Chapter IV: Smallpox (7)

The epidemic of 1819 spread all over East Anglia[1109]. At Lynn there had been a good deal of the disease three years before; in 1819 there were so many deaths from it that in June the clergy ordered the smallpox burials to be specially marked in the register, from which date until the end of August they numbered forty. At Yarmouth the epidemic was still raging at the end of 1819. Of ninety-one surgeons in Norfolk and Suffolk who replied to a circular issued by Cross, all but eleven saw cases of smallpox in 1819, three had had cases in 1818, two had seen the disease in 1817, and one in 1816. Generally speaking, the disease had been in abeyance in those counties for seven years; a surgeon of Prudham, whose practice covered eleven parishes, had seen no case of smallpox for twelve years before. The largest number of deaths in the practice of any one surgeon was twelve. Twenty-eight surgeons together had 598 smallpox patients, with 97 deaths; but in their districts there had been 180 deaths besides from the same disease, in families unvisited by them.

The accounts of this epidemic in London are most meagre. In the bills of mortality, now become quite inadequate to the whole capital, the deaths rose to 1051 in 1817, fell next year to 421, and in 1819 were 712. But it was in the year 1819 that the admissions to the smallpox hospital were most numerous, namely, 193, the highest number since the epidemic of 1805, when they were 280 in the year. The horny or crystalline kind of smallpox was found in London, as elsewhere[1110].

In the spring of 1818, “smallpox _post vaccinationem_” was frequent among the boys of Christ’s Hospital[1111]. None of the cases proved fatal that year, but there was a death in the school from smallpox in 1820, probably the last fatality from that cause in the history of the school[1112].

A few casual notices of smallpox in England in the years following the epidemic of 1817-19 lead one to suppose that the disease did not again fall to that apparent extinction which it had reached before the last epidemic began. It is heard of in and around Chichester in 1821; nineteen surgeons who supplied Dr John Forbes with information had seen about 130 to 140 cases, with 20 deaths; about 80 of the cases were in persons previously inoculated with cowpox, 19 cases (or the most of 19) were in persons previously inoculated with smallpox[1113]. This was doubtless the experience of paying patients only; according to the East Anglian precedent of 1819 there would have been twice as much smallpox in families who received no professional treatment. Canterbury is another town from which a rapidly spreading epidemic of smallpox is reported--in the winter of 1823-4. It continued into the winter and spring of 1824-25, among the poor, fatal cases being by no means rare. Dr Carter frequently saw children exposed in the streets of Canterbury with smallpox upon them; he appealed to the mayor to have some check imposed on the spread of contagion, but nothing was done, and smallpox was still prevalent at the date of his writing in the autumn of 1824[1114]. The same year there was a severe epidemic at Oxford. These were probably only samples of epidemics filling the interval from 1819 to 1825, when smallpox again became general.

Extent of Inoculation with Cowpox or Smallpox, 1801-1825.

Twenty-five years had now passed since cowpox became the rival or substitute of the old matter of inoculation. The history at this point requires some notice of the extent to which each of those methods was practised. Professional opinion, or that part of it which found expression, was for the most part in favour of cowpox. The Smallpox and Inoculation Hospital of London took the lead, under Woodville, in substituting cowpox for smallpox, and other public institutions, such as the Newcastle and Whitehaven Dispensaries, quickly followed. The new mode was practised upon larger numbers than the old. At the Newcastle Dispensary the inoculations of smallpox from 1786 to 1801 had been 3268; the inoculations of cowpox from 1801 to 1825 were 20,264. At the Whitehaven Dispensary 173 children were inoculated with smallpox in 1796, the total inoculations before that having been 906. To the end of 1803 the total vaccinations were 490, of which many were done during the severe outbreak of smallpox in 1803.

In Glasgow, where the old inoculation was either little practised or of little use, the Jennerian mode was received with favour, and was offered to the children of the working classes gratuitously at the Hall of the Faculty of Physicians and Surgeons. From the 15th of May, 1801, to the 31st of December, 1811, these public vaccinations numbered 14,500, an average of about 1400 in the year. In the next seven years they declined as follows:

1812 950
1813 1162
1814 875
1815 926
1816 980
1817 820
1818 650

On the revival of smallpox the Glasgow Cowpock Institution was opened on 28 August, 1818, and vaccinated 146 to the 1st of January, 1819. The smaller demand for even gratuitous vaccination of infants after 1812 was owing to the very small amount of smallpox in Glasgow in those years; in the six years, 1813-19, there were said (by Cleland) to have been only 236 deaths from smallpox in a total of 22,060 deaths from all causes, or 1·07 per cent. of all deaths[1115]. Not more than a fourth part of all the infants born in Glasgow had been vaccinated in the years 1812 to 1818, and that was the time when smallpox was at its lowest point among the infantile causes of death. In some of those years when smallpox was in abeyance measles was most destructive. It was currently said in Glasgow that vaccination, if it discouraged smallpox, predisposed to measles, an opinion of the populace which Malthus shared from the _à priori_ point of view. But in a survey of the individual cases in their practice the Glasgow doctors did not find that those were the relevant circumstances, whatever the truly relevant things may have been. Thus, Dr Robert Watt, a good observer and cautious reasoner, who became president of the Glasgow faculty, wrote: “The only family within my knowledge where three died of the measles in 1808 was one where none of the children had been either vaccinated or had had the smallpox. I met with another family where two died in the same circumstances”--that is to say, five children, in two families, escaped smallpox to die of measles, no artificial interference having been attempted[1116].

