VI.

A continent so subject to earthquakes as South America might be expected, in this hypothesis, to have had some corresponding influenzas. It has indeed had influenzas, some of them peculiar to itself. The Western Hemisphere as a whole has, on several great occasions, had influenzas which were not felt in the Old World. Again, there are one or two instances in which the infection, while it spread widely over the table-lands of Bolivia and Peru, does not appear by existing testimony to have been carried north of the Isthmus. One of these was the influenza of 1720, as special to a region of South America as that of 1688 was to the British Isles. The account of it was given in an essay by Botoni ‘On the Circulation of the Blood,’ published at Lima in 1723[776]. He calls it _catarro maligno_; it was popularly known as _fierro chuto_ or “iron cap.” It appeared at Cuzco in the end of March, or beginning of April, 1720, and was over about November. Four thousand are said to have died of it in the diocese of Cuzco, and it is said to have made so great a scarcity of hands that the first harvest after it was imperfectly gathered. It had all the marks of an influenza, with the addition of bleeding from the nose and lungs. It had also the grand characteristic common to influenza and epidemic ague: “the symptoms were so diverse and even contradictory that no correct diagnosis, or curative plan, could be fixed.” The Lima writer of 1723 says that it followed an eclipse of the sun on the 15th of August, 1719, having begun on the eastern side of the Andes, in the basin of La Plata, about that time, and travelled northwards and westwards, as the South American influenza of 1759 did.

This is a localized influenza in a country of earthquakes. But the two great earthquakes in 1719 are not South American. They both happened in July: one along the coast of Fez and Morocco, which ruined many villages and a part of the city of Morocco (there is also a later disturbance in the Azores in December, followed by the upheaval of a new island), the other in North China. Here we have the choice of following the “aer inimicus” of Lucretius either from China or from the African coast; and if it be the case that the influenza began in the latter part of the year 1719 in the basin of the La Plata, to cross the Andes next year, it may seem, in this hypothesis, that a course from east to west, bringing the infection across the Atlantic from Africa, is to be preferred to a course from west to east, bringing it across the Pacific from North China. In either case there need be no difficulty in finding local clouds of miasmata. Some traces of the corresponding great earthquake in China were found in November of the following year, by Bell, an English traveller who crossed from Moscow to Peking:

“Jumy,” he says, “suffered greatly by the earthquakes that happened in the month of July the preceding year [1719], above one half of it being thereby laid in ruins. Indeed more than one half of the towns and villages through which we travelled this day had suffered much on the same occasion, and vast numbers of people had been buried in the ruins. I must confess it was a dismal scene to see everywhere such heaps of rubbish[777].”

The atmospheric effects of Chinese earthquakes have been pictured since medieval times, in obviously superstitious colours; and there are reasons why a great disturbance of soil in that country should produce remarkable miasmata. The surface soil of China is peculiar in having the bodies of the dead dispersed at large in it, insomuch that excavations for the foundations of houses, or for roads and railway cuttings, can hardly be made without the constant risk of exposing graves[778].

If the soil of China is peculiar in one way, that of the West Coast of Africa is peculiar in another. Without entering on the large question of “malaria” in each of them, I shall take an old illustration of the miasmata of the West Coast of Africa as a cause of dengue-fever, a disease curiously like influenza in its symptoms, and like it also in its occasional wave-like dispersion over wide regions. The authority is Dr Aubrey, who resided many years on the coast of Guinea, saw much of the slave-trade, and wrote a very sensible book in 1729, called ‘The Sea Surgeon, or the Guinea Man’s Vade Mecum.’ He describes quite clearly the fever which was long after described by West Indian physicians as dengue, or three-days’ fever, or break-bone fever, including in his description the characteristic exanthems of it and the penetrating odour of the sweat. He gives also, in clinical form, a series of cases on board the galley ‘Peterborough’ in December, 1717, which are exquisite examples of break-bone fever. This disease, he says, “many times runs over the whole ship, as well negroes as white men, for they infect one the other, and the ship is then in a very deplorable condition unless they have an able man to take care of them.” But the original source of infection, he believed, was the fogs that hung at nightfall over the estuaries of the rivers; and he gives an experimental proof, remarkable but not quite incredible, of the poisonous nature of the miasmata:

“But to let you see the evil, malevolent, contagious, destructive quality of those fogs that fall there in the night, and how far they are inimical to human nature, I will tell you of an experiment of my own. I made a lump of paste with oat-meal somewhat hard, and about the bigness of a hen’s egg, which was exposed to the fog from twilight to twilight, i.e. from the dusk of the evening till daybreak in the morning; after which I crumbled it, and gave it to fowls, which we had on board, and soon after they had eaten it, they turned round and in a kind of vertigo dropt down and expired.”

A great mortality in Guinea in 1754 or 1755 was ascribed by Lind, the least credulous in such matters, to “a noxious stinking fog[779].”

What the alternations of heat and chill, of moisture and drought, produce ordinarily in the way of miasmata, the same, we may suppose, is produced on the great scale, as a phenomenon at some particular time and place, by one of those cataclysms which break the surface of the earth or the bed of the sea, lower or raise the level of wells and springs, and fill the air with particles of dust or vapour which may overhang the locality for months and visibly disperse themselves to a great distance. Nothing relating to miasmata in the air need be hard for belief after the wonderful diffusion and permanence in the atmosphere of the whole globe, for two years or more, of finely divided particles shot up by the earthquakes and eruptions of Krakatoa in the Straits of Sunda on the 27th and 28th of August, 1883[780].

A theory of influenza constructed from such generalities as those of Boyle, Arbuthnot and Webster will have attractions for many over the theory that influenza is always present in some remote country and becomes dispersed now and then over the world by contagion from person to person: it will have superior attractions, for the reason that influenza is a phenomenal thing which needs a phenomenal cause to account for it. But if anyone were to attempt to fit each historic wave of influenza with its

## particular earthquake, or to find the precise locality where clouds of

infective matter had arisen, or the particular circumstances in which they arose, he would certainly find his fragile structure of probabilities pulled to pieces by the professed discouragers and depravers. I make no such attempt; but I am not the less persuaded of the direction in which the true theory of influenza lies.

Influenza at Sea.

There is no point more essential to a correct theory of influenza than to find out in what circumstances it has occurred among the crews of ships on the high seas. If it be true that a ship may sail into an atmosphere of influenza, just as she may sail into a fog, or an oceanic current, or the track of a cyclone, then the possible hypotheses touching the nature, source, and mode of diffusion of influenza become narrowed down within definite limits.

One of the first observations was made in the case of a Scotch vessel in the influenza of 1732-33[781]. The epidemic was earlier in Scotland than in England; it began suddenly in Edinburgh on 17 December, 1732, the horses having been attacked with running of the nose towards the end of October. About the time when the disease began among mankind, in December, a vessel, the ‘Anne and Agnes’ sailed from Leith for Holland. One sailor was sick on this voyage. She sailed on the return voyage to Leith, with the other ten of her crew in perfect health. Just as she made the English coast at Flamborough Head on the 15th of January, 1733, six of the sailors fell ill together, two more the next day, and one more on the day after that, so that when the vessel anchored in Leith Roads there was only one man well, and he fell ill on the day following the arrival. The symptoms were the common ones of the reigning epidemic. The dates are not given more precisely or fully than as above. Influenza was prevalent in Germany and Holland somewhat earlier than in Scotland or England; the men may, of course, have imbibed the infection when they were in the Dutch port, just as it is almost certain that the crews of Drake’s fleet in 1587 had received during a ten days’ stay upon the island of St Jago, of the Cape de Verde group, the miasmatic infection of which they suddenly fell sick in large numbers together in mid-Atlantic some six days after sailing to the westward.

This early case of the ‘Anne and Agnes’ in 1733 may pass as an ambiguous one. The next occasion when influenza on board ship attracted much notice was the epidemic of 1782.

On the 6th of May, Admiral Kempenfelt sailed from Spithead with seven ships of the line and a frigate, on a cruize to the westward; on the 18th May, he came into Torbay, and sailed again soon after; on the 30th May he came again into Torbay with eight sail of the line and three frigates, and on 1 June sailed again to the westward. Sometime before his squadron put into Torbay for the second time, influenza had appeared among them at sea, it is said in the ‘Goliath’ on the 29th of May[782]. A letter from Plymouth, of the 2nd June, after referring to the violence of influenza in that town, at the Dock, and on board the men-of-war lying there, says that the ‘Fortitude’ of 74 guns, and ‘Latona’ frigate came in that afternoon with 250 sick men from the fleet under Admiral Kempenfelt, mostly with fevers. Another Plymouth letter two days later (4 June) says: “Kempenfelt is returning to Torbay: he could keep the sea no longer, on account of the sickness that rages on board his fleet. More than 400 men have been brought to the hospital this morning. Our men drop down with it by scores at a time. The ‘Latona’ frigate, that sailed the other day is returned, the officers being the only hands that could work the ship[783].”

This outbreak on board ships in the Channel was fully as early as the great development of influenza in 1782 on shore, whether in London or Plymouth; but there were almost certainly cases of it at the latter port before the ‘Latona’ sailed to join Kempenfelt’s squadron. Robertson, however, who was surgeon on the ‘Romney’ in the Channel service at that time, says that “hundreds in different ships, towns, and counties, which had _no_ communication with one another, were seized nearly as suddenly and so nigh the same instant as if they had been electrified.... The companies of many of the ships were very well at bed-time, and in the morning there were hardly enough able to do the common business of the ship[784].” This is confirmed by McNair, surgeon of the ‘Fortitude,’ who told Trotter that two hundred of her men, as she lay in Torbay, were seized in one night and were unable to come on deck in the morning[785].

There was another English fleet in the North Sea at the same time, under Lord Howe, watching the Dutch fleet or seeking to intercept the Dutch East Indiamen.

Howe sailed from St Helen’s on the 9th May, with twelve ships of the line. Towards the end of that month he had his fleet in the Texel; the men were in excellent health, “when a cutter arrived from the Admiralty, and the signal was given for an officer from each ship [to come on board the admiral]. An officer was accordingly sent with a boat’s crew from every vessel, and returned with orders, carrying with them also, however, the influenza”--which soon prostrated the crews to the same extraordinary extent as in the ships under Kempenfelt at the other end of the Channel. This was the oral account given to Professor Gregory of Edinburgh, by a lieutenant on board a sixty-four gun ship[786]. Another account says that the disorder first appeared in Howe’s fleet on the Dutch coast about the end of May, on board the ‘Ripon,’ and in two days after in the ‘Princess Amelia’; other ships of the same fleet were affected with it at different periods, some indeed, not until their return to Portsmouth about the second week of June. “This fleet, also, had no communication with the shore until their return to the Downs, on their way back to Portsmouth, towards the 3d and 4th of June[787].”

But, apart from the story of the Admiralty despatch-boat carrying the influenza to Howe’s squadron, it appears that both Kempenfelt and Howe were joined from time to time by additional ships, which might have carried an atmosphere of influenza with them[788]. Still, it was an influenza atmosphere that they had carried, and not merely so many sick persons. The doctrine of contagion from person to person would have to be so widened as to become meaningless, if all those experiences of the fleet in 1782 were to be brought within it. In the history both of sweating sickness and of influenza, there are instances of the disease breaking out suddenly in a place after someone’s arrival; but the new arrival may not have had the disease, it was enough that he came from a place where the disease was[789]. That was, perhaps, the reason why Beddoes, in his inquiry of 1803, framed one of his questions so as to elicit information about the dispersal of influenza by _fomites_.

It is not easy to prove that a ship may meet with an atmosphere of influenza on the high seas; but many have believed that ships have done so. Webster says: “The disease invades seamen on the ocean in the same [western] hemisphere, when a hundred leagues from land, at the same time that it invades people on shore. Of this I have certain evidence from the testimony of American captains of vessels, who have been on their passage from the continent to the West India Islands during the prevalence of this disease[790].” There are several instances of this, authenticated with times, places, and other data of credibility.

The best known of these is the voyage of the East Indiaman ‘Asia’ in September, 1780, through the China Sea from Malacca to Canton: “When the ship left Malacca, there was no epidemic disease in the place; when it arrived at Canton it was found that at the very time when they had the _Influenza_ on board the Atlas (_sic_) in the China seas, it had raged at Canton with as much violence as it did in London in June, 1782, and with the very same symptoms[791].”

In the present century, the cases nearly all come from the medical reports of the navies of Great Britain, France, Germany and the Netherlands, and they relate to ships on foreign service--in the East Indies, the Pacific, Africa, or other foreign stations. In some of the instances influenza went through a ship’s company in port or in a roadstead, others are examples of outbreaks at sea:

1837: “The ship’s company of the ‘Raleigh,’ were attacked by epidemic catarrh--influenza--first in March, while at sea between Singapore and Manilla, and again, although less severely, in June and July while on the coast of China.... Influenza also made its appearance amongst the crew of the ‘Zebra’ in April while she lay at Penang; it was supposed to have been contracted by infection from the people on shore, as they were then suffering from it. No death occurred under this head[792].”

1838: In the ‘Rattlesnake,’ at Diamond Harbour, in the Hooghly River, a large proportion of the men were suffering from epidemic catarrh. Intermittent fever made its appearance; “the change from the catarrhal to the febrile form was sudden and complete, the one entirely superseding the other[793].”

1842: In the ‘Agincourt’ on a voyage from the Cape of Good Hope to Hongkong in August and September, the greater part of 102 cases of catarrh occurred; many of these were accompanied with inflammation of tonsils and fauces, and in some there was deafness with discharge from the ear. This is not claimed as an instance of epidemic influenza, but as an aggregate of common colds, due to cold weather in the Southern Ocean and to wet decks[794].

1857: “Influenza broke out in the ‘Monarch’ while at sea, on the passage from Payta [extreme north of Peru] to Valparaiso. She left the former place on the 23d August, and arrived at the latter on the last day of September. About the 12th of the month [twenty days out], the wind suddenly changed to the south-west, when nearly every person in the ship began to complain of cold, although the thermometer did not show any marked change in the temperature. On the 12th and 13th seven patients were placed on the sick list with catarrhal symptoms; and during the following ten days, upwards of eighty more were added, but by the end of the month the attacks ceased. [She carried 690 men, and had 191 cases of “influenza and catarrh,” in the year 1857.] Some of the cases were severe, ending either in slight bronchitis or pneumonia, accompanied with great prostration of the vital powers. On the arrival of the ship at Valparaiso, the surgeon observes: ‘We found the place healthy, but in the course of a few days some cases of influenza made their appearance, and very soon afterwards the disease extended over the whole town. It was generally believed that we imported it, and the authorities took the trouble to send on board a medical officer to investigate the matter.’ He further observes that the whole coast, from Vancouver’s Island southward to Valparaiso was visited by the epidemic.” It made its appearance on board the ‘Satellite’ at Vancouver’s Island in September, and among the residents ashore, both on the island and mainland, at the same time[795].

1857: Catarrh “assumed the form of influenza in the ‘Arachne’ [149 men, 114 cases] while the vessel was cruizing off the coast of Cuba, with which, however, she had no communication. There was nothing in the state of the atmosphere to attract special attention. A question therefore arises whether it might not have been caused by infection wafted from the shore.” It was prevalent at the time at Havana[796].

1857: “Australian Station:--An eruption of epidemic catarrh occurred in the ‘Juno’ [200 men, 131 cases], but long after she left the station[797].”

Whilst the influenza was on the American Pacific coast in September, 1857, it was on the coast of China three months earlier--on board the ‘Inflexible’ at Hongkong on the 18th of May, and in the ‘Amethyst’ and ‘Niger’ in a creek near Hongkong early in June[798]. But it had been on the Pacific coast of South America the year before, according to the following:

“1856: Epidemic catarrh broke out in the ‘President’ when lying off the island of San Lorenzo in the bay of Callao, first on the 20th October, and the last cases were placed on the sick list on 1st November,--the usual period which influenza takes to pass through a frigate ship’s company. About sixty required to be placed on the sick list.” It had occurred on board English ships of war at Rio de Janeiro, on the other side of the continent, some two months before, in August, 1856[799].

