The Smallpox Epidemic of 1817-19.
The same things that favoured the prevalence of typhus and relapsing fever in times of distress, favoured also the rise of smallpox to the height of an epidemic. Hence the greater epidemics of smallpox in the first half of the 19th century coincided somewhat closely with epidemics of relapsing or typhus fever,—in 1817-19, in 1825-27, in 1837-40, and in 1847-49. That which fever was to the adolescents and adults in times of distress, the same was smallpox to the infants and young children. The young children of a family did, indeed, take fever sometimes as well as the parents or the young persons in it; but the children seldom died of it. They died of smallpox (or of measles or whooping cough or the like), perhaps all the more readily that they would have been weakened by the fever, and by the want of food and comforts which attended it. Thus, while fever and smallpox went somewhat closely hand in hand during times of distress, it was the adolescents and adults that died of fever, the infants and young children that died of smallpox. The following table, compiled from the reports of the Whitehaven Dispensary from 1783 to 1800, will show how many children survived attacks of continued fever in comparison with their elders[1096]:
Continued Fever at Whitehaven Dispensary, 1783-1800.
| Total | Under 2 years | 2-5 | -10 | -15 | -20 | -30 | -40 | -50 | -60 | -70 | -80 | |||||||||||||
| Cases | 1712 | 40 | 142 | 240 | 223 | 150 | 240 | 236 | 202 | 92 | 47 | 15 | ||||||||||||
| Deaths | 85 | 0 | 0 | 5 | 2 | 6 | 14 | 20 | 19 | 12 | 7 | 0 |
The deaths from smallpox are found nearly always to be high when the deaths from fever are high. The correspondence, however, is not always exact to months or quarters, or half-years; for it is not unusual in the London weekly bills to find a run of weeks with high deaths from smallpox just before or after a run of weeks with high deaths from fever. The domestic circumstances which spread the contagion of fever were such as might be expected to spread the contagion of smallpox, namely, the pawning of clothes, bedding and the like, on a vast scale in times of scarcity, the crowding of many in single rooms or in one bed, the wandering of men and women, attended by their children, in search of work, the exposure of children in the smallpox so as to extort alms. All these things were common in Ireland, Scotland and England during the long periods of depressed trade, alternating with periods of speculation and expansion, for which the generation following the Peace of Paris was remarkable. We hear far more of the fever than of the smallpox, because the former touched the lives of breadwinners, while the latter was often regarded as a matter of course[1097]. Thus, in the Irish famine of 1817-18, it is possible to estimate the prevalence of dysentery, relapsing fever and typhus fever by the aid of various records, including two treatises and the reports of a Parliamentary Committee. There are also two or three brief references to smallpox; but no one would have supposed that smallpox caused actually more deaths than fever itself, as in the following returns of burials in the Cathedral churchyard of Armagh, from 1st May to 25th December, 1818[1098]:
| Smallpox deaths | 180 | |
| Fever deaths | 165 | |
| All other deaths | 118 |
—the total of 463 being twice or thrice the numbers for the corresponding months of non-epidemic years. Whether there was as much smallpox in other provinces of Ireland as in Ulster, does not appear; but the following relating to Strabane and Londonderry will serve to prove that Armagh was not exceptional in the north of Ireland. In and around Strabane, smallpox began to spread in May, 1817, having been hardly known in the neighbourhood for years before; it was often confluent and was “fatal to hundreds” of children[1099]. The same severity of the epidemic is reported also from the county of Derry in 1817: “Cases of smallpox appeared in greater numbers than I had ever before witnessed, even previous to the valuable discovery of Jenner[1100].”
The vagrancy of the Irish peasants, not only cottiers but also many small farmers, began in Ulster in the end of the year 1816, after a wet autumn which ruined the crops; and it is probable that the contagion of smallpox began to be spread among their children about the same time. Whether a migration set in to England and Scotland at that time is not clear. It appears, indeed, that the first of the epidemic in England, in Whitehaven, Ulverston, and other places which were in direct communication with the North of Ireland, was at least as early as, and perhaps earlier than, the outbreak of the malady in that country. The whole of the United Kingdom was suffering in 1816 from depression of trade, and many of the labouring class were tramping from place to place in search of work. The following is the account of smallpox being brought to Ulverston[1101]:
“The smallpox were brought to Ulverston from Wigan, by the wife of a nailer, who, with her child had slept in a house where the family had just recovered from them, in the latter end of January, 1816, or beginning of February. She immediately returned to Ulverston and the eruption appeared on the child about ten days afterwards, when it was carried about by the mother and much exposed in different parts of the town. They soon removed from this place; and I believe the child died between this place and Kendal.”
