The original mode of inoculation, with the matter of smallpox itself, was

far from being supplanted by its rival. In Jenner’s first essay the latter

was put forward tentatively, not indeed because of any want of confidence

in asserting its protective powers, but because it was only in certain

circumstances that a substitute was desired for the old inoculation. Some

of those who took up the new matter soon discontinued the old altogether,

as at the Newcastle and Whitehaven Dispensaries. At the London Inoculation

Hospital the old practice was given up for out-patients after 1807, and

for in-patients about 1821. In private practice, tastes or preferences

differed. While ordinary people left it to the discretion of their medical

advisers, commissioning them to inoculate their children “with either kind

of pock,” the upper classes “judge for themselves, and those among them

who are philanthropists and converts to the new faith inoculate their own

children and those of the poor together[1123].” Moseley, in 1808, said

that the “mere operative practice” in cowpox, by which phrase he meant to

contrast the academic countenance of it by eminent physicians and

surgeons, had been “chiefly carried on by lady-doctors, wrong-headed

clergymen, and disorderly men-midwives,” Dr Pearson being named as the

only man of letters or pretensions to science who had been practically

concerned in it of late[1124].

There was really little to choose between the new method and the old so

far as concerned facility of operating; if anything, the inoculation of

smallpox was the more difficult of the two, although that also was largely

practised by amateurs[1125]. Again, as regards remunerativeness,

inoculation with smallpox no longer required the combined services of a

physician, a surgeon and an apothecary; it had become a matter of simple

routine, just as ill paid (or as well paid, according to circumstances) as

inoculation with the matter from the cow. It was not on such grounds, but

on grounds of scientific principle or of sentimental interest, that an

active propaganda was kept up in favour of the old inoculation. The

leading defenders of the latter, such as Moseley, physician to Chelsea

Hospital, and Birch, surgeon to St Thomas’s Hospital, maintained that

cowpox was alien in nature to smallpox and could not be received as its

equivalent. The foreign protagonists, such as Dr Müller, of Frankfort, and

Dr Verdier, of Paris, emphasized still more the radical unlikeness of

cowpox to smallpox. Said Verdier: “The vaccinists appeal to experience,

setting aside all objections based upon the unlikeness of cowpox to

smallpox. We are to be made invulnerable by vaccine as Achilles was made

invulnerable by being dipped in the waters of the Styx. Protection by

cowpox contradicts the received principle of inoculation. It is in vain to

appeal to experience against established principles: for true principles

are the result of the experience of all ages, and become the touchstone of

each successive empirical innovation.”

The English inoculators by the old method gave all sorts of reasons for

their preference, and were doubtless actuated by the usual mixture of

motives. There were medical families, such as the Lipscombs, who had an

hereditary interest and pride in inoculation. It was a Lipscomb who had

recited in the Sheldonian Theatre during the Oxford commemoration of

1772, a poem, “On the Beneficial Effects of Inoculation.” Inoculators to

the third generation, it was not surprising that the Lipscomb family

should have caused to be printed in 1807, as if to shame the changing

fashion of the day, the prize poem of five-and-thirty years before, which

contained such spirited lines as these:

“When, pierced with grief at sad Britannia’s woes,

Her country’s guardian Montagu arose:

Pure patriot zeal her ev’ry thought inspir’d,

Glow’d on her cheek, and all her bosom fir’d.

She saw the Tyrant rage without controul,

While just revenge inflam’d her gen’rous soul.

Full well she knew, when beauty’s charms decay’d,

Britannia’s drooping laurels soon would fade:

Pierc’d with deep anguish at the afflictive thought

And whelm’d with shame, a heav’n-taught Nymph she sought,

Whose potent arm, with wondrous power endued,

Had oft on Turkey’s plains the fiend subdued.

Obedient to her prayer the willing Maid

In pity came to sad Britannia’s aid.

‘Henceforth, fall’n Tyrant!’ cries the Nymph, ‘no more

Hope that just Heav’n will thy lost pow’r restore:

Let now no more thy touch profane defile

The sacred beauties of Britannia’s isle.

By me protected shall they now deride

Thy baffled fury and thy vanquish’d pride[1126].’”

Still it was just among those classes to whom the _argumentum ad nitorem_

came home most forcibly that the fashion had changed. Before the end of

the 18th century, the danger to beauty from an attack of smallpox had

become a matter chiefly of historical interest, carrying the mind back to

the Restoration or the early Georgian era. The richer classes, while they

seem to have countenanced cowpox inoculation as a good thing in general,

were probably apathetic on their own account. Lord Mulgrave said in the

House of Lords on 8 July, 1814; “If their lordships recollected how many

persons of the higher order were reluctant to introduce vaccination into

their families, it really must appear to them a harsh and arbitrary

measure to lay the poor under the necessity of adopting the practice.” The

working class had been manifesting a devotion to the old practice which,

indeed, they had never shown so long as it was unchallenged. Perhaps one

reason to account for the undoubted preference of the poorer classes for

the old inoculation was that they had only lately taken to it. Another was

that a good deal of inoculation was done by amateurs of their own

class--blacksmiths, farriers, tradesmen and women. A third reason was that

the poorer classes, among whom smallpox prevailed most, saw their children

take smallpox all the same, and cared little for the scientific

explanation that a false or spurious kind of cowpox matter had been used.

In October, 1805, a correspondent wrote from London to an Edinburgh

journal: “The many late failures of supposed cowpock to prevent the

smallpox have excited in some parts so much clamour among the lower orders

of people that they insist upon being inoculated for the smallpox at some

of the public institutions[1127].” A report on vaccination made to

Parliament by the College of Physicians in 1807, deplores “the

inconsiderate manner in which great numbers of persons ever since the

introduction of vaccination are still every year inoculated with the

smallpox.” When, in consequence of the same report, a vote was brought

forward in Parliament to give Dr Jenner a national reward of twenty

thousand pounds in addition to the ten thousand that he had got five

years before, the populace were so angry that one of their leaders, John

Gale Jones, himself a medical man, sent a message to Jenner at his

lodgings in Bedford Place to advise him “immediately to quit London, for

there was no knowing what an enraged populace might do[1128].”

Few particulars remain of the old inoculation at this time. One fact

significant of the impression that the criticisms of cowpox had made is

that Dr John Walker, director of the Royal Jennerian Society, who pushed

“vaccination” among the poorer classes more than anyone in London, was all

the while an inoculator in the old manner. He wrote to Lettsom, “I have

from the first introduction of vaccination entertained an opinion

respecting its nature different from those who suppose it a _substitute_

only for smallpox.... I have, from an early part of my practice, been in

the habit of _diluting_ smallpox virus with water previous to its

introduction into the system;” and this he had been doing in the name of

Jenner, under the influence of a belief that, if cowpox were not smallpox,

it ought to be, that it was a pity the disease had ever been called

cowpox, and that the name (which was a very old one) “has only served to

debase it in the eyes of the common people, and prevent its general

adoption[1129].” The very director of the Jennerian institute was among

the prophets of the old inoculation.

With the revival of smallpox in general epidemic diffusion in 1816-19 we

begin to hear more of the old inoculation. The account already cited of

the outbreak at Ulverston contains a table of fourteen previously cowpoxed

children whom it was thought desirable during the epidemic to inoculate

with smallpox, all of them receiving the infection in one degree or

another. A practitioner at Dunse, Berwickshire, not only returned to the

old inoculation (thereby incurring “much odium,” as he believed), but

actually took his matter from the natural smallpox of his cowpox

failures[1130].

When the epidemic reached the Eastern Counties, there were demands for the

old kind of inoculation, not in Norwich only, but in numerous country

parishes. Of ninety-one surgeons in Norfolk and Suffolk, who answered the

queries of Cross, thirty-eight had practised the inoculation of smallpox

in the epidemic of 1819; five of them, after having refused many private

applications for inoculation in the old way, had at length yielded to the

desire of the Overseers of the Poor, and had inoculated whole parishes.

Cross’s correspondents also testified that there was much inoculation

going on at that time in the Eastern Counties by the hands of farriers,

blacksmiths, tailors, shoemakers and women.

Dr John Forbes, who then practised at Chichester, brought to light an

exactly similar state of public feeling in Sussex in 1821-22[1131]. In the

parish of Bosham there lived a farmer named Pearce who had an inherited

skill in inoculating, his father having inserted smallpox into ten

thousand persons in his day, without killing one of them. Pearce offered

to wager with Forbes a considerable sum that he would inoculate any number

of persons and that none of them should have more than twenty pustules. He

believed that the smallpox matter became “as weak as water” by an

uninterrupted transmission from one body to another.

In November, 1821, the Overseers of the Poor employed him to inoculate the

pauper children, and his skill was soon in request for others, so that

from two to three hundred in the parish were inoculated by him within a

short time. He charged half-a-crown or a crown for each. From other

parishes the people flocked to him in such numbers that he inoculated

upwards of a thousand in the winter and spring of 1821-22. Before long he

had three itinerant rivals, a knifegrinder, a tinsmith and a fishmonger,

who claimed to have inoculated together a thousand persons, including four

hundred previously cowpoxed. The surgeons of Emsworthy and Havant at

length joined in the business, and in the space of six or eight weeks

inoculated from twelve to thirteen hundred persons, who had not been

previously vaccinated. Forbes also received from his medical friends in

and around Chichester “an account of 680 cases of previously vaccinated

individuals subjected by them to variolous inoculation.” In the great

majority of these the constitutional symptoms were so slight as to be

only just observable, the eruption consisting of only a few pustules,

which were all that the Pearces, of Bosham, father and son, ever expected

to get with inoculated smallpox where no infection of cowpox had preceded.

Disappointments with the new inoculation had led to a great revival of the

old also at Canterbury, the operators being mostly women.

The same thing happened in Cambridgeshire and in Bucks. In a parish within

eleven miles of Cambridge several hundred persons were inoculated with

smallpox in 1824, and in April, 1825, a medical practitioner inoculated a

number in a village near[1132]. During a severe epidemic in the parish of

Great Missenden, Bucks, which followed a general vaccination, and caused a

prejudice against the latter, the old inoculation was generally resorted

to[1133]. It looked for a brief period, about the time of the epidemic of

1824-26, as if the old inoculation were to return to favour even with the

profession itself. Dr John Forbes wrote of the two kinds of inoculation in

a studiously impartial manner. Dr Robert Ferguson, who was also destined

to make a name, addressed in 1825 a letter to Sir Henry Halford in which

he advocated a singular compromise, namely, two inoculations, one with

cowpox, the other with smallpox, the cowpox to neutralize the

contagiousness of the smallpox for the occasion, while the latter was to

be the prophylactic against itself for the future[1134]. This reaction, if

it deserves that name, corresponds in time to the great decline in the

number of gratuitous vaccinations at Manchester, a decline which had been

equally remarkable at Glasgow for some years before. There was at least an

apathetic spirit towards cowpox inoculation during the epidemic of

1817-19, and for a good many years after it, while there was something

like toleration, even among medical men, for the old inoculation.