1863: The following, in the experience of the French navy, has been elaborately recorded[800]: The frigate ‘Duguay-Trouin’ left Gorée, Senegambia, for Brest, in February. There were no cases of influenza in Gorée when she left; but four days out, an epidemic of influenza began on board, the weather being fine and the temperature genial at the time. Another French frigate, which had left Gorée, on the same voyage to Brest, two days earlier, did not have a single case.

The following instance, here published for the first time, belongs to the most recent pandemics of influenza, 1890-93. It relates to only a single case of influenza, in the captain of a merchantship; it would have been a more satisfactory piece of evidence, if there had been several cases in the ship; but among the comparatively small crew of a merchantman, the same groups of cases are not to be looked for that we find on board crowded men of war; and in this particular case the only other occupants of the quarter-deck were the first mate and the steward.

The ship ‘Wellington,’ sailed from the Thames, for Lyttelton, New Zealand, on the 19th December, 1891. The epidemic of influenza in London in that year had been in May, June and July; the mate of the ‘Wellington’ had had an attack of it ashore, on that occasion, but not the captain nor the steward. On the 2nd of March, 1892, when seventy-four days out and in latitude 42° S., longitude 63 E., near Kerguelen’s Land, the captain began to have lumbago and bilious headaches, for which he took several doses of mercurial purgative followed by saline draughts. The treatment at length brought on continual purging, which, together with three days’ starving from the 22nd to the 24th of March, caused him a loss of weight of eight pounds. The navigation had meanwhile been somewhat difficult and anxious, owing to a long spell of easterly head winds. Quite suddenly, on the 26th March, when the ship was in latitude 44 S., longitude 145 E., or about two hundred miles to the south of Tasmania, he had an aguish shake followed by prolonged febrile heat, which sent him to his berth. The symptoms were acute from the 26th to the 30th March,--intense pain through and through the head, as if it were being screwed tight in an iron casing, pain behind the eyeballs, a perception of yellow colour in the eyes when shut, a feeling of soreness all over the body, which he set down at the time to his uneasy berth while the ship was ploughing through the seas at about twelve knots, and a pulse of 110. The head pains were by far the worst symptom, and were so unbearable as to make the patient desperate. This acute state lasted for four days, and suddenly disappeared leaving great prostration behind. The captain, who had long experience with crews and passengers, and a considerable amateur knowledge of medicine, summed up his illness as a bilious attack, passing into “ague” with “neuralgia of the head.” While the acute attack lasted the ship had covered the distance from Tasmania to the southern end of New Zealand, and on the 31st of March the captain by an effort came on deck to navigate the vessel in stormy weather up the coast to Lyttelton, which was reached on the 2nd of April. The pilot coming on board found the captain ill in his berth, and on being told the symptoms, at once said, “It is the influenza: I have just had it myself.” The doctor who was sent for found the captain “talking foolishly,” as he afterwards told him, and had him removed to the convalescent home at Christchurch, where he remained a fortnight slowly regaining strength. The doctor[801] could find no other name for the illness but influenza, although he had not supposed such a thing possible in mid-ocean. They had just passed through an epidemic of it in New Zealand, and it is reported about the same time in New South Wales, afterwards in the Tonga group, and still later in the summer in Peru. The symptoms of this case are sufficiently distinctive: the intense constricting pain of the head is exactly the “_fierro chuto_” or “iron cap” of South American epidemics; the pain in the eyeballs, the soreness of the limbs and body, and the unparalleled depression and despair, are the marks of influenza without catarrh. The patient was of abstemious habits, and had made the same voyage year after year for a long period without any illness that he could recall. He had reduced himself by purging and starving, on account of a bilious attack during a fortnight of foul winds from the eastward, and had doubtless become peculiarly susceptible of the influenza miasm before the ship came into the longitude of Tasmania on the 26th March.

The Influenzas of Remote Islands.

The full and correct theory of influenza will not be reached by the great pandemics only. On the other hand some very localized epidemics may prove to be signal instances for the pathology, although they do not bear upon the source of the great historic waves of influenza. The instances in view are the influenzas started among a remote community on the arrival of strangers in their ordinary health. This phenomenon has been known at the island of St Kilda, in the Outer Hebrides of Scotland, since the year 1716, when it was recorded in the second edition of an essay upon the island by Martin. Some thought these “strangers’ colds” mythical, so much so that Aulay Macaulay, in preparing a work upon St Kilda, was advised to leave them out; he declined to do so, and Dr Johnson commended him for his magnanimity in recording this marvel of nature. There is now no doubt about the fact. H.M.S. ‘Porcupine’ visited the island in 1860; a day or two after she sailed again, the entire population, some 200 souls, were afflicted with “the trouble,” and another visitor, who landed ten days after the ‘Porcupine’s’ visit, saw the epidemic of influenza in progress. The same thing happened in 1876, on the occasion of the factor landing, and again in 1877 on the occasion of a crew coming ashore from a wrecked Austrian ship. A medical account of this epidemic catarrh was given in 1886: The patient complains of a feeling of tightness, oppression and soreness of the chest, lassitude in some cases, pains in the back and limbs, with general discomfort and lowness of spirits. In severe cases there is marked fever, and great prostration. A cough ensues, at first dry, then attended with expectoration, which may go on for weeks[802].

In the remote island of Tristan d’Acunha, in the South Atlantic midway between the River Plate and the Cape of Good Hope, the same thing happens “invariably” on the arrival of a vessel from St Helena[803]. It is reported also as a common phenomenon of the island of Wharekauri, of the Chatham Group, about 480 miles to the eastward of New Zealand. Residents, both white and coloured, suddenly fall into an illness, one symptom of which is that they feel “intensely miserable.” It lasts acutely for about four days, and gradually declines. It resembles influenza in all respects, and is known by the name of _murri-murri_, which is curiously like the old English name of _mure_ or _murre_. “The mere appearance of murri-murri is proof to the inhabitants, even at distant parts of the island, which is thirty miles long, that a ship is in port, insomuch that, on no other evidence, people have actually ridden off to Waitangi to fetch their letters[804].”

About equally distant in the Pacific from Brisbane, as Wharekauri from Christchurch, lies Norfolk Island, originally colonized by the mutineers of the ‘Bounty.’ A writer in a newspaper says:

“During a seven years’ residence in Norfolk Island, I had opportunities of verifying the popular local tradition that the arrival of a vessel was almost invariably accompanied by an epidemic of influenza among the inhabitants of the island. In spite of the apparent remoteness of cause and effect, the connexion had so strongly impressed itself on the mind of the Norfolk Islanders that they were in the habit of distinguishing the successive outbreaks by the name of the vessel during whose visit it had occurred[805].”

Something similar has long been known in connexion with the Danish trade to Iceland, the first spring arrivals from the mother country bringing with them an influenza which the crews did not suffer from during the voyage, nor, in most cases, during the progress of the epidemic in Reikjavik. The experience at Thorshaven, in the Faröe Islands, has been the same[806].

These are important indications for the pathology of influenza in general. They point to its inclusion in that strange class of infections which fall most upon a population, or upon those orders of a population, who are the least likely to breed disease by anything that they do or leave undone. Veterinary as well as human pathology presents instances of the kind[807]. In seeking for the source of such an infectious principle, we are not to look for previous cases of the identical disease, but for something else of which it had been an emanation or derivative or equivalent, something which may have amounted to no more than a disparity of physical condition or a difference of race. And as the countries of the globe present now as formerly contrasts of civilized and barbarous, nomade and settled, rude and refined, antiquated and modern, with the aboriginal varieties of race, it may be said, in this theory of infection, that mere juxtaposition has its risks. But, in the theory of influenza, the first requisite is an explanation of its phenomenal uprisings and wave-like propagation, at longer or shorter intervals, during a period of many centuries.

## CHAPTER IV.

SMALLPOX.

The history of smallpox in Britain is that of a disease coming gradually into prominence and hardly attaining a leading place until the reign of James I. In this respect it is unlike plague and sweating sickness, both of which burst upon the country in their full strength, just as both made their last show in epidemics which were as severe as any in their history. In the former volume of this work I have shown that smallpox in the first Tudor reigns was usually coupled with measles, that in the Elizabethan period the Latin name _variolae_ was rendered by measles, and that smallpox, where distinguished from measles, was not reputed a very serious malady[808]. From the beginning of the Stuart period, smallpox is mentioned in letters, especially from London, in such a way as to give the impression of something which, if not new, was much more formidable than before; and that impression is deepened by all that is known of the disease later in the 17th century, including the rising figures in the London bills of mortality.

An early notice of a particular outbreak of smallpox is found in the Kirk Session records of Aberdeen in 1610, under the date of 12 August: “There was at this time a great visitation of the young children with the plague of the pocks[809].” In 1612 there are various references to deaths from smallpox in London in rich houses. In 1613, the Lord Harrington, who is said in a letter of Dr Donne’s to be suffering from “the pox and measles mingled,” died of smallpox (probably haemorrhagic) on the Sunday before 3 March, at which date also the Lady Burghley and two of her daughters were sick of the same disease. Those two years were probably an epidemic period. Another epidemic is known from a letter of December, 1621: “The smallpox brake out again in divers places, for all the last hard winter and cool summer, and hitherto we have had no sultry summer nor warm winter that might invite them. The Lord Dudley’s eldest son is lately dead of them, and the young Lady Mordaunt is now sick.” On 28 January, 1623, “the speech that the smallpox be very rife there [Newmarket] will not hinder his [James I.’s] journey.” The years 1623 and 1624 were far more disastrous by the spotted fever all over England; but smallpox attended the typhus epidemic, as it often did in later experience, the two together having “taken away many of good sort as well as mean people.”

The first epidemic of smallpox in London, from which some figures of the weekly mortalities have come down, was in 1628: this was the year before the Parish Clerks began to print their annual bills, but they had kept the returns regularly since 1604, and appear to have made known in one way or another the weekly mortality and the chief diseases contributing thereto. The smallpox deaths in London in the week ending 24 May, 1628, were forty-one, in the following week thirty-eight, and in the third week of June fifty-eight[810]. Such weekly mortalities in a population of about 300,000 belong to an epidemic of the first degree; and it is clear from letters of the time that the London smallpox of 1628 made a great impression. Lord Dorchester, in a letter of 30 August, calls it “the popular disease[811].” Several letters relating to a fatal case of smallpox in June in the house of Sir John Coke in the city (Garlick Hill) bear witness to the dread of contagion through all that circle of society[812]. One of the letters may be cited:

“It pleased God to visit Mrs Ellweys [Coke’s stepdaughter] with such a disease that neither she nor any other of her nearest and dearest friends durst come near her, unless they would hazard their own health. The children and almost all our family were sent to Tottenham before she fell sick, and blessed be God are all in health. Mrs Ellweys was sick with us of the smallpox twelve days or thereabouts.” Before she was out of the smallpox, she was taken in labour on 15 June, and died the next morning at five o’clock, being buried the same night at ten, with only Sir Robert Lee and his lady of her kindred at the funeral. The letter proceeds: “God knows we have been sequestered from many of our friends’ company, who came not near us for fear of infection, and indeed we were very circumspect, careful, and unwilling that any should come to us to impair their health.” Lady Coke was fearful to go to Tottenham because of the children who had been removed thither.

All the indications, whether from letters of the time, from poems and plays, or from statistics, point to the two first Stuart reigns as the period when smallpox became an alarming disease in London among adults and in the upper class. The reference to smallpox at Aberdeen in 1610 is to the disease among children; and so also is an unique entry, opposite the year 1636, on the margin of the register of Trinity parish, Chester: “For this two or three years, divers children died of smallpox in Chester[813].” In London, the disease had not yet settled down to that steady prevalence from year to year which characterized it after the Restoration. On the other hand, the periodic epidemics were very severe while they lasted. The epidemic of 1628 was followed by three years of very slight smallpox mortality in London; then came a moderate epidemic in 1632 and a severe one in 1634, with again two or more years of comparative immunity, as in the following table from the earliest annual printed bills:

_Smallpox deaths in London, 1629-36_[814].

Smallpox Deaths from Year deaths all causes

1629 72 8771 1630 40 10554 1631 58 8532 1632 531 9535 1633 72 8393 1634 1354 10400 1635 293 10651 1636 127 23359

For the next ten years, 1637-46, the London figures are lost[815], excepting the plague-deaths and the totals of deaths from all causes, but it is known from letters that there was a great epidemic of smallpox in one of them, the year 1641: the deaths were 118 in the week ending 26 August, and 101 in the week ending 9 September[816], totals seldom reached a century later, when the population had nearly doubled. In those weeks of 1641, it was second only to the plague as a cause of dread, and was, along with the latter, the reason that “both Houses grow thin,” for all the political excitement of the time. The next London epidemic was in 1649, when the annual bill gives 1190 deaths from smallpox. Willis says that the epidemic was also at Oxford that year, not so very extensive, “yet most died of it” owing to the severe type of the disease[817]. Five years after, in 1654, “at Oxford, about autumn, the smallpox spread abundantly, yet very many escaped with them.” The London deaths from smallpox for a series of years were as follows:

Smallpox Year deaths

1647 139 1648 401 1649 1190 1650 184 1651 525 1652 1279 1653 139 1654 832 1655 1294 1656 823 1657 835 1658 409 1659 1523 1660 354 1661 1246

Smallpox after the Restoration.

The period which must now concern us particularly, from the Restoration onwards, opens with two deaths from smallpox in the royal family within a few months of the return of the Stuarts. When Charles II. left the Hague on 23 May, 1660, to assume the English crown, his two brothers, the Duke of York and the Duke of Gloucester, accompanied him in the fleet. In the first days of September, the Duke of Gloucester was seized at Whitehall with an illness of which various accounts are given in letters of the time[818]. On 4 September, “the duke hath been very sick, and ’tis thought he will have the smallpox.” On the 8th “the doctors say it is a disease between the smallpox and the measles; he is now past danger of death for this bout, as the doctors say”; or, by another account, “the smallpox come out full and kindly, and ’tis thought the worst is past.” On the 11th the duke is “in good condition for one that has the smallpox.” But a day or two afterwards his symptoms took an unfavourable turn; the doctors left him, apparently with a good prognosis, one evening at six o’clock, but shortly after he bled at the nose three or four ounces, then fell asleep, and on awaking passed into an unconscious state, in which he died. When his body was opened, the lungs were full of blood, “besides three or four pints that lay about them, and much blood in his head, which took away his sense.” Pepys says his death was put down to the great negligence of the doctors; and if we can trust a news-letter of the time, their negligence was such as would have been now approved, for “the physicians never gave him anything from first to last, so well was he in appearance to everyone[819].” Three days after his funeral, the king and the Duke of York went to Margate to meet their sister, the princess Mary of Orange, on her arrival from the Hague. Her visit to the Court extended into the winter, and about the middle of December she also took smallpox, of which she died on the 21st. Pepys, dining with Lady Sandwich, heard that “much fault was laid upon Dr Frazer and the rest of the doctors for the death of the princess.” Her sister, the princess Henrietta, who had come on a visit to Whitehall with the Queen-mother in October, was removed to St James’s on 21st December, “for fear of the smallpox”; but she must have been already sickening, for on the 16th January it is reported that she “is recovered of the measles.”

These deaths at Whitehall of a brother and sister of Charles II. happened in the autumn and winter of 1660; but it was not until next year that the smallpox rose to epidemic height in London, the deaths from it having been only 354 in 1660, rising to 1246 in 1661, and 768 in 1662. In 1661 it appears to have been epidemic in other parts of England: Willis, who was then at Oxford, says that smallpox began to rage severely before the summer solstice (adding that it was “a distemper rarely epidemical”), and there are letters from a squire’s wife in Rutlandshire to her husband in London, which speak of the disease raging in their village in May and June[820].

