Such cases were not often heard of. As M_A History of Epidemics in Britain, Volume 2 (of 2) From the Extinction of Plague to the Present Time

happened once, why do we not see it come to pass oftener?” There was,

however, little encouragement for anyone to come forward with adverse

evidence; witness the case of an unfortunate Welshman, one Jones, of

Oswestry, who had innocently mentioned, in writing to his son in London,

that natural smallpox had followed an inoculation done by him, on 9th

August, 1723, and was frightened out of his wits by the _apparatus

criticus_ which Jurin brought to bear upon him[917]. Another reason why so

few failures could be discovered was that the inoculated were not kept

long in sight. A child of Dr Timoni, the first writer on inoculation, was

inoculated at Constantinople in December, 1717, at the age of six months,

and had an average effect, namely ten small _boutons_. She died of

smallpox in 1741, at the age of twenty-four. This failure came to light by

the vigilance of the celebrated De Haën, of Vienna, an opponent of

inoculation, who had been told of it by a Scots physician at

Constantinople[918].

A good instance of the same thing came to light long after in the practice

of the celebrated Dr Rush of Philadelphia. “I lately attended a man in the

smallpox,” he wrote to Lettsom, “whom I inoculated six-and-twenty years

ago. He showed me a deep and extensive scar upon his arm made by the

variolous matter”--without which evidence, and the man’s own reminder,

confirmed by his mother’s recollection, Dr Rush would probably have had no

reason to believe that this particular one of his inoculations had

failed[919].

In the nature of the case, such evidence of failure would seldom be

opportune. It would have needed a more dramatic presentation of these

cases, and many more of them, to discredit the practice of inoculation. It

was, indeed, discredited, so much so that it was not practised at all in

England from 1728 until about 1740; but that was owing to the disasters

directly resulting from it. No amount of evidence as to the inoculated

taking natural smallpox afterwards could have touched the popular

imagination like the following paragraphs in the London newspapers in

1725:

March 16, died Mrs Eyles, niece of Sir John Eyles, alderman of London,

of the smallpox contracted by inoculation. June 17, died of the

smallpox contracted by inoculation Arthur Hill, esquire, eldest son of

Viscount Hilsborough. August 12, died of the smallpox by

inoculation--Hurst, of Salisbury, esquire.

Inoculation seemed hardly worth having on these terms, granting all that

was alleged of its protective power; so that it fell in England into total

disuse[920]. It came on again after a time and had a long career, at first

among the richer classes, and at length among the common people, who did

not cease to use it for their children until it was made a felony by the

Act of 1840. After its first brief success, it was revived about 1739-40,

in consequence of highly favourable accounts from Charleston, South

Carolina, and from Barbados and St Christopher. This second period of

inoculation brings in certain modifications of the practice by which the

casualties of the earlier period were avoided. The danger from

blood-poisoning, pyaemia, or the like, was surmounted. At the same time

the inoculated smallpox ceased to have anything of that reality, or

approximation to the natural disease, which Nettleton succeeded for a time

in giving to it.

Revival of Inoculation in 1740: a New Method.

As early as the Boston inoculations of 1721, the matter had now and again

been taken, not from a case of the natural smallpox, but from the

pustules of a previous inoculation[921]. But at Charleston in 1738 there

really began, doubtless in the way of empirical trial, a systematic

attenuation of virus, which has had great scientific developments in our

time and has come to be considered as of the essence of the inoculation

principle. Describing the South Carolina practice, Kilpatrick says[922]:

“Some persons were of opinion that _the pock of the inoculated_ would

be too mild to convey the disease; or, at least, that it must become

effete by a second or third transplantation. Experience manifested the

contrary. I have inoculated from those who were infected by the matter

taken from others of the inoculated, and found no defect. Mr Mowbray,

who inoculated many more than any other practitioner, assured me he

had infused matter in the fifth or sixth succession from the natural

pock, and observed no difference.... The smallest violation of the

surface, if it was stained with blood, was a sufficient entrance for

the matter, and the least matter was sufficient.”

The last point was a return to the Greek practice, and an abandonment of

the more severe method of Nettleton and Boylston.

The Charleston smallpox of 1738, imported by slave-ships from Africa,

became extensively epidemic and mortal. It had been last in Charleston

fourteen or fifteen years before, but only one or two died on that

occasion, and hardly more than ten were attacked. But for that small

outbreak, it had not been known in the South Carolina port for a

generation previous to 1738. The number of victims in that year is not

known precisely. As at Boston in 1721, the epidemic dragged through the

spring months, and became very extensive and mortal in the hot weather of

June and July. It was then that Mowbray began inoculating, most of the

Charleston faculty being opposed to it. He was soon followed by

Kilpatrick, who had lost one of his children in the epidemic, and was

moved thereby to inoculate the other two. No exact account was kept of the

inoculations, nor, we may be sure, of the protective effects; some said a

thousand were inoculated, Kilpatrick says eight hundred, but the total of

four hundred is also given. Eight died after inoculation, six whites and

two negresses. One child of ten months died in convulsions on the ninth

day after inoculation, with few signs of smallpox; a minister, aged 40,

sickened on the third or fourth day, which was too soon for the artificial

disease, and was almost certainly the effects of the inhaled virus; two

other adult whites died in such circumstances as to make it doubtful

whether they died of inoculation or of coexistent natural smallpox; one

negress died of confluent smallpox, having treated herself unwisely; while

two other children and a negress died after inoculation, of whom no

particulars are known. Besides the fatal cases after inoculation, some

“had an eruption that might be called a moderate confluence”; but in these

cases also it is not clear that infection was not taken in the natural

way: as regards one gentlewoman who had confluent smallpox, it was not

certain in what manner she received the infection, whilst “Miss Mary

Rhett’s eruption did not appear until the 14th day, yet was supposed to be

effected by art.” To meet such cases Kilpatrick adopted the doctrine that

there was “no precise term for the artificial eruption.” Among those

“hardly dealt with” by the disease, supposed to have been given by art,

were two ladies who had their eyes permanently injured. “With regard to a

second infection of the inoculated _who took_, this was asserted by some

who wished for it, but were as soon refuted.” Nineteen in twenty of the

inoculated had an exceedingly slight eruption, so slight indeed that they

thought the confinement indoors irksome and unnecessary. As to the

negroes, who had all been born in Africa (and commonly have smallpox there

or in the voyage across), it was not easy, he admits, to find out whether

they had had smallpox before or not, the pits on their faces being less

obvious than in whites, and the marks of other distempers easily mistaken

for them. On the whole Kilpatrick was confident that inoculation in this

epidemic had saved many lives; and it was the rumour of its success,

together with corresponding reports from the plantations in the West

Indies relating the valuable lives of negroes saved, that gave a fresh

impulse to the practice in England. In 1743 Kilpatrick came to London,

where he republished his Charleston essay, with an historical appendix,

and soon got into the leading practice as an inoculator, having proceeded

to the degree of M.D. and changed the spelling of his name to Kirkpatrick.

Woodville says “he was esteemed the most scientific inoculator in

London.” During the eleven years from his setting up in practice there

until the publication of his _Analysis of Inoculation_ (1754), he had

almost certainly been applying the arm-to-arm method which he learned from

Mowbray in Charleston, having briefly indicated it in his first essay and

avowed it more explicitly in his second. The establishment of Kirkpatrick

in London, to practise the Charleston method of inoculation, corresponds,

as nearly as one can trace it, with the revival of the practice in the

south of England, to the extent of some two thousand cases in the counties

of Kent, Surrey, Sussex, Hampshire and Dorset. We have a glimpse of that

practice in the essay on inoculation published in 1749 by Dr Frewen, of

Rye in Sussex[923], a physician of considerable learning (of the school of

Boerhaave), whose theories of the effects of inoculation are reflected in

Kirkpatrick’s _Analysis_ of 1754. In 350 cases, Frewen had only one

fatality, the death of a child, aged four, from worm fever on the eighth

day of a discrete eruption. He still used the incision on the arm, but

less deep than Nettleton’s, keeping the pledget of lint, moistened with

matter, bound upon it for twenty-four hours; also he encouraged the

rendering from the incision for some weeks, giving the same reason as

before, that “Nature by means of a continual drain is greatly aided in her

attempts to throw off the matter of the disease.” In his general account

of the effects of inoculation, we seem to be reading of as real symptoms

and as many pocks as Nettleton described--the eruption, always of the

simple distinct kind, beginning on the 9th day, all out in three or four

days after, the pocks filling and turning yellow for the next four or five

days, then scabbing and falling, leaving temporary shallow marks. But it

is clear that he had other results than these from trying new ways of

procuring matter. “Experience,” he says, “has convinced me that it is in

reality of no consequence from what kind of smallpox it [the matter] is

procured.” If taken from the natural smallpox, it should be taken from

ripe pustules: “yet I have sometimes applied it sooner, while only a

limpid water.” Oftentimes it happened that an inoculation produced too

“slight” pustules to furnish matter for the succeeding operations. The

question then arose whether the matter rendering from the incisions on the

arms in these cases was merely common pus or whether it had the property

of “variolosity.” This abstract quality, as it were the essence or

quiddity of the pustular exanthem, was assumed to be present if the pus of

the rendering incision could be made to raise a pustule on another arm,

and if the person so infected could stand exposure to natural smallpox

with impunity. One person so inoculated did have an attack of smallpox by

contagion, so that Frewen concluded that the matter used for his

protection had “run off all its variolosity.” But others inoculated with

the same, “in whom the symptoms were remarkably light, and in some few no

pustules at all,” were equally exposed to contagion without catching it,

so that they were “judged to be secure from ever taking the smallpox

again.” Frewen’s general conclusion, if it be not very logical, is at

least modest:

“However, it may be worth the attention to reflect seriously whether

it be not highly probable, from the success attending the numbers I

have been concerned for, that inoculation has been often times a

security against taking the most dangerous kinds of the natural

smallpox.”

Whether Frewen got the ideas of these novelties of method from

Kirkpatrick’s first account of the South Carolina practice, or struck them

out for himself, it is clear that Kirkpatrick, in his next essay of 1754,

has adopted variolosity as an abstract doctrine to surmount certain

difficulties in the concrete reason. Many of his inoculated cases had only

a few bastard pustules of smallpox, some had none. Was their disease

smallpox? Did it warrant their future security?

“As many of the inoculated have very few pustules, and they are

sometimes disposed to scab and wither away with very little

suppuration, it might be of service to discover that the matter from

the incisions would infect. But it would be certainly satisfactory to

find it would where there was no eruption from inoculation, as its

variolosity would greatly warrant the future security of the person it

was taken from. That it is variolous is now evinced by the fact that

it infected others to the like slight degree[924].”

The movement towards attenuating the virus used for inoculation was

general in Europe. One of the mild methods, invented by Tronchin, of

Amsterdam and afterwards of Paris, was to raise a small blister on the arm

and to pass through the fluid a thread moistened with smallpox matter.