The Smallpox Epidemic of 1825-26.

Compared with the epidemic of 1837-40, which was the first in England to

be recorded under the new system of registration of the causes of death,

the smallpox of 1825-26 makes a poor figure in the records. Yet there is

reason to believe that it was an epidemic of the same general kind, if not

of the same duration or fatality. At the Newcastle Dispensary far more

children in the smallpox were visited in 1825 than in any year since its

opening in 1777, namely, 113 cases, with 28 deaths, which would have been

a small fraction of all the cases in Newcastle. At the Rusholme Road

Cemetery, Manchester, which received about a fourth part of the burials,

112 children, all under seven years, were buried from smallpox in the six

months, 18 June to 18 December, 1826[1135]. At Bury St Edmunds smallpox

began to be epidemic about the end of 1824, when the guardians ordered a

general vaccination, and reached its worst in July, 1825, the type being

confluent in many of the cases[1136]. It was in Cambridgeshire villages

the same year, and is casually heard of in Bucks[1137]. It had been severe

at Oxford and Canterbury in 1824. At Glasgow the prevalence of fever is

known for the corresponding years, but the smallpox deaths have not been

taken out of the burial registers. The evidence from London is perhaps the

best indication that the smallpox of 1825 was one of the more severe

periodic visitations.

The extensive prevalence of smallpox was heard of in Paris before the

epidemic attracted much notice in London; the news of persons of

distinction dying by smallpox in the French capital reads like the old

notices of it in 17th century letters. In the same year it was very severe

also in Sweden after a long period of quiescence. As to London, Dr George

Gregory, physician to the Smallpox Hospital, said[1138]: “It may be

inferred that smallpox has been nearly as general in 1825 as in any of

the three great epidemics of the preceding century”--the demand for

admission to the Hospital being, in his opinion, a fair index; while

private information confirmed the estimate of its truly epidemic

prevalence, and of its incidence chiefly upon the lower classes[1139]. In

the years of the 18th century to which he referred, and in four maximum

years of the 19th century, the cases and deaths at the Smallpox Hospital

had been as follows[1140]:

_London Smallpox Hospital._

Year Cases Deaths

1777 497 125

1781 646 257

1796 447 148

1805 280 97

1819 193 61

1822 194 57

1825 419 120

While the demands upon the beds of the hospital pointed, as Gregory

supposed, to the existence of a great epidemic in London, comparable to

those of 1777, 1781 or 1796, in which years the smallpox deaths were

returned by the parish clerks at 2567, 3500 and 3548 respectively, yet in

1825 the bills showed only 1299 deaths from smallpox. Gregory accepted

without demur the figures of the parish clerks’ bills in 1825, although it

is well known that they had become more and more defective, even for the

original parishes, since the end of the 18th century[1141]. “But for the

general prevalence of vaccination,” he said, the smallpox deaths in 1825

would have been 4000 in the same number of attacks, the difference being

in the rate of fatality. His conclusion for all London was based upon the

experience of the Smallpox Hospital. The patients received by that charity

were of the same class as formerly, most of them being adults, among whom

the proportion of fatalities was greater than at all ages. Taking the

three epidemics of the 18th century with which he compared the epidemic of

1825 in respect of extent or number of attacks, we find that 25 per cent.

of the cases admitted died in 1777, 39 per cent. in 1781 (the seasons

were unwholesome by epidemic agues, dysenteries, and typhus), and 33 per

cent. in 1796. The average of fatalities at the hospital from its opening

in 1746 to the end of the century was about 29 per cent., and that was

exactly the ratio of deaths among the 419 patients in 1825. The rate of

fatality was a little higher than in the epidemic of 1777, and a little

lower than in each of the epidemics of 1781 and 1796. Gregory in 1825 was

enabled to separate the sheep from the goats by the dividing line of

cowpox, the former dying at the rate of 8 per cent., the latter at the

rate of 41 per cent. There are various ways of apportioning a general

average. The presence or absence of cowpox scars is one principle, which

could not have been used to break up the 25 per cent of 1777, or the 39

per cent, of 1781, or the 33 per cent. of 1796, into two component parts.

One thing common to all times is the different rate of fatality at

different ages. All the deaths in the 8 per cent. division of 1825 were

between the ages of eighteen and twenty-seven; the ages of the 41 per

cent. division are written in the books of the hospital. In portioning out

the general rate of fatality from typhus fever at the London Fever

Hospital, it is found that the dividing line of age is nearly the same as

the dividing line of social position; in one table the high ratio of

deaths to attacks is among persons in the second half of life, and the low

ratio among persons in the flower of their age; in another table the many

deaths to cases are among paupers, and the few fatalities among paying

patients[1142]. However manifold the cutting up of a general average, some

divisions would be identical, corresponding to natural lines of cleavage.

Having indicated the chief points in the vaccination controversy by the

instance of Gregory’s arguments sixty years since, (to which might have

been added the question of efficient or inefficient vaccination according

to the appearance of the scars in after life[1143]), I shall for the rest

depart from the usual practice of interlocking the history of smallpox

epidemics with the history of vaccination. I shall treat the latter as _ex

hypothesi_ irrelevant, leaving it to each reader to incorporate, as

matter of his own familiar knowledge or belief, whatever effects of cowpox

upon smallpox, whether temporary effects or permanent, modifying effects

or absolutely prophylactic, may suit his particular creed. I am led to

take this course for several reasons. It leaves me free to look at the

epidemics of smallpox from the same point of view as the other epidemics

treated of in this work. It avoids a controversy which, unlike that of

inoculation, is still actual, and unsuited to a historical treatise. It

enables me to omit the excuses for failure, which are apt to be

interminable and to usurp the whole space available for the epidemiology

proper. Lastly, the irrelevancy which I here conveniently assume happens

to be my real belief,--as elsewhere set forth in an examination of the

antecedent probability arising out of the pathological nature and

affinities of cowpox, and in a study of the grounds on which the authority

of the profession was originally given to Dr Jenner’s teaching.

The interval between the epidemic of 1825 and that of 1837-39 was occupied

by a good deal of smallpox steadily from year to year in London, the

deaths from which, in the following table from the bills of mortality, are

to be understood as only a part of the whole, according to the explanation

already given:

Smallpox

Year deaths

1826 503

1827 616

1828 598

1829 736

1830 627

1831 563

1832 771

1833 574

1834 334

1835 863

1836 536

1837 217

The inadequacy of these returns will appear from the fact that the 217

deaths in 1837 rose, under the new system of registration, from 1 July to

31 December, to 762, or to fully three times as many for the last six

months as the parish clerks returned for the whole year. Their bills had

become most defective when they were about to be, or had been superseded;

but even on the special occasion of the cholera in 1832 they returned only

some three-fifths of the known deaths. Besides these London figures there

is little to show the extent of smallpox in England between the epidemic

of 1825 and that of 1837-39. This was the time when many complaints were

made of the so-called loss of power or strength in the current cowpox

matter for inoculation. These complaints appear to have arisen from the

greater frequency of smallpox among the cowpoxed, corresponding to the

increasing numbers of the whole population who had received that kind of

inoculation. “Secondary smallpox,” says a report from Worcestershire in

1833, “has been very prevalent of late years[1144],” the term “secondary”

reflecting the teaching of Baron, chairman of the Smallpox Committee of

the Medical Association, that cowpox itself was the primary smallpox. The

increasing number of the vaccinated who took smallpox was clearly shown in

the returns from the Smallpox Hospital of London, and was believed to be

in proportion to the increasing number of the rising generation who had

been vaccinated[1145].

A generation of Smallpox in Glasgow.

Glasgow had afforded the most striking instance in Britain of the decline

of smallpox after the beginning of the 19th century. The decline was

observed everywhere, but it was most noticeable in Glasgow, partly because

the smallpox mortality of infants at the end of the 18th century had been

excessive there, partly because Dr Watt took the trouble to prove it

statistically from the burial registers. In the last six years of the 18th

century, 1795-1800, smallpox had contributed 18·7 per cent. of the deaths

from all causes; from 1801 to 1806, it contributed 8·9 per cent., and from

1807 to 1812 only 3·9 per cent. In the next six years, 1813-19, if

Cleland’s search of the registers has been as laborious as Watt’s, the

share of smallpox was only 1·07 per cent. of the deaths from all causes,

which would mean that Glasgow was hardly at all touched by the epidemic of

1817-19, reported from many other parts of Scotland[1146]. But the lull

in smallpox, which corresponded on the whole to the still greater lull in

fevers during the prosperous times of the second half of the French war,

was broken in Glasgow, if not in 1817, yet before long. Unfortunately

there is a break in the statistics also. From 1821 the magistrates caused

annual bills of mortality to be published, which did not, however, specify

the causes of death until 1835[1147]. But we have some intermediate

glimpses of the state of the poorer classes and of the prevalence of

smallpox in particular. Writing in 1827, Dr Mac Farlane one of the poor’s

surgeons, remarks upon the feeble stamina, sallow complexions, and the

like, of all but a few children in the more crowded parts, adding that

smallpox both in the virulent and “modified” forms had been more prevalent

during the last three or four years than formerly[1148]. Three years

after, Drs Andrew Buchanan and Weir gave an account of the state of the

poor in Glasgow, which shows that it had actually deteriorated with the

growth of the city. The poorer classes had been in some part displaced

from their old dwellings in the heart of the town owing to the building of

warehouses or the like, and had been provided with no new habitations as

good as the old. “Apartments originally intended for cellars, and occupied

as such until lately, are now inhabited by large families, and the only

opening for light and air is the door, which when shut encloses the poor

creatures in a tainted atmosphere and in total darkness. This is well

exemplified in the cellars belonging to the houses on the south side of St

Andrew’s Street.” Not only the notorious region of the Wynds, containing

part of the three parishes of the Tron, St Enoch’s and St James’s, but

also the Saltmarket and Gallowgate, were crowded with a destitute, vagrant

and often vicious class of people. Many of the houses in the Wynds, with

their network of alleys, were only one or two storeys high, in the old

Scotch fashion; here were the night lodging-houses, with several beds in

one room, two or three persons in a bed, twelve to eighteen people in as

many square feet: “the extreme misery of these poor people is utterly

inconceivable but to those who have actually witnessed it; it has

certainly been carried to the very utmost point at which the existence of

human beings is capable of being maintained. Some of them are lodged in

places where no man of ordinary humanity would put a cow or a horse, and

where those animals would not long remain with impunity.” Buchanan found

sometimes a horse, sometimes an ass, sometimes pigs, in the same dungeon

with one or more families[1149]. Such was the region in which Chalmers

ministered from 1815 to 1822, first in the Tron parish, afterwards in the

poor and crowded parish of St John’s. Things got no better, certainly,

after he left worn out by his exertions, to become professor at St

Andrews. Buchanan thought the best index of the degradation of the people

in 1830 to be that not one in ten ever entered a church (if they had, he

explains, the respectable congregation would have fled from their filth

and rags). “The people are starving,” he exclaims, “and there is a law

against the importation of food[1150].” It took sixteen years longer to

secure the benefits of free trade, and meanwhile the public health of

Glasgow got worse rather than better. The infantile part of it attracted

far less notice than that which touched adults, so that we hear little of

smallpox, while the records of fever and cholera are fairly complete. When

the curtain is lifted in 1835 by the publication of statistics, the

mortality of infants and children by infectious diseases is found to be

proceeding as follows:

_Glasgow Mortalities, 1835-39._

Deaths Deaths Deaths Deaths

from all from from from

Year causes smallpox measles scarlatina

1835 7198 473 426 273

1836 8441 577 518 355

1837 10270 351 350 79

1838 6932 388 405 87

1839 7525 406 783 262

According to the following table of the ages at death from smallpox, it

will appear that a higher ratio of infants died of it in their first year

at Glasgow than was the rule elsewhere, whether in the 18th or in the 19th

century. It was only in the year 1837, when typhus was at its worst and

smallpox had somewhat declined, that the deaths by the latter of infants

under one year were fewer than those of infants in their second year:

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

Under Above

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

1835 204 154 75 17 14 8 1 0 473

1836 202 174 144 23 6 24 2 2 577

1837 93 116 94 24 10 11 4 0 352

1838 111 99 119 28 11 14 4 2 388

1839 137 98 113 19 15 17 5 2 406

Totals of

five years 747 641 545 111 56 74 16 6 2196

\---------v---------/

Percentages 34% 29% 25% 5% 7%

Cowan, who published these figures in 1840, had written eight years

before, “I fear that if the list of infantile diseases were still

published in the mortality bills many deaths from smallpox would annually

be found.” We do, indeed, hear of epidemics of smallpox not far from

Glasgow. At Stranraer, in Sept.-Nov. 1829, “measles and smallpox attacked

with scarcely an exception” all the children in the place who had not

acquired immunity either by previous attacks or by the influence of

vaccination; “and even these powerful protectives were, in many instances,

of no avail.” The subjects of “unmodified” smallpox were nearly all

infants of the poorer class. In St John’s Street, occupied by decent Scots

labouring people, ten children had “unmodified” smallpox and all

recovered; in Little Dublin Street, so called from its Irish tenants,

fourteen children had smallpox, of whom six died[1151]. At Ayr, about the

same time, there was an epidemic, which came to a height in 1830, causing

a considerable mortality[1152]. At Edinburgh in the winter of 1830-31, it

was unusually prevalent and fatal, the epidemic dying out in May,

1831[1153].

For three or four years, 1843-46, there was another lull in the prevalence

of smallpox in Glasgow; but the mortality rose again, reaching in the two

years 1851 and 1852 the total of 1202, in a population of 360,138, which

contrasted with the 2212 deaths in London in the same two years, and with

the Paris mortality of 706 in the two years 1850 and 1851, in a population

of about one million, the deaths being still almost wholly infantile in

Glasgow while they were in great part of adults in Paris[1154].

_Glasgow Smallpox._

Smallpox

Year deaths

1840 455

1841 (pop. 282,134) 347

1842 334

1843 151

1844 99

1845 195

1846 not recorded

1847 592

1848 300

1849 366

1850 456

1851 (pop. 360,138) 618

1852 584

Registration of the causes of death began in Scotland in 1855. In the

first decennial period, to 1864, the smallpox deaths were 10,548, falling

upon infancy and other age-periods as in the following table[1155]:

Age-periods Smallpox deaths

Under three months 774

Three to six months 668

Six to twelve months 1543

One to two years 1765

Two to three years 1132

Three to four years 798

Four to five years 514

----------------------------------

Total under five years 7194

Above five years 3354

------

10,548

Smallpox in Ireland, 1830-40.

Before coming to the epidemic in England let us glance at the prevalence

of smallpox at this period in Ireland. Dr Cowan, of Glasgow, was struck by

the fact that among ninety patients in the Infirmary with smallpox, all

adults, only four were from the considerable Irish population of the

city, the larger number being natives of the Highlands of Scotland. This

leads him to say: “The immunity of the Irish from smallpox is owing to the

general practice of vaccination among the lower classes by the surgeons of

the county and other dispensaries” (another Glasgow writer ascribes the

prevalence of smallpox to the Irish negligence in the same matter). It

happens that we can bring one part of this statement to a statistical

test. The same volume of the _Journal of the Statistical Society_ which

contained the paper on the vital statistics of Glasgow contained also a

statistical account of the public health of Limerick, by Dr Daniel

Griffin, physician to the Dispensary[1156]. Dr Griffin’s figures were of

the only kind that could then be got for an Irish town, and were

representative rather than exhaustive. Struck by the seemingly enormous

death-rate of infants in the poorest quarters of Limerick, he sought to

bring out the facts with numerical precision. He provided a register-book

at the Dispensary, in which he entered the results of his observations and

retrospective inquiries among eight hundred families of the poorest class

during “a good many years” down to 1840. The city of Limerick, and

especially the parish of St Mary, was full of the misery and destitution

that characterized Ireland in the years of its greatest over-population.

The ejected cottiers and broken small farmers of the neighbouring county

flocked to it, living in beggary in wretched lodging-houses with swarms of

infants and children, the breadwinners finding only an occasional day’s

work as labourers. Among 800 such families during the years of his

inquiries the chief causes of death among the infants and children were as

follows:

_Limerick Dispensary Deaths._

Under Five Five to Above

years Ten Ten Total

Convulsions 569 18 7 594

Smallpox 333 55 5 393

Measles 187 32 7 226

Diarrhoea and Dysentery 108 19 24 151

Whooping cough 84 10 1 95

Croup 85 9 1 95

Scarlatina 8 2 0 10

Fever 70 33 66 169

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

were:

Under One and Three and Five to Above

One Two Four Nine Nine

Males 33 72 37 29 2

Females 52 92 47 26 3

-- --- -- -- --

85 164 84 55 5

As compared with Glasgow, measles at Limerick has a much lower place than

smallpox in the infantile mortality, while scarlatina hardly counts at

all. Again, only 1·27 per cent. of the smallpox deaths are above the age

of nine, whereas at Glasgow 7 per cent. are above the age of ten.

Griffin’s data for reckoning the probability of life were incomplete, as

he was well aware; so that the following comparison of the poor attending

Limerick Dispensary with all England and Wales probably errs in making the

Irish town somewhat more fatal to infants of the poor than it really was:

England and Wales Limerick Dispensary

in 1000 deaths in 1000 deaths

Under one year 214·54 327·71

One and under three 128·00 287·67

Three and under five 48·51 128·20

Five and under ten 46·07 97·29

Ten and under fifteen 25·91 24·93

Fifteen and under twenty 34·16 20·37

In a thousand deaths at all ages, 391·05 occurred before the age of five

years in England and Wales, but 743·58 before the age of five years among

a certain section of the poor of Limerick; and in the latter enormous

sacrifice of infant life smallpox was the greatest single means next to

convulsions. Perhaps that was the reason why so few of the Irish in

Glasgow were attacked by smallpox in adult age. The experience of Limerick

was not exceptional in Ireland. In the ten years 1831-40, for which the

causes of death were ascertained by means of queries in the census returns

of 1841, the total of deaths by smallpox was 58,006, nearly double the

mortality by measles (30,735) and seven times that of scarlatina (7,886).

It was almost wholly a malady of infants and children, the first and

second years of life being its most fatal period. Only 129 of these deaths

were returned from hospitals. The bulk of the decennial smallpox deaths

fell in the two years 1837 and 1838, corresponding with the high epidemic

mortality in England[1157].

The Epidemic of 1837-40 in England.

The smallpox epidemic of 1837-40 was already in full force at Liverpool,

Bath and Exeter when the mortality returns began to be made on 1st July,

1837, under the new Registration Act. Whether or not the contagion

travelled from Ireland or the west of Scotland, the epidemic in England

began in the west and south-west, and reached the Eastern counties last.

The following table shows its rise and progress at selected places in the

several quarters, beginning with the third quarter (July-September) of

1837[1158]:

1837 1838 1839

+---------+ +---------------------+ +---------------------+

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

qr qr qr qr qr qr qr qr qr qr

Liverpool 375 132 32 24 18 36 11 29 75 138

Bath 154 18 15 1 1 2 1 25 17 30

Exeter 88 131 6 -- 2 -- -- -- -- --

Bristol 21 74 72 44 4 7 6 -- -- --

Clifton 16 32 49 27 7 -- -- -- 1 7

London 257 506 753 1145 1061 858 364 117 65 60

Manchester 23 98 127 120 111 180 94 40 33 53

Birmingham 34 55 85 86 66 47 26 12 7 10

Sheffield 14 14 27 36 22 12 9 3 4 --

Leeds 4 11 29 69 134 197 74 55 30 15

Newcastle 16 17 66 11 -- 23 54 24 39 25

Abergavenny

and 13 85 102 50 22 21 22 30 26 10

Pontypool

Merthyr

Tydvil 9 54 160 91 10 3 18 16 12 --

Weymouth,

Bridport,

and 4 19 92 31 8 4 10 9 2 --

Beaminster

Plymouth 10 15 11 14 37 48 9 8 1 --

Taunton -- 7 66 40 4 3 -- -- -- --

Leicester 43 5 3 2 3 3 9 21 5 15

Norwich 1 -- -- -- -- 17 180 204 10 7

Lynn etc. -- 1 2 10 7 4 127 81 6 --

Ipswich -- -- 2 6 38 95 23 -- 1 --

Bury St

Edmunds 1 3 30 24 2 3 -- -- -- --

etc.

