The Epidemiology continued from 1721.

The ordinary course of smallpox in Britain was little touched by inoculation. The inoculators were like the fly upon the wheel, with the important difference that they did indeed raise the dust. The writers who kept up the old Hippocratic or Sydenhamian habit of recording the prevalent maladies of successive seasons, such as Huxham, Hillary[985], and Barker, of Coleshill, while they dealt with epidemics impartially and comprehensively, were as if by a common instinct adverse to the fuss made about inoculation. Says Barker, in an essay against inoculation during the Suttonian enthusiasm, “It is undoubtedly a great error that the smallpox is now considered the only bugbear in the whole list of diseases, which, if people can get but over, they think they are safe.” This hits fairly enough the disproportionate share given to inoculation in the medical writings of the time, while it is made more pointed by the author’s suggestions for a scientific study of the conditions of smallpox itself[986]. It is still possible, with much trouble, to bring together the data for a scientific handling of the disease in the 18th century, thanks most of all to the exact school of observers or statisticians which began with Percival, of Manchester, and was continued to the end of the century by Haygarth, Heysham, Ferriar, Aikin and others. The best of the original English inoculators, Nettleton of Halifax, has also left a large number of interesting statistics relating to epidemics in Yorkshire and other northern counties in the years 1721-23; also, upon his suggestion, the figures were procured from many more smallpox epidemics in other parts of England down to 1727. It will be convenient to resume the history with these, as they come next in order after the London epidemic of 1720, at which point the interlude of inoculation came in. The following is a complete table of the figures collected from various sources: it will be observed that most parts of England are represented, the fullest representation being of the northern counties.

Censuses of Smallpox Epidemics in England, 1721-30.

Locality of the
Epidemic		 Period Authority Cases Deaths Percentage
of
Fatalities
Halifax[987] winter of 1721
to April 1722		 Nettleton,
Phil. Trans.
XXXII. 51		 276 43 15·9
Rochdale[988] " " 177 38 21·4
Leeds[989] " " 792 189 23·8
Halifax parish towards
Bradford		 1722 Ibid. p. 221 297 59 19·9
Halifax parish, another
part		 " " 268 28 10·4
Bradford " " 129 36 27·9
Wakefield " " 418 57 13·6
Ashton under Lyne[990] " " 279 56 20·0
Macclesfield " " 302 37 12·2
Stockport " " 287 73 25·4
Hatherfield " " 180 20 11·1
Chichester[991] 1722
(to 15 Oct.)		 Whitaker,
Ibid. p. 223		 994 168 16·9
Haverfordwest 1722 Perrot Williams,
Ibid.		 227 52 22·9
Barstand, Ripponden,
Sorby, and part of
Halifax parish 4
miles from the town		 " Nettleton, in
Jurin’s Acct.
for 1723, p. 7		 230 38 16·5
Bolton 1723? Jurin’s Acct.
for 1723, p. 8		 406 89 21·6
Ware " " 612 72 11·7
Salisbury " " 1244 165 13·2
Rumsey, Hants " " 913 143 15·6
Havant " " 264 61 23·1
Bedford " " 786 147 18·4
Shaftesbury 1724? Ibid. for
1724, p. 12		 660 100 15·1
Dedham, near
Colchester		 " " 339 106 31·3
Plymouth " " 188 32 17·2
Aynho, near Banbury 27 Sept. 1723
to 29 Dec. 1724		 Rev. Mr Wasse,
rector, Ibid.
for 1725, p. 55		 133 25 18·8
Stratford on Avon " Dr Letherland,
Ibid.		 562 89 15·8
Bolton le Moors " Dr Dixon, Ibid. 341 64 18·8
Cobham " Sir Hans Sloane,
Ibid.		 105 20 19·0
Dover 29 Sept. 1725
to 25 Dec. 1726		 Dr Lynch of
Canterbury, in
Jurin’s Acct. for
1726, p. 17		 503 61 12·1
Deal 25 Dec. 1725
to 29 Nov. 1726		 " 362 33 9·1
Kemsey, near
Worcester		 " Dr Beard, in
Jurin, Ibid.		 73 15 20·5
Uxbridge[992] 1727 Dr Thorold, in
Scheuchzer’s
Acct. for
1727 and 1728		 140 51 36·4
Hastings 1729-30 Dr Frewen,
Phil. Trans.
XXXVII. 108		 705 97 13·7

The years 1722 and 1723, to which most of these epidemics belong, were one of the greater smallpox periods in England. In Short’s abstracts of the parish registers those years stand out very prominently by reason of the excess of deaths over births in a large proportion of country parishes (see above, p. 66); and, according to Wintringham’s annals, it was not fever that made them fatal years, but smallpox, along with autumnal dysenteries and diarrhoeas. Of one epidemic centre in the winter of 1721-22, which is not in the table, the district of Hertford, we obtain a glimpse from Maitland, who repaired thither from London to practise inoculation.