Manchester was another populous district where vaccination had been freely offered to the poorer classes. Roberton, writing in 1827, says that it had been on the decline for several years, and gives the following figures for the earlier period, May, 1815, to May, 1823[1117]: At the Manchester Lying-in Charity the annual average of deliveries was 2667, while the number of infants brought back for vaccination averaged 1392 in a year. During the same eight years public vaccinations at the Manchester Infirmary averaged 1700 annually. Great numbers of infants were said, also, to have been vaccinated gratuitously by druggists. The decline in the number of vaccinations, which had perhaps begun some time before (as at Glasgow), was shown conclusively by the returns for the two years May, 1824--May, 1826. The births at the Lying-in Charity averaged 3285 per annum; but the vaccinations in the infants brought back to the charity, together with those brought to the Manchester Infirmary, averaged only 1309 per annum.

Newcastle, Glasgow and Manchester were probably favourable instances of the extent of public vaccinations in the first quarter of the century. In London the proportion of vaccinations to births is known to have been smaller, although there was more money going and at one time four public charities--the Vaccine Pock Institution, the Royal Jennerian Society, Walker’s offshoot from the latter, and the Inoculation Hospital. The following were the vaccinations at the Inoculation Hospital in four periods of five years each from 1806[1118]:

1806-10 7,004
1811-15 9,339
1816-20 13,348
1821-25 16,666
------
46,357

Annual average 2317.

At Norwich, Dr Rigby succeeded in 1812 in persuading the Board of Guardians to offer half-a-crown premium to parents for each child brought to be vaccinated. The premiums paid were as follows:

1812 (12 Aug.-31 Dec.) 1066
1813 511
1814 47
1815 11
1816 348
1817 49
1818 64

--the annual births being from a thousand to twelve hundred[1119].

At the Canterbury Hospital the applications for free vaccinations fluctuated as follows:

1818 52
1819 249
1820 263
1821 47
1822 35
1823 50
1824 (Jan.-July) 588

The sudden rise in 1819-20 and again in 1824 was owing to smallpox being epidemic in the city. During the severe epidemic of 1824 there were 250 vaccinations at the Dispensary, besides the 588 at the hospital[1120]. At Kendal the following is the Dispensary record of vaccinations for three years, the annual average of births being 390[1121]:

1819 221
1820 102
1821 73

These are examples of the spasmodic demand for vaccination in the towns. The following is an instance of general vaccination in a village during an epidemic:

The village of North Queensferry, near Edinburgh, had a population of 390. There was an epidemic of smallpox from 14 December, 1811, to 7 March, 1812, during which time 46 children, from one to fifteen years, were attacked, and seven died, the same number that had died in the last epidemic, in 1797. When the epidemic was over there were only nine persons in the village, most of them aged, who had neither had smallpox nor cowpox. Those who had been vaccinated numbered 132; while of those “formerly vaccinated” only two were included among the 46 children who caught smallpox in 1811-12. The adult population must have nearly all gone through smallpox in former epidemics[1122]. These general vaccinations during or towards the end of an epidemic were exactly comparable to the general inoculations by the old method. At Norwich, where a premium of half-a-crown was given to parents for each vaccination, the epidemic of smallpox in 1819 stimulated the practice somewhat, the increase in July and August having followed a public meeting of the inhabitants and a combined effort of the doctors:

Progress of
Progress of premium
the mortality vaccinations

January 3 26
February 0 51
March 2 101
April 15 226
May 73 226
June 156 92
July 142 301
August 84 359
September 42 14
October 10 4
November 2 2
December 1 0

Cross estimated that a fifth part of the population of Norwich (50,000) were vaccinated--8000 before the epidemic of 1819, and 2000 during the epidemic. Many of the adults had been through the smallpox in the ordinary way in former epidemics. The state of vaccination throughout Norfolk and Suffolk was indicated in the answers made by ninety-one practitioners to the circular of queries sent out by Cross. Twenty-six had done 13,313 vaccinations during the epidemic of 1819. The whole number in the practice of those ninety-one from first to last had been 120,000, two of the practitioners having vaccinated none.

To sum up, as well as the records enable us to do, the extent of the new practice in the first quarter of the century, it was systematically carried out from year to year among the infants of large towns, such as Glasgow, Newcastle, Manchester and London, and in these the maximum of gratuitous vaccinations in proportion to the births may have been one-half. In smaller towns and in country parishes the inoculations of cowpox, like those of smallpox, appear to have been irregular or by fits and starts, the alarm of smallpox being the occasion for them. But after the epidemic of 1817-19, which was the most general since cowpox had been tried, it was not mere negligence or procrastination that kept parents back, it was distrust of the new practice and preference for the old.

The original mode of inoculation, with the matter of smallpox itself, was far from being supplanted by its rival. In Jenner’s first essay the latter was put forward tentatively, not indeed because of any want of confidence in asserting its protective powers, but because it was only in certain circumstances that a substitute was desired for the old inoculation. Some of those who took up the new matter soon discontinued the old altogether, as at the Newcastle and Whitehaven Dispensaries. At the London Inoculation Hospital the old practice was given up for out-patients after 1807, and for in-patients about 1821. In private practice, tastes or preferences differed. While ordinary people left it to the discretion of their medical advisers, commissioning them to inoculate their children “with either kind of pock,” the upper classes “judge for themselves, and those among them who are philanthropists and converts to the new faith inoculate their own children and those of the poor together[1123].” Moseley, in 1808, said that the “mere operative practice” in cowpox, by which phrase he meant to contrast the academic countenance of it by eminent physicians and surgeons, had been “chiefly carried on by lady-doctors, wrong-headed clergymen, and disorderly men-midwives,” Dr Pearson being named as the only man of letters or pretensions to science who had been practically concerned in it of late[1124].