There was much fever of a fatal type in London in 1661, which is more noticed than smallpox itself in the diary of Pepys. The town was in a very unhealthy state; and it would have been in accordance with all later experience if the “pestilential constitution” of fevers, which continued more or less until the plague burst forth in 1665, had been accompanied by much fatal smallpox. The occasion was used by two medical writers to remark upon the fatality of smallpox as something new. The second of the two essays (1663), was anonymous, and bore the significant title of _Hactenus Inaudita_, the hitherto unheard of thing being that smallpox should prove so fatal as it had been lately. The author adopts the dictum of Mercurialis, with which, he says, most men agree: “Smallpox and measles are wont for the most part to terminate favourably”; and he makes it clear in the following passage that the blame of recent fatalities was laid, justly or unjustly, at the door of the doctors, as, indeed, we know that it was from the gossip of Pepys:

“And I know not by what fate physicians of late have more lost their credit in these diseases than ever: witness the severe judgment of the world in the cases of the Duke of Gloucester and the Princess Royal: so that now they stick not to say, with your Agrippa, that at least in these a physician is more dangerous than the malady[821].”

The other essay was by one of the king’s physicians, Dr Tobias Whitaker, who had attended the Court in its exile at St Germain and the Hague. He was by no means an empiric, as some were whom Charles II. delighted to honour; and, although he protests warmly against the modish injudicious treatment of smallpox by blooding and cooling, he has little of the recriminating manner of the time, which Sydenham used from the one side and Morton from the other. He is, indeed, all for moderation: “upon this hinge of moderation turneth the safety of every person affected with this disease.” His moderation is somewhat like that of Sir Thomas Browne (whose colleague he may have been for a few years at Norwich), and is apt to run into paradox. In 1634 he wrote in praise of water, including the waters of spas and of the sea, and in 1638 he wrote with even greater enthusiasm in praise of wine[822]. He says of his “most learned predecessor” at Court, Harvey, that his demonstration of the circular motion of the blood was a farther extension of what none were ignorant of “though not expert in dissection of living bodies.” On his return to London in 1660, he seemed to find as great a change in smallpox as in the disposition of the people towards the monarchy. His statement as to the change for the worse that had come over smallpox within his memory would be of the highest historical importance if we could be sure it was not illusory; it is difficult to reconcile with the London experiences of smallpox in 1628 and 1641, but, such as it is, we must take note of it:

“It is not as yet a complete year since my landing with his Majesty in England, and in this short time have observed as strange a difference in this subject of my present discourse as in the variety of opinions and dispositions of this nation, with whom I have discoursed.” This disease of smallpox, he proceeds, “was antiently and generally in the common place of _petit_ and _puerile_, and the cure of no moment.... But from what present constitution of the ayre this childish disease hath received such pestilential tinctures I know not; yet I am sure that this disease, which for hundreds of yeares and before the practice of medicine was so exquisite, hath been as commonly cured as it hapned, therefore in this age not incurable, as upon my own practice I can testifie.... Riverius will not have one of one thousand of humane principles to escape it, yet in my conjecture there is not one of one thousand in the universe that hath any knowledge or sense of it, from their first ingress into the world to their last egress out of this world; which could not be, if it were so inherent or concomitant with maternal bloud and seed,” referring to the old Arabian doctrine, which Willis adhered to, that every child was tainted in the womb with the retained impure menstrual blood of the mother, and that smallpox (or measles) was the natural and regular purification therefrom. “But smallpox,” he continues, “is dedicated to infants more particularly which are moist, and some more than others abounding with vitious humours drawn from maternal extravagancy and corrupt dyet in the time of their gestation; and by this aptitude are well disposed to receive infection of the ayre upon the least infection[823].”

When Whitaker calls smallpox a “childish disease,” a disease that was “antiently and generally in the common place of _petit_ and _puerile_, and the cure of no moment,” he says no more than Willis and others say of smallpox as it affected infants and children. Says Willis: “there is less danger if it should happen in the age of childhood or infancy”; and again: “the sooner that anyone hath this disease, the more secure they are, wherefore children most often escape”; and again: “the measles are so much akin to the smallpox that with most authors they have not deserved to be handled apart from them,” although he recognizes that measles is sooner ended and with less danger. Nor was Willis singular among seventeenth-century physicians in his view--“the sooner that anyone hath this disease the more secure they are.” Morton in two passages remarks upon the greater mildness of smallpox in “infants”: “For that they are less anxious about the result, infants feel its destructive force more rarely than others”; and again: “Hence doubtless infants, being of course ἀπαθεῖς, are afflicted more rarely than adults with the severe kinds of confluent and malignant smallpox[824].”

In the very first treatise written by an English physician specially on the Acute Diseases of Infants, the work by Dr Walter Harris, there is a statement concerning the mildness of “smallpox and measles in infants” (who are defined as under four years of age), which goes even farther than Morton’s:

“The smallpox and measles of infants, being for the most part a mild and tranquil effervescence of the blood, are wont to have often no bad character, where neither the helping hands of physicians are called in nor the abounding skill of complacent nurses is put in requisition[825].”

It has to be said, however, that Morton’s statement about infants is made to illustrate a favourite notion of his that apprehension as to the result, which infants were not subject to, made smallpox worse; and that Harris’s assertion of the natural mildness of the “smallpox and measles” of infants comes in to illustrate the evil done by the heating regimen of physicians and nurses, who are mentioned in obviously sarcastic terms. So also Sydenham says that “many thousands” of infants had perished in the smallpox through the ill-timed endeavours of imprudent women to check the diarrhoea which was a complication of the malady, but was in Sydenham’s view, although not in Morton’s, at the same time a wholesome relieving incident therein. If we may take it that infants and young children had smallpox in a mild form, or more rarely confluent than in adults, we may also conclude that many of them died, whether from the alexipharmac remedies which Morton advised and Sydenham (with his follower Harris) denounced, or from the attendant diarrhoea which Sydenham thought a natural relief to the disease and Morton thought a dangerous complication.

Making every allowance for motive or recrimination in the statements, from their several points of view, by Willis, Sydenham, Morton, Harris (Martin Lister might have been added), as to the naturally mild course of smallpox in infants, or when not interfered with by erroneous treatment, it cannot but appear that infantile smallpox at that time was more like measles in its severity or fatality than the infantile smallpox of later times. It is perhaps of little moment that Jurin should have repeated in 1723 the statements of Willis and others (“the hazard of dying of smallpox increases after the birth, as the child advances in age”)[826], for he had little intimate knowledge of epidemics, being at that time mainly occupied with mathematics, and with smallpox from the arithmetical side only. But it is not so easy to understand why Heberden should have said the same a generation after[827]; or how much credit should attach to the remark of “an eminent physician from Ireland,” who wrote to Dr Andrew, of Exeter, in 1765: “Infants usually have the natural pock of as benign a kind as the artificial[828].”

Whatever may have been its fatality or severity among infants and children, it was chiefly as a disease of the higher ages that smallpox in the Stuart period attracted so much notice and excited so much alarm. The cases mentioned in letters and diaries are nearly all of adults; and these were the cases, whatever proportion they may have made of the smallpox at all ages, that gave the disease its ill repute. About the middle of the 18th century we begin to have exact figures of the ages at which deaths from smallpox occurred: the deaths are then nearly all of infants, so much so that in a total of 1622, made up from exact returns, only 7 were above the age of ten, and only 92 between five and ten; while an age-incidence nearly the same continued to be the rule until after the great epidemic of 1837-39, when it began gradually to move higher[829]. But we should err in imagining that state of things the rule for the 17th century, just as we should err in carrying it forward into our own time. Not only are we told that smallpox of infants was like measles in that the cure was of no moment (which is strange), but we do know from references to smallpox in the familiar writings of the Stuart period that many of its attacks, with a high ratio of fatalities, must have happened to adults. Thus, to take the diary of John Evelyn, he himself had smallpox abroad when he was a young man, his two daughters died of it in early womanhood within a few months of each other, and a suitor for the hand of one of them died of it about the same time. Medical writings leave the same impression of smallpox attacking many after the age of childhood. Willis gives four cases, all of adults. Morton gives sixty-six clinical cases of smallpox, the earliest record of the kind, and one that might pass as modern: twelve of the cases are under six years of age, nine are at ages from seven to twelve, eleven from thirteen years to twenty, seven from twenty-two to forty, and all but two of the remaining twenty-four clearly indicated in the text, in one way or another, as adolescents or adults, the result being that 23 cases are under twelve and 43 cases over twelve[830].

That ratio of adults to children may have been exceptional. Morton was less likely to be called to infants than to older persons, even among the middle class; and no physician in London at that time knew what was passing among the poorer classes, except from the bills of mortality. But if Morton had practised in London two or three generations later, say in the time of Lettsom, when “most born in London have smallpox before they are seven,” his casebook would not have shown a proportion of forty-three cases over twelve years to twenty-three under that age. Whatever things contributed to the growing evil repute of smallpox among epidemic maladies, there is so much concurrent testimony to the fact itself that we can hardly take it to have been wholly illusion. In some parts the mildness of smallpox was still asserted as if due to local advantages. Thus Dr Plot, who succeeded Willis in his chair of physics at Oxford, wrote in 1677: “Generally here they are so favourable and kind that, be the nurse but tolerably good, the patient seldom miscarries[831].”

The reason commonly assigned for the large number of fatalities in smallpox after the Restoration was erroneous treatment. That is the charge made, not only in the gossip of the town, as Pepys reported it, but in Sydenham’s animadversions on the heating regimen, in Morton’s on the cooling regimen, and in the sarcasms of both physicians upon the practice of “mulierculae” or nurses. One may easily make too much of this view of the matter; it is certain that the incidence of smallpox, its fatality and its frequency in general, were determined in the Stuart period, as at other times, by many things besides. Still, the treatment of smallpox has always had the first place in its epidemiological history. The fashion of it that concerns us at this stage was the famous cooling regimen, commonly joined with the name of Sydenham.

Sydenham’s Practice in Smallpox.

Sydenham occupied his pen largely with smallpox, and gained much of his reputation by his treatment of it. At the root of his practice lay the distinction that he made between discrete smallpox and confluent. His practice in the discrete form was to do little or nothing, leaving the disease to get well of itself. Whether the eventual eruption were to be discrete or confluent, he could not of course tell for certain until two or three days after the patient sickened; but in no case was the sick person to be confined to bed until the eruption came out. If the latter were sparse or discrete, the patient was to get up for several hours every day while the disease ran its course, the physician having small occasion to interfere with its progress: “whoever labours under the distinct kind hardly needs the aid of a physician, but gets well of himself and by the strength of nature.” One may see how salutary a piece of good sense this was at the time, by taking such a case as that of John Evelyn, narrated by himself[832]. He fell ill at Geneva in 1646, and was bled, leeched and purged before the diagnosis of smallpox was made. “God knows,” he says, “what this would have produced if the spots had not appeared.” When the eruption did appear, it was only the discrete smallpox; the pimples, he says, were not many. But he was kept warm in bed for sixteen days, during which he was infinitely afflicted with heat and noisomeness, although the appearance of the eruption had eased him of his pains. For five whole weeks did he keep his chamber in this comparatively slight ailment. When he suggested to the physician that the letting of blood had been uncalled for, the latter excused the depletion on the ground that the blood was so burnt and vicious that the disease would have turned to plague or spotted fever had he proceeded by any other method[833].

As there were many such cases, Sydenham’s radical distinction between discrete and confluent smallpox, with his advice to leave the former to itself, was of great value, and is justly reckoned to his credit. But in the management of confluent smallpox he advised active interference. If there were the slightest indication that the disease was to be confluent (that is to say, the eruption copious and the pocks tending to run together), he at once ordered the patient to receive a vomit and a purge, and then to be bled, with a view to check the ebullition of the blood and mitigate the violence of the disease. Even infants and young children were to have their blood drawn in such an event. This heroic treatment at the outset was according to the rule of _obsta principiis_; by means of it he thought to divert the attack into a milder course. The initial depletion once over, Sydenham had resort to what is known as the cooling regimen. He set his face against the “sixteen days warm in bed,” which Evelyn had to endure even in a discrete smallpox. It was usually a mistake for the patient to take to bed continually before the sixth day from his sickening or the fourth day from the appearance of the eruption; after that stage, when all the pustules would be out, the regimen would differ in different confluent cases, and, of course, in some a continuance in bed would be inevitable as well as prudent. In like manner cardiac or cordial remedies, which were of a heating character, were indicated only by the patient’s lowness. The more powerful diaphoretic treacles, such as mithridate, were always a mistake. The tenth day was a critical time, and then paregoric was almost a specific. In the stage of recovery it was not rarely prudent to prescribe cordial medicines and canary wine. Thus, on a fair review of Sydenham’s ordinances for smallpox in a variety of circumstances, it will appear that he did not carry the cooling regimen to fanatical lengths and that he was sufficiently aware of the risks attending a chill in the course of the disease[834].

Apart from his rule of leaving cases of discrete smallpox to recover of themselves, Sydenham’s management of the disease was neither approved generally at the time, nor endorsed by posterity. His phlebotomies in confluent cases, usually at the outset, but sometimes even after the eruption was out if the patient had been under the heating regimen before, were an innovation borrowed from the French Galenists. The earlier writers had, for the most part, excepted smallpox among the acute maladies in which blood was to be drawn. But the Galenic rules of treatment were made more rigorous in proportion as they were challenged by the Paracelsist or chemical physicians, and it was among the upholders of tradition that blood-letting was extended to smallpox. Whitaker says that, when he was at St Germain with the exiled Stuarts, the French king was blooded in smallpox ten or eleven times, and recovered; “and upon this example they will ground a precept for universal practice.”

The ambiguity of the diagnosis at the outset, and the desire to lose no time, may have been the original grounds of this indiscriminate fashion of bleeding. Evelyn’s doctor at Geneva in 1646, “afterwards acknowledged that he should not have bled me had he suspected the smallpox, which brake out a day after,” but eventually he defended his practice as having made the attack milder. In like manner Sir Robert Sibbald, of Edinburgh, (1684) took four ounces of blood from a child of five, who was sickening for some malady; when it turned out to be smallpox, the mother expressed her alarm that blood should have been drawn; but Sibbald pointed to the favourable character of the eruption as justifying what he had done: “Optime enim eruperunt variolae, et ab earum eruptione febris remissit[835].”

The ill effects of blood-letting, says Whitaker, may be observed in French children, which by this frequent phlebotomizing are “withered in _juvenile_ age.” Therefore, he concludes, blooding in smallpox should not be a common remedy, “but in such extremity as the person must lose some part of his substance to save the whole.” He calls it the rash and inconsiderate practice of modish persons; “and if the disease be conjunct [confluent], with an undeniable plethory of blood, which is the proper indication of phlebotomy, yet such bleeding ought to be by scarification [upon the arms, thighs or back] and cupping-glasses, without the cutting of any major vessel.” Another English physician of the time, Dr Slatholm, of Buntingford in Hertfordshire, who wrote in 1657[836], says that he had known physicians in Paris not to abstain from venesection in children of tender age, even in sucklings. He had never approved the letting of blood in such cases, lest nature be so weakened as to be unable to drive the peccant matter to the skin. For the most part, he says, an ill result follows venesection in smallpox; and although it sometimes succeeds, yet that is more by chance than by good management. As to exposing the sick in smallpox to cold air, he declares that he had known many in benign smallpox carried off thereby, instancing the case of his brother-in-law, the squire of Great Hornham, near Buntingford, whose death from smallpox in November, 1656, in the flower of his age, he set down to a chill brought on “ejus inobedientia et mulierum contumacia[837].”

