The range of severity in Smallpox, and its circumstances.
It has been abundantly shown in the foregoing, by the figures of Nettleton and others for Yorkshire and many other parts of England in 1722-27, of Frewen for Hastings in 1731, by the figures for each of the four parishes of Northampton in 1747, and by Haygarth’s census of each of the nine (or ten) parishes of Chester in 1774, that the average fatality of smallpox was one death in six or seven attacks[1034]. Any average of the kind represents a very wide range, as indeed the table of epidemics on p. 518 sufficiently shows; and as it is a matter of scientific interest to ascertain, if possible for smallpox as for other epidemic infections, the circumstances of its greater or lesser fatality, I shall endeavour to illustrate still farther the fact of its wide range from an extremely mild to an extremely severe disease, and to inquire into the circumstances or conditions of the same.
In the first place, selected ages were below or above the average. Isaac Massey, apothecary to Christ’s Hospital school, having boys to deal with at the most favourable of all ages for smallpox, found that not one had died of the 32 children “who are all that have had the smallpox, in the last two years, in that family”; and that “upon a strict review of thirty years business, and more, I have reason to think not 1 in 40 smallpox patients of the younger life have died, that is, above five and under eighteen[1035].” On the other hand the London Smallpox Hospital, whose patients, as the stereotyped phrase in the reports said, were “most of them adults, often admitted after great irregularities and when there are hardly any hopes of a cure,” had to acknowledge about one death in four or five cases on an average, which average, again, included such an unfavourable year as 1762, with 224 deaths in 844 cases.
Small groups of cases might perchance incline to mildness or to severity. Those of the former kind in the practice of one person were the more likely to be recorded. Thus Deering says that, in London about the year 1731, his method answered so well that “out of one hundred smallpox patients who were under my care within the course of two years, I lost but one. However, sincerity obliges me to own that the smallpocks were not during that whole time generally malignant, for some had them favourable, and the matter in others who had the confluent kind came in most by the eighth day to a good suppuration[1036].” This might be matched with an experience from the seventeenth century already given on the doubtful authority of an empiric[1037]. At Nottingham, in 1737, Deering claimed to have treated fifty-one cases with three deaths. Dr Robertson, physician to the fleet, says of his practice ashore: “When I arrived at Hythe in the beginning of April, 1783, the smallpox was pretty general.... My patients, about fifty in number, all did well[1038].”
The hold of a slave-ship may not seem a very good place to have smallpox in; and yet, in the voyage of the ‘Hannibal,’ 450 tons, 36 guns, from Guinea to Barbados in 1694, with 700 slaves on board, of whom 320 died on the passage from dysentery and white flux, the fatality of smallpox was so slight that “not above a dozen” were lost by it, “though we had a hundred sick of it at a time, and that it went through the ship[1039].” This gives some colour to that remarkable experience in the treatment of smallpox which occupied so much of the attention of Bishop Berkeley and of his friend Prior about the years 1746-7. The captain of a slave-ship on his return home made affidavit before the mayor of Liverpool, “in the presence of several principal persons of that town,” that smallpox attacked the slaves on board, when on the Guinea Coast, to the number of 170, that 169 of them who were induced to partake of tar-water recovered, and that the one negro who proved recalcitrant against the bishop of Cloyne’s panacea died of the disease[1040]. The somewhat low fatality of the Boston epidemic of 1752 (569 deaths in 5545 attacks not including the attacks among inoculated persons) was thought possibly due to the use of tar-water by many[1041].
Sometimes a run of highly favourable cases was followed by a succession of fatalities, or vice versa. Dr Mapletoft, to whom Sydenham dedicated a book, was originally in good physician’s practice and Gresham professor of physic; but he gave up these emoluments to enter the Church, and it is related by one who conversed with him in his extreme old age that he gave a singular reason for changing his profession, namely that, having treated smallpox cases for years without losing one (his treatment being to do nothing at all), he thereafter found that two or three died under his hands[1042].
