Vale of Aylesbury, uses no exaggerated phrase when he speaks of “the merciless manipulations of the milkers.” Men milkers are well known to lack the delicate tact of women; and cowpox has been most common in the great dairying districts where men-milkers are employed. But in some animals cowpox may be produced even under gentler handling or with slighter provocation, of which I give a recent case from my notebook, taken during a visit to the country:

27 April, 1891. Case of cowpox. A maid in the service of Mr J. R. has
on the ulnar side of the fore finger of the right hand, over the joint
of the first and second phalanges, a collapsed bleb the size of a
sixpenny piece, pearly white round the margin, bluish towards the
centre, which is brown. The forefinger, as well as the wrist and hand
generally, bears traces of recent inflammation, and was said to have
been greatly swollen and painful, the pain extending up the arm. There
is a symmetrical rash of bright red papules on both arms as high as
the elbows, more copious and bright on the right arm but abundant on
the left also. The papules are elevated and pointed, with a small zone
of bright redness of the skin round the base of each. The history is
as follows: A cow was bought four or five weeks ago to supplement the
supply of milk from the three ordinarily kept. The new comer proved
“tough” to milk, so that the maid was obliged, contrary to usual
practice, to take the paps in the cleft of the fore and middle
fingers; under this mode of “stripping,” the animal would hardly stand
quiet to be milked. After a time it was found that one of the paps had
a black crust upon it, which might have covered originally a chap of
the skin. The crust would have been displaced in the milking, and
would have grown again; the sore beneath soon healed. Only one pap was
affected. None of the other cows was infected. The “tough” cow was at
length sold as an unsatisfactory milker, and had been sent to a
distance on the morning of the day on which these notes were made. The
maid’s finger began to be affected after two or three weeks of milking
the cow, the beginning of the large and tumid bluish-white vaccine
vesicle having been like a small wart.

Jenner’s opinion that cowpox was a specific disease “coeval with the brute creation,” and that it had been the parent of the great historical smallpox of mankind, is not now received as correct. His other opinion, that cowpox was derived from the hocks of horses affected with “grease,” which held a central place in his original essay, especially in connexion with his doctrine of “true” and “spurious” cowpox, was rejected by most of his contemporaries, and is perhaps unsupported by anyone at the present time[1079].

In the title-page of his first essay, Dr Jenner called this singular malady of the cow’s paps by a new name--_variolae vaccinae_, or smallpox of the cow. Pearson, the earliest and most ardent of Jenner’s original supporters, and for several years thereafter a convinced vaccinist, at once took exception to the name _variolae vaccinae_ “for the sake of precision of language and justness in thinking.” It is a palpable catachresis, says he, to designate what is called the cowpox by the denomination variolae vaccinae, because the cowpox is a specifically different distemper from the smallpox in essential particulars, namely, in the nature of its morbific poison and in its symptoms[1080].

That the term _variolae vaccinae_ in Jenner’s title-page is used tropically can hardly be doubted; but it is not so easy to say which of the great classical tropes it is. It may be objected that “catachresis” is too general for the misuse of a word when that word is a scientific one and occurs in the leading title of a scientific book. Here we have the somewhat specific and purposeful use of a word in an unwonted sense, which, if it fall under any of the scholastic figures of speech, ought to be a figure more specifically defined than mere catachresis. In a matter so important as this one should find the exact figure if possible; but at the outset a difficulty arises, namely whether we should look for it in the usage of the rhetors, as Isocrates teaches, or in the usage of the logicians, as Aristotle lays down the definitions of tropes. If among the former class, the nearest is perhaps the hypocorisma, or attractive, agreeable name for something that is not so nice in itself. If among the latter, we shall hardly find a better than the metalepsis, which is a change more of mood than of meaning, namely the transition without proof from a supposition to an assertion. But in truth no single figure of the ancient teachers suits this modern instance. We require at least two. Metalepsis carries us so far, but synecdoche must supplement it. The term _variolae vaccinae_ is a synecdoche in that it names the cause from the effect; it is a metalepsis in that it passes abruptly from the hypothetical mood to the categorical; and in respect that it does both at a stroke it is probably unique, and without precedent among the examples known to the ancients. Or again, leaving the graver figures, and translating the Latin name of Jenner’s title-page, one may try the figurative conversion of cowpox into smallpox by the standard of pure and legitimate paronomasia, of which there is a familiar English example in the conversion of a plant into an animal by the verbal play of horse-chestnut and chestnut horse in the minor premiss.