The cooling regimen, as well as the danger of it, was familiar long before Sydenham’s time. There could be no better proof of this than a bit of dialogue in Beaumont and Fletcher’s ‘Fair Maid of the Inn’ (Act II. scene 2), a comedy which was licensed in January, 1626:

_Host._ And you have been in England? But they say ladies in England take a great deal of physic.... They say ladies there take physic for fashion.

_Clown._ Yes, sir, and many times die to keep fashion.

_Host._ How! Die to keep fashion?

_Clown._ Yes: I have known a lady sick of the smallpox, only to keep her face from pit-holes, take cold, strike them in again, kick up the heels, and vanish.

Sydenham says that the heating regimen was the practice of empirics and sciolists. Per contra his distinguished colleague Morton says that every old woman and apothecary practised the cooling regimen, and he points the moral of its evil consequences in a good many of his sixty-six clinical cases[838]. He pronounces the results of the cooling regimen to have been disastrous; he had been told that Sydenham himself relaxed the rigour of his treatment in his later years. There was so little smallpox for some fifteen years after the date of Morton’s book (1694) that the controversies on its treatment appear to have dropped. But, on the revival of epidemics in 1710 and 1714, essays were written against blooding, vomits and purges in smallpox[839].

In 1718, Dr Woodward, the Gresham professor of physic and an eminent geologist, published some remarks on “the new practice of purging” in smallpox, which were directed against Mead and Freind. In 1719 Freind addressed a Latin letter to Mead on the subject (the purging was in the secondary fever of confluent smallpox), and a lively controversy arose in which Freind referred to Woodward anonymously as a well-known empiric. On the 10th of June, 1719, about eight in the evening, Woodward was entering the quadrangle of Gresham College when he was set upon by Mead. Woodward drew his sword and rested the point of it until Mead drew his, which he was long in doing. The passes then began and the combatants advanced step by step until they were in the middle of the quadrangle. Woodward declared (in a letter to the _Weekly Journal_) that he was getting the best of it, when his foot slipped and he fell. He found Mead quickly standing over him demanding that he should beg his life. This Woodward declined to do, and the combat degenerated to a strife of tongues[840]. Next year the controversy over the treatment of smallpox assumed a triangular form. The third side was represented by Dr Dover, who had been something of a buccaneer on the Spanish main and was now in practice as a physician. An old pupil of Sydenham’s, he still adhered to blood-letting in smallpox; and in the spring of 1720, when the disease was exceedingly prevalent among persons of quality in London, he claimed to have rescued from death a lady whom Mead had given over, by pulling off the latter’s blisters and ordering a pint of blood to be drawn. “He hath observed the same method with like success with several persons of quality this week, and is as yet in very great vogue.... He declaims against his brethren of the faculty [especially Mead and Freind], with public and great vehemence, and

## particularly against purging and blistering in the distemper, which he

affirms to be the death of thousands[841].”

Huxham, another Sydenhamian, appears to have practised not only blooding in smallpox, but also blistering, purging and salivating[842]. But in that generation the practice was exceptional; so much so that when it revived in some hands about 1752 (including Fothergill’s), it was thus referred to in a letter upon the general epidemic of smallpox in that year: “I have heard that bleeding is more commonly practised by some of the best physicians nowadays than it was formerly, even after the smallpox is come out[843].” In smallpox the lancet, like other methods, has been in fashion for a time, and then out of fashion; but the old teaching that smallpox did not call for blood-letting was ultimately restored. When Barker, in 1747, gave a discourse before the College of Physicians on the “Agreement betwixt Ancient and Modern Physicians,” he did not venture to defend Sydenham’s blooding in smallpox, although he would not admit that he was “a bloodthirsty man[844].”

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.

Pockmarked Faces in the 17th Century.

The smallpox of 1667-68 had among its numerous victims one of the king’s mistresses, the beautiful Frances Stewart, duchess of Richmond, residing in Somerset House, who caught the disease in March 1668 and was “mighty full of it.” Pepys, who records the fact, had seen her portrait taken shortly before: “It would make a man weep,” he exclaims, “to see what she was then and what she is likely to be by people’s discourse now.” Happily the worst fears were not realized. Pepys saw her driving in the Park in August, and remarks, without a strict regard to grammar, that she was “of a noble person as ever I did see, but her face worse than it was considerably by the smallpox.” The king, unlike the Lord Castlewood of romance, suffered no loss of ardour for his mistress, having visited her over the garden wall, as Mr Pepys relates, on the evening of Sunday, the 10th of May. It is rather the idea, and especially the historical idea, of these horrors that “would make a man weep,” and it has moved a great and eloquent historian of our own time to deep pathos[849]. If there be anything that can counteract the effects of agreeable rhetoric it is perhaps statistics. The following numerical estimate of the proportion of pockmarked faces in London after the Restoration is accordingly offered with all deference. It applies mainly to the criminal and lower classes, who were as likely as any to bear the marks of smallpox.

In the _London Gazette_, the first advertisement of a person “wanted” appears in December, 1667; and thereafter until June, 1774, there are a hundred such advertisements of runaway apprentices, of footmen or other servants who had robbed their masters, of horse-stealers, of highwaymen, and the like. There is always a description more or less full; and in the consecutive hundred I have included only such persons as are so particularly described in feature that pock-pits would have been mentioned if they had existed. It is not until the ninth case that “pock-holes in his face” occurs in the description, the eleventh case following close, with the same mark of identity. Then comes a long interval until the twenty-fourth and twenty-fifth cases, both with pock-holes, two of a band of highwaymen concerned in an attempt to rob the Duke of Ormond’s coach near London, one of them having emerged from Frying-pan Alley in Petticoat Lane. Fifteen cases follow, all described by distinctive features, without mention of pock-marks, until we come to the fortieth, a boy of twelve or thirteen, who “hath lately had the smallpox.” The next is the forty-ninth, a Yorkshireman, long-visaged, and “hath had the smallpox,” and close upon him the fiftieth “marked with smallpox.” Then come four in quick succession, the 56th, 59th, 61st and 63d; next the 71st; and then a long series with no marks of smallpox, until the 95th, 97th, 99th and 100th, three of these last four having been negroes.

The result is that sixteen in the hundred are marked more or less with smallpox, four of them being black men or boys. One had “lately had the smallpox,” another had “newly recovered of the smallpox.” One was a cherry-cheeked boy of twelve, “somewhat disfigured with smallpox,” who had run away from Bradford school. Two are described as much disfigured, some as a little disfigured, several others as “full of pock-holes.” The same mark of identity is occasionally mentioned in the advertisements beyond the hundred tabulated, but not more frequently than before, the usual term in the later period being “pock-broken.” This proportion of pock-marked persons among the London populace, sixteen in the hundred, or about twelve in the hundred excluding negroes, does not err on the side of under-statement, if it errs at all. Some such small ratio is what we might have expected in the antecedent probabilities, arising out of the varying degrees of severity of smallpox and the various textures of the human skin. Pitting after smallpox has always been a special risk of a certain texture of the skin, namely, a sufficient thickness of the vascular layer to afford the pock a deep base. Such complexions are common enough even in our own latitudes; and those are the faces that have always borne the most obvious traces of smallpox. It was some of the confluent cases, or rather, of such of them as recovered, that became pock-marked: the babe that became a changeling was not likely to survive. Adults retained the marks more than children, so that there must always have been a good many pock-marked faces in a population where the incidence of the disease was largely upon grown persons, as in the 17th century and in our own time. When smallpox was something of a novelty at the end of the Elizabethan period, a poet addressed a pathetic lyric to his mistress’s pock-marked face. A medical writer of the same period reproduces the old Arabian prescription against pitting, to open the pocks on the face with a golden pin, and adds: “I have heard of some, which, having not used anythinge at all, but suffering them to drie up and fall of themselves, without picking or scratching, have done very well, and not any pits remained after it[850].” Whitaker, in 1661, dismisses the risk of pitting very briefly, remarking that the means of prevention was “commonly the complement of every experienced nurse[851].” Morton, in his sixty-six clinical cases and in his commentary, makes but slight reference to pitting. In his 14th case, a severe one, “no scars remained”; in his general remarks he treats pitting as a bugbear: “women set the fairness of their faces above life itself,” which may mean, as in Beaumont and Fletcher’s comedy, that they would chill themselves at all risks by the cooling regimen so they might drive the pocks in[852].

The Epidemiology continued to the end of the 17th century.

What little remains to be said of smallpox in England to the end of the seventeenth century may be introduced by the following table of the deaths in London.

_Smallpox Deaths in London 1661 to 1700._

Total Smallpox Year deaths deaths

1661 16,665 1246 1662 13,664 768 1663 12,741 411 1664 15,453 1233 1665 97,306 655 1666 12,738 38 1667 15,842 1196 1668 17,278 1987 1669 19,432 951 1670 20,198 1465 1671 15,729 696 1672 18,230 1116 1673 17,504 853 1674 21,201 2507 1675 17,244 997 1676 18,732 359 1677 19,067 1678 1678 20,678 1798 1679 21,730 1967 1680 21,053 689 1681 23,951 2982 1682 20,691 1408 1683 20,587 2096 1684 23,202 1560 1685 23,222 2496 1686 22,609 1062 1687 21,460 1551 1688 22,921 1318 1689 23,502 1389 1690 21,461 778 1691 22,691 1241 1692 20,874 1592 1693 20,959 1164 1694 24,100 1683 1695 19,047 784 1696 18,638 196 1697 20,972 634 1698 20,183 1813 1699 20,795 890 1700 19,443 1031

Sydenham’s remarks throw some light on the smallpox of the several years. While the epidemic of 1667-68 was of a regular and mild type, that of 1670-72, which has fewer deaths in the bills, was of the type of black smallpox complicated with flux. The year 1674 has the highest figures yet reached; the type of the disease was confluent, and so severe that it “almost equalled the plague”; while the smallpox of the year 1681, with a still higher total, was “confluent of the worst kind.”

It is not easy to make out what the differences of “type” described by Sydenham depended on; but it may be hazarded that those who fell into smallpox in an otherwise unhealthy season would die in larger numbers, being weakened by antecedent disease, such as measles or epidemic diarrhoea, influenza or typhus fever. An epidemic of measles in the first six months of 1674 was most probably the reason of the great fatality of smallpox in the second half of that year (see the chapter on Measles). The high figures of smallpox mortality in 1681 followed two hot summers, unhealthy with infantile diarrhoea, and coincided with a third season unhealthy in the same way. The deaths by smallpox in the last week of August, 1681, reached the very high figure of 168, the next highest cause of death that week, and the highest the week after, being “griping in the guts,” or infantile diarrhoea. The smallpox of 1685 was more uniformly distributed over the months of the year, which was one of malignant typhus, the worst week for fever having 114 deaths (ending 29 Sept.), and the worst week for smallpox 99 deaths (ending 18 Aug.).

The deaths by smallpox in the London bills are the only 17th century figures of the disease. According to later experience, a high mortality in London in a certain year meant an epidemic general in England in that or the following year; and the same appears to have held good for the period following the Restoration. In the parish register of Taunton, a weaving town, the smallpox deaths are many in 1658 (“all the year,” which was one of agues and influenza), in 1670, 1677, and 1684 (“very mortal,” the year being noted for a very hot summer and for fevers and dysenteries[853]). The highest total of deaths in London to the end of the 17th century fell in 1681, which is known to have been a year of very fatal smallpox at Norwich[854] and at Halifax. Thoresby’s friend Heywood lost three children by it at the latter town in the epidemic of 1681, which does not appear to have visited Leeds. In 1689 Thoresby himself lost his two children at Leeds within a few days. In 1699 the epidemic returned, and he again lost two of the four children that had been born to him in the interval[855]. Similar calamities befell country houses, of which the following from the correspondence of a titled family in Cumberland is an instance:

“17th April, 1688,--Captaine Kirkby came hither, and told me that Mrs Skelton, my god-daughter, of Braithwaite, dyed the last week, and her two children, of the smallpockes[856].”

Rumours of “smallpox and other infectious disease” at Cambridge in the summer of 1674[857], and at Bath in the summer of 1675[858], threatened to interfere with the studies of the one place and the gaieties of the other.

Smallpox in London in 1694: the death of the Queen.

The epidemic of smallpox in London in 1694 was made memorable by the death of the queen. On 22 November Evelyn notes, “a very sickly time, especially the smallpox, of which divers considerable persons died”; on 29 December: “the smallpox increased exceedingly, and was very mortal,” the queen having died of it the day before. Queen Mary came of a stock to which smallpox had been peculiarly fatal, a brother and sister of her father, James II., having died of it at Whitehall in 1660. Some of the particulars of her illness and death come from bishop Burnet[859], who saw her in the first days of the attack and was about the Court until the end of it; the authentic medical details are by Dr Walter Harris, one of the physicians in attendance, who published them, by leave of his superiors, in order to meet the censures passed on the doctors “by learned men at a great distance[860].”

The symptoms of illness on the first day did not prevent the queen from going abroad; but, as she was still out of sorts at bedtime, she took a large dose of Venice treacle, a powerful diaphoretic which her former physician, the famous physiologist Dr Lower, had recommended her to take as often as she found herself inclined to a fever[861]. Finding no sweat to appear as usual, she took next morning a double quantity of it, but again without inducing the usual effect of perspiration. Up to that time she had not asked advice of the physicians. To this severe dosing with one of the most powerful alexipharmac or heating medicines, the malignant type of the ensuing smallpox was mainly ascribed by Harris, who was a follower of Sydenham and a partizan of the cooling regimen. On the third day from the initial symptoms the eruption appeared, with a very troublesome cough; the eruption came out in such a manner that the physicians were very doubtful whether it would prove to be smallpox or measles. On the fourth day the smallpox showed itself in the face and the rest of the body “under its proper and distinct form.” But on the sixth day, in the morning, the variolous pustules were changed all over her breast into the large red spots “of the measles”; and the erysipelas, or rose, swelled her whole face, the former pustules giving place to it. That evening many livid round petechiae appeared on the forehead above the eyebrows, and on the temples, which Harris says he had foretold in the morning. One physician said these were not petechiae, but sphacelated spots; but next morning a surgeon proved by his lancet that they contained blood. During the night following the sixth day, Dr Harris sat up with the patient, and observed that she had great difficulty of breathing, followed soon after by a copious spitting of blood. On the seventh day the spitting of blood was succeeded by blood in the urine. On the eighth day the pustules on the limbs, which had kept the normal variolous character longest, lost their fulness, and changed into round spots of deep red or scarlet colour, smooth and level with the skin, like the stigmata of the plague. Harris observed about the region of the heart one large pustule filled with matter, having a broad scarlet circle round it like a burning coal, under which a great deal of extravasated blood was found when the body was examined after death. Towards the end, the queen slumbered sometimes, but said she was not refreshed thereby. At last she lay silent for some hours; and some words that came from her shewed, says Burnet, that her thoughts had begun to break. She died on the 28th of December, at one in the morning, in the ninth day of her illness.

The case of Queen Mary was one of discrete smallpox turning to the haemorrhagic form; and it had from first to last the most striking resemblance to that of her uncle, the Duke of Gloucester, in September, 1660[862]. The smallpox, says Burnet, came out, but the pustules “sunk so that there was no hope of raising them”; and in sinking they turned to livid spots or blotches. It is quite possible that the repeated doses of Venice treacle at the outset, which failed in their usual effect of inducing sweat, may have had something to do with the result, as Dr Harris certainly believed and afterwards publicly said with the leave of his superiors. But the queen, with eminent qualities of mind and heart, was not physically of good constitution. She was one of those children of James II. whom Willis had brusquely pronounced, some twenty-five years before, to be affected with _mala stamina vitae_; and her father’s brother, the Duke of Gloucester, who was not treated in the same way, and, by one account, not treated at all, died in exactly the same kind of haemorrhagic smallpox[863].

Circumstances of the great Epidemic in 1710.