Woodbridge

etc. 4 9 27 16 5 11 10 2 -- 4

The epidemic having begun in the west and south-west in the summer of

1837, spread in the winter of 1837-38, all through the hills and valleys

of Wales, causing high mortalities around Abergavenny, Pontypool, Merthyr

Tydvil and other towns in the first quarter of 1838, as well as in the

rural parishes. It was not until the end of 1838 that the contagion spread

widely over the Eastern counties. The epidemic in Norwich was again short

and sharp, like that of 1819, most of the 418 deaths falling within six

months of winter and spring, just as most of the 530 deaths in 1819 fell

within six months of summer and autumn. The population in 1821 was 50,288,

and in 1841, 62,344; the increase was only 1228 between 1831 and 1841, so

that the smallpox of 1839 fell upon a stationary population, whereas that

of 1819 had fallen upon a rapidly increasing one. In the autumn of 1839

and throughout 1840, a second outburst of smallpox took place in the towns

where the epidemic had started two years before, namely, Liverpool, Bath,

Bristol, Clifton, etc[1159].

But the smallpox of 1840, which produced more deaths than that of 1839,

was mostly centred in the Lancashire manufacturing towns, where also the

mortality from scarlet fever was enormous. The circumstances of the

working class in Lancashire at this time have been described in the

chapter on fevers. The following shows the large proportion of smallpox

deaths that fell in 1840 to the North-Western or Lancashire registration

division.

_Smallpox Deaths, 1840._

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

England and Wales 2071 2476 2274 3613

------------------------------------------------------------

Of which in the N.-W.

Division (Lancashire) 1046 986 533 590

The epidemic continued in the manufacturing towns into 1841; in the more

rural registration divisions of England it had almost ceased in 1839. From

the 1st July, 1837 (beginning of registration) until the 31st December,

1840, the epidemic smallpox in England and Wales caused 41,644 deaths. In

1838 it eclipsed both measles and scarlatina as a cause of death among

children; but in 1840 scarlatina gained the leading place and kept it.

Legislation for Smallpox after the Epidemic of 1837-40.

The epidemic of smallpox in 1837-40, which was fatal chiefly to infants

and young children, was one of the greatest, like the corresponding

epidemic of typhus among adults, in the whole history of England. The

troubles of the working class had been more or less chronic ever since the

booming times of the Peninsular War had come to an end; the climax was

reached in the thirties; the enormous sums spent upon railway construction

gave a relief in the forties; and the permanent cheapening of food by Free

Trade made an entirely new era, which became visible in the public health

after the contagion of the Irish famine had ceased in 1848. The great and

hitherto permanent decrease of typhus was brought about by social and

economic causes. There, at least, _laissez faire_ was all powerful: “Let

us be saved,” said Burke, “from too much wisdom of our own, and we shall

do tolerably well.” But there has been at no time since the 18th century

the same passiveness towards smallpox; that is a disease against which we

must always be doing something direct and pointed. The legislation against

smallpox began in England (nothing was done for Ireland and Scotland until

long after) with the Act of 1840.

It is a singular instance of the changes in medical opinion and of the

vicissitudes of things that the first statute against smallpox should have

been instigated by a desire to suppress the old inoculation. Parliament

was first moved to action by the Medical Society of London through a

petition presented by Lord Lansdowne; but things had been moving that way

for some time before in the councils of the British (then the Provincial)

Medical Association, under the influence of Dr Baron, the executor and

biographer of Dr Edward Jenner. The Bill of 1840 was brought into the

House of Lords by the second Lord Ellenborough, and conducted through the

Commons by Sir James Graham, who was not then in office. It purposed to

enable the poorer classes to get their children vaccinated, if they so

desired, at the cost of the ratepayers, and to prohibit under penalties

the practice of the old inoculation by amateurs or empirics. Blomfield,

bishop of London, said in the Lords’ debate that many of the ignorant

poor, in agricultural districts, were strongly prejudiced against

inoculation with cowpox, and that they paid much greater attention to

empirics, meaning inoculators by the old method, than to the advice of the

clergy. In the Commons, Mr Wakley, who was a Radical and the proprietor of

one of the weekly medical journals, declared that “no one could be

ignorant that the working classes entertained great prejudices against

vaccination,” although he did not explain why they were prejudiced.

According to this medical authority, whom the House took seriously on that

subject if on no other, the epidemic of smallpox which the country had

just passed through had been in effect due to the contagiousness of the

smallpox matter used in inoculating; and he succeeded in carrying an

amendment to put down the old practice, not only in the hands of amateurs

but also in those of medical men. The eighth clause of the Act decreed

that any person convicted before two justices in Quarter Sessions of

having wilfully procured the smallpox by inoculation shall be liable to a

penalty of imprisonment for a term not exceeding one calendar month. The

penal clause against the original inoculation was an indirect compliment

to its vitality. Lord Lansdowne also paid it a compliment by recognizing

the correctness of its principle; the rival inoculation-matter of cowpox,

he said, was “perfectly identical” with smallpox, “although the symptoms

were different.” This will be a convenient point in the history at which

to review the rise and progress of the idea that the inoculation of

smallpox was a wilful spreading of contagion and therefore a public

nuisance.

The risk of spreading the contagion of smallpox by inoculating the

disease was one of the objections to the practice raised by Wagstaffe

in his letter to Dr Freind in 1722: “I have considered,” he says, “how

destructive it may prove to spread a distemper that is contagious.”

Still more explicit was Dr Douglass of Boston, New England, writing on

1 May, 1722: “I oppose this novel and dubious practice ... in that I

reckon it a sin against society to propagate infection by this means,

and bring on my neighbour a distemper which might prove fatal, and

which, perhaps, he might escape (as many have done) in the ordinary

way.... However, many of our clergy have got into it, and they scorn

to retract[1160].” Within a few months there was a striking instance

of the alleged danger in one of Maitland’s inoculations at Hertford,

an inoculated child, with only twenty pustules, having been supposed

the probable source of the natural smallpox in five domestics, of whom

one died. The death of the Duchess of Bedford by the natural smallpox

in 1724 happened “after two of her children were recovered of that

distemper, which they both had by inoculation[1161].” That risk,

however, was little made of in the controversy, although it may have

been one of the tacit reasons that led to the total abandonment of

inoculation during the ten or twelve years after 1728. On the revival

of the practice after 1740, when the serjeant-surgeons, the physicians

and the apothecaries were all making it a considerable part of their

business among the richer classes, the danger from contagion was

either non-existent or it was not realized. In 1754 the College of

Physicians of London, by a formal minute, recommended inoculation as

“highly salutary to the human race,” without one word of warning on

the risk of contagiousness. That objection was raised again when

Sutton’s practice in 1765-67 was drawing large crowds to be

inoculated. He was put on his trial at the Chelmsford Summer Assizes

in 1766 on a charge of spreading the contagion of smallpox, which was

epidemic in the town; but the grand jury, charged by Lord Mansfield,

threw out the bill. Sutton’s defence was to have been that he never

brought into Chelmsford a patient capable of spreading the smallpox,

that is to say, an inoculated person with smallpox enough on him to

spread contagion[1162]. Shortly after came the controversy between

Lettsom and Dimsdale as to inoculation of infants at their homes,

which turned upon the risk of increasing the natural smallpox by a

constant succession of artificial cases. Lettsom’s position was the

same as Sutton’s, that the quantity of smallpox matter (he might have

said the quality also) produced by inoculation was not sufficient to

create an appreciable risk. As to the matter of fact, the quantity was

indeed small: Sir William Watson declared that a single limb of an

adult person in a moderate attack of the natural smallpox had as many

pustules on it as all the seventy-four children, in one of his

inoculations at the Foundling Hospital, had on their whole bodies. In

the theory of contagion, an infinitesimal quantity is sufficient; but

in reality it appears that contagion must be in excess to be

effective, just as, in the nearest physiological analogy,

fertilization seems to depend upon the copiousness of the pollen or

seminal particles[1163].

The opposition to Lettsom’s project of general inoculations among the

infants of the working classes in cities shows that the risk of

contagion was made to serve at least an argumentative purpose. As to

experience, Lettsom in 1778 declared that he knew no instance of

contagion from that source during two years of inoculations among the

poor of London[1164]. One writer of the time (1781) appealed boldly to

the experience of sixty years: “Upon the first introduction of

inoculation, physicians, divines, and innumerable other writers [who

were they?] cried out that the infection would be spread, and the

community suffer a greater loss; but after sixty years’ experience, we

should expect those arguments, as well as the writers, had all died

away, and that at this day the same stale dregs of ignorance and

obstinacy would not be again retailed[1165].” The risk, however, was

not altogether imaginary. Some cases of smallpox caught from the

inoculated were known. In Vienna at that time the rule was to allow

no inoculations except on groups of subjects isolated for the purpose.

When Jenner, in 1798, enumerated the advantages of cowpox over

smallpox for inoculation, in certain specified circumstances, one of

his points was its non-contagiousness[1166].

The favourable reception of his project seems to have been determined

more upon that point than upon any other. The theoretical risk of

contagion from inoculated smallpox became at once an actual danger to

the community when it was perceived that they had in “smallpox of the

cow” a non-contagious variety. Jenner was not slow to use that growing

sentiment so as to discredit the old practice. As early as 1802 he

began to urge privately the statutory prohibition of smallpox for

inoculation, and Wilberforce, among others, took the matter up

publicly. The College of Physicians, having been asked by Parliament

in 1807 to inquire into the causes that hindered the progress of

Jenner’s inoculation, inserted the following paragraph in their

report:

“Till vaccination becomes general, it will be impossible to prevent

the constant recurrence of the natural smallpox by means of those who

are inoculated, except it should appear proper to the Legislature to

adopt, in its wisdom, some measure by which those who still, from

terror or prejudice, prefer the smallpox to the vaccine disease, may

in thus consulting the gratification of their own feelings, be

prevented from doing mischief to their neighbours[1167].” The same

year, in the court of King’s Bench, a medical practitioner was

sentenced to fine and imprisonment for having neglected to prevent an

inoculated person from communicating with others[1168].