This became one of the most common continental methods and was in use

until the beginning of the 19th century. Kirkpatrick, who went to see the

practice of Tronchin, found the method by blister to produce as slight

effects in the way of eruption as he describes for his own method:

“I attended and infected five poor children:--three, about seven years

old, by incision; and two, about five years old, by vesication. Of the

first three, one, a girl, had a pretty moderate but very kindly

sprinkling; the two boys very few. The two by blisters, a boy and a

girl, had rather less,--the boy Dudin, a very fair delicate little

child, not having above three or four, all which had not matter enough

to infect one patient[925].”

Everywhere after the middle of the eighteenth century inoculation was

coming into fashion again. In France it was lauded by the _philosophes_,

while it was scouted by the medical faculty. La Condamine, a mathematician

who had acquired fame by his journey to the Amazon to measure the three

first degrees of the meridian, became interested in the subject by hearing

from a credulous Carmelite missionary at Para how he had saved half of his

Indian converts by inoculation after the other half had been destroyed by

the natural smallpox. The mathematical philosopher on his return became an

enthusiast for inoculation, and twice harangued the Académie des Sciences

thereon. “The practice of inoculation,” he said, “was improved during the

time of its disgrace.” What this improvement consisted in he also

explained: “Neither the eruption is essential to the natural nor the

pustules to the artificial smallpox: and perhaps art will one day come to

effect what one hopes for and what Boerhaave and Lobb have even tried--I

mean a change in the external form of this malady without any increase of

its danger[926].”

The Suttonian Inoculation.

Daniel Sutton, though an empiric, has given his name to the slight and

safe method of inoculation which had been used in England for a good many

years before his advent. So completely was his name joined to the practice

of smallpox inoculation in its later period that in a Bill before

Parliament in 1808 it is called “the Suttonian inoculation,” to

distinguish it from cowpox inoculation. The idea of attenuating the virus

used for inoculation, and of making the effects minimal, was not his. It

had been reached empirically years before by Mowbray, of Charleston, in

1738, who carried inoculation from arm to arm to the fifth remove, by

Frewen, of Rye, in 1749, who was satisfied with an abstract “variolosity”

of the incisions, in cases where there was no eruption at all or only a

few pustules that did not fill, by Kirkpatrick, “the most scientific

inoculator in London,” who endorsed the doctrine of variolosity, by La

Condamine, and most of all by Gatti of Paris.

Gatti used the unripe matter from a previous inoculation and inserted a

most minute quantity of it at a very small puncture; and, to make sure

that no general eruption should follow, he used the cooling regimen in

various ways, including the prolonged immersion of the hands in cold

water. Thus he promised his clients “the benefits of inoculation without

its risks.” But Gatti’s career of prosperity was cut short by a series of

conspicuous failures of his artificial smallpox to prevent the natural or

real disease when it was epidemic. One of his patients, the Duchess de

Boufflers, a great lady whose _salon_ was frequented by the _philosophes_

and _beaux esprits_, fell into the natural smallpox two years and a half

after her inoculation[927]. So many others in Paris had the same

disappointment that a discussion arose in the Faculty of Medicine, the

result of which was that the Parliament of Paris prohibited the practice

of inoculation, for various reasons, within the limits of the capital.

Gatti’s friend and correspondent in London was Dr Maty, who, “though born

in Holland might be considered a Frenchman, but he was fixed in London by

the practice of physic and an office in the British Museum[928].” Having

conducted the foreign correspondence of the Royal Society, he became in

1765 its secretary in ordinary, and about the same time Principal

Librarian of the British Museum. His interest in inoculation, which was

shown by his translating La Condamine’s first discourse on that subject in

1755, led him in 1765 to suggest to Gatti that he should write an essay

for publication in England, “both to reclaim the thinking part of Paris,

and to vindicate his own operations from the contemptuous treatment of his

antagonists.” The essay was written in due course, and Maty brought it out

in English[929].

Gatti’s own experiments and those which had previously been made in

England by the most experienced inoculators had satisfied him of the truth

of what he had long suspected, namely, that the operation could be made

“still more harmless, though not less efficacious” (p. 29). There would be

hardly any fever, certainly a very slight eruption and perhaps none at all

(p. 68), It had, indeed, been questioned whether a patient who had but

very few pustules, or only one, has had the smallpox as truly as one who

has been very full, and whether he is equally safe from catching it. He

answers in the affirmative, according to the doctrine of variolosity: “No

reason can be alleged, why we should have the smallpox but once, that will

not equally hold good for one as for ten thousand pustules” (p. 69). Some,

however, will not believe that one pustule is as good as ten thousand,

“notwithstanding the obviousness of this truth.” If one were absolutely

bent upon giving a certain number of pustules, he would advise to

inoculate according to his method (insertion with a needle) at twenty,

thirty, or fifty places: “then you would be sure of one pustule at least

at each puncture, and, probably, of many more in other parts.” He would do

this, however, only to humour prejudice, and with a feeling that he was

doing the patient “more harm than was necessary.” He was seriously

satisfied of the “sufficiency of a single pustule,” and believed that

every wise man should run the venture of it and “embrace the method here

laid down.”

There was no theoretical objection to this method, but there was the

practical one, that it might be _too_ slight in its effects. Patients

could hardly rest satisfied with so little to show for smallpox; and

inoculators themselves found that they might have all their work to do

over again. An eminent Irish physician wrote in 1765 to Dr Andrew, of

Exeter, that crude matter from a previous inoculation was “less

communicative of the disorder and more apt to disappoint us” than matter

from a natural smallpox eruption taken “five or six days before the

maturation of it[930].” It was also the experience of Salmade, of Paris,

in 1798, that serous matter, taken from arm to arm through a long

succession of cases, was apt to go off altogether, or to be “weakened to

the point of nullity,” whereby it disappointed the operator[931]. Reid, of

Chelsea Hospital, was said to have carried the succession to thirty

removes from the natural smallpox. Bromfeild knew for certain of matter

being used at the sixteenth remove.

So long as the operation held at all, and had not to be repeated, Dr

Andrew believed that effects which “no one would have taken for the

smallpox,” were “sufficient security against any future infection[932].”

Heberden, indeed, has recorded a case adverse to that view; but one case

is not enough, even if it had been in as eminent a person as Madame de

Boufflers[933].

Daniel Sutton, who gave his name to the slighter kind of smallpox

inoculation, was not a regular practitioner. His father, a doctor of

medicine in Suffolk, was a specialist inoculator, as others of the regular

profession here and there were becoming, and had operated upon 2514

patients from 1757 to 1767. In 1763 Daniel began business on his own

account at Ingatestone in Essex, where patients from all parts were

boarded and subjected to his regimen, as at a water-cure. In 1764 he made

2000 guineas, and in 1765 £6300. In the three years 1764-66 he inoculated

13,792 persons, and his assistants some 6000 more--without a single death.

Sutton kept his method at first a secret, and for that reason was looked

at askance by eminent physicians. He used pills and powders, which were

found, by the analysis of Ruston, to be a preparation of antimony and

mercury, the drugs supposed to be antidotes to natural smallpox, or the

means of preventing its pustular eruption. But the essence of his method

was found to be, in Chandler’s words, “the taking of the infective humour

in a crude state [from a previous inoculation] before it has been, if I

may allow the expression, variolated by the succeeding fever[934],” or, in

Dimsdale’s words, “inoculating with _recent_ fluid matter,” or in Sir

George Baker’s words, “with the moisture taken from the arm before the

eruption of the smallpox, nay, within four days after the operation has

been performed[935].”

Sutton made it known that the effects of this method were exceedingly

mild--no keeping of bed, no trouble at all: “if any patient has twenty or

thirty pustules, he is said to have the smallpox very heavy.” Being put on

his trial at Chelmsford for spreading abroad the contagious particles of

smallpox by the number of his inoculations, his defence was to have been

(if the bill had not been thrown out by the grand jury), that he “never

brought into Chelmsford a patient who was capable of infecting a

bystander.” The mildness of his artificial smallpox was acknowledged with

satisfaction by some, with dissatisfaction by others. Dr Giles Watts, an

inoculator in Kent, says it was “a most extraordinary improvement. The art

of inoculation is enabled to reduce the distemper to almost as low a

degree as we could wish.... There is now an opportunity of seeing what a

very small number of the multitude of persons of all ages, habits and

constitutions, who have been inoculated in these parts, have been ill

after it.” Comparing it with the method which he had practised before, he

says that he never knew ten or twelve inoculated together “in the old way”

but one or more had the distemper in a pretty severe manner; on the other

hand, he had inoculated four of his children in the new way and all of

them together had not so many as eighty pustules. He adds that sometimes

the inoculated had not even a single pustule (besides the one at the point

of insertion) or at other times not more than two or three[936].

The Suttonian practice was objected to by Bromfeild in an essay dedicated

to Queen Charlotte. Tracing it to Gatti, whose manifesto had been

published in England two years before, he said that it was mere credulity

“to have given credit to a man who should assert, that he would give them

a disease which should not produce one single symptom that could

characterize it from their usual state of health.... Inoculation, though

hitherto a great blessing to our island, will in a very short time be

brought into disgrace,” if it were assumed “that health and security from

the disease can be equally obtained by reducing the patients so low as

only to produce five to fifteen pimples[937].”

Bromfeild was not openly supported except by Dr Langton, of Salisbury, who

contended that “the matter communicated is not the smallpox, because

numbers have been inoculated a second, third and fourth time, that

therefore it is no security against a future infection.” He cites Gatti’s

case of the Duchess de Boufflers, and declares, as to the English

inoculations, that not above one in ten have so many variolous symptoms as

may be remarked in her case. “The old method of inoculating,” he says,

“was to take the infection from a good subject where the pustules were

well maturated, whereby the operation was sure of succeeding; but the

present practice is to take the matter from the incision the fourth day

after the incision is made [this was Sutton’s avowed practice]. By this

means you have a contagious caustic water instead of laudable pus, and a

slight ferment in the lymph is raised, producing a few watery blotches in

the place of a perfect extrusion of the variolous matter[938].”

There was no difference of opinion as to the exact purport and upshot of

the new method; it was to reduce the eruption to the lowest point or to a

vanishing point. Nothing can be more emphatic than Gatti’s profession of

belief that a single pustule, at the place of insertion, was as effectual

as ten thousand; and it is not only likely, on the face of it, that such a

mitigation as Reid’s to the thirtieth remove from natural smallpox, would

produce merely the local pustule, but it is clear that Gatti saw no way of

ensuring more by his method, supposing he were to gratify the prejudices

of the laity in favour of more, than by puncturing the skin at twenty,

thirty, or fifty separate points. It is not to be supposed, however, that

the minimum result was obtained in all cases, or that all inoculators were

equally adroit in procuring it; even Sutton had to admit that some of his

thirteen thousand patients had more pustules on the skin than he desired.