A young woman of Ulverston who was much in the company of the nailer’s wife from Wigan, caught smallpox from her child, and died on 22 February; her sister sickened soon after, and had the disease favourably. An epidemic followed in the town, of which some particulars are known down to October, 1816; the disease was very fatal also in Whitehaven at the same time. Two things gave a particular interest to the Ulverston smallpox of 1816, two things which were found to characterize the epidemic everywhere in England and Scotland as it spread in 1817, 1818 and 1819. These were, first the numerous cases of smallpox among those who had been inoculated with cowpox, a sequel now obvious on a large scale for the first time; and secondly, the admixture of a good many cases of “crystalline” or “hornpox” eruptions among the usual pustular cases. There was nothing new in such crystalline eruptions in smallpox; for example Huxham mentions them at Plymouth in 1752. But they were always curious, and it was always a matter of wonder that they should happen in one epidemic and not in another. Of thirty-five cases tabulated from the Ulverston epidemic of 1816, twelve had the “horny pox,” or the “small horny kind,” all the rest having the ordinary pustules of smallpox, sometimes discrete, sometimes confluent, four being scarred, and one covered by “a complete cake of incrustation.” All those thirty-five cases were above five years of age, except one child of three, and they seem to have nearly all recovered. Nothing is said of the infants and children under the age of five, who then contributed three-fourths of the mortality in every epidemic of smallpox. The crystalline eruption was not chickenpox; for the three first cases of it had all gone through chickenpox before.
Almost identical in tenour with this account from Ulverston is the narrative of an epidemic at Newton Stewart, in Wigton, just across the Solway from Cumberland, which began in the autumn of 1816, but did not extend until the following summer[1102]. The first case was one of “hornpox” in a girl from London; the second case was in a companion of the former, in the same family, her disease being ordinary pustular smallpox; both had been vaccinated. One hundred cases in the epidemic were thus assorted:
| Cases | Deaths | |||
| Smallpox | 43 | 13 | ||
| Modified hornpox, &c. | 47 | 0 | ||
| Varicella | 10 | 0 |
That is to say, the mortality of the whole was thirteen per cent., an ordinary mortality for a country town. There were all extremes, from confluent smallpox to discrete, many of the discrete having no proper pustules “but hard vesicles of more or less tubercular appearance.... These were termed by the people nerles or hornpox, and have long been noticed by very aged matrons, who pretend to no little skill in the diagnostics of smallpox, and who have distinct varieties by name, beyond the enumeration of any nosologist.” Their diagnostic skill was natural enough, for the practice in smallpox had been almost entirely in their hands.
A certain proportion of hornpox cases was so characteristic of this epidemic (1816-19) as to have been remarked everywhere—in England as well as in Scotland. The epidemic was not well reported as a whole at any one place. Sometimes, as at Ulverston, only the vaccinated cases were given; at other times, as at Cupar Fife and Edinburgh, only the “hornpox” cases were given; again, in the account of the Norwich epidemic, which is the fullest, the large number of cases with crystalline or horny eruption were not counted in as smallpox cases at all. Dewar’s table of the Cupar Fife epidemic, in the spring of 1817, included 70 cases, all of crystalline or hornpox[1103]. The latter variety was part of the epidemic at St Andrews[1104].
The Edinburgh cases which Thomson heard of to the end of the epidemic numbered 556, assorted as follows[1105]:
310 had been vaccinated.
41 had had smallpox (doubtless by inoculation).
205 had neither been vaccinated nor had smallpox.
A large proportion had the crystalline eruption, while some of the deaths are put down to “malignant crystalline water-pock.” At Lanark and New Lanark the epidemic was also taken notice of[1106]. At the latter were situated the cotton mills managed under Robert Owen’s co-operative system; and it appears that vaccination had been somewhat generally carried out in this socialist community. The following was the incidence of smallpox upon 322 persons:
251 had been vaccinated.
3 were under vaccination at the time.
11 had been inoculated with smallpox, or had gone through the natural smallpox.
57 had neither been vaccinated nor variolated.
It is clear that this was the first severe and general epidemic in Scotland since the beginning of the century, although we have seen that the disease had never been out of Glasgow. Thomson saw well enough how that epidemiological fact told: “It is to the severity of this epidemic, I am convinced, that we ought to attribute the greatness of the number of the vaccinated who have been attacked by it, and not to any deterioration in the qualities of cowpox virus, or to any defects in the manner in which it has been employed. [Dewar said the same for Cupar Fife.] Had a variolous constitution of the atmosphere, similar to that which we have lately experienced, existed at the time Dr Jenner brought forward his discovery, it may be doubted whether it ever could have obtained the confidence of the public.” Thomson himself, professor of military surgery in Edinburgh and a person of high character, drew the most astonishing inferences from the tolerably simple facts of the epidemic in 1817-19. The crystalline was mixed with the ordinary pustular smallpox in this epidemic, as it had been in some 18th century epidemics; it was common to those who had been vaccinated and to those who had not been so; it occurred in those who had previously gone through the chickenpox. Yet the professor concluded that crystalline or hornpox was smallpox “modified” by vaccination, that it should be called “varioloid,” and that “modified” smallpox and chickenpox were the same disease.