Some in more recent times, mistaking the figurative or rhetorical intention of Jenner, have understood his Latin name of cowpox as if there really were a smallpox of the cow (although not of the bull, nor of the steer, the maiden heifer or the calf of either sex). Not being able to find a smallpox of the cow in the natural way, they have thought to satisfy the legitimate requirements of proof by manufacturing it. Certain Germans of the Lower Rhine, where the cows ordinarily wear blankets, have wrapped the blankets taken from smallpox beds round the bodies of cows, after clipping the hair close; nothing was found to ensue in these interesting experiments except an occasional pimple which had probably been caused by the shears in the preliminary clipping. Others in England, France, America and India, have succeeded in raising a smallpox pustule at the point of puncture in the epidermis of the cow or in the more delicate transitional epithelium, the matter from which has produced smallpox in its turn[1081]. But these are academic exercises. The natural cowpox of the cow has been likened by none to the natural smallpox of man in a sustained comparison of all the anatomical and epidemiological particulars of each; nor, I am persuaded, will anyone ever attempt to draw out such a comparison. _Variolae vaccinae_ as a name for cowpox was a figure of speech, and it is to misunderstand its original use to treat it as anything else.

The proof that cowpox had some power over smallpox consisted in trying to inoculate with the latter those who had been previously inoculated with the former. The accepted mode of testing the power of inoculated smallpox itself was to inoculate it again; at first the test for cowpox was to inoculate with smallpox, but after a few years the testing inoculation was done with cowpox itself. The effects of Suttonian inoculation with smallpox, as we have seen, were nearly always slight, and sometimes invisible (as in Watson’s practice at the Foundling Hospital). A previous inoculation with cowpox made them slighter still; but even with cowpox in the system, the pustules of smallpox rose where the matter had been inserted on the arm. It may be thought that there were only fine shades of difference between the effects of inoculation after cowpoxing and the effects of the same in a virgin soil; but some difference must have been perceived, for it was upon that, and upon nothing else, that the authority in favour of cowpox as a substitute for smallpox in inoculation was promptly established. The relationship between cowpox and smallpox was admitted by all to be in the nature of things “extraordinary,” as Jenner said, or a mystery, as others said; but as an empirical fact many believed it to be true, because the cowpoxed had less to show for the effects of inoculation with smallpox than if they had not been cowpoxed. Jenner himself is known to have made only two variolous tests. He used crude or watery matter from the local pustule of inoculated smallpox, and advised all his readers to do the same. In one of his two trials, a child Mary James had nearly the same effects from inoculation after cowpox that her mother and another child had from it without having been cowpoxed, namely the pustule or confluent group of pustules at the place of puncture, and the eruptive fever at the ninth day[1082].

In the earliest tests made independently of Jenner, five at Stonehouse[1083], near Stroud, and five at Stroud[1084], in the first months of 1799, the cowpoxed received smallpox afterwards by inoculation “in the usual slight manner.” In the practice at the Smallpox and Inoculation Hospital, London, in the spring and summer of 1799, many of the cowpoxed took smallpox by contagion from the atmosphere of the hospital, so that Woodville, after a period of perplexity, at length concluded that cowpox, while it was still active upon the arm, did not shut out the action of the smallpox virus in the constitution[1085].