Perhaps the most exact record of the number of pustules produced in a

comparative trial of various methods is that of Sir William Watson at the

Foundling Hospital in 1768[939]. Of 74 children inoculated in October and

November, twelve had no eruption at all, but yet were held to have been

protected by the operation. The remaining sixty-two had a very small

average of pustules in addition to the local pustules, which average,

small as it was, came mostly from two or three severer cases (e.g. one

with 440 pustules, one with 260, and one with near 200), the most having

three or four or a dozen or perhaps two dozen (e.g. three had only 7

pustules among them, or, in another batch of ten done with crude or

ichorous matter, “the most that any boy had was 25, the least 4, the most

that any girl had was 6, the least 3,” or, in another batch of ten, also

with crude lymph, two had no eruption, seven had 35 pustules among them,

and one had 30). Of the amount of smallpox upon the whole sixty-two cases

which had some eruption Watson says: “Physicians daily see in one limb

only of an adult person labouring under the coherent, not to say confluent

smallpox, a greater quantity of variolous matter than was found in all

these persons put together.”

Watson’s sole measure of “success” in inoculating was the slightness of

the effect produced; and as he found that crude or watery matter from the

punctured spot of a previous inoculation had the least effect, he decided

to use that kind of matter always in future at the Foundling Hospital. On

the other hand, Mudge, of Plymouth, raised a different issue and put it to

the test of experiment on a large scale. Did crude matter infect the

constitution? Did it make the patient insusceptible of the effects of a

second inoculation with purulent matter? The experiment came out thus:

At Plympton, in Devonshire, in the year 1776, thirty persons were

inoculated with crude or watery matter from the arm of a woman who had

been inoculated five days before, and ten persons were at the same time

inoculated with purulent matter from the pustules of a case of natural

smallpox. The thirty done with crude matter had each “a large prominent

pustule” at the place of puncture, “but not one of them had any eruptive

fever or subsequent eruption on any part of the body.” Matter taken from

their local pustules produced exactly the same result in the next remove,

namely, a local pustule, but no eruptive fever nor eruptive pustules. The

thirty were inoculated again, this time with purulent matter (five from

natural smallpox, twenty-five from inoculated smallpox), and all of them

had, besides the local pustule, an eruptive fever and an eruption “in the

usual way of inoculated patients.” The ten who were originally inoculated

with purulent matter had that result at first[940].

In the subsequent history of inoculation it would appear that the method

known by the name of Sutton, of using crude or watery matter from a

previous inoculated case, was the one commonly preferred. But it was not

always preferred. One of the medical neighbours of the afterwards

celebrated Dr Jenner took matter from the pustules and kept it in a phial;

his patients inoculated therewith had somewhat active effects, even

“sometimes eruptions.” But “many of them unfortunately fell victims to the

contagion of smallpox, as if they had never been under the influence of

this artificial disease,” so that Jenner, who had probably not heard of

Mudge’s experiment, was confirmed in his preference for the crude matter

(before the eruptive fever) from a previous inoculation. It was of great

importance, he said, to attend to that point, as it would “prevent much

subsequent mischief and confusion[941].” Of course there were many more

chances of getting matter from natural smallpox than from inoculated; but

it would appear that in the former also it was taken in the ichorous or

unripe stage of the eruption, according to the practice of Sutton, and

despite the experimental proof that Mudge gave of its merely superficial

or formal effects.

Mudge’s experiment was on a large scale, and designed to test a general or

scientific issue. The testing experiment usually made was merely for the

sake of the particular case; the patient was inoculated a second time,

shortly after the first, with the same matter as before, or a third time,

or even a fourth time. Whatever the significance of this for the doctrine

of inoculation in general (as in the issue raised by Mudge), the

individual was both reassured and fortified so far as concerned his own

safety. The experiment of the former generation that was usually cited was

that of the Hon. John Yorke. On his leaving the university at the age of

one and twenty it was thought prudent that he should be inoculated for

smallpox before entering on the great world. He was inoculated by serjeant

surgeon Hawkins, and had the local suppuration, some fever, but little or

no eruption. The inoculator was satisfied, but not so the youth: he

insisted upon a second inoculation, which had no effect. This was

considered a leading case. When the Suttonian method came in, and the

absence of eruption (barring a few pimples or bastard pustules) became the

usual thing, the occasions for a second inoculation became more common,

owing to the prejudice, as Gatti said, of the laity in favour of something

tangible although not excessive[942].

Dimsdale inoculated many of his patients a second time, and produced the

local pustule again, as at first. Of the 74 foundlings in Watson’s

experiment of Oct.-Nov. 1767, there were twelve who had no eruption, of

whom four were re-inoculated with no better result or with no result. Of

the whole twelve he says: “Although they had no eruption, I consider them

as having in all probability gone through the disease, as the punctures of

almost all of them were inflamed and turgid many days.” It was so unusual

for a second inoculation, in a doubtful case, to produce more than the

first, that Kite, of Gravesend, communicated to the Medical Society of

London two cases where that had happened, as being “anomalous.” He had

never before been able to communicate the smallpox, on a second attempt,

“to any patient whose arm had inflamed, and who had even a much less

degree of fever” than Case 1, who had only the local pustule and “on the

eighth day was quite well:” and he cites Dimsdale to the same effect[943].

Perhaps enough has been said to illustrate the subtle casuistry that had

gradually arisen out of the old problem of procuring the smallpox by

artifice. I make one more citation, from a Hampshire inoculator in 1786,

to show how fine were the distinctions, depending, one might suppose, upon

the subjective state of the practitioner, drawn between effective and

non-effective inoculation:

“The incisions sometimes have a partial inflammation for a few days,

which then vanishes without producing any illness; in this case the

patient is certainly still liable to infection; but I believe it very

rarely happens that there is any matter, or even ichor, in the present

slight manner they are made, without producing the smallpox.... I have

constantly remarked that when the punctured part inflames properly,

and is attended with an efflorescence, rather inclining to a crimson

colour, for some distance round the same, about the eleventh or

twelfth day from the inoculation, although the patient should have

very little illness and no eruption, yet that he is secure from all

future infection[944].”

Extent of Inoculation in Britain to the end of the 18th Century.

From 1721 to 1727 the inoculations in all England were known with

considerable accuracy to have been 857; in 1728 they declined to 37; and

for the next ten or twelve years they were of no account. The southern

counties led the revival in the fifth decade of the century, so that

before long some two thousand had been inoculated in Surrey, Kent, Sussex

and Hampshire. Frewen, however, who could point to 350 cases done by

himself in Sussex previous to 1749, says that it “gained but little credit

among the common sort of people, who began to dispute about the lawfulness

of propagating diseases, and whether or no the smallpox produced by

inoculation would be a certain security against taking it by infection,”

etc.

In London, after the revival under Kirkpatrick’s influence in 1743,

inoculation became a lucrative branch of surgical practice, and was done

by the heads of the profession--Ranby, Hawkins, Middleton and others, and

almost exclusively among the well-to-do. In 1747 Ranby had inoculated 827

without losing one; in 1754 his total, still without a death, had reached

1200. In 1754 Middleton had done 800 inoculations, with one death. The

operation was by no means so simple as it looked. It required the combined

wits of a physician, a surgeon, and an apothecary; while the preparation

of the patient to receive the matter was an affair of weeks and of much

physicking and regimen. Thus inoculation was for a long time the privilege

of those who could pay for it. As late as 1781, when a movement was

started for giving the poor of Liverpool the benefits of inoculation, it

was stated in the programme of the charity that, “as the matter now

stands, inoculation in Liverpool is confined almost exclusively to the

higher ranks,” the wealthier inhabitants having generally availed

themselves of it for many years[945].

The first project in London for gratuitous inoculation took shape, along

with the plan of a smallpox hospital, at a meeting held in February, 1746,

in the vestry-room of St Paul’s, Covent Garden[946]. The original house of

the charity, called the Middlesex County Hospital for Smallpox, was opened

in July, 1746, in Windmill Street, Tottenham Court Road, but was shortly

removed to Mortimer Street, and again, to Lower Street, Islington. The

charity opened also a smallpox hospital in Bethnal Green, which eventually

contained forty-four beds. The Inoculation Hospital proper, used for the

tedious preparation of subjects, was a house in Old Street, St Luke’s,

with accommodation for fifteen persons. Besides the smallpox hospital at

Islington, the charity had, in 1750, a neighbouring house in Frog Lane,

for the reception of patients after they had been inoculated in the Old

Street house. Down to the middle of 1750 there had been admitted 620

patients in the natural smallpox, while only 34 had gone through the

process of inoculation. The latter involved a month’s preparation, and

about a fortnight’s detention after the operation was done; so that a new

batch of subjects was inoculated but once in seven weeks. In 1752 the

governors of the charity purchased a large building in Coldbath Fields,

which they fitted with one hundred and thirty beds, as a hospital both for

cases of the natural smallpox and for preparing subjects to undergo

inoculation (the Old Street house being still retained for the latter

purpose). The next important change was in 1768, when a large new hospital

was opened at St Pancras, to be solely a house of preparation, the old

hospital in Coldbath Fields being now turned to the double purpose of

receiving the patients from St Pancras after their inoculation and of

receiving patients in the natural smallpox. Thus the inoculation business

of the charity, which had begun with being subordinate to the treatment of

those sick of the natural smallpox, gradually encroached upon the latter

and became paramount. The inoculations, which had been only 112 in the

year 1752, reached the total of 1084 in the year 1768, while the

admissions for smallpox “in the natural way” from 24 March, 1767, to 24

March, 1768, were 700.

In the year 1762-63, the admissions for natural smallpox had been 844, and

for inoculations 439. One reason of the great increase of patients

received for inoculation after that date was the rise of the Suttonian

practice, which had vogue enough to attract numbers, and at the same time

was so much simplified in the matter of preparation and in its results

that many more could go through the hospitals in a given time. The

inoculations by the Smallpox Charity were done in batches, men and boys at

one time, women and girls at another, on some eight or twelve occasions in

the year, of which public notice was given.

The following table is taken from the annual report of the Smallpox and

Inoculation Hospitals for the year 1868.

Period Inoculations

Previous to

Oct. 1749 17

Oct. 1749-Oct. 1750 29

Oct. 1750-Oct. 1751 85

1752 112

1753 129

1754 135

1755 217

1756 281

1757 247

1758 } 446

1759 }

1760 372

1761 429

1762 496

1763 439

1764 383

1765 394

1766 633

1767 653

1768 1084

These charitable efforts to keep down smallpox in London hardly touched

the mass of the people, and did not touch at all the infants and young

children among whom nearly all the cases occurred. The charity admitted no

subjects for inoculation under the age of seven years. It aimed at giving

to a certain number of the working class, or of the domestics or other

dependents of the rich, the same individual protection that their betters

paid for. Meanwhile there were on an average about twelve thousand cases

of smallpox in London from year to year, mostly in infants and young

children. The first proposal to apply inoculation to these came in 1767,

from Dr Maty, in a paper on “The Advantages of Early Inoculation.” This

physician, distinguished in letters and now become a librarian, sought to

recommend inoculation for infants by glorifying the purity of their juices

and the natural vigour of their constitutions, which was something of a

paradox at a time when half the infants born in London were dying before

the end of their third year. He saw as in a vision how smallpox would be

extinguished by making inoculation universal:

“When once all the adults susceptible of the infection should either

have received it or be dead without suffering from it, the very want

of the variolous matter would put a stop to both the natural and

artificial smallpox. Inoculation then would cease to be necessary, and

therefore be laid aside[947].”