“I own that it seem’d probable that the six persons in Mr Batt’s family might have catched the smallpox of the girl that was inoculated; but it is well-known that the smallpox were rife, not only at Hertford but in several villages round it, many months before any person was inoculated there: witness Mr Dobb’s house in Christ’s Hospital buildings, where he himself died of the worst sort with purples, and his children had it; some other families there, and particularly Mr Moss’s, (where the above-named Elizabeth Harrison, inoculated in Newgate, attended several persons under it to prove whether she would catch the distemper by infection); both Latin boarding-schools, Mr Stout’s and Mr Lloyd’s families, Mr John Dimsdale’s coachman and his wife, and Mr Santoon’s maid-servant, who was brought to the same house and died of the confluent kind of the smallpox[993].”

Here we have the same indication of adults attacked as well as children, which we find in Dover’s practice in London in 1720 and in all the 17th century and early 18th century references to smallpox. The most detailed account is that given for the epidemic of 1724-25 at Plymouth by Huxham, who was not an inoculator but purely an epidemiologist and practitioner in the old manner.

The epidemic was a very severe one and of an anomalous type. Adults, according to his particular references and his general statement, must have been freely attacked. The major part of the adult cases, he says, proved fatal, including one of an old gentlewoman of 72,—“a very uncommon exit for a person of her years”! When the disease raged most severely, some children had it very favourably and required no other physic than to be purged at the end of the attack. The pustules were apt to be small and to remain unfilled. In some there were miliary vesicles, dark red or filled with limpid serum, in the interstices between the smallpox pustules. Some had abundance of purple petechiae among the pocks, the latter also being livid. Only one person survived of all who had that haemorrhagic type. Swelling of the face and throat was also seldom recovered from; in such cases that did well, the maxillary and parotid glands would remain swollen for some time. “It was a remarkable instance of the extraordinary virulence of these smallpox that the women (tho’ they had had the smallpox before and some very severely too) who constantly attended those ill of the confluent kind, whether children or grown persons, had generally several pustules broke out on their face, hands and breast.... I knew one woman that had more than forty on one side of her face and breast, the child she attended frequently leaning on those parts on that side.”

Huxham appears to have adopted the whole Sydenhamian practice of blooding, blistering, purging, and salivating. For the last he used calomel: “Two adults and some children in the confluent sort never salivated. Some very young children drivelled exceedingly through the course of the distemper. A diarrhoea very seldom happened to children[994].”

Corresponding very nearly in time to Huxham’s malignant and anomalous constitution of smallpox at Plymouth, and agreeing exactly with his generalities as to children and adults, there is an interesting table of the ages and fatalities of those who were attacked at Aynho, in Northamptonshire, six miles from Banbury. It was then a small market town, and its smallpox for some fifteen months of 1723-24, as recorded by the rector of the parish, may be taken as a fair instance of what happened at intervals (usually long ones) in the rural districts in the earlier years of the 18th century[995]:

Ages 0-1 -2 -3 -4 -5 -10 -15 -20 -25 -30 -40 -50 -60 -70 above
70		 Total
Cases 0 0 3 4 6 15 33 14 16 9 12 10 4 4 2 132
Deaths 0 0 2 1 0 1 3 1 3 3 3 4 1 2 1 25

The small fatality of the disease between the ages of five years and twenty is according to the experience of all times. But the considerable proportion of attacks at the higher ages would hardly have been found anywhere in England, not even in a country parish, a generation or two later, although it is consistent with all that is known of smallpox in the 17th century and in the first years of the 18th[996].

Another glimpse of a prolonged smallpox epidemic of the same period in a town is given in Frewen’s census of Hastings, with a population of 1636 (males 782, females 854). The disease was prevalent for about a year and a half, and had ceased previous to 28 January, 1732[997]. The table accounts for the whole population:

The number of those that recovered of the smallpox
(including four that were inoculated)		 608
Died of it 97
Escaped it 206
Died of other diseases since the smallpox raged there 50
The whole number of inhabitants in that town are 1636

Leaving out the fifty who died of other diseases as persons who may or may not have had smallpox, it appears that 725 of the inhabitants of Hastings had been through the smallpox in previous epidemics, that 705 were attacked in this epidemic, and that 206 had hitherto escaped, some of them to be attacked, doubtless, in the future. The proportion of attacks above the age of childhood in the epidemic of 1730-31 would have depended on the length of time since the last great epidemic; the interval was probably a long one, by the large number of susceptible persons in the town, just as at Boston, Massachusetts, in 1721 and 1752, and at Charleston, Carolina, in 1738[998]; and, as the fact is known for these places, so it is probable that the epidemic at Hastings had included many adolescents and adults.