Next year, 1808, a bill was brought into the House of Commons by Mr

Fuller, with the following preamble: “Whereas the inoculation of

persons for the disorder called the Smallpox, according to the old or

Suttonian method, cannot be practised without the utmost danger of

communicating and diffusing the infection, and thereby endangering, in

a great degree, the lives of his Majesty’s subjects.”... This bill,

which had clauses also for notification and compulsory isolation of

smallpox cases, the churchwardens to be the authority, was not

persevered with. The inoculators by the old method opposed it, and

they were joined by Joseph Adams, who had been the first English

writer to mention cowpox, in 1795, and had been a staunch vaccinist

subsequently[1169]. In 1813 another attempt was made to restrict the

practice of inoculating the smallpox on the ground of danger from its

contagion, and to get cowpox substituted for it among the poorer

classes. The Vaccine Board were the promoters, Lord Boringdon

(afterwards Earl of Morley) having charge of the bill in the House of

Lords. It was successfully opposed by the Lord Chancellor (Eldon) and

by the Lord Chief Justice (Ellenborough), the latter contending that

the common law was a better remedy than a statute against the nuisance

of contagion from inoculated smallpox. Next year, 1814, Lord Boringdon

brought in a new bill, which did not directly harass the inoculation

interest, but made the rival method of cowpox obligatory upon the

poor. Its provisions were ridiculed by Lord Stanhope, who got help

from Lords Mulgrave and Redesdale to throw it out. Therewith ceased

for many years the talk about the contagiousness of inoculated

smallpox, together with the attempts in Parliament to enforce the

rival inoculation. The next attempt, in 1840, was successful in making

variolation a felony, and in throwing on the rates the cost of

vaccinating the infants of the poorer classes. The danger of contagion

from inoculated smallpox in 1840 was no greater than it had ever been,

and it had never been appreciable among the things favouring an

epidemic.

The common-law maxim, “sic utere tuo ut alienum non laedas,” which gained

statutory force as against inoculation by the Act of 1840, was farther

extended and specifically applied in the Act of 1853, which enforced the

inoculation of cowpox upon all infants before they were three months old.

Legislation, as we know, broadens down from precedent to precedent.

Parliament in 1853 did not debate the preamble of the Bill, but accepted

the principle established by the Act of 1840,--in the constructive sense

that to leave infants without the inoculation of cowpox was, in effect,

“to expose them so as to be infectious,” because they were sure to take

smallpox, and so to become nuisances to others “unprotected” as well as

(less obviously) to their cowpoxed neighbours.

Other effects of the epidemic of 1837-40 on medical opinion.

A second inoculation, except as a mere test of the first and within a few

weeks thereof, was no part of the original 18th century teaching and

practice. The theory of inoculation being based upon the familiar

experience that we seldom have the same infectious disease twice in a

lifetime, it was held that inoculation, if it were effective, was the

giving of smallpox once for all, and that it could not really be given a

second time unless the first inoculation had been ineffective. As soon as

cowpox was recommended, it was remarked as a strange thing that this

disease, according to current accounts of it, was actually acquired by

milkers time after time. That fact in its natural history, said the

_Medical and Physical Journal_ of January, 1799, was “received with

general scepticism merely on account of its improbability.” Dr Pearson was

so troubled by the apparent inconsistency that he wrote to Dr Jenner in

1798 to ask whether it were really so; and although the latter confirmed

the matter of fact, Pearson went on denying it, and did actually deny it

as late as the Report of the Vaccine Pock Institution for 1803. Again, the

report of the Whitehaven Dispensary for 1801, while it admitted the matter

of fact, adverted to the anomaly in these words: “As we know from

experience that the cowpock can be repeatedly introduced by inoculation,

it appears remarkable that it can act as a preventive of a similar equally

specific but more malignant disease.” Those were theoretical difficulties,

which the practical minds of the profession did not stand upon. When we

next hear of the possibility of having cowpox more than once, it is no

longer an intellectual stumbling-block but is turned to account in the way

of re-vaccination. _Lapidem quem reprobaverunt aedificantes, hic factus

est in caput anguli._

The practice of re-vaccination was usual on the Continent long before the

English took to it. The reason of this was that a second inoculation of

cowpox was not resorted to for the greater security of infants and young

children, who were then the principal victims of smallpox in this country,

but for the protection of adults, who made a great part of the subjects of

the epidemics in other countries. There were so many adult deaths in the

great Paris epidemic of 1825 that the news of it reads like the English

references to smallpox in the time of the Stuarts. We obtain exact

statistics of the ages in the 3323 fatal cases of smallpox in Paris from

1842 to 1851. Reduced to percentages they were as follows:

All ages 0-5 5-10 10-20 20-30 30-40 Over 40

100 33·8 5·9 13·25 32·95 10·95 3·15

Two-thirds of the deaths were above the age of five years, an

age-incidence that was not reached in London until a whole generation

after. The contrast with British experience comes out in concrete form in

the following table of the age-incidence of 342 fatal attacks of smallpox

in 1850 and 364 in 1851, in Paris (pop. 1,000,000), and of 584 fatal

attacks in Glasgow in the single year 1852 (pop. 370,000)[1170]:

_Age-incidence of fatal Smallpox in Paris and in Glasgow._

Paris, 1850-51 Glasgow, 1852

(706 deaths) (584 deaths)

Under one year 126 188

One to two 32 150

Two to five 94 189

Five to ten 31 20

Ten to fifteen 20 4

Fifteen to twenty 51 2

Twenty to twenty-five 109 19

Twenty-five to thirty 89 2

Thirty to forty 128 8

Forty to fifty 22 1

Over fifty 4 1

In other parts of the Continent of Europe the frequency of smallpox in

adults was not less remarked than in France in the second quarter of the

19th century. English writers had been able at one time to point to

foreign countries for the success of infantile vaccination. Sweden and

Denmark were for a long time classical illustrations; then it was

Germany’s turn. “In Berlin during 1821 and 1822,” said Roberton, “only one

died of smallpox in each year. In the German States, vaccination has

become universal, and in them as well as in various other countries the

smallpox is almost unknown.” When we next find German experience appealed

to, it is to enforce the need of re-vaccination: “In 1829,” said Gregory,

“the principal Governments of Germany took alarm at the rapid increase of

smallpox, and resorted to re-vaccination as a means of checking it. In

Prussia, 300,000 had been re-vaccinated, and the same number in

Würtemberg. In Berlin nearly all the inhabitants had undergone

re-vaccination[1171].” It was about the same time that a second

vaccination became obligatory in the armies of Prussia, Würtemberg, Baden

and other German States, and among the pupils of schools when they reached

the age of twelve years. Dr Gregory, in his speech at the Medical and

Chirurgical Society of London in December, 1838, urged the need of

re-vaccination not only by the example of Germany, but also by the

experience of Copenhagen, where a thousand cases of smallpox had been

received into the hospital (it was nearly always adults that were taken to

the general hospitals) in twenty-one months of 1833-34, nine hundred of

them being of vaccinated persons[1172]. Gregory was in advance of his age

in advocating re-vaccination for England. His own cases at the Smallpox

Hospital of London were, it is true, nearly all adults, according to the

rules of the charity. But they were not representative even of the

smallpox of the capital; and in England at large smallpox in 1839 was

still distinctively a malady of the first years of life. It was not until

youths and adults began to have smallpox in large numbers in the epidemic

of 1871-72 that the doctrine of re-vaccination was generally apprehended

in England. Medical truth, like every other kind of truth except that of

geometry, is conditioned by time and place. What was a truth to the

Germans in 1829 was not a truth to us until some forty years after. Dr

Gregory, Sir Henry Holland and others advised re-vaccination after the

epidemic of 1837-40; but as late as 1851 the National Vaccine

Establishment denounced it as incorrect in theory and uncalled-for in

practice.

* * * * *

After the great epidemic of 1837-40, there was an interval of a whole

generation until smallpox broke out again on anything like the same scale,

in 1871 and 1872. But it had risen to a considerable height at shorter

intervals--in 1844-45, which were the years when vast numbers of navvies

were employed making railroads all over England, in 1847 and successive

years to 1852, which was the period of the great Irish migration after the

potato-famine, in 1858, for which I find no explanation, and in the period

from 1863 to 1865, which was again a time of somewhat high typhus

mortality, not only in the Lancashire cotton-districts but also in London.

The great epidemic of 1871 and 1872 finds no better explanation than our

neighbourhood to Germany and Belgium, where the mortality from smallpox

was far greater than in Britain, and was doubtless favoured by the state

of war in 1870-71. The following tables for London, and for England and

Wales in comparison with measles, scarlatina and diphtheria, show the

progress of smallpox from the epidemic of 1837-40 to the present time:

_Smallpox Deaths in London from the beginning of Registration._

Year Deaths

1837 (6 mo.) 763

1838 3817

1839 634

1840 1235

1841 1053

1842 360

1843 438

1844 1804

1845 909

1846 257

1847 255

1848 1620

1849 521

1850 499

1851 1062

1852 1150

1853 211

1854 694

1855 1039

1856 531

1857 156

1858 242

1859 1158

1860 898

1861 217

1862 366

1863 1996

1864 547

1865 640

1866 1391

1867 1345

1868 597

1869 275

1870 973

1871 7912

1872 1786

1873 113

1874 57

1875 46

1876 736

1877 2551

1878 1417

1879 450

1880 471

1882 430

1883 146

1884 898

1885 914

1886 5

1887 7

1888 5

1889 0

1890 3

1891 1

1892 11

1893 206

_England and Wales: Deaths by Smallpox, Measles, Scarlatina and Diphtheria

from the beginning of Registration._

Smallpox Measles Scarlet Fever Diphtheria

1837 (½) 5811 4732 2550 --

1838 16268 6514 5862 --

1839 9131 10937 10325 --

1840 10434 9326 19816 --

1841 6368 6894 14161 --

1842 2715 8742 12807 --

1847 4227 8690 14697 --

1848 6903 6867 20501 --

1849 4644 5458 13123 --

1850 4665 7082 13371 --

1851 6997 9370 13634 --

1852 7320 5846 18887 --

1853 3151 4895 15699 --

1854 2868 9277 18528 --

1855 2523 7354 16929 385

1856 2277 7124 13557 603

1857 3236 5969 12646 1583

1858 6460 9271 23711 6606

1859 3848 9548 19310 10184

1860 2749 9557 9681 5212

1861 1320 9055 9077 4517

1862 1638 9860 14834 4903

1863 5964 11340 30473 6507

1864 7684 8322 29700 5464

1865 6411 8562 7700 4145

1866 3029 10940 11683 3000

1867 2513 6588 12380 2600

1868 2052 11630 21912 3013

1869 1565 10309 27641 2606

1870 2620 7543 32543 2699

1871 23062 9293 18567 2525

1872 19022 8530 11922 2152

1873 2308 7403 13144 2531

1874 2084 12235 24922 3560

1875 849 6173 20469 3415

1876 2468 9971 16893 3151

1877 4278 9045 14456 2731

1878 1856 9765 18842 3498

1879 536 9185 17613 3053

1880 648 12328 17404 2810

1881 3698 7300 14275 3153

1882 1317 12711 13732 3992

1883 957 9329 12645 4218

1884 2216 11324 11143 5020

1885 2827 14495 6355 4471

1886 275 12013 5986 4098

1887 506 16765 7859 4443

1888 1026[1173] 9784 6378 4815

1889 23 14732 6698 5368

1890 16 12614 6974 5150

1891 49 12673 4959 5036

1892 431 13553 5618 6552

1893 1455 10764 6869 8918

The great epidemic of 1837-40 was the last in England which showed

smallpox in its old colours. The disease returned once more as a great

epidemic in 1871-72, after an interval of a whole generation (in which

there had been, of course, a good deal of smallpox); but the epidemic of

1871-72 was different in several important respects from that of 1837-40.