Eight years after, in 1775, Dr Lettsom seriously took up the project of

inoculating infants in London[948]. He started a Society for Inoculation

at the Homes of the People, which effected nothing besides some

inoculations done by Lettsom himself during an epidemic “in confined

streets and courts.” In 1779 he launched another scheme for a “General

Inoculation Dispensary for the benefit of the poor throughout London,

Westminster and Southwark, without removing them from their own

habitations[949].” That also was frustrated by the active opposition of

Dimsdale[950]. The objection to it was that there was no prospect of

making the practice universal, and that partial inoculations in the

crowded quarters of London would merely serve to keep the contagion of

smallpox more active than ever. Lettsom answered that the danger of

contagion from inoculated smallpox was more theoretical than real,

inasmuch as the amount of smallpox matter produced upon the inoculated was

a mere trifle[951].

At Newcastle, Lettsom’s design had at least a trial, under the influence

of his friend Dr John Clark[952]. The Dispensary, founded in 1777, was

designed from the outset to undertake gratuitous inoculations; but it was

not until 13 April, 1786, that it got to work. The “liberality of the

public” enabled the managers in that year to offer premiums to parents, to

cover the expense of having their children sick from inoculation--five

shillings for one child, seven shillings for two, nine shillings for

three, and ten shillings for four or more of a family. On the first

occasion, 208 children were inoculated, and all recovered. From 1786 to

1801, the cases numbered 3268. It was the aim of Dr Clark to get the

operation done in infancy; accordingly in the space of four and a half

years (1786-1790), of 1056 inoculations 460 were on infants under one

year, 270 from one to two, 122 from two to three, 69 from three to four,

62 from four to five, 66 from five to ten, and 7 from ten to fifteen. This

was perhaps the most systematic attempt at infant inoculation from year to

year. The other dispensaries at which inoculation was steadily offered to

the children of the poor were at Whitehaven (1079 inoculations from 1783

to 1796), at Bath, and at Chester.

Before the society was started at Chester for the purpose, the

inoculations were some fifteen or twenty in a year, and these, we may

suppose, in the richer families. The society got to work in 1779, but its

operations were stopped in 1780 by a singular cause--the general diffusion

of smallpox in the town by a regiment of soldiers. The whole inoculations

of poor children from the spring of 1780 until September, 1782, were 213,

besides which 203 were done in private practice. The year 1781 was

tolerably free from epidemic smallpox (8 deaths), but in January, 1782, a

very mortal kind prevailed in several parts of the town.

At Liverpool the first gratuitous general inoculation was in the autumn of

1781, to the number of about 517. “The affluent,” says Currie, “being

alarmed at the advertisement for this purpose, presented their children

also in great numbers, and 161 passed through the disease.” There was a

second gratuitous inoculation in the spring of 1782 (to which some of the

above numbers may have belonged), and it was intended to continue the same

at regular intervals; but there is no record of more than those two[953].

Although Dimsdale opposed “general” inoculations in the large towns, for

the reasons mentioned, he was in favour of inoculating together all the

susceptible subjects in a smaller place or country district; and that kind

of general inoculation was not unfrequently undertaken, sometimes

hurriedly at the beginning of an epidemic, at other times after an

epidemic had been running its course for months, and here or there, it

would seem, during a free interval and by way of general precaution.

Dimsdale himself, with the help of Ingenhousz, carried out on one

occasion, in Berkhamstead and three or four other villages of

Hertfordshire, a general inoculation to the number, he guesses, of some

six hundred persons of all ages, including some quite old persons. In 1765

or 1766 Daniel Sutton at Maldon, Essex, inoculated in one morning 417 of

all ages, who were said to be all those in the town that had not had

smallpox in the natural way. Some hundreds were also inoculated by him at

one time in Maidstone.

In the small Gloucestershire town of Painswick in 1786, a very violent and

fatal smallpox broke out during a time of typhus and intermittent fever.

In consequence of the epidemic, one surgeon inoculated 738 persons from

the 26th of May to the end of June[954]. In another Gloucestershire

parish, Dursley, a single surgeon in the spring of 1797 inoculated 1475

persons of all ages, “from a fortnight to seventy years.” But in certain

villages near Leeds in 1786-7 a general inoculation, organised by a

zealous clergyman and paid for by a nobleman, mustered only eighty. About

the same time, during an epidemic of malignant smallpox at Luton,

Bedfordshire, 1215 were inoculated, and thereafter about 700 more; the

average number annually attacked by smallpox during a period of nine years

had been about twenty-five[955].

Inoculation was tried first in Scotland in 1726 by Maitland, during a

visit to his native Aberdeenshire, but was not persevered with owing to

one or two fatalities among the half-dozen cases. About 1733 it was begun

at Dumfries by Gilchrist, who practised it during the next thirty years

upon 560 persons, most of them, doubtless, paying patients. The returns

made to Professor Monro, of Edinburgh, showed in the chief medical

practices 5554 inoculations down to 1765; of which 703 were in Edinburgh

and Leith, 950 in Glasgow, 208 in Stirling, 260 in Irvine, 157 in

Aberdeen, 310 in Banff, 243 in Thurso, and 560 in Dumfries as above[956].

Seventy-two deaths are put down to the practice. When the Statistical

Account of the 938 parishes was compiled in the last decade of the

century, a few of the parish ministers made reference to inoculation.

Thus, in Applecross, Ross-shire, and three neighbouring parishes, an

uneducated man is said to have inoculated 700 after a very fatal

epidemic in 1789; it happened, however, that the pestilence

reappeared, whereupon inoculation was “generally adopted[957].”

Applecross may have been populous then; now there is not a smoke to be

seen in it for miles. Again, the practice is said to have become

“universal” in Skye from about 1780[958]. In Durness parish, which the

tourist may now traverse for thirteen miles to Cape Wrath without

seeing anyone but a shepherd, inoculation was rendered “general” about

1780 by the benevolence of a gentleman belonging to the parish[959].

From October, 1796, to July, 1797, a surgeon of Thurso inoculated 645

in that town and in country parishes of Caithness during a very severe

epidemic[960]. In the parish of Jedburgh the cost of an inoculation

was defrayed by the heritors, in that of Kirkwall by the kirk session,

in another by the commissioners of annexed estates, in Earlstown,

Berwickshire (on 70 children) by the chief proprietor. The ministers

who mention it at all were mostly strong advocates of it, but they

usually imply that the common people were (or had been) apathetic or

prejudiced. It was sometimes recommended from the pulpit, and actually

done by the ministers; it was even recommended that students of

divinity should be instructed in the art. Statements that it had

become “general” or “universal” are made for several parishes, mostly

in the Highlands or Islands. The very full and trustworthy account of

the parish of Banff says that “inoculation is by no means become

general among the lower ranks[961];” which is perhaps about the truth

for the country at large.

At the end of an epidemic at Leeds, in 1781, which had attacked 462 and

killed 130 during six months, “in the next six months there were

inoculated 385, of whom four died” (two by contagious smallpox). A second

general inoculation was carried out in Leeds sometime previous to 1788.

Lucas, writing in that year, says: “The result of two general inoculations

in Leeds has been that the smallpox has since been less frequent and less

fatal[962].” This will be a convenient opportunity of considering the

gross effects of inoculation upon the prevalence of smallpox.

The first and most obvious consideration is that it usually came too late.

“Most born in London,” said Lettsom quite correctly, “have smallpox before

they are seven”--i.e. before the age for admission to the inoculation

hospital. He might have added that, if they had run the gauntlet of

smallpox in London until they were seven, they were little likely to take

it at all. The inoculations in London were therefore done upon a very

select class (they were, in fact, a very small number), who may be assumed

to have escaped the perils of smallpox in London in their childhood, or to

have come to London (as many did) from country places where smallpox broke

out as an epidemic only at long intervals. In other large towns as well as

the capital the inoculated must have been a residual class. At Leeds, with

a population of 17,117, “the number of those who were still uninfected was

found on a survey to be 700” at the end of an epidemic, of whom 385 were

inoculated. If a general inoculation had been tried at Chester after the

epidemic of 1774, there would have been only 1060, in a population of

14,713, to try it on. How many of these, above the age of childhood, were

constitutionally proof against smallpox? The case of Ware, in

Hertfordshire, after the epidemic in the summer of 1777, is so related by

Lettsom as to bring out the ambiguity of much that was claimed for

inoculation. “After about eighty had been carried off by it, a general

inoculation was proposed, to prevent those who had not yet been attacked,

and whose number was still considerable, from sharing the same fate. The

alarm which had been excited induced most of the survivors to adopt this

proposition, after which not one died, and the infection was wholly

eradicated.” Eighty deaths in one epidemic is a large mortality for such a

place as Ware in any circumstances; the smallpox for once had done its

worst. But, says Lettsom, there were a few families of those hitherto

untouched by the epidemic who did not submit to inoculation. Not one of

them caught the disease--from their inoculated neighbours (Lettsom is

arguing that there was no danger in that way), nor, of course, from the

epidemic contagion. It cannot but appear strange to us that the natural

cessation or exhaustion of an epidemic should not have been thought of. Dr

Currie, of Liverpool, records that in the first general inoculation there

in 1781 there were 417 inoculated gratuitously and about 100 more in

private practice, and that “about three or four thousand liable to the

disease were scattered in the same manner [as the inoculated], not one of

whom caught the infection.” For a few weeks there was not a case of

smallpox known in Liverpool, so that no matter could be got for

inoculation. He adds, in the most ingenuous manner: “An important

particular has been recalled to my mind by Mr Park; that previous to this

first general inoculation, which extinguished the smallpox in so

extraordinary a way, the disease raged in town with much violence and was

very fatal[963].”

The general inoculations were often carried out in so haphazard a manner

as to make them valueless for a scientific as well as for a practical

purpose. A Bath surgeon of long experience wrote in 1800: “Whenever the

inoculating rage once takes place whole parishes are doomed, without the

least attention to age, sex, or temperament--no previous preparation, no

after treatment or concern.... Are not scores and hundreds seized upon at

once, for the incisions, scratchings, puncturings and threadings, without

even a possibility of their being properly attended to? and whether they

may or may not receive the infection is just as little known or cared

about[964].” It must have been equally little known or cared about whether

they had had smallpox in the natural way before. What Dimsdale found to

obtain at St Petersburg would have been the rule elsewhere: “The general

method was to search for marks, and, if none were found, it was concluded

the party had not had the disease[965].”

