A History of Epidemics in Britain, Volume 2 (of 2) / From the Extinction of Plague to the Present Time

by Charles Creighton

Causes of Mild or Severe Smallpox.

Besides the errors of the heating or the cooling regimen respectively, there is another thing that may have had something to do with the greater fatality of smallpox, as remarked by many, about the middle of the 17th century. “How is it,” asks Sydenham, “that so few of the common people die of this disease compared with the numbers that perish by it among the rich[845]?” Sydenham may not have known how much smallpox mortality there was in the poorer quarters of London. But the Restoration was certainly a great time of free living in the upper classes of society, and it is equally certain that smallpox was apt to prove a deadly disease to a broken constitution. Willis believed that excesses even predisposed people to take the infection: “I have known some to have fallen into this disease from a surfeit or immoderate exercise, when none besides in the whole country about hath been sick of it.” There were, of course, families in which smallpox was for some unknown reason peculiarly fatal. Again, the origins of constitutional weakness are lost in ancestry, the poor stamina of children being often determined by the lives of their grandfathers or great-grandfathers. In the royal family of Stuart smallpox proved more than ordinarily fatal, but it was among the grand-children and great grand-children of James I. that those fatalities happened. Of the children of Charles I., the Duke of Gloucester and the Princess of Orange died of smallpox within a few months of each other in the year of the Restoration. The disease was not less fatal a generation after in the family of the Duke of York (James II.). Dr Willis fell into disgrace with that prince because he bluntly told him that the ailment of one of his sons was “mala stamina vitae.” All his sons, says Burnet, died young and unhealthy, one of them by smallpox. Of his two daughters, Queen Mary died of haemorrhagic smallpox in 1694, and the Duke of Gloucester, only child of the other, Princess Anne of Denmark (afterwards Queen Anne), died at the age of eleven, of a malady which was called smallpox by some, and malignant sore-throat by others[846].

Among the medical writers of this period, who gave reasons why smallpox should be so severe or deadly in some while it was so slight in others, Morton was the most systematic. He made three degrees of smallpox—benign, medium and malignant: these did not answer quite to the discrete, confluent and haemorrhagic of other classifiers, for his malignant class included so many confluent cases that in one place he uses malignae as the equivalent of confluentes seu cohaerentes, while his middle class was made up of some confluent cases,—perhaps such medium cases as had confluent pocks on the face but not elsewhere,—and a certain proportion of discrete. The medium kind were the most common (frequentissimae sunt et maxime vulgares variolae mediae). Still, it was the benign type that he made the norma or standard of smallpox, from which the disease was “deflected” towards the medium type, or still farther deflected towards the malignant. He gives a list of fourteen things that may serve to deflect an attack of smallpox from the norma of mildness to the degrees of mean severity or malignity:

1. If the eruption come out too soon or too late.

2. If the patient be sprung from a stock in which smallpox is wont to prove fatal, as if by hereditary right.

3. If the attack fall in the flower of life, when the spirits are keener and more inclined to febrile heats.

4. If the patient be harassed by fever, or by sorrow, love or any other passion of the mind.

5. If the patient be given to spirituous liquors, vehement exercise or anything else of the kind that tends to irritate the spirits.

6. If the attack come upon women during certain states of health peculiar to them.

7. If cathartics, emetics and blooding had been used.

8. If the heating regimen had been carried to excess, or other ill-judged treatment followed.

9. If the patient had met a chill at the outset, checking the eruption.

10. If the attack happen in summer.

11. If the attack happen during a variolous epidemic constitution of the air.

12. If the patient be pregnant or newly married.

13. If the patient be consumptive or syphilitic.

14. If the patient be apprehensive as to the result.

Morton having made the benign type the norm, made the medium type the commonest; and that was really true of the first great epidemic in London in his experience, in the years 1667-68. Sydenham says of it that the cases were more than he ever remembered to have seen, before or after: “nevertheless, as the disease was regular and of a mild type, it cut off comparatively few among the immense number of those who took it.” Pepys enters this epidemic under the date of 9 Feb. 1668: “It also hardly ever was remembered for such a season for the smallpox as these last two months have been, people being seen all up and down the streets newly come out after the smallpox.” Let us pause here for a moment to ask what Pepys may have meant by recognising the people all up and down the streets newly come out after the smallpox. Did he mean that they were pock-marked? We may answer the question by the testimony of Dr Fothergill for a correspondingly mild and extensive prevalence of smallpox in London some three generations later, which I shall take out of its order because it bears upon the question of pitting. His report for December 1751 is:[847]

“Smallpox began to make their appearance more frequently than they had done of late, and became epidemic in this month. They were in general of a benign kind, tolerably distinct, though often very numerous. Many had them so favourably as to require very little medical assistance, and perhaps a greater number have got through them safely than has of late years been known.” The January (1752) report is: “A distinct benign kind of smallpox continued to be the epidemic of this month; a few confluent cases, but rarely.” In February he writes: “Children and young persons, unless the constitution is very unfavourable, get through it very well; and the height to which the weekly bills are swelled ought to be considered, in the present case, as an argument of the frequency, not the fatality, of this distemper.” In June the type was still favourable: “Crowds of such whom we see daily in the streets without any other vestige than the remaining redness of a distinct pock.”

This was an epidemic such as Sydenham alleges that of 1667-68 to have been; and the vestiges of smallpox by which Pepys recognized those who were newly come out of the disease were probably the same that Fothergill saw in 1752.

A practitioner at Chichester does indeed say as much of those treated by himself about the same date: “when the distemper did rage so much in and about Chichester, ten or a dozen years since [written in 1685], it was a great many that fell under my care, I believe sixty at the least, and yet I lost but one person of the disease. Nor was one of my patients marked with them to be seen but half a year after[848].” As these experiences must have been somewhat exceptional I shall give a section to the general case.