Fothergill’s sixteen cases, in a certain locality of London in 1752, with only one death, are an instance of a run of mild cases. At the Whitehaven Dispensary in 1796 there was a good instance of how an average is made up; of the first seven cases attended from the dispensary three died, and then followed a run of thirty-four cases with only two of them fatal. Again, a high or low degree of fatality might seem to pertain to a particular spot. Bateman gives an instance in 1807 of 28 deaths within a month in a single court off Shoe Lane; also in 1812, “in one small court in Shoe Lane, seventeen individuals have lately been cut off by this variolous plague[1043].” One can understand that of the old Shoe Lane; but why should Nantwich have been reputed never to have its smallpox mortal? Worse things are told of country smallpox in Scotland than in England. In 1758, it is said, 8 died out of 28 near Cupar Fife, and in some parts of Teviotdale “three or four died for one that recovered[1044].” Similar unparalleled mortalities are reported by some parish ministers in the ‘Statistical Account.’
Cleghorn stationed with British troops in Minorca had a good opportunity of comparing two epidemics of smallpox, one in 1742 and the other in 1746. There had been no smallpox since 1725, so that when it did come in March, 1742, it found many susceptible of it: “every house was a hospital”; but “in proportion to the numbers, not many died; and what mortality there was happened chiefly among children at the breast and the common soldiers. About the end of July the disease suddenly disappeared, most of those who were susceptible of it having by that time undergone it.” Four and a half years after, in December, 1745, the infection was brought in by one of H. M. ships from Constantinople, and produced in many cases attacks of a bad type; which leads Cleghorn to remark that “it is a matter of chance whether the best or the worst kind is got in the natural way[1045].” Barbados had its epidemic maladies noted from season to season for several years by Hillary, who enters smallpox once: “May, 1752, smallpox epidemic: in general of the distinct kind; and in those few who had the confluent sort, they were generally of a good kind[1046].” Foreign observers were sometimes struck by the same mildness of a whole epidemic[1047].
The often cited remark of Wagstaffe in 1722, that there were cases which a physician could not save and cases which a nurse could not lose, had many illustrations. The cases of Queen Mary, in 1694, with the best physicians at her bed-side, and of the Duke of Gloucester in 1660, show the one event; the following from the Gentleman’s Magazine, shows the other:
In the parish of Whittington, Derbyshire, seventeen patients in all had the smallpox in the year 1752; the first was seized June 7, and the last August 12. They were all children, of various ages, and all did well. An apothecary was called to one only of them[1048].
A note added says:
“William Cave, a tradesman of Rugby, had twelve children, who, with three nephews, were seized with the smallpox; some of them had it severely, but all did well through the care of their mothers, without the intervention of an apothecary.”
Or there might be the average fatality in village epidemics left to domestic treatment only. At Kelsall and Ashton, two small Cheshire villages, sixty-nine persons had smallpox during seven months of 1773, of whom twelve died. “No medical practitioner visited any of the patients during the whole disease[1049].”
To find a single principle of cleavage through the smallpox of the 18th century, dividing it into good and bad, is impossible. The determining things were manifold, and they are to us obscure. Things proper to the individual constitution or temperament, hidden in what has been called “the abysmal deeps of personality,” cover a good deal in our reactions towards smallpox as in more important relationships. Generalizing such facts to the utmost, we do not get beyond the notion that the greater or lesser degree of proclivity runs in families. Morton could recall no case of smallpox fatal in his own family, nor, curiously enough, among his wife’s relations. On the other hand he introduces a case, his 53rd, as if to illustrate the contrary—a fair and elegant young lady, sprung of a distinguished stock, but one to which this disease was wont to prove calamitous as if by hereditary right[1050]. The royal family of Stuart had a peculiar fatality in smallpox; and so, it appears, had the family of the earl of Huntingdon, who wrote to Thomas Coke on 18 June, 1701: “I am informed Lord Kilmorey [married to his sister] is ill of a fever, and that some think it may prove the smallpox. For the love of God, send for my sister to your house. She never has had them and they have proved fatal in our family[1051].” A similar fatality in the family of John Evelyn can be traced in the pages of his diary.