Thus in any attempt to estimate the gross advantages of inoculation in the

18th century we are met on every hand by sources of fallacy. Whatever its

theoretical correctness, it does not follow that the inoculation of

smallpox was a practical success to the extent of its trial; and even its

theoretical correctness will be thought by some, and was so thought at the

time, to have gone by the board when the artificial disease was brought

down to a pustule at the point of puncture, with or without a few bastard

pocks on the skin near. I have found two instances in the 18th century

history in which there are data for a rough practical judgment, although

not for a precise statistical one. The first is the town of Blandford, in

Dorset; the other is the Foundling Hospital in London.

During the smallpox year 1766, smallpox of a very malignant type broke

out at Blandford in the first week of April[966]. It was estimated

that 700 persons in the town (population 2110 in 1773) had not had the

natural smallpox, and a general inoculation was resolved upon on the

13th April. “A perfect rage for inoculation,” says Dr Pulteney[967],

“seized the whole town,” and in the week following the 16th April some

300 were inoculated, the total rising to 384 before the panic ceased;

of these, 150 were paid for by the parish. There were thirteen deaths

among the inoculated, but most of these confluent or haemorrhagic

cases, seem to have been due to the epidemic contagious smallpox,

which had been peculiarly fatal, with haemorrhagic symptoms, to the

few that were seized before the inoculation began, and continued to be

fatal to many. The mortality from smallpox for the year in the parish

normal[967]. The last epidemic of smallpox in Blandford had been in

1753, when 40 died of it, the deaths from all causes being 96. In that

year also there had been a general inoculation to the number of 309.

The parish register gives the deaths in an earlier epidemic, in 1741,

which was a year of great distress and typhus fever all over England:

76 deaths are ascribed to smallpox (102 to all causes), which is a

larger total from smallpox than in either of the subsequent occasions

when general inoculations were tried. Comparing these three epidemics

in a Table, with the associated circumstances, we get the following:

_Statistics of Blandford in three Smallpox Years (Population in 1773,

2110)._

| | | | Annual Averages of

Year of |Deaths| Deaths |Inoculations| eight previous years

Epidemic| from | from | |-----------------------

| all |Smallpox| | | |

--------|------|--------|------------|---------|------|------

1741 | 102 | 76 | --- | 24·87 |63·37 | 49·25

1753 | 96 | 40 | 309 | 19·37 |50·62 | 49·62

1766 | 104 | 44 | 384 | 20·62 |54·12 | 49·12

It will be seen that the higher mortality from smallpox in 1741 was

associated with other things besides the absence of inoculation. The

annual average of deaths for eight years preceding each of the three

epidemics is almost the same. But the marriages and births for eight

years preceding 1741 were much in excess of those in the periods

preceding the other two epidemic years. In the former there was a much

larger susceptible population of children, upon which the smallpox

mainly fell; and that alone would account for more deaths from

smallpox in the epidemic of 1741. But the year 1741 was peculiar in

another way; it was the worst year of typhus fever and general

distress in the whole of the 18th century, and in the circumstances

the deaths from smallpox would have been unusually numerous for the

cases. Another epidemic of smallpox without inoculation, in 1731,

showed how mild smallpox could be. At a time when sixty families had

the disease among them, a fire broke out on 4 June, and burned down

the town. It is said that 150 ill of smallpox were removed to gardens,

hedgerows and the arches of bridges, and that only one of the whole

number died[968]. This is usually cited to show the benefits of fresh

air; but if it be true, it shows more than that.

The Foundling Hospital may seem to offer all the conditions for a fair

trial of the question. It had been a standing rule of the Governors, since

the opening of the charity in 1749, that all children received into it

should be inoculated. Sir William Watson, who states the fact, adds that

he himself was “in a situation of superintending every year the

inoculation of some hundreds.” Still, the rule may not have been uniformly

carried out; and even in this community of children, it was not always

possible to learn on their admission whether they had had smallpox before

in the natural way[969].

The lists of the inoculated are longer in the later periods than in

the earlier: thus, from March, 1759 to May, 1766, the annual average

is something under a hundred, the inmates having been 312 in 1763; but

from May, 1766 to July, 1769, the annual average is some two hundred

and fifty, the inmates in 1768 having been 438. Sir William Watson, in

his essay upon the inoculations at the Foundling, breathes no hint

that such a thing as natural smallpox ever happened there[970]; but in

another context he does casually mention that there was an epidemic of

sixty cases, with four deaths, in the end of 1762, and another

epidemic in the following summer, of “many” cases, nineteen of which,

with eleven fatalities, occurred in children who had lately been

through the measles and were weakened in consequence[971]. Another

epidemic, as I find by the apothecary’s book of weekly admissions to

the infirmary, happened in the winter of 1765-66, twenty-six names

being entered as admitted for “natural smallpox.” After that date all

the great epidemics appear to have been of measles, whooping-cough,

influenza or scarlatina; but almost every year smaller groups of

“natural smallpox” occur, of which the following have been collected

from the available records:

_Foundling Hospital, London._

Natural

Year Smallpox

1766 8

1767 2

1768 8

1769 7

1770 1

1771 2

1772 3

1773 1

1774 4

1775 3

1783 1

1784 0

1785 8 (or 16?)

1786 0

1787 5

1788 4

The occurrence of one or more cases seems to have been the signal for

a general inoculation; or, again, it may be that the few cases of

natural smallpox in the infirmary at one time had followed a general

inoculation. Thus, in June-July, 1767, one case is entered on the

second day from the inoculation (of a large number), and another on

the fourth day. Again, in Nov.-Dec., 1768, one of the four cases of

natural smallpox is marked “soon after his inoculation.”

The received cases in which inoculation failed to save individuals from

the natural smallpox are few. Besides those already given for the first

period of the practice, and the case from Heberden, there are six fully

detailed by Kite of Gravesend, in two groups of three each, all in the

spring of 1790[972]. Apart from exact records, there are various

testimonies more or less trustworthy. The Marquis of Hertford is said to

have told Dr Jenner that his father, having been inoculated by Caesar

Hawkins, the serjeant surgeon, and thereafter attended by him during a

tour abroad, caught smallpox at Rheims and died[973]. Bromfeild, surgeon

to Queen Charlotte, is said to have “abandoned the practice of inoculation

in consequence of its failure[974].” Jenner and his friends made a

collection of cases in which inoculation had failed, to the number of

“more than one thousand, and fortunately seventeen of them in families of

the nobility[975].” A Bath surgeon said he had heard of “innumerable”

cases of attacks of natural smallpox long after inoculation, and had

himself professionally seen “not a few[976].” A surgeon of Frampton on

Severn knew of four cases, out of five inoculated together in 1784, that

took smallpox afterwards in the natural way, of whom one died[977]. In an

epidemic of smallpox at Enmore Green, a suburb of Shaftesbury, in 1808, a

surgeon from Shaston found that “nearly twenty” of the victims had been

inoculated “by the late Mr John White” about ten years before, and were

supposed to have had it “very fine[978].” Dr John Forbes learned that some

nineteen cases of natural smallpox in and around Chichester in 1821-22

were of inoculated persons[979]. It would be incorrect to say that such

cases could be multiplied indefinitely; on the contrary, they are hard to

find. Whether that shows that inoculation was on the whole a success, to

the extent that it was tried, or that its failures are in part unrecorded,

I am not competent to decide. But it cannot be doubted that the usual

estimates of the saving of life by inoculation were extravagant and

fallacious. La Condamine, a mathematician, counted up the saving to the

slave-owner in an ideal plantation of three hundred negroes[980]. Watson,

with the epidemics in the Foundling fresh in his memory, estimated that

inoculation might have saved 23,000 out of the 23,308 who had died of

smallpox in London in ten years, 1758-68[981]. Haygarth[982] reckoned that

351 might have been saved by inoculation of the 378 children who died of

smallpox at Chester from 1772 to 1777. Woodville, who wrote the history of

inoculation down to the advent of Sutton, declared in 1796 that the art of

inoculation, originally a fortuitous discovery, “is capable of saving more

lives than the whole _materia medica_[983].” Arnot, the historian of

Edinburgh (1779), asserted inoculation to be “a remedy so compleat that we

hesitate not in the least to pronounce those parents, who will not

inoculate their children for the smallpox, accessory to their death[984].”

The College of Physicians, in a formal minute of 1754, pronounced it

“highly salutary to the human race.”

Despite all those academic pronouncements, inoculation was somehow not a

practical success. It cannot be maintained that it failed because the

people were averse to it; for it continued to be in popular request far

into the 19th century, until it was at length suppressed by statute. For

the present we may return to the proper subject of epidemic smallpox,

premising, on the ground of what has been said, that inoculation made but

little difference to the epidemiological history.

The Epidemiology continued from 1721.

The ordinary course of smallpox in Britain was little touched by

inoculation. The inoculators were like the fly upon the wheel, with the

important difference that they did indeed raise the dust. The writers who

kept up the old Hippocratic or Sydenhamian habit of recording the

prevalent maladies of successive seasons, such as Huxham, Hillary[985],

and Barker, of Coleshill, while they dealt with epidemics impartially and

comprehensively, were as if by a common instinct adverse to the fuss made

about inoculation. Says Barker, in an essay against inoculation during the

Suttonian enthusiasm, “It is undoubtedly a great error that the smallpox

is now considered the only bugbear in the whole list of diseases, which,

if people can get but over, they think they are safe.” This hits fairly

enough the disproportionate share given to inoculation in the medical

writings of the time, while it is made more pointed by the author’s

suggestions for a scientific study of the conditions of smallpox

itself[986]. It is still possible, with much trouble, to bring together

the data for a scientific handling of the disease in the 18th century,

thanks most of all to the exact school of observers or statisticians which

began with Percival, of Manchester, and was continued to the end of the

century by Haygarth, Heysham, Ferriar, Aikin and others. The best of the

original English inoculators, Nettleton of Halifax, has also left a large

number of interesting statistics relating to epidemics in Yorkshire and

other northern counties in the years 1721-23; also, upon his suggestion,

the figures were procured from many more smallpox epidemics in other parts

of England down to 1727. It will be convenient to resume the history with

these, as they come next in order after the London epidemic of 1720, at

which point the interlude of inoculation came in. The following is a

complete table of the figures collected from various sources: it will be

observed that most parts of England are represented, the fullest

representation being of the northern counties.