It was a more sudden explosion, destroying about the same number in two

years (in a population increased between a third and a half) that the

epidemic a generation earlier did in four years. It was an epidemic of the

towns and the industrial counties, more than of the villages and the

agricultural counties; it was an epidemic of London more than of the

provinces; and it was an epidemic of young persons and adults more than of

infants and children. The great epidemic of 1871-72 brought out clearly

for the first time all those changes in the incidence of smallpox; but

things had been moving slowly that way in the whole generation between

1840 and 1871. Experience subsequent to 1871-72 has shown the same

tendency at work.

To begin with the changed incidence upon rural and urban populations, a

glance down the following Table, will show that the counties marked *,

with a smaller share in 1871-72, in a total of deaths in all England and

Wales which was nearly the same as in the great epidemic a generation

before, are nearly all those with a population more purely rural[1174]:

_Incidence of the Smallpox Epidemics of 1837-40 (four years) and 1871-72

(two years) respectively upon the Counties of England and Wales._

1837-40 1871-72

England and Wales 41,253 42,084

Metropolis 6421 9698

*Surrey (extra-metr.) 383 231

*Kent (extra-metr.) 817 537

*Sussex 161 126

Hampshire 348 1103

*Berkshire 450 46

*Middlesex (extra-metr.) 418 306

*Hertfordshire 260 157

*Buckinghamshire 268 53

*Oxfordshire 199 109

Northamptonshire 399 563

*Huntingdonshire 65 14

Bedfordshire 125 128

*Cambridgeshire 400 175

*Essex 773 583

*Suffolk 506 348

*Norfolk 1038 895

*Wiltshire 548 85

*Dorsetshire 329 163

*Devonshire 1097 838

*Cornwall 767 531

*Somersetshire 1466 412

*Gloucestershire 1072 323

*Herefordshire 191 34

*Shropshire 345 161

*Worcestershire 1002 529

Staffordshire 1328 3050

*Warwickshire 957 785

Leicestershire 528 622

Rutlandshire 8 7

Lincolnshire 482 498

Nottinghamshire 562 983

*Derbyshire 329 297

*Cheshire 1141 310

†Lancashire 7105 4151

†Yorkshire W. Riding 2858 2609

" E. Riding 480 452

" N. Riding 236 405

Durham 798 4767

Northumberland 569 1512

*Cumberland 549 366

*Westmoreland 98 41

Monmouthshire 672 904

*Wales 2699 2314

The counties which were most lightly visited in 1871-72, as compared with

1837-40, were the agricultural and pastoral. In the outbreaks subsequent

to 1871-72, smallpox has almost ceased to be a rural infection in Scotland

and Ireland as well as in England. The great change that has come over it

in that respect is shown in the following table, in which the annual

death-rates from smallpox per 100,000 living are contrasted, for children

under five, in each of several agricultural counties, with the mean of all

England and of London, 1871-80, and with the corresponding scarlatinal

death-rates in the right-hand column:

_Annual Death-rates of Children under five, per 100,000 living, 1871-80._

Smallpox Scarlatina

All England 53 349

London 113 307

-------------------------------------------

Sussex 9 100

Berkshire 4 141

Bucks 4 160

Oxfordshire 9 167

Huntingdonshire 3 205

Bedfordshire 11 242

Cambridgeshire 18 112

Suffolk 12 136

Wiltshire 5 210

Dorsetshire 15 152

Herefordshire 5 166

Shropshire 12 247

But the history of smallpox since the great epidemic of 1871-72 has

brought out still another tendency in the same direction, namely, the

increasing share of London in the whole smallpox of England. In the

epidemic of 1837-40, which reached to almost every parish of England and

Wales, London had 6449 deaths in a total of 41,644, or between a sixth and

a seventh part, having rather less than an eighth part of the population.

In the epidemic of 1871-72, London had between a fourth and a fifth part

of the deaths (9698 in a total of 42,084), having then about a seventh

part of the population. In 1877, more than half of all the smallpox deaths

were in London, and in the year after as many as 1417 in a total of 1856.

In 1881, London had about two-thirds of the deaths from smallpox in all

England and Wales; but in the epidemic of 1884-85, it had only over a

third part (1812 in a total of 5043). This excess of London’s share over

that of the provinces is expressed in the following table, showing the

respective rates of smallpox mortality per million of the population:

_Smallpox Deaths in London and the Provinces, per million of population._

1847-9 1850-4 1855-9 1860-4 1865-9 1870-4 1875-9 1880-4

London 460 300 237 281 276 654 292 244

Provinces 274 271 192 175 172 339 48 34

If the table were continued to the very latest date, it would show the

provinces recovering their share, but upon a slight prevalence of the

epidemic as a whole, the deaths in London having been mere units from 1886

to 1892, while in 1888 there was a severe epidemic in Sheffield and in

1892-93 a good deal of the disease in a few manufacturing towns of the

North-western and Midland divisions. It would be a not incorrect summary

of the incidence of smallpox in Britain to say, that it first left the

richer classes, then it left the villages, then it left the provincial

towns to centre itself in the capital; at the same time it was leaving the

age of infancy and childhood. Of course it did none of these things

absolutely; but the movement in any one of those directions has been as

obvious as in any other. Measles and scarlatina have not shown the same

tendency to change or limit their incidence. Smallpox may have surprises

in store for us; but, as it is an exotic infection, its peculiar behaviour

may not unreasonably be taken to mean that it is dying out,--dying, as in

the death of some individuals, gradually from the extremities to the

heart.

With all those changes, the fatality of smallpox, or the proportion of

deaths to attacks, came out in the great epidemic of 1871-72 curiously

near that of the 18th century epidemics, namely, one death in about six

cases. This rate comes from the hospitals of the Metropolitan Asylums

Board according to the following table:

_Admissions for Smallpox, with the Deaths, at the hospitals of the

Metropolitan Asylums Board, from the opening of the several hospitals to

30 April, 1872._

Males Females Both Sexes

Age-periods Percentage Percentage Percentage

of of of

Adm. Died deaths Adm. Died deaths Adm. Died deaths

Under 5 434 235 54·15 | 469 236 50·32 | 903 471 52·15

5-10 851 236 27·73 | 821 196 23·87 | 1672 432 25·83

10-20 2827 265 9·37 | 2513 237 9·43 | 5340 502 9·40

20-30 2561 465 18·15 | 1922 285 14·82 | 4483 750 16·72

30-40 939 244 26·00 | 665 136 20·45 | 1604 380 23·69

40-50 316 100 31·64 | 242 64 26·45 | 558 164 29·39

50-60 85 18 21·17 | 88 31 35·22 | 173 49 28·32

Above 60 40 8 20·00 | 35 7 20·00 | 75 15 20·00

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

8053 1571 19·49 | 6755 1192 17·64 |14,803 2763 18·65

These admissions to hospitals included attacks of every degree of

severity, the intention of the hospitals being to isolate all cases, mild

and severe alike; so that, although these are technically hospital cases,

they are not comparable to the select class admitted to the old Smallpox

Hospital of London, but to the cases of smallpox in former times in the

community at large. Although the general average of deaths in 14,808

cases, namely, 18·65 per cent., is nearly the same as (being slightly

higher than) that of the equally comprehensive totals of 18th century

cases given at p. 518, yet the average is made up in a different way. In

some of the 18th century epidemics, such as that of Chester in 1774, all

the deaths were under ten years of age, and yet the average rate of

fatality was only 14 or 15 per cent. The much higher rate of fatality from

birth to five years and from five years to ten in the London epidemic of

1871-72 (which is confirmed in part by the Berlin statistics of the same

years), must have had some special reasons. One reason, doubtless, was

that the attack of smallpox in recent times has fallen upon comparatively

few children, whereas in former times it fell upon nearly the whole; and

it may be inferred that the infants who have been in recent times subject

to the attack of smallpox have also been of the class that are most likely

to die of it. The high rates of fatality at the ages above thirty in the

table agree with the experience of all times.

The percentages of fatalities from smallpox in the hospitals of the

Metropolitan Asylums Board have varied as follows from their opening to

the present time:

Percentage

Cases of deaths

1 Dec. 1870-3 Feb. 1871 582 20·81

4 Feb. 1871-31 Jan. 1872 13,145 18·95

1872-3 2362 17·84

1873-4 191}

1874 (11 mo.) 120} 17·02

1875 111}

1876 2150 21·64

1877 6620 17·92

1878 4654 17·99

1879 1688 15·69

1880 2032 15·95

1881 8671 16·61

1882 1854 12·96

1883 626 16·06

1884 6567 15·98

1885 6344 15·8

1886 132}

1887 59}

1888 67} 14·28

1889 5}

1890 27}

1891 64}

1892 348 11·29

1893 2376 7·75

The decline in average fatality in the last two years is remarkable, and

is to be explained chiefly by the mild type of smallpox which has been

prevalent; a very small fraction of the patients attacked between the ages

of ten and twenty-five have died; and these are some two-fifths of the

whole. This is shown in the following age-table of 2374 cases admitted to

the Metropolitan Board Hospitals in 1893:

_Smallpox in London, 1893._

Age-period Cases Deaths %

0-5 168 53 31·5

5-10 191 16 8·3

10-15 230 7 3·0

15-20 340 7 2·0

20-25 393 13 3·3

25-30 298 23 7·7

30-35 250 14 5·6

35-40 182 13 7·1

40-50 199 18 9·0

50-60 79 9 11·4

60-70 35 6 17·1

70-80 9 1 11·1

The low rate of fatality during the slight epidemic revival of smallpox in

1892-93 has been found to obtain wherever the disease has occurred:

_Smallpox in the Provinces, 1892-93._

Fatalities

Cases Deaths per cent.

Birmingham 1203 96 8

Warrington 598 60 10

Halifax 513 44 8·5

Manchester 406 27 6·7

Glasgow 279 23 8·2

Liverpool 194 15 7·7

Brighouse 134 15 11·2

Aston Manor 113 6 5·3

Leicester 362 21 5·8

St Albans 58 6 10·4

---- --- ----

3860 313 8·10

The ages under ten years had only 290 in 3644 of these cases; but those

290 cases had 70 in 302 of the deaths.

In the comparative table for Ireland, of deaths by smallpox, measles,

scarlatina and diphtheria, measles in a decreasing population has changed

little, while scarlatina has declined greatly, and smallpox has fallen

during the last ten years almost to extinction.