There was really little to choose between the new method and the old so far as concerned facility of operating; if anything, the inoculation of smallpox was the more difficult of the two, although that also was largely practised by amateurs[1125]. Again, as regards remunerativeness, inoculation with smallpox no longer required the combined services of a physician, a surgeon and an apothecary; it had become a matter of simple routine, just as ill paid (or as well paid, according to circumstances) as inoculation with the matter from the cow. It was not on such grounds, but on grounds of scientific principle or of sentimental interest, that an active propaganda was kept up in favour of the old inoculation. The leading defenders of the latter, such as Moseley, physician to Chelsea Hospital, and Birch, surgeon to St Thomas’s Hospital, maintained that cowpox was alien in nature to smallpox and could not be received as its equivalent. The foreign protagonists, such as Dr Müller, of Frankfort, and Dr Verdier, of Paris, emphasized still more the radical unlikeness of cowpox to smallpox. Said Verdier: “The vaccinists appeal to experience, setting aside all objections based upon the unlikeness of cowpox to smallpox. We are to be made invulnerable by vaccine as Achilles was made invulnerable by being dipped in the waters of the Styx. Protection by cowpox contradicts the received principle of inoculation. It is in vain to appeal to experience against established principles: for true principles are the result of the experience of all ages, and become the touchstone of each successive empirical innovation.”

The English inoculators by the old method gave all sorts of reasons for their preference, and were doubtless actuated by the usual mixture of motives. There were medical families, such as the Lipscombs, who had an hereditary interest and pride in inoculation. It was a Lipscomb who had recited in the Sheldonian Theatre during the Oxford commemoration of 1772, a poem, “On the Beneficial Effects of Inoculation.” Inoculators to the third generation, it was not surprising that the Lipscomb family should have caused to be printed in 1807, as if to shame the changing fashion of the day, the prize poem of five-and-thirty years before, which contained such spirited lines as these:

“When, pierced with grief at sad Britannia’s woes,
Her country’s guardian Montagu arose:
Pure patriot zeal her ev’ry thought inspir’d,
Glow’d on her cheek, and all her bosom fir’d.
She saw the Tyrant rage without controul,
While just revenge inflam’d her gen’rous soul.
Full well she knew, when beauty’s charms decay’d,
Britannia’s drooping laurels soon would fade:
Pierc’d with deep anguish at the afflictive thought
And whelm’d with shame, a heav’n-taught Nymph she sought,
Whose potent arm, with wondrous power endued,
Had oft on Turkey’s plains the fiend subdued.
Obedient to her prayer the willing Maid
In pity came to sad Britannia’s aid.
‘Henceforth, fall’n Tyrant!’ cries the Nymph, ‘no more
Hope that just Heav’n will thy lost pow’r restore:
Let now no more thy touch profane defile
The sacred beauties of Britannia’s isle.
By me protected shall they now deride
Thy baffled fury and thy vanquish’d pride[1126].’”

Still it was just among those classes to whom the _argumentum ad nitorem_ came home most forcibly that the fashion had changed. Before the end of the 18th century, the danger to beauty from an attack of smallpox had become a matter chiefly of historical interest, carrying the mind back to the Restoration or the early Georgian era. The richer classes, while they seem to have countenanced cowpox inoculation as a good thing in general, were probably apathetic on their own account. Lord Mulgrave said in the House of Lords on 8 July, 1814; “If their lordships recollected how many persons of the higher order were reluctant to introduce vaccination into their families, it really must appear to them a harsh and arbitrary measure to lay the poor under the necessity of adopting the practice.” The working class had been manifesting a devotion to the old practice which, indeed, they had never shown so long as it was unchallenged. Perhaps one reason to account for the undoubted preference of the poorer classes for the old inoculation was that they had only lately taken to it. Another was that a good deal of inoculation was done by amateurs of their own class--blacksmiths, farriers, tradesmen and women. A third reason was that the poorer classes, among whom smallpox prevailed most, saw their children take smallpox all the same, and cared little for the scientific explanation that a false or spurious kind of cowpox matter had been used. In October, 1805, a correspondent wrote from London to an Edinburgh journal: “The many late failures of supposed cowpock to prevent the smallpox have excited in some parts so much clamour among the lower orders of people that they insist upon being inoculated for the smallpox at some of the public institutions[1127].” A report on vaccination made to Parliament by the College of Physicians in 1807, deplores “the inconsiderate manner in which great numbers of persons ever since the introduction of vaccination are still every year inoculated with the smallpox.” When, in consequence of the same report, a vote was brought forward in Parliament to give Dr Jenner a national reward of twenty thousand pounds in addition to the ten thousand that he had got five years before, the populace were so angry that one of their leaders, John Gale Jones, himself a medical man, sent a message to Jenner at his lodgings in Bedford Place to advise him “immediately to quit London, for there was no knowing what an enraged populace might do[1128].”

Few particulars remain of the old inoculation at this time. One fact significant of the impression that the criticisms of cowpox had made is that Dr John Walker, director of the Royal Jennerian Society, who pushed “vaccination” among the poorer classes more than anyone in London, was all the while an inoculator in the old manner. He wrote to Lettsom, “I have from the first introduction of vaccination entertained an opinion respecting its nature different from those who suppose it a _substitute_ only for smallpox.... I have, from an early part of my practice, been in the habit of _diluting_ smallpox virus with water previous to its introduction into the system;” and this he had been doing in the name of Jenner, under the influence of a belief that, if cowpox were not smallpox, it ought to be, that it was a pity the disease had ever been called cowpox, and that the name (which was a very old one) “has only served to debase it in the eyes of the common people, and prevent its general adoption[1129].” The very director of the Jennerian institute was among the prophets of the old inoculation.