On the other hand, where smallpox came in epidemics at short intervals, or where it was always present, the incidence, even in the first half of the 18th century, was much more exclusively upon childhood. Thus at Nottingham there was always some smallpox, with a great outburst perhaps once in five years. The year 1736 was one of those fatal periods of smallpox, the victims being “mostly children.” From the end of May to the beginning of September, great numbers were swept away; the burials in St Mary’s churchyard were 104 in May; the burials from all causes for the whole year exceeded the baptisms by 380; there had been no such mortality since thirty years. Such excessive incidence of smallpox upon the earliest years of life happened in places where the infant mortality was high from all causes. Nottingham was one of those places. Leaving out the great smallpox year, 1736, the other seven years of the period 1732-39 had a total of 2590 baptisms to 2226 burials, of which burials no fewer than 1072 were of “infants,” meaning probably children under five years, although the work of Harris on the Acute Diseases of Infants, which was current at that time, defines the infantine age as under four years[999].

The years of distress and typhus fever in England, Scotland, and Ireland from 1740 to 1742 were another great period of smallpox epidemics throughout the country. The mortality from that cause is known to have been excessive in Norwich, Blandford, Edinburgh and Kilmarnock, which may be taken as samples of a larger number of epidemics in the same years. The association of much smallpox of a fatal type with much typhus fever, which can be traced in the London bills from an early period, is at length seen to be the rule for the country at large. After 1740-42, the next instances of it were in 1756 and 1766: it is most definitely indicated again in 1798-1800, very clearly in 1817-19, and in 1837-39. In all the later instances smallpox was the peculiar scourge of the infants and children in times of distress, while the contagious fever was as distinctively fatal to the higher ages. There is some reason to think that the law of incidence was the same in populous cities in 1740-42.

Thus at Edinburgh there died in the two worst years of the distress (population in 1732 estimated at 32,000)[1000]:

Edinburgh Mortalities.

1740 1741
Under two years 439 562
From two to five 198 269
From five to ten 53 93
Above ten 547 687
1237 1611
Fever 161 304
Flux 3 36
Consumption 278 349
Aged 102 156
Suddenly 56 62
{
{
{
{		Smallpox 274 206
Measles 100 112
Chincough 26 101
Convulsions 22 16
Teething 111 141
Stillborn 29 50
Other diseases 77 78

More than half the deaths were under five years, and among those deaths it will be necessary to include most of the smallpox mortality. That disease in the two exceptional years made 17 per cent. of all deaths, or one in six. But in its somewhat steady prevalence among children in Edinburgh from year to year, smallpox accounted for one death in about ten, as in the following[1001]:

Deaths by Smallpox and all causes in Edinburgh, including St Cuthbert’s parish, 1744-63.

Year All
Burials		 Dead of
Smallpox		 Year All
Burials		 Dead of
Smallpox
1744 1345 167 1754 1215 104
1745 1463 141 1755 1187 89
1746 1712 128 1756 1316 126
1747 1200 71 1757 1267 113
1748 1286 167 1758 1001 52
1749 1132 192 1759 1136 232
1750 1038 64 1760 1123 66
1751 1241 109 1761 903 6
1752 1187 147 1762 1305 274
1753 1105 70 1763 1160 123
12709 1256 11613 1185
or 1 in 9·6 or 1 in 9·8

As in other epidemics, it was not until its second year that the smallpox reached Norwich. The mortality had been enormous in 1741, owing to the distress and the fever, 1456 burials to 851 baptisms; but in 1742 the burials were 1953 (to 825 baptisms), the excess over the previous year being ascribed, in general terms, to the smallpox[1002]. It is probable that the enormous excess of burials over baptisms at Newcastle in 1741 was due in great part to the same disease among the children; but the statistics do not show it.