The antecedent objections to cowpox, arising out of its non-variolous nature, were met by appealing to the results of experiments. The authority in favour of cowpox was speedily established on that ground, and has been continuous to the present time. The experimenters had to decide very nice points both in the way of observation and of reasoning. They had to appraise the margin of difference between the effects of Suttonian inoculation where cowpox had preceded and where it had not preceded. They had to allow for the first virus causing a swelling in the absorbent glands, which would obstruct the entrance of the second testing virus into the blood. They had to average the varying effects of Suttonian inoculation for its own sake, and the equally varying effects of it as the variolous test, and to find a broad difference between the two averages. Having decided that preceding cowpox infection did make a real and appreciable difference to the number of pustules resulting, at the spot or elsewhere, from the insertion of inoculated smallpox matter, or to the amount of fever, they had next to consider whether that degree of resistance by a cowpoxed person to inoculation were a good measure of his power to resist contagion reaching his vitals in the natural way. Their diligence and acumen may or may not have been equal to these things--it was a slack tide in medical science. Also they received little or no help from Dr Jenner himself, whose inventive genius was of the kind that is apt to leave the practical value, and even the theoretical probability, of the project to be tried by others. The inventor made interest with great personages--with the king, the duke of York, and the aristocracy of his county. His priority, and the merits of his project, were referred in 1802 to a Committee of the House of Commons, with Admiral Berkeley as chairman, which entered on its labours with a strong recommendation from the king, endorsed by Addington, the prime minister. They decided in favour of Dr Jenner’s claim for remuneration on all the issues, and on 2 June, 1802, the Committee of the whole House unanimously voted: “That it is the opinion of the Committee that a sum not exceeding £10,000 be granted to his Majesty to be paid as a remuneration to Dr Edward Jenner for promulgating the discovery of the Vaccine Inoculation, by which mode that dreadful malady the smallpox was prevented[1086].” On 29 July, 1807, a farther sum of £20,000 was voted to him; and on 8 June, 1808, a National Vaccine Establishment was appointed, at an annual cost of about £5,000.

Chronology of epidemics resumed from 1801.

In resuming the history of smallpox from the beginning of the present century, we come first to the deaths in the London Bills of Mortality, which are the only continuous figures. The bills of Parish Clerks’ Hall had failed, before they ceased, to include more than two-thirds, perhaps not much more than a half, of all the deaths in the capital. The great parishes of St Pancras and St Marylebone, which returned a somewhat excessive share of the deaths both from smallpox and from fever in the first two or three years of the Registration Act (1837-39), as well as the parishes of Chelsea and Kensington, were never included within the Bills; also much of the suburban extension on the other sides of London was never taken in. Meanwhile the area of the old Bills had actually become less populous owing to the displacement of dwelling houses by warehouses, workshops, counting houses, and the like, in the City, the Liberties and in certain out-parishes such as those bordering the Thames at the east end.

Still, the bills of mortality may be taken as showing on the whole fairly the proportion of smallpox deaths to other deaths, and the years of its greater outbursts.

_Smallpox in the London Bills of Mortality, 1801-37._

Smallpox All
deaths deaths

1801 1461 19,374
1802 1579 19,379
1803 1202 19,582
1804 622 17,034
1805 1685 17,565
1806 1158 17,938
1807 1297 18,334
1808 1169 19,954
1809 1163 16,680
1810 1198 19,983
1811 751 17,043
1812 1287 18,295
1813 898 17,322
1814 638 19,283
1815 725 19,560
1816 653 20,316
1817 1051 19,968
1818 421 19,705
1819 712 19,928
1820 722 19,348
1821 508 18,451
1822 604 18,865
1823 774 20,587
1824 725 20,237
1825 1299 21,026
1826 503 20,758
1827 616 22,292
1828 598 21,709
1829 736 23,524
1830 627 21,645
1831 563 25,337
1832 771 28,606
1833 574 26,577
1834 334 21,679
1835 863 21,415
1836 536 18,229
1837 217 21,063