With the revival of smallpox in general epidemic diffusion in 1816-19 we begin to hear more of the old inoculation. The account already cited of the outbreak at Ulverston contains a table of fourteen previously cowpoxed children whom it was thought desirable during the epidemic to inoculate with smallpox, all of them receiving the infection in one degree or another. A practitioner at Dunse, Berwickshire, not only returned to the old inoculation (thereby incurring “much odium,” as he believed), but actually took his matter from the natural smallpox of his cowpox failures[1130].

When the epidemic reached the Eastern Counties, there were demands for the old kind of inoculation, not in Norwich only, but in numerous country parishes. Of ninety-one surgeons in Norfolk and Suffolk, who answered the queries of Cross, thirty-eight had practised the inoculation of smallpox in the epidemic of 1819; five of them, after having refused many private applications for inoculation in the old way, had at length yielded to the desire of the Overseers of the Poor, and had inoculated whole parishes. Cross’s correspondents also testified that there was much inoculation going on at that time in the Eastern Counties by the hands of farriers, blacksmiths, tailors, shoemakers and women.

Dr John Forbes, who then practised at Chichester, brought to light an exactly similar state of public feeling in Sussex in 1821-22[1131]. In the parish of Bosham there lived a farmer named Pearce who had an inherited skill in inoculating, his father having inserted smallpox into ten thousand persons in his day, without killing one of them. Pearce offered to wager with Forbes a considerable sum that he would inoculate any number of persons and that none of them should have more than twenty pustules. He believed that the smallpox matter became “as weak as water” by an uninterrupted transmission from one body to another.

In November, 1821, the Overseers of the Poor employed him to inoculate the pauper children, and his skill was soon in request for others, so that from two to three hundred in the parish were inoculated by him within a short time. He charged half-a-crown or a crown for each. From other parishes the people flocked to him in such numbers that he inoculated upwards of a thousand in the winter and spring of 1821-22. Before long he had three itinerant rivals, a knifegrinder, a tinsmith and a fishmonger, who claimed to have inoculated together a thousand persons, including four hundred previously cowpoxed. The surgeons of Emsworthy and Havant at length joined in the business, and in the space of six or eight weeks inoculated from twelve to thirteen hundred persons, who had not been previously vaccinated. Forbes also received from his medical friends in and around Chichester “an account of 680 cases of previously vaccinated individuals subjected by them to variolous inoculation.” In the great majority of these the constitutional symptoms were so slight as to be only just observable, the eruption consisting of only a few pustules, which were all that the Pearces, of Bosham, father and son, ever expected to get with inoculated smallpox where no infection of cowpox had preceded. Disappointments with the new inoculation had led to a great revival of the old also at Canterbury, the operators being mostly women.

The same thing happened in Cambridgeshire and in Bucks. In a parish within eleven miles of Cambridge several hundred persons were inoculated with smallpox in 1824, and in April, 1825, a medical practitioner inoculated a number in a village near[1132]. During a severe epidemic in the parish of Great Missenden, Bucks, which followed a general vaccination, and caused a prejudice against the latter, the old inoculation was generally resorted to[1133]. It looked for a brief period, about the time of the epidemic of 1824-26, as if the old inoculation were to return to favour even with the profession itself. Dr John Forbes wrote of the two kinds of inoculation in a studiously impartial manner. Dr Robert Ferguson, who was also destined to make a name, addressed in 1825 a letter to Sir Henry Halford in which he advocated a singular compromise, namely, two inoculations, one with cowpox, the other with smallpox, the cowpox to neutralize the contagiousness of the smallpox for the occasion, while the latter was to be the prophylactic against itself for the future[1134]. This reaction, if it deserves that name, corresponds in time to the great decline in the number of gratuitous vaccinations at Manchester, a decline which had been equally remarkable at Glasgow for some years before. There was at least an apathetic spirit towards cowpox inoculation during the epidemic of 1817-19, and for a good many years after it, while there was something like toleration, even among medical men, for the old inoculation.

The Smallpox Epidemic of 1825-26.

Compared with the epidemic of 1837-40, which was the first in England to be recorded under the new system of registration of the causes of death, the smallpox of 1825-26 makes a poor figure in the records. Yet there is reason to believe that it was an epidemic of the same general kind, if not of the same duration or fatality. At the Newcastle Dispensary far more children in the smallpox were visited in 1825 than in any year since its opening in 1777, namely, 113 cases, with 28 deaths, which would have been a small fraction of all the cases in Newcastle. At the Rusholme Road Cemetery, Manchester, which received about a fourth part of the burials, 112 children, all under seven years, were buried from smallpox in the six months, 18 June to 18 December, 1826[1135]. At Bury St Edmunds smallpox began to be epidemic about the end of 1824, when the guardians ordered a general vaccination, and reached its worst in July, 1825, the type being confluent in many of the cases[1136]. It was in Cambridgeshire villages the same year, and is casually heard of in Bucks[1137]. It had been severe at Oxford and Canterbury in 1824. At Glasgow the prevalence of fever is known for the corresponding years, but the smallpox deaths have not been taken out of the burial registers. The evidence from London is perhaps the best indication that the smallpox of 1825 was one of the more severe periodic visitations.