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

Percentage

Locality of the Deaths of

Epidemic Period Authority Cases Fatalities

Halifax[987] winter of 1721 Nettleton, 276 43 15·9

to April 1722 _Phil. Trans._

XXXII. 51

Rochdale[988] " " 177 38 21·4

Leeds[989] " " 792 189 23·8

Halifax parish 1722 _Ibid._ p. 221 297 59 19·9

towards Bradford

Halifax parish, " " 268 28 10·4

another part

Bradford " " 129 36 27·9

Wakefield " " 418 57 13·6

Ashton under Lyne[990] " " 279 56 20·0

Macclesfield " " 302 37 12·2

Stockport " " 287 73 25·4

Hatherfield " " 180 20 11·1

Chichester[991] 1722 Whitaker, 994 168 16·9

(to 15 Oct.) _Ibid._ p. 223

Haverfordwest 1722 Perrot Williams, 227 52 22·9

_Ibid._

Barstand, Ripponden, " Nettleton, in 230 38 16·5

Sorby, and part of Jurin’s _Acct._

Halifax parish for 1723, p. 7

4 miles from the

town

Bolton 1723? Jurin’s _Acct._ 406 89 21·6

for 1723, p. 8

Ware " " 612 72 11·7

Salisbury " " 1244 165 13·2

Rumsey, Hants " " 913 143 15·6

Havant " " 264 61 23·1

Bedford " " 786 147 18·4

Shaftesbury 1724? _Ibid._ for 660 100 15·1

1724, p. 12

Dedham, near " " 339 106 31·3

Colchester

Plymouth " " 188 32 17·2

Aynho, near 27 Sept. 1723 Rev. Mr Wasse, 133 25 18·8

Banbury to 29 Dec. 1724 rector, _Ibid._

for 1725, p. 55

Stratford on Avon " Dr Letherland, 562 89 15·8

_Ibid._

Bolton le Moors " Dr Dixon, _Ibid._ 341 64 18·8

Cobham " Sir Hans Sloane, 105 20 19·0

_Ibid._

Dover 29 Sept. 1725 Dr Lynch of 503 61 12·1

to 25 Dec. 1726 Canterbury, in

Jurin’s _Acct._

for 1726, p. 17

Deal 25 Dec. 1725 " 362 33 9·1

to 29 Nov. 1726

Kemsey, " Dr Beard, in 73 15 20·5

near Jurin, _Ibid._

Worcester

Uxbridge[992] 1727 Dr Thorold, in 140 51 36·4

Scheuchzer’s

_Acct._ for

1727 and 1728

Hastings 1729-30 Dr Frewen, 705 97 13·7

_Phil. Trans._

XXXVII. 108

The years 1722 and 1723, to which most of these epidemics belong, were one

of the greater smallpox periods in England. In Short’s abstracts of the

parish registers those years stand out very prominently by reason of the

excess of deaths over births in a large proportion of country parishes

(see above, p. 66); and, according to Wintringham’s annals, it was not

fever that made them fatal years, but smallpox, along with autumnal

dysenteries and diarrhoeas. Of one epidemic centre in the winter of

1721-22, which is not in the table, the district of Hertford, we obtain a

glimpse from Maitland, who repaired thither from London to practise

inoculation.

“I own that it seem’d probable that the six persons in Mr Batt’s

family might have catched the smallpox of the girl that was

inoculated; but it is well-known that the smallpox were rife, not only

at Hertford but in several villages round it, many months before any

person was inoculated there: witness Mr Dobb’s house in Christ’s

Hospital buildings, where he himself died of the worst sort with

purples, and his children had it; some other families there, and

particularly Mr Moss’s, (where the above-named Elizabeth Harrison,

inoculated in Newgate, attended several persons under it to prove

whether she would catch the distemper by infection); both Latin

boarding-schools, Mr Stout’s and Mr Lloyd’s families, Mr John

Dimsdale’s coachman and his wife, and Mr Santoon’s maid-servant, who

was brought to the same house and died of the confluent kind of the

smallpox[993].”

Here we have the same indication of adults attacked as well as children,

which we find in Dover’s practice in London in 1720 and in all the 17th

century and early 18th century references to smallpox. The most detailed

account is that given for the epidemic of 1724-25 at Plymouth by Huxham,

who was not an inoculator but purely an epidemiologist and practitioner in

the old manner.

The epidemic was a very severe one and of an anomalous type. Adults,

according to his particular references and his general statement, must

have been freely attacked. The major part of the adult cases, he says,

proved fatal, including one of an old gentlewoman of 72,--“a very

uncommon exit for a person of her years”! When the disease raged most

severely, some children had it very favourably and required no other

physic than to be purged at the end of the attack. The pustules were

apt to be small and to remain unfilled. In some there were miliary

vesicles, dark red or filled with limpid serum, in the interstices

between the smallpox pustules. Some had abundance of purple petechiae

among the pocks, the latter also being livid. Only one person survived

of all who had that haemorrhagic type. Swelling of the face and throat

was also seldom recovered from; in such cases that did well, the

maxillary and parotid glands would remain swollen for some time. “It

was a remarkable instance of the extraordinary virulence of these

smallpox that the women (tho’ they had had the smallpox before and

some very severely too) who constantly attended those ill of the

confluent kind, whether children or grown persons, had generally

several pustules broke out on their face, hands and breast.... I knew

one woman that had more than forty on one side of her face and breast,

the child she attended frequently leaning on those parts on that

side.”

Huxham appears to have adopted the whole Sydenhamian practice of

blooding, blistering, purging, and salivating. For the last he used

calomel: “Two adults and some children in the confluent sort never

salivated. Some very young children drivelled exceedingly through the

course of the distemper. A diarrhoea very seldom happened to

children[994].”

Corresponding very nearly in time to Huxham’s malignant and anomalous

constitution of smallpox at Plymouth, and agreeing exactly with his

generalities as to children and adults, there is an interesting table of

the ages and fatalities of those who were attacked at Aynho, in

Northamptonshire, six miles from Banbury. It was then a small market town,

and its smallpox for some fifteen months of 1723-24, as recorded by the

rector of the parish, may be taken as a fair instance of what happened at

intervals (usually long ones) in the rural districts in the earlier years

of the 18th century[995]:

above

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

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

Deaths 0 0 2 1 0 1 3 1 3 3 3 4 1 2 1 25

The small fatality of the disease between the ages of five years and

twenty is according to the experience of all times. But the considerable

proportion of attacks at the higher ages would hardly have been found

anywhere in England, not even in a country parish, a generation or two

later, although it is consistent with all that is known of smallpox in the

17th century and in the first years of the 18th[996].

Another glimpse of a prolonged smallpox epidemic of the same period in a

town is given in Frewen’s census of Hastings, with a population of 1636

(males 782, females 854). The disease was prevalent for about a year and a

half, and had ceased previous to 28 January, 1732[997]. The table accounts

for the whole population:

The number of those that recovered of the smallpox

(including four that were inoculated) 608

Died of it 97

Escaped it 206

Died of other diseases since the smallpox raged there 50

The whole number of inhabitants in that town are 1636

Leaving out the fifty who died of other diseases as persons who may or may

not have had smallpox, it appears that 725 of the inhabitants of Hastings

had been through the smallpox in previous epidemics, that 705 were

attacked in this epidemic, and that 206 had hitherto escaped, some of them

to be attacked, doubtless, in the future. The proportion of attacks above

the age of childhood in the epidemic of 1730-31 would have depended on the

length of time since the last great epidemic; the interval was probably a

long one, by the large number of susceptible persons in the town, just as

at Boston, Massachusetts, in 1721 and 1752, and at Charleston, Carolina,

in 1738[998]; and, as the fact is known for these places, so it is

probable that the epidemic at Hastings had included many adolescents and

adults.

On the other hand, where smallpox came in epidemics at short intervals, or

where it was always present, the incidence, even in the first half of the

18th century, was much more exclusively upon childhood. Thus at Nottingham

there was always some smallpox, with a great outburst perhaps once in five

years. The year 1736 was one of those fatal periods of smallpox, the

victims being “mostly children.” From the end of May to the beginning of

September, great numbers were swept away; the burials in St Mary’s

churchyard were 104 in May; the burials from all causes for the whole year

exceeded the baptisms by 380; there had been no such mortality since

thirty years. Such excessive incidence of smallpox upon the earliest years

of life happened in places where the infant mortality was high from all

causes. Nottingham was one of those places. Leaving out the great smallpox

year, 1736, the other seven years of the period 1732-39 had a total of

2590 baptisms to 2226 burials, of which burials no fewer than 1072 were of

“infants,” meaning probably children under five years, although the work

of Harris on the Acute Diseases of Infants, which was current at that

time, defines the infantine age as under four years[999].

The years of distress and typhus fever in England, Scotland, and Ireland

from 1740 to 1742 were another great period of smallpox epidemics

throughout the country. The mortality from that cause is known to have

been excessive in Norwich, Blandford, Edinburgh and Kilmarnock, which may

be taken as samples of a larger number of epidemics in the same years. The

association of much smallpox of a fatal type with much typhus fever, which

can be traced in the London bills from an early period, is at length seen

to be the rule for the country at large. After 1740-42, the next instances

of it were in 1756 and 1766: it is most definitely indicated again in

1798-1800, very clearly in 1817-19, and in 1837-39. In all the later

instances smallpox was the peculiar scourge of the infants and children in

times of distress, while the contagious fever was as distinctively fatal

to the higher ages. There is some reason to think that the law of

incidence was the same in populous cities in 1740-42.

Thus at Edinburgh there died in the two worst years of the distress

(population in 1732 estimated at 32,000)[1000]:

_Edinburgh Mortalities._

1740 1741

Under two years 439 562

From two to five 198 269

From five to ten 53 93

Above ten 547 687

---- ----

1237 1611

Fever 161 304

Flux 3 36

Consumption 278 349

Aged 102 156

Suddenly 56 62

{Smallpox 274 206

{Measles 100 112

{Chincough 26 101

{Convulsions 22 16

{Teething 111 141

{Stillborn 29 50

Other diseases 77 78

More than half the deaths were under five years, and among those deaths it

will be necessary to include most of the smallpox mortality. That disease

in the two exceptional years made 17 per cent. of all deaths, or one in

six. But in its somewhat steady prevalence among children in Edinburgh

from year to year, smallpox accounted for one death in about ten, as in

the following[1001]:

_Deaths by Smallpox and all causes in Edinburgh, including St Cuthbert’s

parish, 1744-63._

All Dead of

Year Burials Smallpox

1744 1345 167

1745 1463 141

1746 1712 128

1747 1200 71

1748 1286 167

1749 1132 192

1750 1038 64

1751 1241 109

1752 1187 147

1753 1105 70

----- ----

12709 1256

or 1 in 9·6

1754 1215 104

1755 1187 89

1756 1316 126

1757 1267 113

1758 1001 52

1759 1136 232

1760 1123 66

1761 903 6

1762 1305 274

1763 1160 123

----- ----

11613 1185

or 1 in 9·8

As in other epidemics, it was not until its second year that the smallpox

reached Norwich. The mortality had been enormous in 1741, owing to the

distress and the fever, 1456 burials to 851 baptisms; but in 1742 the

burials were 1953 (to 825 baptisms), the excess over the previous year

being ascribed, in general terms, to the smallpox[1002]. It is probable

that the enormous excess of burials over baptisms at Newcastle in 1741 was

due in great part to the same disease among the children; but the

statistics do not show it.