Several cases of smallpox had occurred in the spring of 1816 at Quarndon, two miles from Derby, one or two of the nine cases proving fatal. Several of the Derby doctors went to see them, some calling them “aggravated chickenpox,” and others “mild smallpox after vaccination.” In the spring following (1817), most of the children and young people in the villages of Breadsall, Smalling, Spondon, Heaver, and others near Derby, were afflicted with the epidemic, which declined in autumn. It came back in the spring of 1818, when it spread more generally than before, and was still prevalent at the end of that year, in Nottinghamshire and Staffordshire as well as in Derbyshire. In Herefordshire, also, in February, 1818, “typhus, measles and smallpox were at once raging.” The disease proved fatal in many instances among the lower orders in Derbyshire, who still followed the heating regimen, giving the children saffron to drink, and holding them in blankets before a strong fire, to bring the eruption out; but it was fatal also to some who were treated more rationally. In this part of England, as in Lancashire, Wigtonshire, Fifeshire, Edinburgh, and elsewhere, a large proportion of the cases had the crystalline eruption of smallpox, horny or glassy pimples or hard vesicles, which dried about the sixth day. But, said Dr Bent, the peculiar form “is the same in those persons who have never had the cowpox and in those who have passed through that disease satisfactorily.” His two drawings of the characteristic hornpox were made from unvaccinated children. On the very day of his writing he had seen two children in the same family, both with the crystalline eruption, the one vaccinated and the other not. In his practice at the Derby Infirmary, one in-patient and one out-patient had died of smallpox after vaccination, and one out-patient had died of it who had not been vaccinated. He was greatly astonished, after all that had been said of the certainty of cowpox protection[1107].
The epidemic of 1817-19 was longest in reaching the Eastern Counties, just as that of 1741-42 had been, and that of 1837-39 was to be. It was also towards the close of 1818 and beginning of 1819 that the disease became frequent in Canterbury. When it did reach Norwich, Lynn and many other places in Norfolk and Suffolk it became unusually destructive. The history of smallpox in Norwich from the beginning of the century was a history of the usual periodic epidemics, such as the city had been visited by in former times, according to the records in Blomefield’s History or other sources. The first epidemic was in the year 1805, when smallpox was unusually common in London also. The next, with 203 deaths, lasted from 1807 to 1809. In 1813, the bills again showed many deaths by it from 10 February to 3 September. For fully four years after that there was not a death from smallpox reported in Norwich. In June, 1818, by which time the epidemic had reached large dimensions in Ireland, Scotland, and part of England, it was brought to Norwich by a girl who had come with her parents from York; it spread little at the time, the deaths to the end of the year being only two. Meanwhile measles was a very frequent and fatal disease among the children in Norwich throughout the year 1818. The smallpox began to rage in April, 1819, after which the measles was hardly met with, and only a few cases of scarlatina. The following table shows the enormous rapidity with which smallpox went through the infants and children of the Norwich populace when it had once fairly begun[1108]:
| 1819 | Deaths from smallpox | Deaths from other diseases | Total | |||
| January | 3 | 61 | 64 | |||
| February | 0 | 71 | 71 | |||
| March | 2 | 68 | 70 | |||
| April | 15 | 61 | 76 | |||
| May | 73 | 63 | 136 | |||
| June | 156 | 70 | 226 | |||
| July | 142 | 61 | 203 | |||
| August | 84 | 63 | 147 | |||
| September | 42 | 96 | 138 | |||
| October | 10 | 63 | 73 | |||
| November | 2 | 62 | 64 | |||
| December | 1 | 83 | 84 | |||
| 530 | 822 | 1352 | ||||
In one week of June, there were forty-three burials from smallpox. Half the deaths were of infants under two years; nearly all the rest were of children under ten:
| Total | 0-2 | -4 | -6 | -8 | -10 | -15 | -20 | -30 | -40 | |||||||||
| 530 | 260 | 132 | 85 | 26 | 17 | 5 | 2 | 2 | 1 |
If the deaths were at the rate of one in about six cases, there would have been some three thousand children attacked in a population of 50,000 of all ages. Two hundred cases which Cross kept notes of were classified by him thus:
| Mild | 75 | |
| Severe | 78 | |
| Confluent | 42 | |
| Petechial | 5 |
Forty-six of these died, a rather high rate of 23 per cent., which is due perhaps to the crystalline or hornpox cases being excluded from the definition of smallpox altogether; all the petechial or haemorrhagic cases died, and most of the confluent. Sloughing of the face, lips or labia, occurred in three children, and bloody stools in many of the worst cases. Those 200 cases occurred in 112 families, comprising 603 individuals, of whom nearly one-half (297) “had smallpox formerly” (including the inoculated form of it, doubtless).