_Ireland: Deaths by Smallpox, Measles, Scarlatina and Diphtheria from the

beginning of Registration._

Smallpox Measles Scarlatina Diphtheria

1864 854 630 2605 661

1865 461 1036 3683 480

1866 194 851 3501 317

1867 21 1292 2145 189

1868 23 1251 2696 202

1869 20 948 2670 243

1870 32 954 2978 188

1871 665 547 2707 226

1872 3248 1380 2459 257

1873 504 1303 2092 326

1874 569 667 4034 565

1875 535 898 3845 443

1876 24 664 2112 368

1877 71 1562 1117 288

1878 873 2212 1079 296

1879 672 860 1688 320

1880 389 1025 1344 314

1881 72 402 1230 323

1882 129 1518 2443 385

1883 16 801 1765 239

1884 1 559 1377 354

1885 4 1323 1147 296

1886 2 284 850 336

1887 14 1307 973 381

1888 3 1935 849 447

1889 0 574 457 358

1890 0 726 319 346

1891 7 240 308 281

1892 0 1183 419 286

In the great Irish famine of 1846-49, comparatively little is heard of

smallpox. It would appear to have been less diffused through the country

than in former famines, such as that of 1817-18, or those of the first

part of the 18th century, just in proportion as the vagrancy of

famine-times was checked by the establishment of workhouses. In the

workhouses and auxiliary workhouses during the ten years 1841-51, smallpox

is credited with 5016 deaths, while measles has 8943, fever 34,644,

dysentery 50,019, diarrhoea 20,507, and Asiatic cholera 6716.

Registration began in Ireland in 1864, and showed little smallpox for the

first few years. The next great epidemic, of 1871-72, showed the incidence

upon the large towns, and the comparative immunity of the country

population, even more strikingly than in England. In a total mortality of

3913 during the two years of 1871 and 1872, the three counties of Dublin,

Cork and Antrim had the following enormous share, which fell mostly to the

three cities of Dublin, Cork and Belfast:

Dublin Co. 1825

Cork Co. 1070

Antrim 510

-----

3405 deaths in 3913 for all Ireland.

In that epidemic the whole province of Connaught had only 25 deaths from

smallpox; but a subsequent visitation, a few years after, fell mainly upon

Connaught.

The epidemic which began in Scotland in 1871 was distributed over a

somewhat longer period than the corresponding outbreak in England; but the

bulk of it fell in the two years 1871 and 1872. The total of 3890 deaths

in those two years was distributed as follows:

Eight largest towns 2441

Next largest towns 259

Small town districts 574

Mainland rural districts 586

Insular rural districts 30

----

3890

Glasgow had a considerably smaller relative share than Edinburgh, and

altogether a much lighter incidence of the disease than in the years

1835-52, for which the figures have been given above (pp. 600-1). In the

following table of the annual deaths in Scotland from the beginning of

registration, the four other infective diseases of childhood included

along with smallpox show by comparison the remarkable decline of smallpox

since 1874, scarlatina being the only other infection of childhood which

has become greatly less common or less fatal.

_Scotland. Deaths by Smallpox, Measles, Scarlatina, Diphtheria and

Whooping-Cough, from the beginning of Registration._

Smallpox Measles Scarlatina Diphtheria Whooping-Cough

1855 1209 1180 2138 -- 1903

1856 1306 1033 3011 -- 2331

1857 845 1028 2235 76 1539

1858 332 1538 2671 294 1963

1859 682 975 3614 415 2660

1860 1495 1587 2927 480 1812

1861 766 971 1764 681 2204

1862 426 1404 1281 997 2799

1863 1646 2212 3413 1745 1649

1864 1741 1102 3411 1740 1993

1865 383 1195 2244 995 2318

1866 200 1038 2706 685 1860

1867 100 1341 2253 610 1728

1868 15 1149 3141 749 2490

1869 64 1670 4680 663 2461

1870 114 834 4356 630 1783

1871 1442 2057 2586 880 1504

1872 2448 925 2101 1045 2850

1873 1126 1450 2227 1203 1598

1874 1246 1103 6321 1163 1690

1875 76 1022 4720 867 2431

1876 39 1241 2364 861 2250

1877 38 1019 1374 956 1571

1878 4 1372 1870 1033 2788

1879 8 769 1592 862 2483

1880 10 1427 2165 838 2641

1881 19 1012 1573 816 1620

1882 3 1289 1583 961 2108

1883 11 1629 1336 747 2968

1884 14 1440 1266 830 2511

1885 39 1426 944 688 2157

1886 24 681 1058 583 1882

1887 17 1598 1179 805 3212

1888 3 1406 732 872 1722

1889 8 1948 701 968 2268

1890 0 2509 739 1018 3039

1891 0 1775 736 830 2437

The age-incidence of Smallpox in various periods of history.

Among the various changes of incidence that have attended the recent

decline of smallpox in England, Ireland and Scotland, there is one that

calls for more extended notice, namely, the fact that the malady has in

great part ceased to be an infection of infancy and childhood and has

become more distinctively an infection of adolescence and mature age. In

no period of its history has smallpox been so purely an infantile

complaint as measles[1175], nor so purely a malady of childhood and early

youth as scarlatina or diphtheria[1176]. When it first rose to prominence

in England, from the reign of James I. onwards, it attacked adults in a

large proportion; of which fact the evidence, although not statistical, is

sufficient. But, as the disease became nearly universal and ubiquitous, it

was so commonly passed in infancy or childhood, that few grew to maturity

without having had it. The number of adult cases diminished in proportion

as the disease became more nearly universal. In the great period of

smallpox in the 18th century, about nine-tenths of the deaths occurred

under the age of five, and nearly all the remaining fraction between five

and ten years, at Manchester, Chester, Warrington, Carlisle and

Kilmarnock. But in London there were always a good many adult deaths, the

reason commonly given being that there was a steady influx to the capital

of domestic servants and others from country parishes where the epidemics

came at sufficiently long intervals to let many children grow up without

incurring the risk of it. Also at Geneva and the Hague, in the 18th

century, there were many more deaths above the age of five than in the

English provincial towns at the same time.

_Ages at Death from Smallpox at Geneva (including Measles) and at the

Hague (Duvillard)._

All 0-1 -2 -3 -4 -5 -6 -7 -8 -9 -10 -15 -20

ages

Geneva

(1700-83)} 3328 555 608 588 426 346 232 185 99 67 44 84 36

The Hague}

(15 years}

of } 1455 172 170 179 224 160 148 114 78 58 23 47 17

18th }

cent.) }

-25 -30 -35 -40 -45

Geneva

(1700-83)} 26 21 0 0 0

The Hague}

(15 years}

of } 24 14 10 8 3

18th }

cent.) }

Twenty-four per cent. of the smallpox deaths in the 18th century at Geneva

were above the age of five years, and at the Hague thirty-seven per cent.,

while in the former the ratio would probably have been higher but for the

inclusion of measles. But, with this comparatively high ratio of deaths

above the age of five, smallpox was a much less important cause of

mortality at Geneva and the Hague than at Manchester, Glasgow, Chester,

and most other provincial cities of this country, making about a fifteenth

part of the deaths from all causes in the former, and as high as a sixth

part in the latter.

The infantile character of smallpox was as marked as ever in the epidemic

of 1817-19; of which the Norwich statistics are sufficient proof. As late

as the epidemic of 1837-40, smallpox was still distinctively a malady of

infants and young children in Britain, although that was by no means the

case on the continent of Europe at the same time. The following was the

age-incidence of fatal smallpox at Liverpool and Bath in the last six

months of 1837.

At all Under Above

ages 1 1-2 2-3 3-4 4-5 5-6 6-10 10

Liverpool

Deaths 495 143 127 77 64 24 19 20 25

+------+ +------+

Ratios 100 28·65 25·45 15·43 17·63 7·81 5·01

per cent.

Bath

Deaths 151 33 31 33 17 17 6 6 10

+------+ +-----+

Ratios 100 21·56 20·26 21·56 22·2 7·84 6·53

per cent.

In the third year of the epidemic, 1839, the ratio of deaths above the age

of five was still less at Manchester, Liverpool and Birmingham, being only

four and a half per cent. (26 in a total of 522). At Glasgow, from 1835 to

1839, twelve per cent. of the smallpox deaths were above the age of five

(see p. 600). These are the rates of provincial cities; but in a total of

8714 deaths in the year 1839, added together from London and the

provinces, about twenty-five per cent. were over five, and of these a

moiety were over ten years:

All ages Under five Five to ten Above ten

8714 6453 1122 1139

A good deal of that mortality above the age of five must have come from

London, according to the probability of the following table, which is of

six years’ later date, but the nearest that can be got for London alone:

_London, 1845. Ages at Death from Smallpox, Measles and Scarlatina._

Smallpox Measles Scarlatina

Total at all ages 909 2318 1085

-----------------------------------------------------

Under One year 209 353 88

One to Two 133 832 167

Two to Three 91 511 181

Three to Four 81 272 183

Four to Five 63 153 115

Five to Ten 136 168 254

Ten to Fifteen 33 18 46

Fifteen to Twenty 34 3 14

Twenty to Twenty-five 54 1 8

Twenty-five to Thirty 38 2 6

Above Thirty 37 5 23

The ratio of smallpox deaths above five was 37·5 per cent., of measles

deaths 8·4 per cent., and of scarlatina deaths 32·3 per cent. Measles and

scarlatina have kept these ratios somewhat uniformly to the present time,

but the ratio of smallpox deaths above the age of five has increased

according to the following table for England and Wales from 1851 to 1890:

Percentage of Percentage of Percentage of

smallpox deaths measles deaths scarlatina deaths

Period above five years above five years above five years

1851-60 38 10 36

1861-70 46 8 36

1871-80 70 8 34

1881-90 77 8 36

The progressive raising of the age of fatal smallpox is shown in another

way by taking the ratio of the deaths per million living at all ages and

at each of eleven age-periods[1177]:

_Smallpox Deaths per million living at each age-period._

Period All 75 and

ages 0- 5- 10- 15- 20- 25- -35 -45 -55 -65 over

1851-60 221 1034 257 73 93 130 92 53 38 24 18 14

1861-70 163 654 145 56 86 136 102 73 49 36 26 22

1871-80 236 527 284 137 197 300 239 168 111 71 46 35

It was the great epidemic of 1871-72 that brought out the change of

age-incidence most concretely, just as it brought out, in contrast to the

last great epidemic in 1837-40, the decline in the rural and the increase

in the industrial centres. In the three years before the outburst of 1871

the deaths under five and over five were approaching an equality; in the

epidemic itself the old ratios were suddenly reversed:

Smallpox deaths Smallpox deaths

Year under five over five

1868 1234 818

1869 892 673

1870 1245 1375

1871 7770 15356

1872 5758 13336

In the whole generation between 1840 and 1871, in which there was no great

and general epidemic of smallpox, many had passed from childhood to

adolescence and maturity without encountering the risk of it. When the

epidemic of 1871 began, it found many in youth or mature years who had not

been through the smallpox, and it attacked a certain proportion of them

accordingly. The proportion above the age of five so attacked in 1871-72

was greater than it had been in this country since the beginning of the

18th century; indeed, as the information is not in statistical form for

the earlier period, it may be asserted, and it may happen to be true, that

it was greater than it had ever been in this country at any time. The

reason for the large proportion of adult cases was the same in the rise of

smallpox as in its decline, namely, that in the respective circumstances

an epidemic found many who had not been through the disease in infancy or

childhood. The same happened in those parts of the world where the

epidemics of smallpox came at long intervals, during which many had passed

from childhood to youth or mature age without once encountering the risk

of smallpox.