Northampton is an instance of a town with very moderate mortality for the

18th century; for that and other reasons its bills were used by Price as

the basis of a table of the expectation of life. It had certainly shared

in the fever epidemic of 1741 and 1742, for in the latter of those years

the annual bill shows the very high fever-mortality of 37 in 130 deaths

from all causes in All Saints’ parish, which had fully one-half of the

population. But in that year there are no smallpox deaths recorded, and

only nine in the next four years. The great periodic outburst of smallpox

came in 1747[1003]:

_Smallpox in Northampton, 1747._

Percentage

Parish Cases Deaths of Fatalities

All Saints 485 76 15·6

St Sepulchre 175 21 12·0

St Giles 131 23 17·5

St Peter 30 6 20·0

----- ---- ------

821 126 15·3 or 1 in 6·5

Of the 76 deaths in All Saints’ parish only 58 were buried there. The

deaths from all causes in that parish were 189, of which 103, or 54 per

cent., were under five years of age, and 10 between five and ten years.

Next year, when things had improved much, although the mortality was still

high, All Saints’ parish had 119 burials, of which 47, or 40 per cent.,

were under five years, and 4 from five to ten, only three of the deaths

being from smallpox. Only a few smallpox deaths appear in the bills of All

Saints’ parish until 1756 and 1757, when an epidemic occurred, part of it

in each year, which produced in that greatest of the four parishes 85

burials, or half as many again as in the epidemic of ten years before. It

is singular that the deaths under and over five are in a very different

ratio in the two successive years of the epidemic:

_All Saints’ Parish, Northampton._

1756 1757

All deaths 140 135

Smallpox deaths 31 54

All deaths under 2 54 24

" " 2-5 12 18

" " 5-10 7 21

" " 10-20 5 6

" " 20-30 13 18

" " 30-40 7 12

" " 40-50 4 5

" " above 50 38 31

This looks as if a good many more had died of smallpox at the higher ages

in the second year of its prevalence than in the first; but the great

difference between the deaths under two in 1756 and 1757 is explained

chiefly by the article “convulsions,” which is 28 in the former year and

only 10 in the latter.

In Boston, Lincolnshire, a town almost as healthy as Northampton, the

intervals between epidemics of smallpox were almost as long, and the

effect in raising the mortality for the year nearly the same. The

population in the last year but one of the table was 3470. The deaths

averaged 104 in a year, the smallpox deaths 9·45, or one in eleven[1004].

_Smallpox in Boston, Lincolnshire, 1749-68._

Died by

Year Baptised Buried Smallpox

1749 68 120 48

1750 80 93 --

1751 55 59 --

1752 88 85 --

1753 79 73 --

1754 88 111 1

1755 74 102 19

1756 66 110 34

1757 93 86 4

1758 83 88 4

1759 102 91 --

1760 106 84 2

1761 80 94 --

1762 95 134 3

1763 92 206 69

1764 130 102 5

1765 112 113 --

1766 144 117 --

1767 129 95 --

1768 131 117 --

This was a favourable instance of urban smallpox in the 18th century,

Boston having “no circumstances of narrow streets, crowded houses,

manufactories or want of medical assistance.” We may compare with it an

industrial town only a little larger, the weaving town of Kilmarnock,

Ayrshire, the smallpox epidemics of which came as follows[1005]:

_Smallpox in Kilmarnock, 1728-63._

Died by

Year Baptised Buried Smallpox

1728 111 162 66

1729 -- -- --

1730 -- -- --

1731 -- -- --

1732 -- -- --

1733 -- -- 45

1734 -- -- --

1735 -- -- --

1736 135 147 66

1737 -- -- --

1738 -- -- --

1739 -- -- --

1740 95 164 66

1741 -- -- --

1742 -- -- --

1743 -- -- --

1744 -- -- --

1745 116 102 74

1746 -- -- 8

1747 -- -- --

1748 -- -- 2

1749 134 149 79

1750 -- -- 5

1751 -- -- 1

1752 -- -- --

1753 -- -- 1

1754 146 203 95

1755 -- -- --

1756 -- -- --

1757 125 132 37

1758 -- -- 9

1759 -- -- --

1760 -- -- --

1761 -- -- --

1762 132 173 66

1763 -- -- 2

Although Kilmarnock had an average annual excess of baptisms over burials

(134 to 107), which was more than that of Boston, its smallpox mortality

was higher than that of the Lincolnshire market town. On an annual

average, one death in eleven from all causes was by smallpox at Boston,

one in six at Kilmarnock. In the former the epidemics came at intervals of

about five years, in the latter at intervals of three or four. The oftener

the epidemic came, the earlier in life it attacked children; and in all

subsequent experience it has been found that smallpox is far more mortal

to the ages below five than to the ages from five to ten or fifteen. More

generally, the conditions were worse for young children in a weaving town

than in a market town of nearly the same size. In the populous weaving

parish of Dunse, 130 children are said to have died of smallpox in 1733,

during a space of three months[1006].

The ages at which deaths from smallpox occurred in Kilmarnock from 1728 to

1763 are strikingly different from those already given for the small

market town or village of Aynho, near Banbury, in 1723-24; at the latter

the greater part of the fatalities, although not of the attacks, happened

to persons between twenty and fifty; at the former nine-tenths of the

deaths were of infants and young children, as in the following:

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

Deaths

at all Under One to Two to Three to Four to Five to Above Age not

ages One Two Three Four Five Six Six stated

622 118 146 136 101 62 23 27 9

This almost exclusive incidence of fatal smallpox upon infants and young

children in a weaving town during the middle third of the 18th century we

shall find abundantly confirmed for English manufacturing and other

populous towns in the last third of the 18th century, and thereafter until

the middle of the 19th century. On the other hand, the less populous towns

and the country districts continued in the 18th century to furnish a fair

share of adult cases, for the reason that epidemics came to them at longer

intervals, wherein many had passed from infancy to childhood, and even

from childhood to youth or maturity, without once encountering the risk of

epidemic contagion.

Of such less populous places we have an instance in Blandford, Dorset.

Particulars of its smallpox have been given in connexion with general

inoculations; here let us note that in this typical market town of 2110

inhabitants (in 1773), the known epidemics were in 1731, 1741, 1753 and

1766--at intervals of ten or a dozen years. In the villages the intervals

were longer. Haygarth gives the instance of three parishes in Kent with

only ten deaths from smallpox in twenty years, and of Seaford, in Sussex,

with one death “eleven years ago[1007].” An authentic instance is the

parish of Ackworth, Yorkshire, whose register of burials contains only one

smallpox death in the ten years 1747-57, while there are thirteen such

deaths in it in the next ten-years period, clearly the effects of an

epidemic, perhaps in 1766[1008]. This parish, judged by the excess of

births, was not so healthy as many[1009], while its mortality by “fevers”

was considerable. The following somewhat general statements are made for

the parish of Kirkmaiden, Wigtonshire[1010]:

1717. “Nearly thirty-seven died of the smallpox.”

1721. Forty-eight died, “mostly of fevers.”

1725. Forty-three died, “mostly of the smallpox.”

By means of this law of periodic return, at short intervals in the

populous industrial towns, at longer intervals in the market towns, and at

very long intervals in the villages, we may realize in a measure what

smallpox was at its worst. It was the great infective scourge of infancy

and childhood, admitting but few or feeble rivals or competitors, as we

shall see in the historical accounts of measles, whooping-cough and

scarlatina. The table of epidemics from 1721 to 1727, given at p. 518, is

of a kind that might have been furnished by any series of years in the

18th century; they were so much of a commonplace that hardly anyone

thought of chronicling them unless for a special statistical purpose, such

as the inoculation controversy. Thus, the Salisbury epidemic of 1723, with

1244 cases and 165 deaths, must have been only one of a series at

intervals, which may or may not have become more frequent, or of

different age-incidence, or of more fatal type, as the century proceeded.

We have a glimpse of one of them in 1752-3. Lord Folkestone having given a

hundred pounds to the poor of Salisbury, it was ordered on 15 December,

1752, “that five shillings be given to every inhabitant who hath had the

smallpox in the natural way since 1 September, or that shall have it

hereafter.” The epidemic went on for months; it was not until the end of

1753 that the mayor advertised the city free of smallpox. In September of

that year ten guineas were voted to Mr Hall, the apothecary, for his

trouble during the smallpox, and a like sum to Mr Dennis, the

surgeon[1011].

The year 1753 was also the time of one of the periodical Blandford

outbreaks. For a year or two before there had been much smallpox at

Plymouth, the account of which by Huxham will serve as a sample of his

numerous references to the disease there from the beginning of his annals

in 1728.

In May, 1751, smallpox was brought in by Conway’s regiment; it spread

in July and August, becoming worse in type in the autumn as it became

more common. In January 1752 it was still prevalent, the pustules

often crude, crystalline, undigested to the end; sometimes very

confluent, small and sessile; sometimes black and bloody, attended now

and then with petechiae. In March the type grew more mild; in April

the malady was still up and down, some cases being of a bad sort. It

became more frequent again in June, and was epidemic all the summer,

the eruption often confluent, small, sometimes black, with

haemorrhages from the nose, especially in children. In August it was

epidemic everywhere, and more fatal, becoming milder in September and

October. In December, “the crusts of the black confluent kind many

times remained for at least thirty days after the eruption.” It

declined from January, 1753, and entirely ceased in May, having had a

prevalence of two years[1012].

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

There is hardly any epidemic malady in London of which so few particular

records remain as of smallpox, except in the bills of mortality. The

monthly notes in the _Gentleman’s Magazine_ from 1751 to 1755 by Dr

Fothergill, who practised at that time in White Hart Court, Lombard Street

(having afterwards removed westward to Harpur Street, Red Lion Square),

contain the following references to it:

1751, May. Smallpox uncommonly mild in general, few dying of it in

comparison of what happens in most years.

1751, December. Smallpox began to make their appearance more

frequently than they had done of late, and became epidemical in this

month. They were in general of a benign kind, tolerably distinct,

though often very numerous. Many had them so favourably as to require

very little medical assistance, and perhaps a greater number have got

through them safely than has of late years been known.

1752, January. A distinct benign kind of smallpox continued to be the

epidemic of this month.... A few confluent cases, but rarely.

February--Children and young persons, unless the constitution is very

unfavourable, get through it very well, and the height to which the

weekly bills are swelled ought to be considered in the present case as

an argument of the frequency, not fatality, of this distemper.

1752, April. Smallpox continued to be the principal epidemic, as in

the preceding months; during which time it attacked most of those who

had not hitherto had the distemper, and it is now spread into the

suburbs and the neighbouring villages, but still in a favourable way

in general. Some have the confluent, a few the bleeding kind, but

these are not very common.

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

had it before.

1752, July. Smallpox inclined to become malignant, but the

constitution on the whole remarkably mild. Children from one to three

years old have, I believe, suffered more from the distemper during

this constitution than those of any other ages; at least it has so

fallen out under the writer’s observation.

1753, December. Smallpox of a bad type.

1754, August. Smallpox frequent in many parts of the City, and eastern

suburbs especially. In general the kind was mild, distinct and

favourable. Out of sixteen who had the disease in a certain district,

of different ages, one only died. In some it was very virulent, with

livid petechiae.

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

for years.

1755, January. Smallpox more favourable.