The extensive prevalence of smallpox was heard of in Paris before the epidemic attracted much notice in London; the news of persons of distinction dying by smallpox in the French capital reads like the old notices of it in 17th century letters. In the same year it was very severe also in Sweden after a long period of quiescence. As to London, Dr George Gregory, physician to the Smallpox Hospital, said[1138]: “It may be inferred that smallpox has been nearly as general in 1825 as in any of the three great epidemics of the preceding century”--the demand for admission to the Hospital being, in his opinion, a fair index; while private information confirmed the estimate of its truly epidemic prevalence, and of its incidence chiefly upon the lower classes[1139]. In the years of the 18th century to which he referred, and in four maximum years of the 19th century, the cases and deaths at the Smallpox Hospital had been as follows[1140]:

_London Smallpox Hospital._

Year Cases Deaths

1777 497 125
1781 646 257
1796 447 148
1805 280 97
1819 193 61
1822 194 57
1825 419 120

While the demands upon the beds of the hospital pointed, as Gregory supposed, to the existence of a great epidemic in London, comparable to those of 1777, 1781 or 1796, in which years the smallpox deaths were returned by the parish clerks at 2567, 3500 and 3548 respectively, yet in 1825 the bills showed only 1299 deaths from smallpox. Gregory accepted without demur the figures of the parish clerks’ bills in 1825, although it is well known that they had become more and more defective, even for the original parishes, since the end of the 18th century[1141]. “But for the general prevalence of vaccination,” he said, the smallpox deaths in 1825 would have been 4000 in the same number of attacks, the difference being in the rate of fatality. His conclusion for all London was based upon the experience of the Smallpox Hospital. The patients received by that charity were of the same class as formerly, most of them being adults, among whom the proportion of fatalities was greater than at all ages. Taking the three epidemics of the 18th century with which he compared the epidemic of 1825 in respect of extent or number of attacks, we find that 25 per cent. of the cases admitted died in 1777, 39 per cent. in 1781 (the seasons were unwholesome by epidemic agues, dysenteries, and typhus), and 33 per cent. in 1796. The average of fatalities at the hospital from its opening in 1746 to the end of the century was about 29 per cent., and that was exactly the ratio of deaths among the 419 patients in 1825. The rate of fatality was a little higher than in the epidemic of 1777, and a little lower than in each of the epidemics of 1781 and 1796. Gregory in 1825 was enabled to separate the sheep from the goats by the dividing line of cowpox, the former dying at the rate of 8 per cent., the latter at the rate of 41 per cent. There are various ways of apportioning a general average. The presence or absence of cowpox scars is one principle, which could not have been used to break up the 25 per cent of 1777, or the 39 per cent, of 1781, or the 33 per cent. of 1796, into two component parts. One thing common to all times is the different rate of fatality at different ages. All the deaths in the 8 per cent. division of 1825 were between the ages of eighteen and twenty-seven; the ages of the 41 per cent. division are written in the books of the hospital. In portioning out the general rate of fatality from typhus fever at the London Fever Hospital, it is found that the dividing line of age is nearly the same as the dividing line of social position; in one table the high ratio of deaths to attacks is among persons in the second half of life, and the low ratio among persons in the flower of their age; in another table the many deaths to cases are among paupers, and the few fatalities among paying patients[1142]. However manifold the cutting up of a general average, some divisions would be identical, corresponding to natural lines of cleavage.

Having indicated the chief points in the vaccination controversy by the instance of Gregory’s arguments sixty years since, (to which might have been added the question of efficient or inefficient vaccination according to the appearance of the scars in after life[1143]), I shall for the rest depart from the usual practice of interlocking the history of smallpox epidemics with the history of vaccination. I shall treat the latter as _ex hypothesi_ irrelevant, leaving it to each reader to incorporate, as matter of his own familiar knowledge or belief, whatever effects of cowpox upon smallpox, whether temporary effects or permanent, modifying effects or absolutely prophylactic, may suit his particular creed. I am led to take this course for several reasons. It leaves me free to look at the epidemics of smallpox from the same point of view as the other epidemics treated of in this work. It avoids a controversy which, unlike that of inoculation, is still actual, and unsuited to a historical treatise. It enables me to omit the excuses for failure, which are apt to be interminable and to usurp the whole space available for the epidemiology proper. Lastly, the irrelevancy which I here conveniently assume happens to be my real belief,--as elsewhere set forth in an examination of the antecedent probability arising out of the pathological nature and affinities of cowpox, and in a study of the grounds on which the authority of the profession was originally given to Dr Jenner’s teaching.

The interval between the epidemic of 1825 and that of 1837-39 was occupied by a good deal of smallpox steadily from year to year in London, the deaths from which, in the following table from the bills of mortality, are to be understood as only a part of the whole, according to the explanation already given:

Smallpox
Year deaths

1826 503
1827 616
1828 598
1829 736
1830 627
1831 563
1832 771
1833 574
1834 334
1835 863
1836 536
1837 217

The inadequacy of these returns will appear from the fact that the 217 deaths in 1837 rose, under the new system of registration, from 1 July to 31 December, to 762, or to fully three times as many for the last six months as the parish clerks returned for the whole year. Their bills had become most defective when they were about to be, or had been superseded; but even on the special occasion of the cholera in 1832 they returned only some three-fifths of the known deaths. Besides these London figures there is little to show the extent of smallpox in England between the epidemic of 1825 and that of 1837-39. This was the time when many complaints were made of the so-called loss of power or strength in the current cowpox matter for inoculation. These complaints appear to have arisen from the greater frequency of smallpox among the cowpoxed, corresponding to the increasing numbers of the whole population who had received that kind of inoculation. “Secondary smallpox,” says a report from Worcestershire in 1833, “has been very prevalent of late years[1144],” the term “secondary” reflecting the teaching of Baron, chairman of the Smallpox Committee of the Medical Association, that cowpox itself was the primary smallpox. The increasing number of the vaccinated who took smallpox was clearly shown in the returns from the Smallpox Hospital of London, and was believed to be in proportion to the increasing number of the rising generation who had been vaccinated[1145].