Such were the epidemics at Boston, New England, and Charleston, South

Carolina, in the 18th century. Not only do the accounts of them speak

of the disease as if it were mainly one of the higher ages, but it

follows from the ratio of attacks to population, known in the case of

Boston, that adolescence and adult age must have had a full share,

considering that these age-periods included all who were protected by

a previous attack. The years of epidemic smallpox at Boston were 1702,

1721, 1730 and 1752: of these four the two worst were 1721 and 1752,

the one epidemic following a clear interval of nineteen years, the

other a more or less clear interval of twenty-two years:

_Smallpox in Boston, Massachusetts_[1178].

Population, Attacked Died Had Moved

whites by of smallpox out

and blacks smallpox smallpox before of town

1721 10,565 5989 844 All the --

rest less

750

1752 15,684 5545 569 5598 1843

These enormous mortalities in Boston were comparable to those of the

old plague itself in European cities, not only in falling upon all

ages but also in doubling or trebling for a single year at long

intervals the annual average of deaths:

Deaths of Deaths of

whites blacks Total

1701 146 -- 146

*1702 441 -- 441

1720 261 68 329

*1721 968 134 1102

1722 240 33 273

*1730 740 160 909

1731 318 90 408

*1752 893 116 1009

* Smallpox years.

Just as smallpox in its first great outbursts in the London of the

Stuarts, or in its rare outbreaks in the American colonies in the 18th

century, fell impartially upon children and adults, so in its last

outbursts in the London of Victoria it fell upon persons at all ages. The

notable thing is, not that smallpox should have of late been attacking

adults, for that it has ever done except in times and places in which

there were few or no adults who had not been through the disease in

childhood; but that it should have ceased to so large an extent to attack

infants and children. It has ceased to attack infants and children because

other infective and non-infective diseases more appropriate to the modern

conditions of the population are attacking them instead. These are measles

and whooping-cough, scarlatina and diphtheria, infantile diarrhoea, and

the more chronic after-effects of these. The annual death-rate from all

diseases under the age of five has fluctuated somewhat per million living

from 1837 to the present time, but it can hardly be said that it has

fallen much or steadily[1179].

Keeping still to the epidemic of 1871-72, let us consider whether there

was any natural or epidemiological reason for its cutting off a smaller

ratio of infants and children in its whole mortality than that of 1837-40

did. There had been a most disastrous epidemic of scarlatina for three

years just before, which had caused 21,912 deaths in 1868, 27,641 in 1869,

and 32,543 in 1870, a total of 82,096 in three years, about two-thirds of

which were under the age of five, or at the age-period which smallpox used

to be fatal to almost exclusively and to be the greatest single epidemic

scourge of. Even in the two smallpox years themselves the scarlatinal

deaths were 18,567 and 11,922, of which the share that fell to children

under five was one and a half times the deaths in that age-period from the

co-existing smallpox. The three years of excessive scarlatina, before the

epidemic of smallpox began, had removed large numbers of the class of

infants and children who succumb to any infectious disease; if we cannot

give the whole _rationale_ of one infection dispossessing or anticipating

another, we can at least understand that the earlier and more dominant

infection takes off the likely subjects. What scarlatina did egregiously

during the three years just before the great explosion of smallpox, it

had been doing steadily (along with measles, &c.) throughout a whole

generation since the last great sacrifice of infants and children by

smallpox in 1837-40. But the fact that scarlatina had in great part

dispossessed smallpox among the factors of mortality under the age of

five, did not prevent the latter infection from attacking those of the

higher ages who were susceptible of it and were at the same time unvexed

by any other great epidemic malady proper to their time of life. If the

epidemic of smallpox in 1871-72 had cut off as large a ratio under the age

of five years as its immediate predecessor in 1837-40 did, its whole

mortality would have been about 70,000 more than it actually was. But in

no state of the population or of the public health can we suppose that

three years of excessive mortality of children by one kind of contagion

would be followed immediately by two years of equally special mortality at

the same ages by contagion of another kind. It is not only epidemiological

science that tells us this, but also common sense--_est modus in rebus_.

The saving of life by checking the prevalence of smallpox was a favourite

rhetorical topic in the 18th century. Voltaire, La Condamine, Bernoulli,

Watson, Haygarth and others, were fond of estimating how many thousands of

lives might be saved in a year if inoculation were thoroughly carried out.

Dr Lettsom, Sir Thomas Bernard and Mr James Neild, who were interested in

prison reforms and in whatever else would reduce the prevalence of typhus,

reckoned the possible saving of life under that head as almost equal to

the possible saving from smallpox[1180]. For typhus there was no

artificial means of restraint; it had to decline before natural causes, if

it declined at all,--which, indeed, it has done. But no one at that time

thought of keeping down smallpox except by the inoculation of itself or of

cowpox. The economists and statisticians treated each of these artifices

in its turn as a factor having a certain absolute value, which they might

use like the _a_ and _b_ of a problem in algebra. This they did, of

course, in deference to medical authority. What Bernoulli had worked out

for the old inoculation, Duvillard did for the new, in his “Tables showing

the Influence of Smallpox on the Mortality of each period of Life, and the

Influence that such a preservative as Vaccine may have on the Population

and on Longevity[1181].” Malthus fell into the conventional way of

thinking when he assumed that smallpox alone among the epidemic checks of

population was to be controlled artificially; but he introduced an

important new consideration. “For my own part,” he wrote in 1803, “I feel

not the slightest doubt, that if the introduction of the cowpox should

extirpate the smallpox, and yet the number of marriages continue the same,

we shall find a very perceptible difference in the increased mortality of

some other diseases[1182].”

Five years after this was written, there came, in 1808, the disastrous

epidemic of measles, which in Glasgow killed more infants in a few months

than smallpox had ever done at its worst in the same city. In the winter

of 1811-12 there was another severe epidemic of measles in Glasgow; and in

1813, Dr Watt, a leading physician of the place, and a man now famous in

all countries for his vast labours as a bibliographer, gave to the world

his statistical proof, from the Glasgow burial registers, of that law of

substitution which Malthus had found necessary in his deduced principles.

“The first thing,” said Watt, “that strikes the mind in surveying the

preceding Table (1783-1812), is the vast diminution in the proportion

of deaths by the smallpox, a reduction from 19·55 to 3·90. But the

increase in the subsequent column [measles] is still more remarkable,

an increase from 0·95 to 10·76. In the smallpox we have the deaths

reduced to nearly a fifth of what they were twenty-five years ago [in

ratio of the deaths from all causes]; in the same period the deaths by

measles have increased more than eleven times. This is a fact so

striking that I am astonished it has not attracted the notice of older

practitioners, who have had it in their power to compare the mortality

by measles in former periods with what all of them must have

experienced during the last five years[1183].”

The high ratio of measles and the low ratio of smallpox did not remain as

Watt’s researches left them. When Cowan resumed the tabulation of figures

from 1835 to 1839 he found the ratios of those two infantile infections

almost equal, and the two together contributing to the whole mortality of

Glasgow only a little more than half their joint share in the end of the

18th century. The substitution which Watt saw during a few years was only

the most dramatic part of a general movement forwards of measles among the

causes of infantile mortality. He supposed, as everyone did at that time,

that smallpox was forcibly repressed, and that another infectious disease

had seized the opportunity to become exuberant. The most relevant thing in

the whole situation was urged by those who thought, with Jenner, that the

doctrine of substitution had an “evil tendency” as detracting from the

absolute value of the inoculation principle. In order to discredit Dr Watt

altogether, they pointed out that his ratios of smallpox and measles took

no account of the diminished death-rate of Glasgow by all diseases in the

earlier years of the 19th century.

Great changes were proceeding in the old city, the Glasgow of ‘Rob Roy.’

The population which was reckoned at 45,889 in the year 1785, had

increased to 66,578 in the year 1791, and thereafter, at a slower rate, to

83,769 in 1801 and to 100,749 in 1811. The first great increase after the

American War meant overcrowding; but in a short time new suburbs spread

over such an extent that, in the year 1798, more than half the burials

were in the graveyards attached to chapels-of-ease and meeting-houses

outside the original parishes. The modern expansion of Glasgow, like that

of London and of all other large cities, has been an increase of area

still more than an increase of numbers. The public health improved

steadily, at all events until 1817, the improvement being shown first in

the increasing number of infants that survived their second year. That

rise in the probability of life corresponded to the substitution of

measles for smallpox, and in part depended upon the ascendancy of the

milder infection. Still more remarkable was the rise of scarlatina, which

Dr Watt did not live to see; so little was made of it at the date of his

writing that he found “scarlatina, typhus, &c., all comprehended under the

same head.” The seeds of measles and scarlatina had long existed beside

the seeds of smallpox, but the ascendancy of each of the two former had to

wait events. Said Banquo to the witches who hailed Macbeth as king and

himself as the sire of later kings:

“If you can look into the seeds of time,

And say which grain will grow, and which will not--”

The succession of reigning infections is the same problem. All we can say

is that each new predominant type is somehow suited to the changed

conditions. In the long period covered by this history we have seen much

coming and going among the epidemic infections, in some cases a dramatic

and abrupt entrance or exit, in other cases a gradual and unperceived

substitution. Some of the greatest of those changes have fallen within the

two hundred years since Sydenham kept notes of the prevalent epidemics of

London. We are that posterity, or a generation of it, which he expected

would have its own proper experiences of epidemics and at the same time

would know all that had passed meanwhile--“posteris quibus integrum

epidemicorum curriculum venientibus annis sibi invicem succedentium

intueri dabitur.”