Fothergill, who pointed out the defects of the London bills of mortality

and made a serious attempt to get them reformed[1013], was disposed to

take their figures of smallpox deaths as on the whole trustworthy: “The

smallpox, of all diseases mentioned in the weekly bills, is perhaps the

only one of which we have any tolerably exact account, it being a disease

which the most ignorant cannot easily mistake for another.” Reserving this

opinion for some critical remarks in the sequel, we may now resume the

London statistics from the year last given.

_Smallpox Mortality in London, 1721-60._

Deaths Deaths

from from

Year smallpox all causes

1721 2,375 26,142

1722 2,167 25,750

1723 3,271 29,197

1724 1,227 25,952

1725 3,188 25,523

1726 1,569 29,647

1727 2,379 28,418

1728 2,105 27,810

1729 2,849 29,722

1730 1,914 26,761

1731 2,640 25,262

1732 1,197 23,358

1733 1,370 29,233

1734 2,688 26,062

1735 1,594 23,538

1736 3,014 27,581

1737 2,084 27,823

1738 1,590 25,825

1739 1,690 25,432

1740 2,725 30,811

1741 1,977 32,169

1742 1,429 27,483

1743 2,029 25,200

1744 1,633 20,606

1745 1,206 21,296

1746 3,236 28,157

1747 1,380 25,494

1748 1,789 23,069

1749 2,625 25,516

1750 1,229 23,727

1751 998 21,028

1752 3,538 20,485

1753 774 19,276

1754 2,359 22,696

1755 1,988 21,917

1756 1,608 20,872

1757 3,296 21,313

1758 1,273 17,576

1759 2,596 19,604

1760 2,181 19,830

The year 1752, to which Fothergill refers most fully in the notes cited,

had the highest total of deaths from smallpox in the period 1721-60,

namely, 3538, and was exceeded by only two years in the latter part of the

century, 1772, with 3992 deaths and 1796 with 3548. Fothergill says twice

that the disease in 1752 was on the whole mild, but so universal that not

many escaped it who had not had it before; and that children from one to

three years suffered most from it. As the year was not an unhealthy one

in general, this epidemic of smallpox may be chosen to show its effect

upon the weekly mortalities, of children in particular.

_London Weekly Mortalities: Smallpox Epidemic of 1752._

Under Two Five Convulsions

Week All two to to Smallpox deaths

Ending deaths years five ten deaths

March 3 438 162 54 19 64 113

10 441 165 40 16 63 116

17 477 177 56 15 76 110

24 456 161 61 19 87 111

31 471 169 62 8 96 117

April 7 500 185 58 14 87 129

14 431 144 52 27 76 99

21 397 145 37 18 77 106

28 458 161 47 25 94 98

May 5 421 133 52 17 81 85

12 414 140 62 24 93 101

19 461 235 52 20 119 104

26 456 157 66 24 120 92

June 2 452 159 65 28 125 98

9 415 172 51 17 113 87

16 421 165 56 20 120 98

23 380 160 57 15 102 82

30 353 127 52 19 92 74

July 7 390 142 68 19 107 87

14 339 142 44 12 79 98

21 351 144 38 23 73 97

28 368 168 53 14 92 93

Aug. 4 316 141 37 13 72 90

11 350 155 44 13 58 99

18 297 145 26 9 43 98

25 371 168 46 12 57 109

The weeks with highest smallpox mortalities have not always the highest

deaths from all causes; but they correspond to a marked rise of the deaths

from two to five years. If the table were continued to the end of the

year, to show the decline of smallpox to a fourth or fifth of its highest

weekly figures, the decline in the deaths from two to five, as well as

from five to ten, would be seen to correspond more strikingly[1014]. The

other notable suggestion of the figures is that the article “convulsions,”

which included at that time nearly the whole of infantile diarrhoea, is

not so high as usual when the article smallpox rises most. The highest

weekly deaths from convulsions are in the first months of the year, when

the smallpox epidemic was beginning, and in September and October, the

season of infantile diarrhoea, when the smallpox epidemic was nearly

spent.

The ages at which persons died in the several diseases were not given in

the Bills, although they were recorded in the books of Parish Clerks’

Hall; so that the incidence of smallpox mortality upon infants and young

children cannot be proved for the capital as it can for other great towns

in the 18th century. Not only can it not be proved, but it was not the

fact that the disease was so exclusively an affair of childhood as it was

in the populous provincial centres. The London population was peculiar in

receiving a constant recruit direct from the country. Many of them came

from parishes where, as Lettsom says, “the smallpox seldom appears”; they

must often have passed their childhood without meeting with it, to

encounter the risk when they came to London[1015]. Many of the class of

domestic servants were in that position; and it was especially for them

that the London Smallpox Hospital existed, the admission to it being by

subscribers’ letters, as in the voluntarily supported hospitals at

present.

Its small accommodation was given up to some extent also to persons in

exceptionally distressed circumstances[1016]. From its opening on 26

September, 1746, to 24 March, 1759, it had admitted 3946 cases, of which

1030 had died; these are stated in the annual reports to have been “mostly

adults, in many cases admitted after great irregularities and when there

was little hope of a cure”; so that the practice of this hospital alone

may be taken as evidence of several hundreds of adult cases of smallpox in

the year in London (the whole annual cases averaging perhaps twelve

thousand).

The exact statistics which we shall come to in a later period of the

century, for Manchester, Chester, Warrington and Carlisle, show that

nearly all the deaths by smallpox were under five years; and it can

hardly be doubted that the bulk of them in London also, with all its

influx of country people, were at the same age-period. “Most born in

London,” said Lettsom, “have smallpox before they are seven.” It is

singular, therefore, that smallpox should have caused a much smaller

proportion of the deaths from all causes in London than in the populous

provincial cities. The annual average for London was one smallpox death to

about ten or twelve other deaths; in other large towns it was one in about

six or seven. Lettsom held that the proportion in London would have come

out nearly the same if the classification of deaths in the London bills

had been correct, the generic article “convulsions” having swallowed up,

in his opinion, a large number of the smallpox deaths of infants. An

assertion such as that is more easily made than refuted. Everyone agreed

that there was no difficulty in recognising smallpox[1017]. Whoever had

seen confluent smallpox all over an infant’s body was not likely to have

set down its death under any other name, for there is hardly anything more

distinctive or more loathsome. It is possible, however, that many infants

with mild smallpox had died of complications, such as autumnal diarrhoea.

Sydenham, indeed, says as much under the year 1667, blaming the nurses for

killing the infants by trying to check the diarrhoea. The truly incredible

sacrifice of infant life in London in the 17th and 18th centuries by

summer diarrhoea, as shown in another chapter, may have caused a certain

number of deaths of infants to be classed under “griping in the guts” in

the earlier period, and under “convulsions” in the later, which were

primarily cases of smallpox. But the true probability of the matter--and

it is wholly for us a question of probability--is that London’s smaller

ratio of smallpox deaths and greater ratio of infantile deaths from other

causes, was not artificially made by transferring deaths from the one to

the other, but was actual, owing to a really greater liability of the

London infants to die of other more or less nondescript maladies before

smallpox could catch them[1018].

The Epidemiology continued to the end of the 18th century.

The London bills, which are the only continuous series of figures, show

the following annual mortalities by smallpox from 1761 to the end of the

century:

_Smallpox Mortality in London, 1761-1800._

Smallpox All

Year deaths deaths

1761 1,525 21,063

1762 2,743 26,326

1763 3,582 26,148

1764 2,382 23,202

1765 2,498 23,230

1766 2,334 23,911

1767 2,188 22,612

1768 3,028 23,639

1769 1,968 21,847

1770 1,986 22,434

1771 1,660 21,780

1772 3,992 26,053

1773 1,039 21,656

1774 2,479 20,884

1775 2,669 20,514

1776 1,728 19,048

1777 2,567 23,334

1778 1,425 20,399

1779 2,493 20,420

1780 871 20,517

1781 3,500 20,709

1782 636 17,918

1783 1,550 19,029

1784 1,759 17,828

1785 1,999 18,919

1786 1,210 20,454

1787 2,418 19,349

1788 1,101 19,697

1789 2,077 20,749

1790 1,617 18,038

1791 1,747 18,760

1792 1,568 20,213

1793 2,382 21,749

1794 1,913 19,241

1795 1,040 21,179

1796 3,548 19,288

1797 522 17,014

1798 2,237 18,155

1799 1,111 18,134

1800 2,409 23,068

The last twenty years of the century show a decrease in the annual

averages of smallpox deaths, along with a decrease of deaths from all

causes. The health of the capital had undoubtedly improved since the reign

of George II., especially in the saving of infant life. But it is not

worth while instituting a statistical comparison, for the reason that some

large parishes, containing poor and unwholesome quarters, had become

populous in the latter part of the century, but were not included in the

bills, while some of the old parishes, including those of the City, were

probably become less populous owing to the conversion of dwelling-houses

into business premises of various kinds. The decrease of fever-deaths in

the bills is closely parallel with the decrease of smallpox, and it is

probable that both were real; but as there is an element of uncertainty in

the data it would be unprofitable to abstract statistical ratios from

them, or to aim at demonstrating numerically what can only be in a measure

probable. Perhaps the safest generality from these London figures is that

smallpox once more fluctuates a good deal from year to year, seldom,

indeed, falling below a thousand deaths, but showing a considerable drop

for several years after some greater epidemic, as in the earlier history.

This becomes most obvious by exhibiting the mortality in a graphic

tracing.

Manchester, which was a healthier place than the capital, having an excess

of births over deaths, had a smallpox mortality for six successive years,

1769-1774, as follows, the population, exclusive of Salford, having been

22,481 by a careful survey in 1773[1019]:

_Smallpox Deaths in Manchester._

Year All deaths Smallpox deaths

1769 549 74

1770 689 41

1771 678 182

1772 608 66

1773 648 139

1774 635 87

----- ----

3,807 589

Between a seventh and a sixth part of all the deaths in Manchester (15·3

per cent.) were from smallpox. All but one were under the age of ten

years:

All deaths Under One to Two to Three to Five to Ten to

by smallpox One year Two Three Five Ten Twenty

589 140 216 110 93 29 1

Manchester was one of the towns that had smallpox continuously from year

to year at this period. It had a rapidly growing population, and an excess

of births over deaths which was in great part due to the very large number

of new families settling in it. It was probably this rapid increase of

children that explained the great height of the smallpox mortality in

1781, namely, 344, rising from three deaths in January and falling to

thirteen in December, the maximum being in the third quarter of the

year[1020].

Liverpool, like Manchester, had smallpox among its infants and children

steadily from year to year, and a higher rate of fatality from that cause

than Manchester. With a population half as great again as that of

Manchester, namely, 34,407 in 1773, it had the following deaths from

smallpox, according to the figures taken from the registers by Dobson and

supplied to Haygarth[1021]:

A History of Epidemics in Britain, Volume 2 (of 2) From the Extinction of Plague to the Present Time · 第 12 / 24 章

Such cases were not often heard of. As Mead said, “If such a thing