A generation of Smallpox in Glasgow.

Glasgow had afforded the most striking instance in Britain of the decline of smallpox after the beginning of the 19th century. The decline was observed everywhere, but it was most noticeable in Glasgow, partly because the smallpox mortality of infants at the end of the 18th century had been excessive there, partly because Dr Watt took the trouble to prove it statistically from the burial registers. In the last six years of the 18th century, 1795-1800, smallpox had contributed 18·7 per cent. of the deaths from all causes; from 1801 to 1806, it contributed 8·9 per cent., and from 1807 to 1812 only 3·9 per cent. In the next six years, 1813-19, if Cleland’s search of the registers has been as laborious as Watt’s, the share of smallpox was only 1·07 per cent. of the deaths from all causes, which would mean that Glasgow was hardly at all touched by the epidemic of 1817-19, reported from many other parts of Scotland[1146]. But the lull in smallpox, which corresponded on the whole to the still greater lull in fevers during the prosperous times of the second half of the French war, was broken in Glasgow, if not in 1817, yet before long. Unfortunately there is a break in the statistics also. From 1821 the magistrates caused annual bills of mortality to be published, which did not, however, specify the causes of death until 1835[1147]. But we have some intermediate glimpses of the state of the poorer classes and of the prevalence of smallpox in particular. Writing in 1827, Dr Mac Farlane one of the poor’s surgeons, remarks upon the feeble stamina, sallow complexions, and the like, of all but a few children in the more crowded parts, adding that smallpox both in the virulent and “modified” forms had been more prevalent during the last three or four years than formerly[1148]. Three years after, Drs Andrew Buchanan and Weir gave an account of the state of the poor in Glasgow, which shows that it had actually deteriorated with the growth of the city. The poorer classes had been in some part displaced from their old dwellings in the heart of the town owing to the building of warehouses or the like, and had been provided with no new habitations as good as the old. “Apartments originally intended for cellars, and occupied as such until lately, are now inhabited by large families, and the only opening for light and air is the door, which when shut encloses the poor creatures in a tainted atmosphere and in total darkness. This is well exemplified in the cellars belonging to the houses on the south side of St Andrew’s Street.” Not only the notorious region of the Wynds, containing part of the three parishes of the Tron, St Enoch’s and St James’s, but also the Saltmarket and Gallowgate, were crowded with a destitute, vagrant and often vicious class of people. Many of the houses in the Wynds, with their network of alleys, were only one or two storeys high, in the old Scotch fashion; here were the night lodging-houses, with several beds in one room, two or three persons in a bed, twelve to eighteen people in as many square feet: “the extreme misery of these poor people is utterly inconceivable but to those who have actually witnessed it; it has certainly been carried to the very utmost point at which the existence of human beings is capable of being maintained. Some of them are lodged in places where no man of ordinary humanity would put a cow or a horse, and where those animals would not long remain with impunity.” Buchanan found sometimes a horse, sometimes an ass, sometimes pigs, in the same dungeon with one or more families[1149]. Such was the region in which Chalmers ministered from 1815 to 1822, first in the Tron parish, afterwards in the poor and crowded parish of St John’s. Things got no better, certainly, after he left worn out by his exertions, to become professor at St Andrews. Buchanan thought the best index of the degradation of the people in 1830 to be that not one in ten ever entered a church (if they had, he explains, the respectable congregation would have fled from their filth and rags). “The people are starving,” he exclaims, “and there is a law against the importation of food[1150].” It took sixteen years longer to secure the benefits of free trade, and meanwhile the public health of Glasgow got worse rather than better. The infantile part of it attracted far less notice than that which touched adults, so that we hear little of smallpox, while the records of fever and cholera are fairly complete. When the curtain is lifted in 1835 by the publication of statistics, the mortality of infants and children by infectious diseases is found to be proceeding as follows:

_Glasgow Mortalities, 1835-39._

Deaths Deaths Deaths Deaths
from all from from from
Year causes smallpox measles scarlatina

1835 7198 473 426 273
1836 8441 577 518 355
1837 10270 351 350 79
1838 6932 388 405 87
1839 7525 406 783 262

According to the following table of the ages at death from smallpox, it will appear that a higher ratio of infants died of it in their first year at Glasgow than was the rule elsewhere, whether in the 18th or in the 19th century. It was only in the year 1837, when typhus was at its worst and smallpox had somewhat declined, that the deaths by the latter of infants under one year were fewer than those of infants in their second year:

_Glasgow: Table of Deaths from Smallpox 1835 to 1839._

Under Above
1 1-2 2-5 5-10 10-20 20-30 30-40 40 Total

1835 204 154 75 17 14 8 1 0 473
1836 202 174 144 23 6 24 2 2 577
1837 93 116 94 24 10 11 4 0 352
1838 111 99 119 28 11 14 4 2 388
1839 137 98 113 19 15 17 5 2 406

Totals of
five years 747 641 545 111 56 74 16 6 2196
\---------v---------/
Percentages 34% 29% 25% 5% 7%