Next to the individual constitution, we may take the epidemic constitution, in the Hippocratic sense. No one keeping before him the strange diversities of type in whole epidemics of scarlatina and measles will say that the Hippocratic doctrine of varying constitutions is not requisite to cover a certain element of mystery. But we should rationalize it wherever we can; and there are some obvious considerations that may be used to explain why smallpox, throughout a whole epidemic, had so high an average fatality in some years or in some localities. Rutty, who noted the fevers and other prevalent maladies in Dublin and elsewhere in Ireland from year to year, and the associations of the same with famine or the like, says that some had dysentery in 1757, “promoted perhaps by the badness of their bread, as it was a time of great scarcity,” that a low, putrid, petechial fever followed in the winter, fatal to not a few of the young and strong both in Dublin and in the country, and that as the cases of petechial fever increased much beyond the usual number in January, 1758, “it was observable that the smallpox kept pace in malignity with the fevers[1052].” That was the same year, 1758, for which Whytt records, along with the fatal smallpox of Fifeshire and Teviotdale, a dysentery and pestilential fever a month or two before, disastrous in Argyllshire, less mortal in Haddington and Newcastle, as well as an influenza all over Scotland[1053]. Again, in the country town and parish of Painswick, Gloucestershire, there was an epidemic of smallpox in the summer of 1785 so fatal that nearly one in three of the infected died. “This fatality,” says J. C. Jenner, “may in some measure perhaps be attributed to a contagious fever and epidemic ague which prevailed at the same time, and to the heat of the atmosphere”—many being dropsical from the agues that had afflicted them for months, and many reduced by the typhus fever[1054]. A striking instance of the fatality of smallpox among children in a poor state of health owing to previous disease is given by Sir William Watson:
At the Foundling Hospital of London, containing upwards of 300 children, there were 60 cases of smallpox during the last six months of the year 1762, of which only 4 died, or 1 in 15. In April and May of next year (1763) measles of a bad type broke out among the 312 inmates, attacking 180, of whom 19 died (over 1 in 10), while many who recovered were greatly weakened, having ulcerations of the lips and mouth for some time after. In May and June, when the children were recovering from measles, the smallpox attacked many in the hospital, including 18 who had lately gone through the measles. No fewer than 11 of those 18 died of smallpox. A corresponding fatality of smallpox was observed shortly before among children at the Foundling who were recovering from or had lately passed through the dysentery or “dysenteric fever[1055].”
It happens that we can compare a mild or average smallpox with an unusually fatal one, and the conditions on which they respectively depended, in the two neighbouring towns of Warrington and Chester in the two successive years 1773 and 1774. Chester in 1774 had the average kind of epidemic—1385 cases with 202 deaths (1 in 6·85), all in children. The Chester populace, as described by Haygarth, lived for the most part in poor houses of the newer suburbs; they were filthy in their persons and their houses were often visited by typhus fever (supra, p. 41). But the occupations of the men were not unhealthy, and the women would seem to have been left to their domestic duties in the usual way. At Warrington the circumstances were different. A seat of the sailcloth weaving from the Elizabethan period (as early as 1586 the “poledavies” of Warrington are mentioned), it had retained its repute and extended its industry as sailcloth came more into demand[1056]. The American War, and the earlier war with the French in Canada, caused an immense number of ships to be commissioned for the royal navy, and the Warrington looms are said to have furnished half of all the sailcloth that the fleets needed[1057]. Its manufacturers made their fortunes, new looms were added, population was drawn to the town from the country, marriages multiplied and were unusually prolific, and the swarms of children were hardly into their teens before they were set to earn wages along with their fathers and their mothers. We have vital statistics from the parish register by Aikin[1058], and an account of the industries by Arthur Young, as he saw them in 1769[1059]. During the twenty years from 1702 to 1722, each marriage, according to the register, produced only 2·9 children; from 1752 to 1772, the marriages averaged 73 in a year, and the baptisms 237, being 3·25 children to each marriage[1060]. But in the last three years of that period, 1770-72, the marriages had risen rapidly to an annual average of 95, and the baptisms to 331, being about 3·5 children to each marriage. From 1773 to 1781 the marriages averaged 85 and the fecundity reached 4·5 children to each. Arthur Young found the whole of this community, men, women, and children, engaged in sailcloth or sacking manufacture, boot-making, and pin-making.