The 18th century had ended with a severe epidemic of smallpox (2409 deaths) in the year 1800; and excepting in the year 1804, the deaths kept at a somewhat high level for ten years longer. The rise at the end of the last century corresponded to a time of distress and a severe epidemic of typhus fever. The fever declined after 1803, and remained for a dozen years at so low a level that Bateman, in his quarterly reports on the practice of the Carey Street Dispensary, expresses surprise that there should have been so little of it. The same writer, however, has occasion to remark upon the fatality of smallpox; twice he mentions large mortalities from it in courts adjoining Shoe Lane[1087]. According to the figures, also, smallpox declined less than fever. This means that, in the same circumstances, adult lives fared better than infancy and childhood. But, on the whole, smallpox shared with fever the advantageous conditions for health which obtained in all parts of the kingdom (in Ireland as well as in Britain) from the decline of the epidemics of 1799-1803 until the rise of the next epidemics in 1816-19. This period of comparative freedom from smallpox and fever corresponded to the second period of the great French War from its resumption after the failure of the Peace of Amiens until its termination with the Peace of Paris. It may seem surprising that this should have been a time of comparatively good public health in Great Britain and Ireland, inasmuch as it was a time of dear food and heavy taxes. The amount of typhus or relapsing fever is the best test; and those diseases, by all accounts, were at a lower level in all parts of the United Kingdom from 1804 to 1817 than they had been for many years before or than they were for many years after. Again, if precedents count for anything, the same kind of lull in smallpox and fever together is shown in the London bills during the war of the Allies against Louis XIV., and during the Seven Years War.

In Glasgow the decline of smallpox deaths for a few years in the 19th century was perhaps more marked than elsewhere because it was a decline from an excessively high level in the end of the 18th century.

_Glasgow Mortalities, 1801-12._

Smallpox Measles All
Year deaths deaths deaths

1801 245 8 1434
1802 156 168 1770
1803 194 45 1860
1804 213 52 1670
1805 56 90 1671
1806 28 56 1629
1807 97 16 1806
1808 51 787 2623
1809 159 44 2124
1810 28 19 2111
1811 109 267 2342
1812 78 304 2348

Here it is not until 1805 that a marked fall in the smallpox deaths takes place. In Norwich there was a clear interval from the last severe period in the end of the 18th century, until the year 1805, when smallpox, “after being for a time almost extinct,” became prevalent again. At the Whitehaven Dispensary, the contrast between the last years of the 18th century and first years of the 19th is not striking[1088]:

_Smallpox at Whitehaven Dispensary._

Cases Deaths

1795 8 0
1796 41 5
1797 (no table)
1798 51 3
1799 7 1
1800 120 11
1801 9 3
1802 (no table)
1803 67 16
1804 1 0

Carlisle, which used to share in smallpox as much as Whitehaven, seems to have been almost wholly free from it in the first twelve years of the century: at least Dr Heysham, who was no longer statistical, “had reason to believe” that no person died there of smallpox from the autumn of 1800 (when cowpox inoculation was introduced) until November, 1812[1089].

The Newcastle Dispensary, like that of Whitehaven, treated a small fraction of all the cases of smallpox in the town; but it continued to have a fair average of cases and deaths after the century was turned:

_Smallpox cases attended from Newcastle Dispensary._

Cases Deaths

1795 7 1
1796 19 3
1797 12 0
1798 15 3
1799 -- --
1800 -- --
1801 14 4
1802 -- --
1803 7 4
1804 0 0
1805 7 0
1806 16 6

Most places continued to have their periodical epidemics of smallpox as before, although both measles and scarlatina were becoming more and more its rivals. Boston, Lincolnshire, had its sexennial epidemic in 1802 with thirty-three deaths. Besides the year 1805, there were two periods in which smallpox was somewhat general, 1807-9 and 1811-13. At Norwich from 1807 to the end of 1809 the bills of mortality showed 203 deaths from smallpox[1090]. In 1808 we happen to hear of it also at Sherborne, in Dorset, at Ringwood, in Hampshire, at Cheltenham, at Cambridge and at Edinburgh, although the great epidemic malady of children in that year was measles[1091]. Lettsom wrote on 25 January, 1808: “The smallpox (infanticides) and measles have been prevalent and fatal. The coffins for the parish poor in England for the smallpox deaths alone have cost £10,000[1092].”