Cowan, who published these figures in 1840, had written eight years before, “I fear that if the list of infantile diseases were still published in the mortality bills many deaths from smallpox would annually be found.” We do, indeed, hear of epidemics of smallpox not far from Glasgow. At Stranraer, in Sept.-Nov. 1829, “measles and smallpox attacked with scarcely an exception” all the children in the place who had not acquired immunity either by previous attacks or by the influence of vaccination; “and even these powerful protectives were, in many instances, of no avail.” The subjects of “unmodified” smallpox were nearly all infants of the poorer class. In St John’s Street, occupied by decent Scots labouring people, ten children had “unmodified” smallpox and all recovered; in Little Dublin Street, so called from its Irish tenants, fourteen children had smallpox, of whom six died[1151]. At Ayr, about the same time, there was an epidemic, which came to a height in 1830, causing a considerable mortality[1152]. At Edinburgh in the winter of 1830-31, it was unusually prevalent and fatal, the epidemic dying out in May, 1831[1153].

For three or four years, 1843-46, there was another lull in the prevalence of smallpox in Glasgow; but the mortality rose again, reaching in the two years 1851 and 1852 the total of 1202, in a population of 360,138, which contrasted with the 2212 deaths in London in the same two years, and with the Paris mortality of 706 in the two years 1850 and 1851, in a population of about one million, the deaths being still almost wholly infantile in Glasgow while they were in great part of adults in Paris[1154].

_Glasgow Smallpox._

Smallpox
Year deaths

1840 455
1841 (pop. 282,134) 347
1842 334
1843 151
1844 99
1845 195
1846 not recorded
1847 592
1848 300
1849 366
1850 456
1851 (pop. 360,138) 618
1852 584

Registration of the causes of death began in Scotland in 1855. In the first decennial period, to 1864, the smallpox deaths were 10,548, falling upon infancy and other age-periods as in the following table[1155]:

Age-periods Smallpox deaths

Under three months 774
Three to six months 668
Six to twelve months 1543
One to two years 1765
Two to three years 1132
Three to four years 798
Four to five years 514
----------------------------------
Total under five years 7194
Above five years 3354
------
10,548

Smallpox in Ireland, 1830-40.

Before coming to the epidemic in England let us glance at the prevalence of smallpox at this period in Ireland. Dr Cowan, of Glasgow, was struck by the fact that among ninety patients in the Infirmary with smallpox, all adults, only four were from the considerable Irish population of the city, the larger number being natives of the Highlands of Scotland. This leads him to say: “The immunity of the Irish from smallpox is owing to the general practice of vaccination among the lower classes by the surgeons of the county and other dispensaries” (another Glasgow writer ascribes the prevalence of smallpox to the Irish negligence in the same matter). It happens that we can bring one part of this statement to a statistical test. The same volume of the _Journal of the Statistical Society_ which contained the paper on the vital statistics of Glasgow contained also a statistical account of the public health of Limerick, by Dr Daniel Griffin, physician to the Dispensary[1156]. Dr Griffin’s figures were of the only kind that could then be got for an Irish town, and were representative rather than exhaustive. Struck by the seemingly enormous death-rate of infants in the poorest quarters of Limerick, he sought to bring out the facts with numerical precision. He provided a register-book at the Dispensary, in which he entered the results of his observations and retrospective inquiries among eight hundred families of the poorest class during “a good many years” down to 1840. The city of Limerick, and especially the parish of St Mary, was full of the misery and destitution that characterized Ireland in the years of its greatest over-population. The ejected cottiers and broken small farmers of the neighbouring county flocked to it, living in beggary in wretched lodging-houses with swarms of infants and children, the breadwinners finding only an occasional day’s work as labourers. Among 800 such families during the years of his inquiries the chief causes of death among the infants and children were as follows:

_Limerick Dispensary Deaths._

Under Five Five to Above
years Ten Ten Total

Convulsions 569 18 7 594
Smallpox 333 55 5 393
Measles 187 32 7 226
Diarrhoea and Dysentery 108 19 24 151
Whooping cough 84 10 1 95
Croup 85 9 1 95
Scarlatina 8 2 0 10
Fever 70 33 66 169

The more exact ages at death from smallpox in male and female children were:

Under One and Three and Five to Above
One Two Four Nine Nine

Males 33 72 37 29 2
Females 52 92 47 26 3
-- --- -- -- --
85 164 84 55 5

As compared with Glasgow, measles at Limerick has a much lower place than smallpox in the infantile mortality, while scarlatina hardly counts at all. Again, only 1·27 per cent. of the smallpox deaths are above the age of nine, whereas at Glasgow 7 per cent. are above the age of ten. Griffin’s data for reckoning the probability of life were incomplete, as he was well aware; so that the following comparison of the poor attending Limerick Dispensary with all England and Wales probably errs in making the Irish town somewhat more fatal to infants of the poor than it really was:

England and Wales Limerick Dispensary
in 1000 deaths in 1000 deaths

Under one year 214·54 327·71
One and under three 128·00 287·67
Three and under five 48·51 128·20
Five and under ten 46·07 97·29
Ten and under fifteen 25·91 24·93
Fifteen and under twenty 34·16 20·37

In a thousand deaths at all ages, 391·05 occurred before the age of five years in England and Wales, but 743·58 before the age of five years among a certain section of the poor of Limerick; and in the latter enormous sacrifice of infant life smallpox was the greatest single means next to convulsions. Perhaps that was the reason why so few of the Irish in Glasgow were attacked by smallpox in adult age. The experience of Limerick was not exceptional in Ireland. In the ten years 1831-40, for which the causes of death were ascertained by means of queries in the census returns of 1841, the total of deaths by smallpox was 58,006, nearly double the mortality by measles (30,735) and seven times that of scarlatina (7,886). It was almost wholly a malady of infants and children, the first and second years of life being its most fatal period. Only 129 of these deaths were returned from hospitals. The bulk of the decennial smallpox deaths fell in the two years 1837 and 1838, corresponding with the high epidemic mortality in England[1157].