“At Warrington the manufactures of sailcloth and sacking are very considerable. The first is spun by women and girls, who earn about 2d. a day. It is then bleached, which is done by men, who earn 10s. a week; after bleaching, it is wound by women, whose earnings are 2s. 6d. a week; next it is warped by men, who earn 7s. a week; and then starched, the earnings 10s. 6d. a week. The last operation is the weaving in which the men earn 9s., the women 5s., the boys 3s. 6d. a week. The spinners (women) in the sacking branch earn 6s. a week. Then it is wound on bobbins by women and children, whose earnings are 4d. a day.... The sailcloth employs about 300 weavers, and the sacking 150; and they reckon 20 spinners and 2 or 3 other hands to every weaver.”
On that basis of reckoning, Young estimated that the Warrington manufactures employed about eleven thousand hands; but as Aikin, in 1781, counted the whole inhabitants of the borough and three adjoining hamlets at 9501, it is clear that a good many spinners of the flax and hemp who lived in the country near Warrington must be allowed for in the eleven thousand. At all events Warrington was an early and an extreme instance of that hurry and scramble of wage-earning, by fathers, mothers and children, which the growth of manufactures in the latter part of the 18th century gave rise to, and of which many particulars came to light long after during the discussions that preceded the passing of the Factory Act. The mothers were workers, and all the while breeders at a somewhat high rate. It is difficult to imagine how the household duties were got through, and the infants reared, in such an industrial hive. Nor was there much attention given, during those great days of the sailcloth industry, to the scavenging and lighting of the town, and probably little to the overcrowded state of its old-fashioned streets and lanes. It was in January and February, 1775, fully a year after the great smallpox epidemic had ceased, that Mr Blackburne, who had become lord of the manor in 1764, “promoted the design of establishing a court of requests at Warrington, cleansing and lighting the town, and removing the butchers’ stalls.” These proposals, we are told, gave rise to a paper war[1061].
Ferriar has described what was apt to happen when country people migrated to manufacturing towns, got married, and had children born to them:
“A young couple live very happily, till the woman is confined by her first lying-in. The cessation of her employment then produces a deficiency in their income, at a time when expenses unavoidably increase. She therefore wants many comforts, and even the indulgences necessary to her situation: she becomes sickly, droops, and at last is laid up by a fever or a pneumonic complaint; the child dwindles, and frequently dies; the husband, unable to hire a nurse, gives up most of his time to attendance on his wife and child; his wages are reduced to a trifle; vexation and want render him diseased, and the whole family sometimes perishes, from the want of a small timely supply which their future industry would have amply repaid to the public[1062].”
What Ferriar saw so often some years after at Manchester must have been a not uncommon case at Warrington during the bustling time that Arthur Young describes. Its infantile mortality was certainly excessive, according to the following comparison with that of Chester, from the figures supplied to Price by Aikin from the Warrington burial registers of nine years, 1773-81, and by Haygarth from the Chester bills for ten years, 1772-81[1063]. The deaths are reduced to annual averages, and those of Warrington are raised, in the third column, to the ratio of the population of Chester by making them half as much again.