This was a great epidemic for Norwich in the 19th century. The public health there, as elsewhere, had improved greatly since the 18th century. In 1742 the deaths had been increased 502 by smallpox; but in that year, a year of severe typhus, the deaths from all causes were 1953, against 1352 in 1819. One reason of the enormous smallpox mortality from May to September, 1819, was the number of susceptible children, all the greater that there had been hardly any smallpox for five years, whereas in towns such as Norwich in the 18th century it appears to have been perennial: all the greater, also, because “the removal of families from the country to Norwich, during a flourishing and improving state of our manufactures for two or three preceding years, gave a sudden increase to the number of those liable to the disease.” Norwich may have been better off than many other towns; but the winter of 1816-17, when the smallpox epidemic began, was a time of depressed trade, many families being on the move in search of work; and it does not appear that all those who crowded to Norwich had found employment. The epidemic was “confined almost exclusively to the very lowest orders of the people;” the contagion was spread abroad among them by the shifts they were reduced to in their indigence—“the public exposure of hideous objects just recovering, loaded with scabs, at the street corners.” Yet this deplorable state of want and beggary does not seem to have been accompanied with much typhus fever among the adult population, as it certainly was in 1742. Cross describes a petechial fever, in May, June and July, 1819, which was fatal in all the cases that he was called to; but he speaks of it only among children. Whenever the population increases rapidly, as it had been doing in the second decade of the 19th century, it is upon the young lives that epidemic mortality falls most. The smallpox epidemic at Norwich in 1819 caused rather more deaths than in 1742, when the public health was very much worse; but it would hardly have caused so many had it not been aided by the state of population.
The epidemic of 1819 spread all over East Anglia[1109]. At Lynn there had been a good deal of the disease three years before; in 1819 there were so many deaths from it that in June the clergy ordered the smallpox burials to be specially marked in the register, from which date until the end of August they numbered forty. At Yarmouth the epidemic was still raging at the end of 1819. Of ninety-one surgeons in Norfolk and Suffolk who replied to a circular issued by Cross, all but eleven saw cases of smallpox in 1819, three had had cases in 1818, two had seen the disease in 1817, and one in 1816. Generally speaking, the disease had been in abeyance in those counties for seven years; a surgeon of Prudham, whose practice covered eleven parishes, had seen no case of smallpox for twelve years before. The largest number of deaths in the practice of any one surgeon was twelve. Twenty-eight surgeons together had 598 smallpox patients, with 97 deaths; but in their districts there had been 180 deaths besides from the same disease, in families unvisited by them.
The accounts of this epidemic in London are most meagre. In the bills of mortality, now become quite inadequate to the whole capital, the deaths rose to 1051 in 1817, fell next year to 421, and in 1819 were 712. But it was in the year 1819 that the admissions to the smallpox hospital were most numerous, namely, 193, the highest number since the epidemic of 1805, when they were 280 in the year. The horny or crystalline kind of smallpox was found in London, as elsewhere[1110].
In the spring of 1818, “smallpox post vaccinationem” was frequent among the boys of Christ’s Hospital[1111]. None of the cases proved fatal that year, but there was a death in the school from smallpox in 1820, probably the last fatality from that cause in the history of the school[1112].
A few casual notices of smallpox in England in the years following the epidemic of 1817-19 lead one to suppose that the disease did not again fall to that apparent extinction which it had reached before the last epidemic began. It is heard of in and around Chichester in 1821; nineteen surgeons who supplied Dr John Forbes with information had seen about 130 to 140 cases, with 20 deaths; about 80 of the cases were in persons previously inoculated with cowpox, 19 cases (or the most of 19) were in persons previously inoculated with smallpox[1113]. This was doubtless the experience of paying patients only; according to the East Anglian precedent of 1819 there would have been twice as much smallpox in families who received no professional treatment. Canterbury is another town from which a rapidly spreading epidemic of smallpox is reported—in the winter of 1823-4. It continued into the winter and spring of 1824-25, among the poor, fatal cases being by no means rare. Dr Carter frequently saw children exposed in the streets of Canterbury with smallpox upon them; he appealed to the mayor to have some check imposed on the spread of contagion, but nothing was done, and smallpox was still prevalent at the date of his writing in the autumn of 1824[1114]. The same year there was a severe epidemic at Oxford. These were probably only samples of epidemics filling the interval from 1819 to 1825, when smallpox again became general.