In 1811 it began to be somewhat general again, and rose in London to a considerable epidemic in 1812, the deaths in summer rising to sixty in a week[1093]. A village epidemic of 46 cases and 7 deaths is reported from North Queensferry, near Edinburgh, from 14 December, 1811 to 7 March, 1812[1094]. At Norwich from 10 February to 3 September, 1813, there were 65 deaths[1095]. The rise from 1811 to 1813 coincided with an increase of fever, the winter of 1811-12 having been a time of dearth and depressed trade, especially in the manufacturing districts. After that came a notable lull both in fever and smallpox, which was at length broken by the epidemics of each in 1817 in Ireland, Scotland and England, coincidently with the depression of trade and dislocation of commerce that began everywhere as soon as the great war was over.

The Smallpox Epidemic of 1817-19.

The same things that favoured the prevalence of typhus and relapsing fever in times of distress, favoured also the rise of smallpox to the height of an epidemic. Hence the greater epidemics of smallpox in the first half of the 19th century coincided somewhat closely with epidemics of relapsing or typhus fever,--in 1817-19, in 1825-27, in 1837-40, and in 1847-49. That which fever was to the adolescents and adults in times of distress, the same was smallpox to the infants and young children. The young children of a family did, indeed, take fever sometimes as well as the parents or the young persons in it; but the children seldom died of it. They died of smallpox (or of measles or whooping cough or the like), perhaps all the more readily that they would have been weakened by the fever, and by the want of food and comforts which attended it. Thus, while fever and smallpox went somewhat closely hand in hand during times of distress, it was the adolescents and adults that died of fever, the infants and young children that died of smallpox. The following table, compiled from the reports of the Whitehaven Dispensary from 1783 to 1800, will show how many children survived attacks of continued fever in comparison with their elders[1096]:

_Continued Fever at Whitehaven Dispensary, 1783-1800._

Under
Total 2 years 2-5 -10 -15 -20 -30 -40 -50 -60 -70 -80

Cases 1712 40 142 240 223 150 240 236 202 92 47 15
Deaths 85 0 0 5 2 6 14 20 19 12 7 0

The deaths from smallpox are found nearly always to be high when the deaths from fever are high. The correspondence, however, is not always exact to months or quarters, or half-years; for it is not unusual in the London weekly bills to find a run of weeks with high deaths from smallpox just before or after a run of weeks with high deaths from fever. The domestic circumstances which spread the contagion of fever were such as might be expected to spread the contagion of smallpox, namely, the pawning of clothes, bedding and the like, on a vast scale in times of scarcity, the crowding of many in single rooms or in one bed, the wandering of men and women, attended by their children, in search of work, the exposure of children in the smallpox so as to extort alms. All these things were common in Ireland, Scotland and England during the long periods of depressed trade, alternating with periods of speculation and expansion, for which the generation following the Peace of Paris was remarkable. We hear far more of the fever than of the smallpox, because the former touched the lives of breadwinners, while the latter was often regarded as a matter of course[1097]. Thus, in the Irish famine of 1817-18, it is possible to estimate the prevalence of dysentery, relapsing fever and typhus fever by the aid of various records, including two treatises and the reports of a Parliamentary Committee. There are also two or three brief references to smallpox; but no one would have supposed that smallpox caused actually more deaths than fever itself, as in the following returns of burials in the Cathedral churchyard of Armagh, from 1st May to 25th December, 1818[1098]:

Smallpox deaths 180
Fever deaths 165
All other deaths 118

--the total of 463 being twice or thrice the numbers for the corresponding months of non-epidemic years. Whether there was as much smallpox in other provinces of Ireland as in Ulster, does not appear; but the following relating to Strabane and Londonderry will serve to prove that Armagh was not exceptional in the north of Ireland. In and around Strabane, smallpox began to spread in May, 1817, having been hardly known in the neighbourhood for years before; it was often confluent and was “fatal to hundreds” of children[1099]. The same severity of the epidemic is reported also from the county of Derry in 1817: “Cases of smallpox appeared in greater numbers than I had ever before witnessed, even previous to the valuable discovery of Jenner[1100].”