Annual average of deaths from all causes under five years.
| Ages at death | Warrington. Pop. 9,501 in 1781 | Chester. Pop. 14,173 in 1774 | Warrington raised to the ratio of Chester | |||
| Under one year | 72·7 | 80·6 | 109·0 | |||
| One to two | 43·5 | 36·1 | 65·2 | |||
| Two to three | 20·1 | 23·4 | 30·1 | |||
| Three to four | 11·5 | 14·4 | 17·2 | |||
| Four to five | 7·0 | 8·7 | 10·5 |
It was among infants and young children born and brought up with such comparatively poor chances of surviving, that smallpox broke out at Warrington in January, 1773, reaching its climax in May and ending about October, with a mortality of 209 or 211. Aikin says:
“Its victims were chiefly young children, whom it attacked with such instant fury that the best-directed means for relief were of little avail. In general the sick were kept sufficiently cool, and were properly supplied with diluting and acidulous drinks; yet where they recovered, it seemed rather owing to a less degree of malignity in the disease or greater strength to struggle with it, than any peculiar management. When it ended fatally, it was usually before the pustules came to maturation; and, indeed, in many they showed no disposition to advance after the complete eruption, but remained quite flat and pale”—a sure sign of poor stamina vitae. “In one neighbourhood I found that out of 29 who had the disease, 12 died, or about 2 in 5; in others the mortality was still greater, and I have reason to believe it was not less on the whole.”
The monthly progress of the mortality at Warrington and Chester respectively was as follows[1064]:
| Deaths. Warrington, 1773 | Deaths. Chester, 1774 | ||||
| Jan. | 4 | 0 | |||
| Feb. | 4 | 1 | |||
| March | 13 | 0 | |||
| April | 23 | 0 | |||
| May | 63 | 3 | |||
| June | 49 | 3 | |||
| July | 33 | 11 | |||
| Aug. | 11 | 26 | |||
| Sept. | 7 | 28 | |||
| Oct. | 3 | 46 | |||
| Nov. | 0 | 44 | |||
| Dec. | 1 | 40 | [1065] | ||
| 211 | 202 | ||||
The following are the ages at which the children died of smallpox, and of all causes, in each town during the epidemic year[1066]:
| Warrington (pop. in 1781, 9501) | Chester (pop. in 1774, 14,713) | |||||||
| Ages | Smallpox | Other deaths | Smallpox | Other deaths | ||||
| Under one month | 0 | 18 | 0 | 17 | ||||
| One to three months | 4 | 9 | 3 | 19 | ||||
| Three to six months | 4 | 9 | 4 | 10 | ||||
| Six to twelve months | 39 | 15 | 44 | 8 | ||||
| One to two years | 84 | 24 | 38 | 14 | ||||
| Two to three years | 33 | 5 | 42 | 3 | ||||
| Three to five years | 33 | 14 | 49 | 13 | ||||
| Five to ten years | 12 | 15 | 22 | 8 | ||||
| Above ten years | 0 | — | 0 | — | ||||
| 209 | — | 202 | — | |||||
Comparing the ages at death in the two epidemics, we see at a glance that the second year was most fatal to children at Warrington, whereas at Chester the deaths fell more at the higher ages, although in ratio of its population it was only on a par with Warrington even at these ages.
If the great smallpox year at each town be left out, 1773 at Warrington, 1774 at Chester, the mortality of infants in their second year from all causes is found to be one-third more at Warrington than at Chester on an annual average of eight (or nine) years. Some such difference Haygarth says was well known between the smallpox of great and small towns, namely, that it “attacks children at an earlier age, and consequently is fatal to a larger proportion of people, in great than in small towns[1067].” Although Warrington was the smaller town, infants died earlier there than at Chester (from smallpox and from all causes), or the probability of life was less;—a statistical fact which Price made out, but was unable to explain. The explanation is the poor stamina of the Warrington children, which was due most of all to the circumstance that the married women were at once wage-earners and prolific breeders.
In the smallpox year at Warrington, the deaths from all causes under five years of age were 62·5 of the whole mortality, (in infants under two years they were 43·5 per cent. of all deaths) smallpox having caused them in the ratio of 199 to 291. Although Aikin’s estimate of two deaths in five cases is improbable for the whole epidemic, we may admit a rate of one death in four, which would give Warrington in 1773 about as many cases in proportion to its numbers as Chester had in 1774—844 in a population of some 9000, as compared with 1385 in a population of 14,713.