For fifteen years after the year of Queen Mary’s death by haemorrhagic smallpox, there was comparatively little of the disease in London. In seven of the years the deaths were counted by hundreds, while the average of the whole period from 1695 to 1710, which included the years of Marlborough’s campaigns, was unaccountably low. There was a corresponding lull in the fever mortality in London; and as precisely the same kind of lull took place both in fever and smallpox during the next great war with France a century after, it may seem as if a state of war, instead of spreading infectious disease as it did in the countries where the war raged, had the effect in England of reducing it. The period of comparative immunity came to an end, both for fever and smallpox, with the great epidemic of each disease in 1710, in which year smallpox cut off 3138 in London and “great numbers in Norwich[864].” In 1714 there was another severe epidemic of smallpox in London, again in company with one of fever, and thereafter a high average for many years.

_Smallpox deaths in London, 1701-1720._

Deaths from Deaths from Year smallpox all causes

1701 1099 20,471 1702 311 19,481 1703 398 20,720 1704 1501 22,684 1705 1095 22,097 1706 721 19,847 1707 1078 21,600 1708 1687 21,291 1709 1024 21,800 1710 3138 24,620 1711 915 19,833 1712 1943 21,198 1713 1614 21,057 1714 2810 26,589 1715 1057 22,232 1716 2427 24,436 1717 2211 23,446 1718 1884 26,523 1719 3229 28,347 1720 1442 25,454

The marked increase of smallpox deaths in 1710 and 1714, after an interval of low or moderate annual mortalities, caused the same cry to be raised as in the Restoration period, namely, that the medical treatment was to blame. Lynn, writing in 1714, says that many complaints were made of the destructiveness of smallpox in the epidemic four years before (1710), and of “the great want of better help, care or advice therein[865].” Woodward also ascribed the great increase of smallpox fatalities from 1710 onwards to erroneous treatment[866]. All the lives that might have been saved by better medical treatment or by more assiduous visiting of the sick would, in the then circumstances of the London populace, have made little difference to the bills of mortality. The causes that made fever so mortal in the same years were in great part the causes that made smallpox mortal, the former chiefly among those in the prime or maturity of life, the latter chiefly among the children. London had nearly reached its maximum of overcrowding; its population advanced but little for a good many years, and its mortality from all causes was so great that the numbers were only kept up by a constant recruit from the country. The necessity of doing something for the health of the poorer classes was felt, but nothing adequate was done or could be done[867]. So far as concerned the richer classes, they incurred constant danger of smallpox infection. In one of those fatal years, probably 1720, when there was smallpox among persons of quality in London, the Duchess of Argyll wrote to the Countess of Bute, to congratulate her on the birth of a daughter and on having two fine boys in her family already, “and he that has had the smallpox as good as two, so mortal as that distemper has been this year in town was never known[868].”

The domestics also of great houses frequently caught smallpox and spread it, a trouble which gave occasion at length, in 1746, to the first Smallpox Hospital for the admission of such of them as brought subscribers’ letters. Before that it had been the practice of the rich to send their domestics to private houses kept by nurses[869].

It was in these circumstances, and for the benefit of the upper classes and their domestics, that a project of getting through smallpox on easy terms was brought to the notice of London society in 1721.

Inoculation brought into England.

The first that was heard in England of engrafting the smallpox was through a communication by Dr Timoni, a Greek of Constantinople, to Dr Woodward, Gresham professor of physic, who had the paper printed in the _Philosophical Transactions_ of the Royal Society[870]. After a statement that “the Circassians, Georgians and other Asiatics” had brought the practice to Constantinople, and that it had been followed there for forty years by “the Turks and others” (statements never confirmed but on inquiry contradicted by those who knew), he proceeds to matters more within his own competence. During these eight years past “thousands” of subjects have been inoculated, and the value of the practice has now been put beyond all suspicion and doubt. The practice is to take fluid smallpox matter from the pustules of a discrete case of the natural disease, and convey it warm in a stopped phial to the scene of inoculation. A few punctures with a three-edged surgeon’s needle are made in any of the fleshy parts (but preferably over the muscles of the arm or forearm) until the blood comes; a drop of the fluid matter of smallpox is then to be mixed with the blood, and the inoculated part to be protected by a walnut shell bound over it. The symptoms that follow are very slight, some being scarce sensible that they are ill. The pocks that ensue are for the most part distinct, few, and scattered; commonly ten or twenty break out; now and then the patient may have only two or three; few have a hundred. The matter is hardly a thick pus, as in the common sort, but a thinner kind of _sanies_. There are some in whom no pustules appear except at the points of insertion, where purulent tubercles arise; yet these have never had the smallpox afterwards in their whole lives, though they have consorted with persons having it. On one occasion fifty were inoculated together, and of these four developed smallpox which was nearly confluent; but there was a suspicion that they must have been already infected by contagion. Timoni had never observed any mischievous accident from this incision hitherto; reports of such had sometimes spread abroad among the vulgar, “yet having gone on purpose to the houses whence such rumours have arisen I have found the whole to be absolutely false.” But, to keep nothing back, he will mention two fatalities of children inoculated; both of them were cases of hereditary _lues_ with marasmus, and it was about the fortieth day from their inoculation that death ensued. The rest of Timoni’s paper is printed in the original Latin, being devoted to a theory of engrafting which afterwards passed current:--one attack of smallpox secures from a second, a mild attack serves as well as a severe, as also in the natural way, the reason being that smallpox, in whatever degree, causes a fermentation of the mass of the blood.

A year after this, in 1715, there was published in London _An Essay on External Remedies_, of which the 37th chapter was “Of the Variolae or Small Pox, the manner of ingrafting or giving them, and of their Cure.” The author was Peter Kennedy, Chir. Med., a Scot of good but impoverished family, who had spent several years in various parts of Europe visiting the schools of medicine and surgery, and had found his way to Constantinople[871]. His account of the engrafting of smallpox, which he had seen or heard of there, differs somewhat from that of Timoni, whom he just refers to: “Dr Timoni, a Grecian who resides there, had taken or followed this same method with his two sisters a little before my arrival at Constantinople.”

Kennedy says that engrafting the smallpox was practised in the Peloponnesus or Morea, “and at this present time is very much used both in Turkey and Persia, where they give it in order to prevent its more severe effects by the early knowledge of its coming; as also probably to prevent them being troubled with it a second time.” In Persia, however, the smallpox was taken internally in a dose of dried powder. In Constantinople the matter was inserted at scarifications upon the forehead, wrists, and ankles. After eight or ten days the smallpox came forward in a kindly manner, and not nearly so numerous as if naturally taken. “The greatest objection commonly proposed is, whether or not it hinders the patient from being infected a second time. But, in answer to this, it is advanced that we do rarely or never find any to have been troubled with this distemper twice in the same manner or the same fulness of malignity”--i.e. we rarely find this in the natural way.

Kennedy’s object was, not to recommend the engrafting of smallpox in England, but to show how easily distempers or contagions, “as well as medicines,” may be communicated to the blood from the surface of the body: “and this is more confirmed by some of the country people in Italy, in the more remote parts from towns, so also in some parts of the highlands of Scotland, where they infect their children by rubbing them with a kindly pock, as they term it.”

Meanwhile Timoni’s essay in the _Philosophical Transactions_ had stirred up Sir Hans Sloane to make farther inquiries[872]. He applied to the British consul at Smyrna, Dr Sherrard, who was fortunately able to get information at first hand from an old Smyrna colleague, Dr Pylarini, consul for Venice, who had practised inoculation at Constantinople in the first years of the century. Pylarini, who had retired to Venice, was induced to draw up an account of what he knew of the beginnings and original methods of engrafting, which was printed at Venice, with a dedication to Sherrard, in 1715, and at once copied into the _Philosophical Transactions_[873]. This, the most trustworthy account of the Constantinople practice, ignores the earlier essay of Timoni altogether.

Pylarini carries the authentic history of the practice at Constantinople back to the year 1701. Its history before that was obscure; but it is most certain, he says, that it began in Greece, more particularly in Thessaly, and crept gradually from place to place until it reached Constantinople, where it attracted little notice for several years, being rarely practised and only among the lower class. A noble Greek having spoken of it to him in 1701, with a view to the protection of his children from the epidemic then raging, Pylarini had to confess his entire ignorance of it, but being at the Greek’s house four days after he there met a Greek woman who expounded the practice clearly in detail and gave him many instances of persons who had gone through it safely. Pylarini inquired into some of these cases and found them to be genuine; but in that great city he could not search them all out. Soon after this interview, the woman came and operated on the four children of the rich Greek, of whom the three younger had a very mild disease, but the eldest a severe attack, which nearly cost her life. Many other rich Greek families followed suit, so that, says Pylarini in 1715, “every one wishes to have the advantage of transplantation.” He adds, however, that “the Turks have hitherto neglected it.” He confirms Timoni in saying that the pocks raised by transplantation were nearly always of the distinct kind and few in number--ten to twenty or thirty, rarely a hundred, very rarely two hundred,--although he does not reach Timoni’s minimum of “two or three,” or the pustules only at the punctured spots.

These accounts from Constantinople, printed in London in 1714, 1715 and 1716 were regarded, says Douglass, “as virtuoso amusements[874]” until the spring of 1721, when inoculation began to be tried tentatively in London, and in a bold and confident way during the very same weeks at Boston, New England.

Dr Pitcairn, of Edinburgh, had received an account of inoculation from Bellini, an Italian physician, who had read Pylarini’s essay. Douglass says that Pitcairn “was very fond of it, but could not persuade himself to venture it in practice[875].” Sometime in March, 1721, one à Castro had issued in London a pamphlet on inoculation, full of inaccuracies and of no moment[876]. In a lecture on the plague given at the College of Physicians on the 17th of April, 1721, Dr Walter Harris made a passing reference to the Constantinople practice of engrafting smallpox[877]; and shortly after that, or shortly before, the Lady Mary Wortley Montagu set about having her younger child inoculated in London, her elder child having been inoculated at Constantinople three or four years before. This lady had, in 1717, accompanied her husband as ambassador to the Porte, where the embassy remained about a year. During her residence at Pera she heard of the Greek practice of engrafting or transplanting the smallpox; the French ambassador had said in pleasantry to her: “They take the smallpox here by way of diversion, as they take the waters in other countries.” According to her information, there was a set of old women who made it their business to perform the operation every autumn, in the month of September, when the great heat is abated. People send to one another to know if any of their family has a mind to have the smallpox; they make parties for this purpose, and when they are met (commonly fifteen or sixteen together) the old woman comes with a nut-shell full of matter. Every year thousands undergo the operation (but according to the information of the British embassy in 1755 not more than twenty in a year, which may perhaps mean that it had fallen into disuse[878]). There is no example of anyone that has died of it. She intended to have it performed upon her little son, and had patriotic visions of bringing “this useful invention” into fashion in England. Accordingly her boy, aged five, was inoculated in March, 1717/18, by a Greek woman, under the direction of Maitland, a Scots surgeon who attended the embassy. The child suffered very little inconvenience and, according to Maitland, “had about an hundred pox all upon his body.”

Lady Mary returned to London in 1718; but it was not until some three years after, in the spring of 1721, that she stirred the matter again. Whether it was that she herself was the cause of the talk about inoculation in London in April, 1721, or that she merely had the subject brought back to her mind by the essay of à Castro, the lecture by Harris, or by what others were saying, she sent sometime in April for Maitland, who had assisted at the inoculation of her elder child at Pera, with a view to having the operation done on the younger, who was now four or five years old. In a week or two Maitland found suitable smallpox matter and engrafted the child on both arms; on the tenth night she was a little feverish, but the smallpox began to appear next morning and in a few days she was perfectly recovered. Three physicians of the College visited the case, as well as several ladies and other persons of distinction. One of those physicians, Dr Keith, resolved to have a boy of his own, aged six, engrafted, which was done by Maitland on both arms on the 11th of May, 1721, five ounces of blood having been drawn before the operation.

Among Lady Mary’s intimates was the Princess of Wales, who became interested in the project for the sake of her own children[879]. She proposed to the king (George I.) that he should remit the capital sentence of six Newgate felons on condition that they would submit to be inoculated. The king consulted Sir Hans Sloane, who applied to Dr Terry of Enfield, formerly in practice at Constantinople. Terry’s report was that not more than one in eight hundred had died from the effects of inoculation in Turkey. The upshot was that the six Newgate convicts, three men and three women, were inoculated by Maitland on the 9th of August, 1721, in the presence of several eminent physicians, surgeons, Turkey merchants, and others. The matter was inserted on both arms and on the right leg of each, and the insertion was repeated on the arms of five of them three days after. Dr Mead, having heard that the Chinese procured smallpox by stuffing the matter up their noses, got a pardon for a seventh convict under sentence of death, a young woman, on condition that she would submit to a pledget of cotton dipped in smallpox matter being inserted in her nostril: it produced, besides a fair smallpox, much severe pain along the Schneiderian membrane and the frontal sinuses, and was not thought a satisfactory experiment. The trial upon the other six was reassuring; they all escaped with the slightest possible eruption; “the most that anyone had was sixty pustules.”

The next step was on the part of the Princess of Wales, who procured the inoculation of six charity children of the parish of St James’s. Four of them had smallpox “very favourably”; one did not have it at all, “having evidently had the smallpox before”; and the sixth had not only the prolonged effects of inoculation, but also an attack of the natural smallpox, of a favourable kind, eleven weeks after. This experiment was followed by the inoculation of five more hospital children, from eight to fourteen weeks old, of whom three had no effects, their bodies being “morbid.” The Princess of Wales was at length resolved in April, 1722, to run the risk of the operation on her two daughters, the princess Amelia, aged eleven, and the princess Caroline, aged nine, being urged by the fact that another daughter, the princess Anne, afterwards princess royal of Orange, had just had the natural smallpox so dangerously that Sloane feared for her life. The inoculations were done on the 19th of April, by serjeant-surgeon Amyand under the direction of Sir Hans Sloane. What passed between that physician and the king shows at once the apprehension of danger from a novel operation and the temper in which it was undertaken:

“I told his Majesty,” says Sloane, “that it was impossible to be certain but that, raising such a commotion in the blood, there might happen dangerous accidents not foreseen; but he replied that such might, and had happened, to persons who had lost their lives by bleeding in a pleurisy, and taking physic in any distemper, let never so much care be taken. I told his Majesty that I thought this to be the same case; and the matter was concluded upon, and succeeded as usual, without any danger during the operation, or the least ill symptom or disorder since.”

The news of the successful inoculation of the two princesses had hardly time to create a vogue for the practice, when there came word, in the same month of April, of the death by inoculation of the Earl of Sunderland’s son, aged two and a half, and of Lord Bathurst’s footman, aged nineteen.

Meanwhile, in the autumn of 1721, Maitland had gone down to Hertford, where smallpox would seem to have been more rife than elsewhere, and had done several inoculations. In the family of a Quaker, near Hertford, an infant of two and a half years developed no more than twenty pustules, which lasted only three or four days; but six domestics of the house, four men and two maids, “who all in their turn were wont to hug and caress this child whilst under the operation and the pustules were out upon her” (Maitland), caught natural smallpox in varying degrees of severity, some of them having a narrow escape, while one of the maids died.