Northampton is an instance of a town with very moderate mortality for the 18th century; for that and other reasons its bills were used by Price as the basis of a table of the expectation of life. It had certainly shared in the fever epidemic of 1741 and 1742, for in the latter of those years the annual bill shows the very high fever-mortality of 37 in 130 deaths from all causes in All Saints’ parish, which had fully one-half of the population. But in that year there are no smallpox deaths recorded, and only nine in the next four years. The great periodic outburst of smallpox came in 1747[1003]:

Smallpox in Northampton, 1747.

Parish Cases Deaths Percentage
of Fatalities
All Saints 485 76 15·6
St Sepulchre 175 21 12·0
St Giles 131 23 17·5
St Peter 30 6 20·0
821 126 15·3or 1 in 6·5

Of the 76 deaths in All Saints’ parish only 58 were buried there. The deaths from all causes in that parish were 189, of which 103, or 54 per cent., were under five years of age, and 10 between five and ten years. Next year, when things had improved much, although the mortality was still high, All Saints’ parish had 119 burials, of which 47, or 40 per cent., were under five years, and 4 from five to ten, only three of the deaths being from smallpox. Only a few smallpox deaths appear in the bills of All Saints’ parish until 1756 and 1757, when an epidemic occurred, part of it in each year, which produced in that greatest of the four parishes 85 burials, or half as many again as in the epidemic of ten years before. It is singular that the deaths under and over five are in a very different ratio in the two successive years of the epidemic:

All Saints’ Parish, Northampton.

1756 1757
All deaths 140 135
Smallpox deaths 31 54
All deaths under 2 54 24
""2-5 12 18
""5-10 7 21
""10-20 5 6
""20-30 13 18
""30-40 7 12
""40-50 4 5
""above 50 38 31

This looks as if a good many more had died of smallpox at the higher ages in the second year of its prevalence than in the first; but the great difference between the deaths under two in 1756 and 1757 is explained chiefly by the article “convulsions,” which is 28 in the former year and only 10 in the latter.

In Boston, Lincolnshire, a town almost as healthy as Northampton, the intervals between epidemics of smallpox were almost as long, and the effect in raising the mortality for the year nearly the same. The population in the last year but one of the table was 3470. The deaths averaged 104 in a year, the smallpox deaths 9·45, or one in eleven[1004].

Smallpox in Boston, Lincolnshire, 1749-68.

Year Baptised Buried Died by
Smallpox
1749 68 120 48
1750 80 93 —
1751 55 59 —
1752 88 85 —
1753 79 73 —
1754 88 111 1
1755 74 102 19
1756 66 110 34
1757 93 86 4
1758 83 88 4
1759 102 91 —
1760 106 84 2
1761 80 94 —
1762 95 134 3
1763 92 206 69
1764 130 102 5
1765 112 113 —
1766 144 117 —
1767 129 95 —
1768 131 117 —

This was a favourable instance of urban smallpox in the 18th century, Boston having “no circumstances of narrow streets, crowded houses, manufactories or want of medical assistance.” We may compare with it an industrial town only a little larger, the weaving town of Kilmarnock, Ayrshire, the smallpox epidemics of which came as follows[1005]:

Smallpox in Kilmarnock, 1728-63.

Year Baptised Buried Died by
Smallpox
1728 111 162 66
1729 — — —
1730 — — —
1731 — — —
1732 — — —
1733 — — 45
1734 — — —
1735 — — —
1736 135 147 66
1737 — — —
1738 — — —
1739 — — —
1740 95 164 66
1741 — — —
1742 — — —
1743 — — —
1744 — — —
1745 116 102 74
1746 — — 8
1747 — — —
1748 — — 2
1749 134 149 79
1750 — — 5
1751 — — 1
1752 — — —
1753 — — 1
1754 146 203 95
1755 — — —
1756 — — —
1757 125 132 37
1758 — — 9
1759 — — —
1760 — — —
1761 — — —
1762 132 173 66
1763 — — 2

Although Kilmarnock had an average annual excess of baptisms over burials (134 to 107), which was more than that of Boston, its smallpox mortality was higher than that of the Lincolnshire market town. On an annual average, one death in eleven from all causes was by smallpox at Boston, one in six at Kilmarnock. In the former the epidemics came at intervals of about five years, in the latter at intervals of three or four. The oftener the epidemic came, the earlier in life it attacked children; and in all subsequent experience it has been found that smallpox is far more mortal to the ages below five than to the ages from five to ten or fifteen. More generally, the conditions were worse for young children in a weaving town than in a market town of nearly the same size. In the populous weaving parish of Dunse, 130 children are said to have died of smallpox in 1733, during a space of three months[1006].