The Epidemic of 1837-40 in England.

The smallpox epidemic of 1837-40 was already in full force at Liverpool, Bath and Exeter when the mortality returns began to be made on 1st July, 1837, under the new Registration Act. Whether or not the contagion travelled from Ireland or the west of Scotland, the epidemic in England began in the west and south-west, and reached the Eastern counties last. The following table shows its rise and progress at selected places in the several quarters, beginning with the third quarter (July-September) of 1837[1158]:

1837 1838 1839
+---------+ +---------------------+ +---------------------+
3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th
qr qr qr qr qr qr qr qr qr qr

Liverpool 375 132 32 24 18 36 11 29 75 138
Bath 154 18 15 1 1 2 1 25 17 30
Exeter 88 131 6 -- 2 -- -- -- -- --
Bristol 21 74 72 44 4 7 6 -- -- --
Clifton 16 32 49 27 7 -- -- -- 1 7
London 257 506 753 1145 1061 858 364 117 65 60
Manchester 23 98 127 120 111 180 94 40 33 53
Birmingham 34 55 85 86 66 47 26 12 7 10
Sheffield 14 14 27 36 22 12 9 3 4 --
Leeds 4 11 29 69 134 197 74 55 30 15
Newcastle 16 17 66 11 -- 23 54 24 39 25
Abergavenny
and 13 85 102 50 22 21 22 30 26 10
Pontypool
Merthyr
Tydvil 9 54 160 91 10 3 18 16 12 --
Weymouth,
Bridport,
and 4 19 92 31 8 4 10 9 2 --
Beaminster
Plymouth 10 15 11 14 37 48 9 8 1 --
Taunton -- 7 66 40 4 3 -- -- -- --
Leicester 43 5 3 2 3 3 9 21 5 15
Norwich 1 -- -- -- -- 17 180 204 10 7
Lynn etc. -- 1 2 10 7 4 127 81 6 --
Ipswich -- -- 2 6 38 95 23 -- 1 --
Bury St
Edmunds 1 3 30 24 2 3 -- -- -- --
etc.
Woodbridge
etc. 4 9 27 16 5 11 10 2 -- 4

The epidemic having begun in the west and south-west in the summer of 1837, spread in the winter of 1837-38, all through the hills and valleys of Wales, causing high mortalities around Abergavenny, Pontypool, Merthyr Tydvil and other towns in the first quarter of 1838, as well as in the rural parishes. It was not until the end of 1838 that the contagion spread widely over the Eastern counties. The epidemic in Norwich was again short and sharp, like that of 1819, most of the 418 deaths falling within six months of winter and spring, just as most of the 530 deaths in 1819 fell within six months of summer and autumn. The population in 1821 was 50,288, and in 1841, 62,344; the increase was only 1228 between 1831 and 1841, so that the smallpox of 1839 fell upon a stationary population, whereas that of 1819 had fallen upon a rapidly increasing one. In the autumn of 1839 and throughout 1840, a second outburst of smallpox took place in the towns where the epidemic had started two years before, namely, Liverpool, Bath, Bristol, Clifton, etc[1159].

But the smallpox of 1840, which produced more deaths than that of 1839, was mostly centred in the Lancashire manufacturing towns, where also the mortality from scarlet fever was enormous. The circumstances of the working class in Lancashire at this time have been described in the chapter on fevers. The following shows the large proportion of smallpox deaths that fell in 1840 to the North-Western or Lancashire registration division.

_Smallpox Deaths, 1840._

1st qr 2nd qr 3rd qr 4th qr

England and Wales 2071 2476 2274 3613
------------------------------------------------------------
Of which in the N.-W.
Division (Lancashire) 1046 986 533 590

The epidemic continued in the manufacturing towns into 1841; in the more rural registration divisions of England it had almost ceased in 1839. From the 1st July, 1837 (beginning of registration) until the 31st December, 1840, the epidemic smallpox in England and Wales caused 41,644 deaths. In 1838 it eclipsed both measles and scarlatina as a cause of death among children; but in 1840 scarlatina gained the leading place and kept it.

Legislation for Smallpox after the Epidemic of 1837-40.

The epidemic of smallpox in 1837-40, which was fatal chiefly to infants and young children, was one of the greatest, like the corresponding epidemic of typhus among adults, in the whole history of England. The troubles of the working class had been more or less chronic ever since the booming times of the Peninsular War had come to an end; the climax was reached in the thirties; the enormous sums spent upon railway construction gave a relief in the forties; and the permanent cheapening of food by Free Trade made an entirely new era, which became visible in the public health after the contagion of the Irish famine had ceased in 1848. The great and hitherto permanent decrease of typhus was brought about by social and economic causes. There, at least, _laissez faire_ was all powerful: “Let us be saved,” said Burke, “from too much wisdom of our own, and we shall do tolerably well.” But there has been at no time since the 18th century the same passiveness towards smallpox; that is a disease against which we must always be doing something direct and pointed. The legislation against smallpox began in England (nothing was done for Ireland and Scotland until long after) with the Act of 1840.