The question that people were really anxious about was the immediate risk to the inoculated; and as there were occasional fatalities, especially to the age of childhood, inoculation made little progress. In the first year of its trial in England it was done on the greatest scale by Dr Nettleton, of Halifax, whose practice remains for more particular notice. Apart from his cases, which numbered sixty-one, the following are all that were known in England from the month of April, 1721, to the end of 1722[880]:

By Mr Amyand, surgeon, London 17 " Mr Maitland, surgeon, London and elsewhere 57 " Dr Dover, London 4 " Mr Weymish, London 3 " Rev. Mr Johnson, London 3 " Dr Brady, Portsmouth 4 " Messrs Smith and Dymes, Chichester 13 " Mr Waller, Gosport 3 " A woman at Leicester 8 " Dr Williams, Haverfordwest 6 " Two others near Haverfordwest 2 " Dr French, Bristol 1

The inoculations in all England in 1723 reached the considerable total of 292; but in 1724 they were no more than 40, being distributed among the various operators as follows:

Amyand, London 11 Maitland, London 4 Pemberton, London 3 Cheselden, London 1 Pawlett, London 1 Howman and Offley, Norwich 3 Beeston, Ipswich 3 Lake, Sevenoaks 3 Goodwin, Winchester 1 Mrs Ringe, Shaftesbury 2 Skinner, Ottery St Mary 6 Tolcher, Plymouth 2

In the next two years, 1725-26, Amyand and Maitland had respectively 66 and 37 cases in London, the other known cases in London being 30. Maitland had also 16 cases in Scotland. Sir Thomas Lyttelton had 4 at Hagley. All the known cases in those two years, including Nettleton’s at Halifax, came to 256, with four deaths of somewhat conspicuous persons. In 1727 the inoculations fell to 87, and in 1728 to 37. The total in eight years was 897, with 17 deaths. For the next ten or twelve years none were heard of in Britain. The check, however, was only temporary. The practice revived, extended among the rich, at length reached the common people in some counties, and gave rise to important developments of scientific doctrine. The greater these developments the more interesting the origins, which we shall now examine.

The popular Origins of Inoculation.

Six years before the Greek inoculation was tried in London, Kennedy, the travelled Scot, had compared the Constantinople practice with one that he knew of in his native country: “So also in some parts of the highlands of Scotland they infect their children by rubbing them with a kindly pock.” This indigenous Scots practice was confirmed by Professor Monro, the first, of Edinburgh, in 1765:

“When the smallpox appears favourable in one child of a family, the parents generally allow commerce of their other children with the one in the disease; nay, I am assured that in some of the remote highland parts of this country it has been an old practice of parents whose children have not had the smallpox to watch for an opportunity of some child having a good mild smallpox, that they may communicate the disease to their own children by making them bedfellows to those in it, and by tying worsted threads wet with the pocky matter round their wrists.”

And, to make it clear that this was not the same as the method afterwards used of procuring the smallpox, he adds that the latter was not known in Scotland until Maitland introduced it, in 1726[881]. In Wales the curious practice of buying the smallpox was found to be indigenous[882]. One young woman in a village near Milford Haven testified in 1722 that, some eight or nine years before, she had bought twenty pocky scabs of one in the smallpox, and had held them in her hand, with the result that she sickened with the infection in ten or twelve days and had upwards of thirty large pustules in her face and elsewhere--at least ten more than she had bargained for. A schoolboy of Oswestry, who had since become an attorney and must have known the nature of an affidavit, bought, as he positively affirmed, for three-pence of a certain lady twelve pustules of smallpox (at a farthing each), and rubbed the matter into his hand with the back of his pocket-knife; a sore remained on the hand as well as pockpits in his face.

There was nothing remarkable in these methods of procuring smallpox except an occasional element of superstition or freak. It was not unusual in England for educated persons to let smallpox go through all their children after it had attacked one of them, just as it is regarded an economy by many to have done with the measles. On 15 September, 1685, Evelyn travelling to Portsmouth in the company of Pepys, stopped to make a call at Bagshot at the house of Mrs Graham, a former maid of honour to the queen. “Her eldest son was now sick of the smallpox, but in a likely way to recover, and others of her children ran about and among the infected, which she said she let them do on purpose that they might whilst young pass that fatal disease she fancied they were to undergo one time or other, and that this would be for the best.” It would be for the best because children from five to ten or fifteen (the older writers said even infants) ran far less risk from the attack than at the higher ages, and seldom died of it.

Similar means of procuring smallpox for children were used in other countries. La Motraye, who rode through the Caucasus in 1712, was told that children, to give them the smallpox, were placed in the same bed with one who had it, the mothers sometimes carrying them a whole day’s journey to any village where they heard of someone being attacked. He professes also to have seen a child of four inoculated with smallpox matter at five places (the region of the heart, the pit of the stomach, the navel, the right wrist and the left foot) by an old woman who used “three needles tied together[883].” The idea of barter was widely spread in those practices of procuring smallpox on favourable terms. We have seen that the Welsh had it. Bruce found it in his travels to the sources of the Nile[884]. African negroes are known also to have carried with them to the West Indies the practice of “buying the yaws,” which is also a contagious and inoculable disease of the skin. The earliest medical notices of buying the smallpox come from Poland in 1671 and 1677. A case having been published in the _Miscellanea Curiosa_ of the Imperial German Academy, in which a quartan ague was alleged to have been got rid of by transferring it to a brute animal, Dr Vollgnad, of Warsaw wrote: “There is a similar superstition not uncommon among our nurses, who instruct the children under their charge to buy for a few farthings a certain number of pocks from one infected with the smallpox, in the belief that those who purchase that disagreeable commodity will be affected with a more scanty eruption and will be the sooner freed from the disease and with the less risk[885].” Six years after, Dr Simon Schultz, of Thorn, physician to the king of Poland, wrote that the same practice of buying the smallpox obtained also in that part of Poland: “What I have first to remark,” he says, “is that, in most cases if not in all, those infants that buy of the infected (whether in their proper persons or through others), while they may have few pocks, yet fall into a more serious illness than otherwise (_gravius reliquis decumbant_): which I remember to have happened to my younger brother Johannes, to say nothing of others[886].”

These early references to buying the smallpox were made _à propos_ of the 17th century practice of sympathetic transference of disease from one to another, or from man to brute, or to plants, stones, holes in the ground, etc.[887], and were published as instances of “a similar superstition.” The case of a transferred ague which called them forth had been sent to the _Curiosa_ of the Academy by Thomas Bartholin, the celebrated anatomist of Copenhagen. Ten years before, he had written in the _Theatrum Sympatheticum Auctum_[888] (to which also Dr Sylvester Rattray, of Glasgow, and Sir Kenelm Digby contributed): “I disclose a great mystery of nature. The transplantation of diseases is a stupendous remedy, by means of which the ailments of this or that person are transferred to a brute animal, or to another person, or to some inanimate thing”--various methods being instanced. He returned to the subject in 1673 under the title of the Transplantation of Disease, the name by which Pylarini first described the engrafting of smallpox[889]. It was the transfusion of blood, a foible of the time, especially at the Royal Society in London, which set Bartholin to his second essay. He expected that health, in the one case, or disease in the other, might be transplanted to another’s veins with the blood. It would be an incomparable addition to the amenities of life to be able to draw off in a syringe the diseased blood of a familiar friend and bring it to a better coction by one’s own juices[890].

Bartholin discovered the germ of these scientific developments in the scape-goat of the Israelites and in the miracle of the swine of Gadara[891]. In his own doctrine of transplantation, others in turn have found the germ of inoculation, Pylarini having actually adopted the 17th century name, with the proviso that the transplantation of smallpox was not sympathetic but _res vera mera pura_. The older idea of transplanting smallpox was to get rid of it. “Some persons in the smallpox,” says Slatholm, of Buntingford, in 1657, “keep a sheep or a wether beside them in the chamber, those animals being apt to receive the envenomed matter and to draw it to themselves[892].” The developments of folk-lore are erratic; one thing leads to another, but not necessarily in a logical sequence. Transference had somehow become the inoculation which Pylarini first found in the practice of a woman from the Morea or from Bosnia, being still in its superstitious stage. The woman drew blood and rubbed the smallpox matter into the bleeding points; but whether she did so with a physiological or a symbolical intent we shall probably never know. She told Dr Le Duc[893], who submitted to inoculation at her hands, that she had received the secret from the Virgin; during the operation she muttered prayers to the Virgin, and, on finishing it, requested an oblation of two wax candles to be sent to the shrine of the Virgin her patroness in Thessaly. She pricked the skin of the face at the four points which are touched in making the sign of the Cross, and at the points of the hands and feet which are pierced by the nails in the Crucifix. Voltaire says that Lady Mary Wortley Montagu’s chaplain objected to inoculation because it was an un-Christian practice. He must have been strangely ill-informed if he did so; for at Constantinople it was practised by the Christians only and not at all by the Mussulmans, who, by Kennedy’s account, were somewhat doubtful of its utility.

Pylarini and Timoni very properly dropped the symbolism of the Greek woman, and inserted the matter at any convenient spot, choosing usually the skin of the forearm. Therewith they took the practice under scientific protection. At the same time Pylarini was careful to explain that this transference of disease, although he called it by Bartholin’s old name of “transplantation,” was a real thing, and in no way akin to the sympathetic or magnetic transference whose name it bore. A real thing it undoubtedly was: a visible effect did follow in most cases--some ten, or twenty or thirty watery pimples on the skin. The effect being thus real, Pylarini and Timoni laid down at the outset the doctrine that the smallpox matter inserted in minute quantity was a ferment, which produced an ebullition in the mass of the blood. The common people, who had been procuring the smallpox for their children in other ways than by puncture and insertion, also knew that the transplanting was a real thing: it was smallpox, and nothing else, that they designed to procure, peradventure it might be mild smallpox.

While Pylarini used the name of Transplantation, Timoni used the name of Inoculation. Both names were figures of speech taken from the gardener’s art. Inoculation, or ineying, was a form of grafting, the taking of the “eye” or resting-bud of one kind of fruit-tree and fixing it upon the stock of another kind. The effect of a graft upon a fruit-tree is one of the most remarkable in nature: the incorporation of a bud from a nearly allied species at a particular part of the stock causes the whole tree to assume some characters of the other tree, the change being greatest in the fruit. An effect at once so real, so useful, and so familiar could not fail to take hold of the imagination. Accordingly we find the ineying or grafting of trees used in a correct figure, as in Hamlet’s “for virtue cannot so inoculate our old stock but we shall relish of it.” Between a fruit-tree modified as to its fruit by the permanent incorporation of a strange shoot, and an animal body infected of purpose with diseased matter, there is no very exact analogy. Figurative names, as well as metaphors, are apt to be mixed ideas. Correct science avoids the one vice, as correct style avoids the other. Transplantation had in any case too many fanciful associations to be retained as the name for the new practice in smallpox; inoculation, on the other hand, was still unspoiled as a medical term, while its wonderful effects were obvious in the familiar art of the gardener.

In all the developments or modifications of this practice, the intention was still to procure the smallpox by art. The idea of antidote or counter-poison did not enter into it at all. Yet the idea of a counter-poison was quite familiar, as in the following passage from a medical writer of the time of James I.[894]:

“But here a great doubt and controversie may arise: whether, as sometimes we see one poyson to be the expeller of another poyson, so in like sort, whether one stinking savour, and graveolent or ill odour, and vapour of some pestilent breath or ayre, may bee the proper amulet or preservative against any such poyson, to bee hanged about the necke: for at this time let it bee granted (to please some) that tabacco is of no good smell or sent, and that it is a little poysonous. For wee see some daily in the time of any generall or grievous infection of the plague, for avoidance thereof, and for preservation sake, will smell unto the stinking savour of some loathsome privie, or filthy camerine and sinke; and this they make reckoning is one of the best counter-poysons that may be devised against any pestiferous infection: for their nature being inured to these, they will afterwards not seeme to passe for any pestilent malignitie of the ayre, and dare boldly adventure without any prejudice, or impeachment to their health, into any place or companie whatsoever. And to perswade us the more easily to this, they object to us for example sake, those women that spend their dayes continually in hospitals for pilgrims, and for poore travellers, who are accustomed to every abominable savour of the sicke; whereof we shall never see, or very seldome, any of them either to be taken or die with any pestiferous infection though never so dangerous.”

While he admits these to be instances of counter-poisons having a prophylactic effect against epidemic sickness, he denies, what some had maintained, that “either the French Pockes or the quartan ague is a _Superseder_ of the plague[895].”

Results of the first Inoculations; the Controversy in England.

Thus far we have traced the rise of inoculation as an idea. It was one way of procuring the smallpox, which had gradually arisen out of other fanciful or real modes of infection. The populace for long retained a preference for giving their children the smallpox by exposing them to the contagion of it; in the last quarter of the 18th century, Haygarth found the common people of Chester still following the earlier practice of inviting the smallpox in the natural way[896]. It is even more remarkable that Huxham, the ablest epidemiologist in England during the first period of inoculation, preferred that children should take the disease naturally, believing that they might be so “prepared” to receive the seeds of it by the breath as to have always a sufficiently mild but effective dose of it. Still, the insertion of smallpox matter at a puncture or wound of the arm appeared to many to have advantages over the natural way. In London it was taken up by the Court, by the Court doctors, and by the Royal Society, the leading physicians in favour of it having been Sloane, Mead, Arbuthnot and Jurin. It appears that Freind, a more learned physician than any of these, was adverse to it. It was to him that Wagstaffe, physician to St Bartholomew’s Hospital, dedicated a hostile essay on inoculation when it was new; and Freind himself brought into his _History of Physic_, published in 1725-26, the following sarcastic passage upon John of Gaddesden, whom he regarded as a high-placed charlatan:

“He had an infallible plaster and caustick for a rupture; could cure a cancer from an outward cause with red dock. And if he had lived in our day, he would, I don’t question, have been at the head of the Inoculators; and in this case the position he lays down, contrary to the experience of the best physicians, that one may have the smallpox _twice_, might have served him in good stead for salvo’s upon many occasions.”

--which means that, in Freind’s opinion, the inoculated smallpox was no security against a subsequent attack in the natural way[897].

Wagstaffe, in his printed letter to Freind, sums up the objections to inoculated smallpox as follows:

“Some have had the distemper not at all, others to a small degree, others the worst sort, and some have died of it. I have given instances of those who have had it after inoculation in the common way; and consequently as it is hazardous, so ’twill neither answer the main design of preventing the distemper for the future. I have considered what the effects may be of inoculating on an ill habit of body, and how destructive it may prove to spread a distemper that is contagious: and how widely at length the authors in this subject disagree among themselves, and how little they have seen of the practice:--all which seem to me to be just and necessary consequences of these new-fangled notions, as well as convincing reasons for the disuse of the practice[898].”

These objections were shared by several, including Blackmore, Clinch, and Massey, the apothecary to Christ’s Hospital.

On the other hand Jurin, who took the lead in defending inoculation, reduced the issues to two[899]:

1. Whether the distemper given by inoculation be an effectual security to the patient against his having the smallpox afterwards in the natural way?

2. Whether the hazard of inoculation be considerably less than that of the natural smallpox?

These questions, thus put forward as of equal moment, did not receive equally full handling. Jurin dismissed the former question in a brief sentence: “Our experience, so far as it goes, has hitherto strongly favoured the affirmative side”--a conditional assent which became an absolute affirmative after a short time. Having thus disposed of the question which has all the scientific or pathological interest, he turned with his whole energy to give a precise arithmetical demonstration of what no one could doubt, namely, that inoculated smallpox was many times less fatal than smallpox in the natural way,--having got the idea of such a comparison from Nettleton as well as a large part of the statistics necessary for it. Jurin’s statement of the questions at issue, and his manner of answering them, became the received mode, so much so that even towards the end of the eighteenth century one finds capable medical men contrasting the almost infinitesimal mortality from inoculation, as then practised, with the high mortality from the natural smallpox, as if that were the question at issue. The permanent impression in favour of inoculation made by Jurin’s arithmetic was shown a generation later, when Dr George Baker pronounced an eulogy upon him in the Harveian Oration before the College of Physicians in 1761[900]. “It was his special glory,” said the orator, to have “confirmed the practice of inoculation by his experiments and his authority.” There was only one experiment, and it was a remarkable one. The Princess of Wales had begged George I. to pardon six Newgate criminals under sentence of death on condition that they would submit to be inoculated. It was assumed that those six had not had smallpox in infancy or childhood, and Sloane, relating the facts in a letter to Ranby some years after, does in fact call them “six condemned criminals who had not had the smallpox[901].” The concurrence of six persons belonging to the criminal classes and about to be hanged together in Newgate, of whom none had already gone through the common infantile trouble of London and other large towns, was singular. They were inoculated, and it was found that they had escaped the death penalty on very easy terms: John Alcock, aged twenty, had most smallpox, but even he had “not more than sixty pustules”; Richard Evans, aged nineteen, had none, but his antecedents were inquired into, and then it was found that he had had smallpox in gaol only six months before. One of the others, a woman named Elizabeth, was chosen for the grand crucial experiment. Sir Hans Sloane and Dr Steigerthal clubbed together to pay her expenses to Hertford where smallpox was then very prevalent; thither Elizabeth went and ministered among the sick; she lay in bed with one in the smallpox, or she lay in bed with various in the smallpox; at all events she exposed herself to contagion and did not catch it, according to certificates from the woman she lodged with and from another person, which certificates were published with much formality and lawyer-like precision[902]. This was the single experiment in which Jurin had any part. What were the chances of her having had smallpox in childhood? What were the chances of her knowing anything about it, or telling the truth about it if she knew? (One of her fellows in the experiment upon the pardoned convicts had smallpox only six months before, but the fact was not discovered until it was wanted.) What were the chances of her taking smallpox at Hertford, supposing that she had hitherto escaped it? These questions do not appear to have been debated[903].