The epidemics of smallpox at Carlisle in 1779 and Leeds in 1781 were unusually mortal, for reasons analogous to those assigned in the case of Warrington. Both towns had increased fast in numbers, owing to the growth of the weaving and spinning industries, both were overcrowded, ill ventilated, and filthy, and both had high mortalities from typhus fever among the adults, as described in another chapter. At Carlisle, the great epidemic of smallpox, which was the children’s special scourge, came in 1779, two years before the typhus fever reached a height. The smallpox caused 90 deaths, while “a species of scarlet fever” at the same time caused 39 deaths. Heysham estimated somewhat vaguely that these 90 deaths occurred in 300 cases, or one case fatal in 3·3, which is double the average[1068]. Lucas gives the proportion at Leeds more exactly—462 cases, in six months, with 130 fatalities, or 1 in 3·5. The epidemic at Leeds in 1721-22, which Nettleton described as “more than usually mortal,” caused 189 deaths in 792 attacks, or 1 in 4·2. There were fewer attacks in the much larger population (17,117) of 1781, perhaps because there were fewer persons who had not had the disease already, and these almost exclusively the infants born and the young children who had grown up since the last epidemic[1069]. In those circumstances it is hardly surprising that the Leeds smallpox of 1781 should have been a degree more mortal than that of 1721-22, which was itself “more than usually mortal.”
A complete survey of smallpox in its great period, the eighteenth century, in all places and continuously from year to year, is impossible even if it were to be desired. Had it not been for the exact diligence of a few, especially in the North of England, we should have been left in doubt on some of the main epidemiological generalities. A system of registration such as was applied for the first time in the epidemic of 1837-39 would have saved much research and would have made it possible to bring the facts within a smaller compass. By comparison and classification of many scattered particulars we may still acquire a tolerably clear notion of what smallpox was in the 18th century. It was chiefly a disease of infancy and early childhood. It was always present in one part or another of the capital and of the larger towns, rising at intervals to the height of a great and general epidemic[1070]. At its worst, as in Glasgow, it took about a third part of the lives under the age of five, and perhaps a sixth part of the lives at all ages. It came in epidemics at somewhat regular intervals in the smaller towns, and at longer intervals in the country parishes. The village epidemics were apt to be very searching when they did come. Haygarth gives the instance of Christleton, a small village two miles from Chester, in 1778: “The distemper began in March and continued till October. At the commencement of the epidemic, 107 poor children had never been exposed to the variolous infection; of these 100 had the distemper, probably all who were capable of receiving the smallpox.” In all places, with the possible exception of London where the risks from infantile diarrhoea and “convulsions” were peculiar, it cut off the infants and young children more than any other single disease, infectious or other; and indeed it had few rivals among infectious diseases until towards the close of the century, being for a time the grand epidemic scourge of the first years of life just as the plague was once the unique scourge of youth and mature age. It was more mortal in some seasons than in others, and at certain places. Towards the end of the 18th century, much more is heard of it in the northern industrial towns than in England south of the Trent. If the statistics of Boston, Lincolnshire, are at all representative, smallpox certainly declined much in market towns in the last twenty years of the century. It appears to have declined also in the capital during the same period. In the parishes of Scotland, by the almost unanimous testimony of the articles which refer to it in the ‘Statistical Account,’ it had become much less frequent and less dangerous for some years previous to the publication of that work (1792-98). In Glasgow, with the worst statistics of children’s deaths in the whole kingdom, the maximum had been reached, and passed, in the period between the close of the American war and the first years of the great war with France. As the French war proceeded, and vast sums of public money were poured out (the bill being left to Prince Posterity to pay), the effects of this abundance were seen in the remarkable decline, and almost total disappearance, of fevers all over England, Scotland and Ireland. Corresponding with the lull in fevers there was a lull in smallpox, not so marked as the former, but very significantly covering the same period and lasting until the great depression of trade in 1816 which followed the Peace. This will appear in continuing the chronology of epidemics; but before we come to that, it remains to make clear the scientific or pathological nature of a new kind of inoculation which became at this juncture the rival of the old. The extent to which each of the rival methods was practised will become a subject of inquiry after the epidemic of 1817-19 has been dealt with.