The vagrancy of the Irish peasants, not only cottiers but also many small farmers, began in Ulster in the end of the year 1816, after a wet autumn which ruined the crops; and it is probable that the contagion of smallpox began to be spread among their children about the same time. Whether a migration set in to England and Scotland at that time is not clear. It appears, indeed, that the first of the epidemic in England, in Whitehaven, Ulverston, and other places which were in direct communication with the North of Ireland, was at least as early as, and perhaps earlier than, the outbreak of the malady in that country. The whole of the United Kingdom was suffering in 1816 from depression of trade, and many of the labouring class were tramping from place to place in search of work. The following is the account of smallpox being brought to Ulverston[1101]:

“The smallpox were brought to Ulverston from Wigan, by the wife of a
nailer, who, with her child had slept in a house where the family had
just recovered from them, in the latter end of January, 1816, or
beginning of February. She immediately returned to Ulverston and the
eruption appeared on the child about ten days afterwards, when it was
carried about by the mother and much exposed in different parts of the
town. They soon removed from this place; and I believe the child died
between this place and Kendal.”

A young woman of Ulverston who was much in the company of the nailer’s wife from Wigan, caught smallpox from her child, and died on 22 February; her sister sickened soon after, and had the disease favourably. An epidemic followed in the town, of which some particulars are known down to October, 1816; the disease was very fatal also in Whitehaven at the same time. Two things gave a particular interest to the Ulverston smallpox of 1816, two things which were found to characterize the epidemic everywhere in England and Scotland as it spread in 1817, 1818 and 1819. These were, first the numerous cases of smallpox among those who had been inoculated with cowpox, a sequel now obvious on a large scale for the first time; and secondly, the admixture of a good many cases of “crystalline” or “hornpox” eruptions among the usual pustular cases. There was nothing new in such crystalline eruptions in smallpox; for example Huxham mentions them at Plymouth in 1752. But they were always curious, and it was always a matter of wonder that they should happen in one epidemic and not in another. Of thirty-five cases tabulated from the Ulverston epidemic of 1816, twelve had the “horny pox,” or the “small horny kind,” all the rest having the ordinary pustules of smallpox, sometimes discrete, sometimes confluent, four being scarred, and one covered by “a complete cake of incrustation.” All those thirty-five cases were above five years of age, except one child of three, and they seem to have nearly all recovered. Nothing is said of the infants and children under the age of five, who then contributed three-fourths of the mortality in every epidemic of smallpox. The crystalline eruption was not chickenpox; for the three first cases of it had all gone through chickenpox before.

Almost identical in tenour with this account from Ulverston is the narrative of an epidemic at Newton Stewart, in Wigton, just across the Solway from Cumberland, which began in the autumn of 1816, but did not extend until the following summer[1102]. The first case was one of “hornpox” in a girl from London; the second case was in a companion of the former, in the same family, her disease being ordinary pustular smallpox; both had been vaccinated. One hundred cases in the epidemic were thus assorted:

Cases Deaths

Smallpox 43 13
Modified hornpox, &c. 47 0
Varicella 10 0

That is to say, the mortality of the whole was thirteen per cent., an ordinary mortality for a country town. There were all extremes, from confluent smallpox to discrete, many of the discrete having no proper pustules “but hard vesicles of more or less tubercular appearance.... These were termed by the people _nerles_ or _hornpox_, and have long been noticed by very aged matrons, who pretend to no little skill in the diagnostics of smallpox, and who have distinct varieties by name, beyond the enumeration of any nosologist.” Their diagnostic skill was natural enough, for the practice in smallpox had been almost entirely in their hands.

A certain proportion of hornpox cases was so characteristic of this epidemic (1816-19) as to have been remarked everywhere--in England as well as in Scotland. The epidemic was not well reported as a whole at any one place. Sometimes, as at Ulverston, only the vaccinated cases were given; at other times, as at Cupar Fife and Edinburgh, only the “hornpox” cases were given; again, in the account of the Norwich epidemic, which is the fullest, the large number of cases with crystalline or horny eruption were not counted in as smallpox cases at all. Dewar’s table of the Cupar Fife epidemic, in the spring of 1817, included 70 cases, all of crystalline or hornpox[1103]. The latter variety was part of the epidemic at St Andrews[1104].