Such was the experiment by which Jurin “confirmed the practice of inoculation.” As for his authority, it was doubtless considerable; but it was more as a follower of the Newtonian mathematics than as a pathologist or physician, and most of all as one of the secretaries of the Royal Society in the last years of Newton’s presidency, that he spoke with authority[904]. His influence, such as it was, availed little. The practice of inoculation fell into total disuse in England after a few years’ trial, so that in 1728 Jurin himself was prepared to see it “exploded.”

The principal reason of inoculation having been tried upon decreasing numbers in England after the first year or two, and of its having been dropped absolutely for a time, was the death of some persons of good family, both adults and children--a sacrifice of life which could not but seem gratuitous. Those deaths were not from the fulness of the eruption but from anomalous effects. When inoculation began in London in 1721, it was according to the Greek method of inserting a minute quantity of matter at two or more places. In the case of the Newgate felons, Maitland had reason to do the inoculations over again after three days, being dissatisfied with the appearance of the original punctures. They are admitted to have had a slight disease (the man who had most had only some sixty pustules on his whole body), so that Dr Wagstaffe, who went to see them, said in his letter to Dr Freind: “Upon the whole, Sir, in the cases mentioned, there was nothing like the smallpox, either in symptoms, appearances, advance of the pustules, or the course of the distemper.” Many of the other early cases had likewise a slight eruption; when numbers are given, the pocks are “not more than eleven to eighteen” (as in Maitland’s case of Prince Frederick at Hanover in 1724), or “not above twenty in all upon her” (as in Maitland’s case of a child near Hertford, in 1721). Of the first six charity children inoculated, one had no eruption; of the next five, three had no smallpox from inoculation. The cases that died after inoculation during the first seven years of the practice--seventeen in England and Scotland and two in Dublin, most of them children--owed the fatal result for the most part to some peculiar prostration or lowered vitality, in two cases actually to pyaemia, the eruption being kept back altogether or but feebly thrown out[905]. This was the danger of arbitrarily procuring the smallpox which Dr Schultz remarked upon in 1677, with reference to the Polish practice of “buying” the disease; most, if not all the cases known to him, although they may have had few pocks, yet fell into more serious illness (_gravius reliquis decumbant_). The risk of arbitrarily forcing infection upon a child at a time when it might not be ready for it, or in a position to deal with it in its blood, was afterwards recognized, and was provided against in the long and tedious preparation which the subject for inoculation had to undergo.

While those in England who followed Maitland in inoculating after the Greek fashion produced for the most part an infinitesimal number of pustules or watery pimples, there were others at a distance from London who inoculated by a method of their own and gave their patients a more real smallpox. The chief of these were Dr Thomas Nettleton of Halifax, and Dr Zabdiel Boylston, of Boston, New England[906]. Nettleton made a long incision through the whole thickness of the skin of one arm and of the opposite leg, and laid therein a small piece of cotton soaked in smallpox matter, which he secured in the wound with a plaister for twenty-four hours. Boylston says: “The Turkey way of scarifying and applying the nutshell &c., I soon left off, and made an incision through the true skin,” the rest also of his procedure being the same as Nettleton’s. And just as those two inoculators devised for themselves a more real method of giving the smallpox by insertion, taking means to ensure the absorption of the matter into the blood, so they procured in many cases, although not in all, an eruption of pustules on the skin which came near to being the same as that of natural smallpox of the average discrete type.

In the Boston practice, “the number of the pustules is not alike in all; in some they are very few; in others they amount to an hundred; yea in many they amount unto several hundreds, frequently unto more than what the accounts from the Levant say is usual there[907].” Nettleton’s account, which was printed in the same number of the _Philosophical Transactions_ as that from New England, says of the pustules on the skin at large: “The number was very different: in some not above ten or twenty, most frequently from fifty to two hundred; and some have had more than could well be numbered, but never of the confluent sort.... They commonly come out very round and florid, and many times rose as large as any I have observed of the natural sort, going off with a yellow crust or scab as usual[908].”

The smallpox procured by inoculation in these English and American trials was thus a more real form of that disease than at Constantinople; compared with the number of pustules given by Timoni and Pylarini, the Boston and Halifax numbers are multiplied ten times.

Nettleton thus expressed his belief that inoculated smallpox saved from the natural disease, at the same time grounding that belief on the reality or substantial nature of the artificial disease:

“Some of those who have been inoculated, that are grown up, have afterwards attended others in the smallpox, and it has often happen’d that in families where some children have been inoculated, others have been afterwards seized in the natural way, and they have lain together in the same bed all the time; but we have not yet found that ever any had the distemper twice; neither is there any reason to suppose it possible, there being no difference that can be observed betwixt the natural and artificial sort, but only that in the latter the pustules are fewer in number, and all the rest of the symptoms are in the same proportion more favourable[909].”

Nettleton returned to the question of the reality of inoculated smallpox, which is the root of the whole matter, in his second letter, to Jurin[910]: “The question whether the distemper raised by inoculation is really the smallpox is not so much disputed now as it was at first.... There is usually no manner of difference to be observed betwixt the one sort and the other, when the number of pustules is nearly the same; but in both there are almost infinite degrees of the distemper according to the difference of that number. All the variation that can be perceived of the ingrafted smallpox from the natural is, that in the former the pustules are commonly fewer in number, and all the rest of the symptoms are in the same proportion more favourable. They exactly resemble what we call the distinct sort.... It will follow as a corollary, that those who have been inoculated are in no more danger of receiving the distemper again than those who have had it in the ordinary way. And this is also thus far confirmed by experience.”

It does not appear that Nettleton based so much upon the subsequent experience as upon the antecedent probability. Thus he says of some cases:

“These had the eruptions so imperfect as to leave me a little in doubt, but two of these have since been sufficiently try’d by being constantly with those who had the smallpox, without receiving any infection; which makes me inclined to believe they will always be secure from any danger. As to all the rest, neither I nor anybody else who saw them did in the least question that they had the true smallpox.”

Nettleton began his inoculations in and around Halifax during a considerable epidemic of smallpox in the winter of 1721-22, of which the following figures were collected by himself (as well as statistics for Leeds, Bradford, Rochdale and other places):

Cases Deaths

Halifax 276 43 Part of Halifax parish towards Bradford 297 59 Another part of Halifax parish 268 28

In the town of Halifax the smallpox was of a more favourable type than usual, whereas in Leeds at the same time (792 cases and 189 deaths) it was more than usually mortal. In the country round Halifax there was more smallpox than in the town; but the epidemic in general ceased in the spring of 1722. As the people mostly disliked the idea of inoculation, Nettleton did not urge it upon them, but inoculated only the children of those who favoured it. Down to the 22nd of April, 1722, he had inoculated about forty, with one death; at the date of 16 June, he had done fifteen more, his total to the end of 1722 being 61. In 1723 he did nineteen inoculations, in 1724 none, in 1725 and 1726 about forty (in an epidemic of 230 cases, and 28 deaths in Barstand Ripponden and another part of Halifax parish), and in writing to Hartley of Bury St Edmunds in 1730, he gave his total at that date as 119, from which it appears that he had ceased to inoculate after 1726. His name does not appear again in the controversy, and it is probable that he acquiesced in the tacit verdict against inoculation which Jurin himself, in 1728, seemed to think was imminent.

Besides this centre of inoculation in Yorkshire in the midst of epidemic smallpox, the only other of importance in the first trials of the practice was at Boston, New England. The smallpox epidemic there in 1721 was a very severe one. There had been no smallpox in Boston since 1702, so that a large part of the population were susceptible of it. The infection was brought by a ship from Barbados in the middle of April, 1721, and made slow progress at first, according to the following table of deaths from it[911]:

_Deaths from Smallpox in Boston._

1721-1722

May 1 June 8 July 20 August 26 September 101 October 402 November 249 December 31 January 6 ---- Total 844

In the course of the epidemic some 5989 persons were attacked, or more than half the population (10,565). All the rest, save about 750, had been through the smallpox before. Inoculation played a very subordinate part amidst these dreadful scenes of smallpox. Its instigator was the Rev. Dr Cotton Mather, who had been shown by Dr Douglass the numbers of the _Philosophical Transactions_ with Timoni’s and Pylarini’s papers in them. The reverend doctor “surreptitiously” employed Douglass’s rival, Dr Boylston, to begin inoculating, in July, 1721, or a few months after the first trials in London. Boylston inoculated 244, whites and negroes, and admitted the deaths of six of them, probably by inhaled infection[912]. But Douglass says:

“The precise number of those who dyed by inoculation in Boston, I am afraid will never be known because of the crowd of the sick and dead whilst inoculation prevailed most, the inoculator and relations inviolably keeping the secret.... Some porters who at that time were employed to carry the dead to their graves say that it was whispered, in sundry houses where the dead were carried from, that the person had been inoculated. I could name some who are suspected, but having only hearsay and conjectural evidence, I forbear to affront the surviving relations. I myself am certain of one more who died ‘after inoculation’ as they express it.”

He then gives the case, which was clearly one of the natural contagion of smallpox acquired at the same time as the inoculation. In the Charleston inoculations of 1738, which were also done in the midst of an epidemic, there is little doubt that the fatalities were mostly from natural smallpox which the inoculated infection had failed to anticipate or prevent. The inoculators were often in that dilemma with their fatal cases: either the inoculation had killed the patient or it had been powerless to keep off the contagion; sometimes they confess the former as an untoward accident, at other times they plead the latter, which appears to me to have been the more usual of the two in a time of epidemic smallpox[913].

Douglass, for all his bitterness against his rival Boylston, and his severity against the extravagant assertions and loose reasoning of the first inoculators, was far from denying the merits of inoculation, whether in theory or in practice. “We may confidently pronounce,” he says, “that those who have had a genuine smallpox by inoculation never can have the smallpox again in a natural way, both by reason and experience; but there are some who have had the usual feverish symptoms, a discharge by their incisions, with a few _imperfect_ eruptions, that may be obnoxious to the smallpox,”--of which he gives instances. In like manner Nettleton, in Yorkshire, who took pains to make his smallpox a real thing, and succeeded in doing so as well as any inoculator ever did succeed, was persuaded that inoculated smallpox counted for a natural attack. He admitted only one failure, a case at Halifax which had been inoculated without an eruption ensuing and took smallpox by contagion a month after. Failures in England, in that sense, were fewer than the deaths directly from inoculation. The deaths were freely admitted, but any alleged failure of inoculation to ward off the natural smallpox was challenged, investigated, and denied, so that Mead, writing in 1747, declared that he knew of none. There were, however, a few cases recorded, which appear to be authentic. One of the six charity children inoculated at the instance of the Princess of Wales had taken natural smallpox twelve weeks after. The child of one Degrave, a surgeon, had a similar experience. Another familiar case was the son of a person of distinction, inoculated on 7 May, 1724, by the Rev. Mr Johnson.

On the 14th a rash came out, on the 15th there was fever, on the 16th, very little eruption to be seen and the fever gone, and on the 18th he was pronounced “secure.” On that day (18th May), his sister was inoculated in the same place, both children remaining together at the inoculator’s house until the 2nd of June, when the boy went home. For a day or two before the 8th of June the boy was ill, and on the 9th he began to have smallpox in the natural way, of a good sort, the disease keeping its natural course. He was supposed to have caught it from his sister, who was inoculated after his own protection was over, and was “very full of smallpox” until the 27th of May, her brother being with her[914].

Another case of failure, which must have been known to some at the time, was not published until some ten years after, when Deering brought it to light[915]:

“I was an eyewitness of the inoculation of a little boy, the child of Dr Craft, who is now a sugar-baker in the Savoy. He was inoculated by one Ahlers under the direction of Dr Steigerthal, the late king’s physician in ordinary; and notwithstanding the great care there was taken in the choice of the pus, had the confluent kind severely; and twelve months after had them naturally, and though a favourable sort, yet was very full.”

A boy aged three, the son of Mr Richards, M.P. for Bridport, was inoculated in 1743, and had fifty to sixty pocks which maturated and scabbed. About two years after (“one year ago”) he had smallpox again, the pustules numbering from 200 to 300; when the eruption came out the fever declined and did not return. These facts are given in a letter to Dr Dod from Dr Brodrepp, grandfather of the child, who attended him on both occasions[916].

Such cases were not often heard of. As Mead said, “If such a thing happened once, why do we not see it come to pass oftener?” There was, however, little encouragement for anyone to come forward with adverse evidence; witness the case of an unfortunate Welshman, one Jones, of Oswestry, who had innocently mentioned, in writing to his son in London, that natural smallpox had followed an inoculation done by him, on 9th August, 1723, and was frightened out of his wits by the _apparatus criticus_ which Jurin brought to bear upon him[917]. Another reason why so few failures could be discovered was that the inoculated were not kept long in sight. A child of Dr Timoni, the first writer on inoculation, was inoculated at Constantinople in December, 1717, at the age of six months, and had an average effect, namely ten small _boutons_. She died of smallpox in 1741, at the age of twenty-four. This failure came to light by the vigilance of the celebrated De Haën, of Vienna, an opponent of inoculation, who had been told of it by a Scots physician at Constantinople[918].

A good instance of the same thing came to light long after in the practice of the celebrated Dr Rush of Philadelphia. “I lately attended a man in the smallpox,” he wrote to Lettsom, “whom I inoculated six-and-twenty years ago. He showed me a deep and extensive scar upon his arm made by the variolous matter”--without which evidence, and the man’s own reminder, confirmed by his mother’s recollection, Dr Rush would probably have had no reason to believe that this particular one of his inoculations had failed[919].

In the nature of the case, such evidence of failure would seldom be opportune. It would have needed a more dramatic presentation of these cases, and many more of them, to discredit the practice of inoculation. It was, indeed, discredited, so much so that it was not practised at all in England from 1728 until about 1740; but that was owing to the disasters directly resulting from it. No amount of evidence as to the inoculated taking natural smallpox afterwards could have touched the popular imagination like the following paragraphs in the London newspapers in 1725:

March 16, died Mrs Eyles, niece of Sir John Eyles, alderman of London, of the smallpox contracted by inoculation. June 17, died of the smallpox contracted by inoculation Arthur Hill, esquire, eldest son of Viscount Hilsborough. August 12, died of the smallpox by inoculation--Hurst, of Salisbury, esquire.