The ages at which deaths from smallpox occurred in Kilmarnock from 1728 to 1763 are strikingly different from those already given for the small market town or village of Aynho, near Banbury, in 1723-24; at the latter the greater part of the fatalities, although not of the attacks, happened to persons between twenty and fifty; at the former nine-tenths of the deaths were of infants and young children, as in the following:

Ages at Death from Smallpox, Kilmarnock, 1728-63.

Deaths
at all
ages		 Under
One		 One to
Two		 Two to
Three		 Three to
Four		 Four to
Five		 Five to
Six		 Above
Six		 Age not
stated
622 118 146 136 101 62 23 27 9

This almost exclusive incidence of fatal smallpox upon infants and young children in a weaving town during the middle third of the 18th century we shall find abundantly confirmed for English manufacturing and other populous towns in the last third of the 18th century, and thereafter until the middle of the 19th century. On the other hand, the less populous towns and the country districts continued in the 18th century to furnish a fair share of adult cases, for the reason that epidemics came to them at longer intervals, wherein many had passed from infancy to childhood, and even from childhood to youth or maturity, without once encountering the risk of epidemic contagion.

Of such less populous places we have an instance in Blandford, Dorset. Particulars of its smallpox have been given in connexion with general inoculations; here let us note that in this typical market town of 2110 inhabitants (in 1773), the known epidemics were in 1731, 1741, 1753 and 1766—at intervals of ten or a dozen years. In the villages the intervals were longer. Haygarth gives the instance of three parishes in Kent with only ten deaths from smallpox in twenty years, and of Seaford, in Sussex, with one death “eleven years ago[1007].” An authentic instance is the parish of Ackworth, Yorkshire, whose register of burials contains only one smallpox death in the ten years 1747-57, while there are thirteen such deaths in it in the next ten-years period, clearly the effects of an epidemic, perhaps in 1766[1008]. This parish, judged by the excess of births, was not so healthy as many[1009], while its mortality by “fevers” was considerable. The following somewhat general statements are made for the parish of Kirkmaiden, Wigtonshire[1010]:

1717. “Nearly thirty-seven died of the smallpox.”
1721. Forty-eight died, “mostly of fevers.”
1725. Forty-three died, “mostly of the smallpox.”

By means of this law of periodic return, at short intervals in the populous industrial towns, at longer intervals in the market towns, and at very long intervals in the villages, we may realize in a measure what smallpox was at its worst. It was the great infective scourge of infancy and childhood, admitting but few or feeble rivals or competitors, as we shall see in the historical accounts of measles, whooping-cough and scarlatina. The table of epidemics from 1721 to 1727, given at p. 518, is of a kind that might have been furnished by any series of years in the 18th century; they were so much of a commonplace that hardly anyone thought of chronicling them unless for a special statistical purpose, such as the inoculation controversy. Thus, the Salisbury epidemic of 1723, with 1244 cases and 165 deaths, must have been only one of a series at intervals, which may or may not have become more frequent, or of different age-incidence, or of more fatal type, as the century proceeded. We have a glimpse of one of them in 1752-3. Lord Folkestone having given a hundred pounds to the poor of Salisbury, it was ordered on 15 December, 1752, “that five shillings be given to every inhabitant who hath had the smallpox in the natural way since 1 September, or that shall have it hereafter.” The epidemic went on for months; it was not until the end of 1753 that the mayor advertised the city free of smallpox. In September of that year ten guineas were voted to Mr Hall, the apothecary, for his trouble during the smallpox, and a like sum to Mr Dennis, the surgeon[1011].

The year 1753 was also the time of one of the periodical Blandford outbreaks. For a year or two before there had been much smallpox at Plymouth, the account of which by Huxham will serve as a sample of his numerous references to the disease there from the beginning of his annals in 1728.

In May, 1751, smallpox was brought in by Conway’s regiment; it spread in July and August, becoming worse in type in the autumn as it became more common. In January 1752 it was still prevalent, the pustules often crude, crystalline, undigested to the end; sometimes very confluent, small and sessile; sometimes black and bloody, attended now and then with petechiae. In March the type grew more mild; in April the malady was still up and down, some cases being of a bad sort. It became more frequent again in June, and was epidemic all the summer, the eruption often confluent, small, sometimes black, with haemorrhages from the nose, especially in children. In August it was epidemic everywhere, and more fatal, becoming milder in September and October. In December, “the crusts of the black confluent kind many times remained for at least thirty days after the eruption.” It declined from January, 1753, and entirely ceased in May, having had a prevalence of two years[1012].