The Edinburgh cases which Thomson heard of to the end of the epidemic numbered 556, assorted as follows[1105]:

310 had been vaccinated.
41 had had smallpox (doubtless by inoculation).
205 had neither been vaccinated nor had smallpox.

A large proportion had the crystalline eruption, while some of the deaths are put down to “malignant crystalline water-pock.” At Lanark and New Lanark the epidemic was also taken notice of[1106]. At the latter were situated the cotton mills managed under Robert Owen’s co-operative system; and it appears that vaccination had been somewhat generally carried out in this socialist community. The following was the incidence of smallpox upon 322 persons:

251 had been vaccinated.
3 were under vaccination at the time.
11 had been inoculated with smallpox, or had gone through the natural
smallpox.
57 had neither been vaccinated nor variolated.

It is clear that this was the first severe and general epidemic in Scotland since the beginning of the century, although we have seen that the disease had never been out of Glasgow. Thomson saw well enough how that epidemiological fact told: “It is to the severity of this epidemic, I am convinced, that we ought to attribute the greatness of the number of the vaccinated who have been attacked by it, and not to any deterioration in the qualities of cowpox virus, or to any defects in the manner in which it has been employed. [Dewar said the same for Cupar Fife.] Had a variolous constitution of the atmosphere, similar to that which we have lately experienced, existed at the time Dr Jenner brought forward his discovery, it may be doubted whether it ever could have obtained the confidence of the public.” Thomson himself, professor of military surgery in Edinburgh and a person of high character, drew the most astonishing inferences from the tolerably simple facts of the epidemic in 1817-19. The crystalline was mixed with the ordinary pustular smallpox in this epidemic, as it had been in some 18th century epidemics; it was common to those who had been vaccinated and to those who had not been so; it occurred in those who had previously gone through the chickenpox. Yet the professor concluded that crystalline or hornpox was smallpox “modified” by vaccination, that it should be called “varioloid,” and that “modified” smallpox and chickenpox were the same disease.

Several cases of smallpox had occurred in the spring of 1816 at Quarndon, two miles from Derby, one or two of the nine cases proving fatal. Several of the Derby doctors went to see them, some calling them “aggravated chickenpox,” and others “mild smallpox after vaccination.” In the spring following (1817), most of the children and young people in the villages of Breadsall, Smalling, Spondon, Heaver, and others near Derby, were afflicted with the epidemic, which declined in autumn. It came back in the spring of 1818, when it spread more generally than before, and was still prevalent at the end of that year, in Nottinghamshire and Staffordshire as well as in Derbyshire. In Herefordshire, also, in February, 1818, “typhus, measles and smallpox were at once raging.” The disease proved fatal in many instances among the lower orders in Derbyshire, who still followed the heating regimen, giving the children saffron to drink, and holding them in blankets before a strong fire, to bring the eruption out; but it was fatal also to some who were treated more rationally. In this part of England, as in Lancashire, Wigtonshire, Fifeshire, Edinburgh, and elsewhere, a large proportion of the cases had the crystalline eruption of smallpox, horny or glassy pimples or hard vesicles, which dried about the sixth day. But, said Dr Bent, the peculiar form “is the same in those persons who have never had the cowpox and in those who have passed through that disease satisfactorily.” His two drawings of the characteristic hornpox were made from unvaccinated children. On the very day of his writing he had seen two children in the same family, both with the crystalline eruption, the one vaccinated and the other not. In his practice at the Derby Infirmary, one in-patient and one out-patient had died of smallpox after vaccination, and one out-patient had died of it who had not been vaccinated. He was greatly astonished, after all that had been said of the certainty of cowpox protection[1107].

The epidemic of 1817-19 was longest in reaching the Eastern Counties, just as that of 1741-42 had been, and that of 1837-39 was to be. It was also towards the close of 1818 and beginning of 1819 that the disease became frequent in Canterbury. When it did reach Norwich, Lynn and many other places in Norfolk and Suffolk it became unusually destructive. The history of smallpox in Norwich from the beginning of the century was a history of the usual periodic epidemics, such as the city had been visited by in former times, according to the records in Blomefield’s _History_ or other sources. The first epidemic was in the year 1805, when smallpox was unusually common in London also. The next, with 203 deaths, lasted from 1807 to 1809. In 1813, the bills again showed many deaths by it from 10 February to 3 September. For fully four years after that there was not a death from smallpox reported in Norwich. In June, 1818, by which time the epidemic had reached large dimensions in Ireland, Scotland, and part of England, it was brought to Norwich by a girl who had come with her parents from York; it spread little at the time, the deaths to the end of the year being only two. Meanwhile measles was a very frequent and fatal disease among the children in Norwich throughout the year 1818. The smallpox began to rage in April, 1819, after which the measles was hardly met with, and only a few cases of scarlatina. The following table shows the enormous rapidity with which smallpox went through the infants and children of the Norwich populace when it had once fairly begun[1108]:

Deaths from Deaths from
1819 smallpox other diseases Total

January 3 61 64
February 0 71 71
March 2 68 70
April 15 61 76
May 73 63 136
June 156 70 226
July 142 61 203
August 84 63 147
September 42 96 138
October 10 63 73
November 2 62 64
December 1 83 84
---- ---- ----
530 822 1352

In one week of June, there were forty-three burials from smallpox. Half the deaths were of infants under two years; nearly all the rest were of children under ten:

Total 0-2 -4 -6 -8 -10 -15 -20 -30 -40

530 260 132 85 26 17 5 2 2 1

If the deaths were at the rate of one in about six cases, there would have been some three thousand children attacked in a population of 50,000 of all ages. Two hundred cases which Cross kept notes of were classified by him thus:

Mild 75
Severe 78
Confluent 42
Petechial 5

Forty-six of these died, a rather high rate of 23 per cent., which is due perhaps to the crystalline or hornpox cases being excluded from the definition of smallpox altogether; all the petechial or haemorrhagic cases died, and most of the confluent. Sloughing of the face, lips or labia, occurred in three children, and bloody stools in many of the worst cases. Those 200 cases occurred in 112 families, comprising 603 individuals, of whom nearly one-half (297) “had smallpox formerly” (including the inoculated form of it, doubtless).

This was a great epidemic for Norwich in the 19th century. The public health there, as elsewhere, had improved greatly since the 18th century. In 1742 the deaths had been increased 502 by smallpox; but in that year, a year of severe typhus, the deaths from all causes were 1953, against 1352 in 1819. One reason of the enormous smallpox mortality from May to September, 1819, was the number of susceptible children, all the greater that there had been hardly any smallpox for five years, whereas in towns such as Norwich in the 18th century it appears to have been perennial: all the greater, also, because “the removal of families from the country to Norwich, during a flourishing and improving state of our manufactures for two or three preceding years, gave a sudden increase to the number of those liable to the disease.” Norwich may have been better off than many other towns; but the winter of 1816-17, when the smallpox epidemic began, was a time of depressed trade, many families being on the move in search of work; and it does not appear that all those who crowded to Norwich had found employment. The epidemic was “confined almost exclusively to the very lowest orders of the people;” the contagion was spread abroad among them by the shifts they were reduced to in their indigence--“the public exposure of hideous objects just recovering, loaded with scabs, at the street corners.” Yet this deplorable state of want and beggary does not seem to have been accompanied with much typhus fever among the adult population, as it certainly was in 1742. Cross describes a petechial fever, in May, June and July, 1819, which was fatal in all the cases that he was called to; but he speaks of it only among children. Whenever the population increases rapidly, as it had been doing in the second decade of the 19th century, it is upon the young lives that epidemic mortality falls most. The smallpox epidemic at Norwich in 1819 caused rather more deaths than in 1742, when the public health was very much worse; but it would hardly have caused so many had it not been aided by the state of population.