Inoculation seemed hardly worth having on these terms, granting all that was alleged of its protective power; so that it fell in England into total disuse[920]. It came on again after a time and had a long career, at first among the richer classes, and at length among the common people, who did not cease to use it for their children until it was made a felony by the Act of 1840. After its first brief success, it was revived about 1739-40, in consequence of highly favourable accounts from Charleston, South Carolina, and from Barbados and St Christopher. This second period of inoculation brings in certain modifications of the practice by which the casualties of the earlier period were avoided. The danger from blood-poisoning, pyaemia, or the like, was surmounted. At the same time the inoculated smallpox ceased to have anything of that reality, or approximation to the natural disease, which Nettleton succeeded for a time in giving to it.

Revival of Inoculation in 1740: a New Method.

As early as the Boston inoculations of 1721, the matter had now and again been taken, not from a case of the natural smallpox, but from the pustules of a previous inoculation[921]. But at Charleston in 1738 there really began, doubtless in the way of empirical trial, a systematic attenuation of virus, which has had great scientific developments in our time and has come to be considered as of the essence of the inoculation principle. Describing the South Carolina practice, Kilpatrick says[922]:

“Some persons were of opinion that _the pock of the inoculated_ would be too mild to convey the disease; or, at least, that it must become effete by a second or third transplantation. Experience manifested the contrary. I have inoculated from those who were infected by the matter taken from others of the inoculated, and found no defect. Mr Mowbray, who inoculated many more than any other practitioner, assured me he had infused matter in the fifth or sixth succession from the natural pock, and observed no difference.... The smallest violation of the surface, if it was stained with blood, was a sufficient entrance for the matter, and the least matter was sufficient.”

The last point was a return to the Greek practice, and an abandonment of the more severe method of Nettleton and Boylston.

The Charleston smallpox of 1738, imported by slave-ships from Africa, became extensively epidemic and mortal. It had been last in Charleston fourteen or fifteen years before, but only one or two died on that occasion, and hardly more than ten were attacked. But for that small outbreak, it had not been known in the South Carolina port for a generation previous to 1738. The number of victims in that year is not known precisely. As at Boston in 1721, the epidemic dragged through the spring months, and became very extensive and mortal in the hot weather of June and July. It was then that Mowbray began inoculating, most of the Charleston faculty being opposed to it. He was soon followed by Kilpatrick, who had lost one of his children in the epidemic, and was moved thereby to inoculate the other two. No exact account was kept of the inoculations, nor, we may be sure, of the protective effects; some said a thousand were inoculated, Kilpatrick says eight hundred, but the total of four hundred is also given. Eight died after inoculation, six whites and two negresses. One child of ten months died in convulsions on the ninth day after inoculation, with few signs of smallpox; a minister, aged 40, sickened on the third or fourth day, which was too soon for the artificial disease, and was almost certainly the effects of the inhaled virus; two other adult whites died in such circumstances as to make it doubtful whether they died of inoculation or of coexistent natural smallpox; one negress died of confluent smallpox, having treated herself unwisely; while two other children and a negress died after inoculation, of whom no

## particulars are known. Besides the fatal cases after inoculation, some

“had an eruption that might be called a moderate confluence”; but in these cases also it is not clear that infection was not taken in the natural way: as regards one gentlewoman who had confluent smallpox, it was not certain in what manner she received the infection, whilst “Miss Mary Rhett’s eruption did not appear until the 14th day, yet was supposed to be effected by art.” To meet such cases Kilpatrick adopted the doctrine that there was “no precise term for the artificial eruption.” Among those “hardly dealt with” by the disease, supposed to have been given by art, were two ladies who had their eyes permanently injured. “With regard to a second infection of the inoculated _who took_, this was asserted by some who wished for it, but were as soon refuted.” Nineteen in twenty of the inoculated had an exceedingly slight eruption, so slight indeed that they thought the confinement indoors irksome and unnecessary. As to the negroes, who had all been born in Africa (and commonly have smallpox there or in the voyage across), it was not easy, he admits, to find out whether they had had smallpox before or not, the pits on their faces being less obvious than in whites, and the marks of other distempers easily mistaken for them. On the whole Kilpatrick was confident that inoculation in this epidemic had saved many lives; and it was the rumour of its success, together with corresponding reports from the plantations in the West Indies relating the valuable lives of negroes saved, that gave a fresh impulse to the practice in England. In 1743 Kilpatrick came to London, where he republished his Charleston essay, with an historical appendix, and soon got into the leading practice as an inoculator, having proceeded to the degree of M.D. and changed the spelling of his name to Kirkpatrick. Woodville says “he was esteemed the most scientific inoculator in London.” During the eleven years from his setting up in practice there until the publication of his _Analysis of Inoculation_ (1754), he had almost certainly been applying the arm-to-arm method which he learned from Mowbray in Charleston, having briefly indicated it in his first essay and avowed it more explicitly in his second. The establishment of Kirkpatrick in London, to practise the Charleston method of inoculation, corresponds, as nearly as one can trace it, with the revival of the practice in the south of England, to the extent of some two thousand cases in the counties of Kent, Surrey, Sussex, Hampshire and Dorset. We have a glimpse of that practice in the essay on inoculation published in 1749 by Dr Frewen, of Rye in Sussex[923], a physician of considerable learning (of the school of Boerhaave), whose theories of the effects of inoculation are reflected in Kirkpatrick’s _Analysis_ of 1754. In 350 cases, Frewen had only one fatality, the death of a child, aged four, from worm fever on the eighth day of a discrete eruption. He still used the incision on the arm, but less deep than Nettleton’s, keeping the pledget of lint, moistened with matter, bound upon it for twenty-four hours; also he encouraged the rendering from the incision for some weeks, giving the same reason as before, that “Nature by means of a continual drain is greatly aided in her attempts to throw off the matter of the disease.” In his general account of the effects of inoculation, we seem to be reading of as real symptoms and as many pocks as Nettleton described--the eruption, always of the simple distinct kind, beginning on the 9th day, all out in three or four days after, the pocks filling and turning yellow for the next four or five days, then scabbing and falling, leaving temporary shallow marks. But it is clear that he had other results than these from trying new ways of procuring matter. “Experience,” he says, “has convinced me that it is in reality of no consequence from what kind of smallpox it [the matter] is procured.” If taken from the natural smallpox, it should be taken from ripe pustules: “yet I have sometimes applied it sooner, while only a limpid water.” Oftentimes it happened that an inoculation produced too “slight” pustules to furnish matter for the succeeding operations. The question then arose whether the matter rendering from the incisions on the arms in these cases was merely common pus or whether it had the property of “variolosity.” This abstract quality, as it were the essence or quiddity of the pustular exanthem, was assumed to be present if the pus of the rendering incision could be made to raise a pustule on another arm, and if the person so infected could stand exposure to natural smallpox with impunity. One person so inoculated did have an attack of smallpox by contagion, so that Frewen concluded that the matter used for his protection had “run off all its variolosity.” But others inoculated with the same, “in whom the symptoms were remarkably light, and in some few no pustules at all,” were equally exposed to contagion without catching it, so that they were “judged to be secure from ever taking the smallpox again.” Frewen’s general conclusion, if it be not very logical, is at least modest:

“However, it may be worth the attention to reflect seriously whether it be not highly probable, from the success attending the numbers I have been concerned for, that inoculation has been often times a security against taking the most dangerous kinds of the natural smallpox.”

Whether Frewen got the ideas of these novelties of method from Kirkpatrick’s first account of the South Carolina practice, or struck them out for himself, it is clear that Kirkpatrick, in his next essay of 1754, has adopted variolosity as an abstract doctrine to surmount certain difficulties in the concrete reason. Many of his inoculated cases had only a few bastard pustules of smallpox, some had none. Was their disease smallpox? Did it warrant their future security?

“As many of the inoculated have very few pustules, and they are sometimes disposed to scab and wither away with very little suppuration, it might be of service to discover that the matter from the incisions would infect. But it would be certainly satisfactory to find it would where there was no eruption from inoculation, as its variolosity would greatly warrant the future security of the person it was taken from. That it is variolous is now evinced by the fact that it infected others to the like slight degree[924].”

The movement towards attenuating the virus used for inoculation was general in Europe. One of the mild methods, invented by Tronchin, of Amsterdam and afterwards of Paris, was to raise a small blister on the arm and to pass through the fluid a thread moistened with smallpox matter. This became one of the most common continental methods and was in use until the beginning of the 19th century. Kirkpatrick, who went to see the practice of Tronchin, found the method by blister to produce as slight effects in the way of eruption as he describes for his own method:

“I attended and infected five poor children:--three, about seven years old, by incision; and two, about five years old, by vesication. Of the first three, one, a girl, had a pretty moderate but very kindly sprinkling; the two boys very few. The two by blisters, a boy and a girl, had rather less,--the boy Dudin, a very fair delicate little child, not having above three or four, all which had not matter enough to infect one patient[925].”

Everywhere after the middle of the eighteenth century inoculation was coming into fashion again. In France it was lauded by the _philosophes_, while it was scouted by the medical faculty. La Condamine, a mathematician who had acquired fame by his journey to the Amazon to measure the three first degrees of the meridian, became interested in the subject by hearing from a credulous Carmelite missionary at Para how he had saved half of his Indian converts by inoculation after the other half had been destroyed by the natural smallpox. The mathematical philosopher on his return became an enthusiast for inoculation, and twice harangued the Académie des Sciences thereon. “The practice of inoculation,” he said, “was improved during the time of its disgrace.” What this improvement consisted in he also explained: “Neither the eruption is essential to the natural nor the pustules to the artificial smallpox: and perhaps art will one day come to effect what one hopes for and what Boerhaave and Lobb have even tried--I mean a change in the external form of this malady without any increase of its danger[926].”

The Suttonian Inoculation.

Daniel Sutton, though an empiric, has given his name to the slight and safe method of inoculation which had been used in England for a good many years before his advent. So completely was his name joined to the practice of smallpox inoculation in its later period that in a Bill before Parliament in 1808 it is called “the Suttonian inoculation,” to distinguish it from cowpox inoculation. The idea of attenuating the virus used for inoculation, and of making the effects minimal, was not his. It had been reached empirically years before by Mowbray, of Charleston, in 1738, who carried inoculation from arm to arm to the fifth remove, by Frewen, of Rye, in 1749, who was satisfied with an abstract “variolosity” of the incisions, in cases where there was no eruption at all or only a few pustules that did not fill, by Kirkpatrick, “the most scientific inoculator in London,” who endorsed the doctrine of variolosity, by La Condamine, and most of all by Gatti of Paris.

Gatti used the unripe matter from a previous inoculation and inserted a most minute quantity of it at a very small puncture; and, to make sure that no general eruption should follow, he used the cooling regimen in various ways, including the prolonged immersion of the hands in cold water. Thus he promised his clients “the benefits of inoculation without its risks.” But Gatti’s career of prosperity was cut short by a series of conspicuous failures of his artificial smallpox to prevent the natural or real disease when it was epidemic. One of his patients, the Duchess de Boufflers, a great lady whose _salon_ was frequented by the _philosophes_ and _beaux esprits_, fell into the natural smallpox two years and a half after her inoculation[927]. So many others in Paris had the same disappointment that a discussion arose in the Faculty of Medicine, the result of which was that the Parliament of Paris prohibited the practice of inoculation, for various reasons, within the limits of the capital.

Gatti’s friend and correspondent in London was Dr Maty, who, “though born in Holland might be considered a Frenchman, but he was fixed in London by the practice of physic and an office in the British Museum[928].” Having conducted the foreign correspondence of the Royal Society, he became in 1765 its secretary in ordinary, and about the same time Principal Librarian of the British Museum. His interest in inoculation, which was shown by his translating La Condamine’s first discourse on that subject in 1755, led him in 1765 to suggest to Gatti that he should write an essay for publication in England, “both to reclaim the thinking part of Paris, and to vindicate his own operations from the contemptuous treatment of his antagonists.” The essay was written in due course, and Maty brought it out in English[929].

Gatti’s own experiments and those which had previously been made in England by the most experienced inoculators had satisfied him of the truth of what he had long suspected, namely, that the operation could be made “still more harmless, though not less efficacious” (p. 29). There would be hardly any fever, certainly a very slight eruption and perhaps none at all (p. 68), It had, indeed, been questioned whether a patient who had but very few pustules, or only one, has had the smallpox as truly as one who has been very full, and whether he is equally safe from catching it. He answers in the affirmative, according to the doctrine of variolosity: “No reason can be alleged, why we should have the smallpox but once, that will not equally hold good for one as for ten thousand pustules” (p. 69). Some, however, will not believe that one pustule is as good as ten thousand, “notwithstanding the obviousness of this truth.” If one were absolutely bent upon giving a certain number of pustules, he would advise to inoculate according to his method (insertion with a needle) at twenty, thirty, or fifty places: “then you would be sure of one pustule at least at each puncture, and, probably, of many more in other parts.” He would do this, however, only to humour prejudice, and with a feeling that he was doing the patient “more harm than was necessary.” He was seriously satisfied of the “sufficiency of a single pustule,” and believed that every wise man should run the venture of it and “embrace the method here laid down.”

There was no theoretical objection to this method, but there was the practical one, that it might be _too_ slight in its effects. Patients could hardly rest satisfied with so little to show for smallpox; and inoculators themselves found that they might have all their work to do over again. An eminent Irish physician wrote in 1765 to Dr Andrew, of Exeter, that crude matter from a previous inoculation was “less communicative of the disorder and more apt to disappoint us” than matter from a natural smallpox eruption taken “five or six days before the maturation of it[930].” It was also the experience of Salmade, of Paris, in 1798, that serous matter, taken from arm to arm through a long succession of cases, was apt to go off altogether, or to be “weakened to the point of nullity,” whereby it disappointed the operator[931]. Reid, of Chelsea Hospital, was said to have carried the succession to thirty removes from the natural smallpox. Bromfeild knew for certain of matter being used at the sixteenth remove.

So long as the operation held at all, and had not to be repeated, Dr Andrew believed that effects which “no one would have taken for the smallpox,” were “sufficient security against any future infection[932].” Heberden, indeed, has recorded a case adverse to that view; but one case is not enough, even if it had been in as eminent a person as Madame de Boufflers[933].

Daniel Sutton, who gave his name to the slighter kind of smallpox inoculation, was not a regular practitioner. His father, a doctor of medicine in Suffolk, was a specialist inoculator, as others of the regular profession here and there were becoming, and had operated upon 2514 patients from 1757 to 1767. In 1763 Daniel began business on his own account at Ingatestone in Essex, where patients from all parts were boarded and subjected to his regimen, as at a water-cure. In 1764 he made 2000 guineas, and in 1765 £6300. In the three years 1764-66 he inoculated 13,792 persons, and his assistants some 6000 more--without a single death. Sutton kept his method at first a secret, and for that reason was looked at askance by eminent physicians. He used pills and powders, which were found, by the analysis of Ruston, to be a preparation of antimony and mercury, the drugs supposed to be antidotes to natural smallpox, or the means of preventing its pustular eruption. But the essence of his method was found to be, in Chandler’s words, “the taking of the infective humour in a crude state [from a previous inoculation] before it has been, if I may allow the expression, variolated by the succeeding fever[934],” or, in Dimsdale’s words, “inoculating with _recent_ fluid matter,” or in Sir George Baker’s words, “with the moisture taken from the arm before the eruption of the smallpox, nay, within four days after the operation has been performed[935].”

Sutton made it known that the effects of this method were exceedingly mild--no keeping of bed, no trouble at all: “if any patient has twenty or thirty pustules, he is said to have the smallpox very heavy.” Being put on his trial at Chelmsford for spreading abroad the contagious particles of smallpox by the number of his inoculations, his defence was to have been (if the bill had not been thrown out by the grand jury), that he “never brought into Chelmsford a patient who was capable of infecting a bystander.” The mildness of his artificial smallpox was acknowledged with satisfaction by some, with dissatisfaction by others. Dr Giles Watts, an inoculator in Kent, says it was “a most extraordinary improvement. The art of inoculation is enabled to reduce the distemper to almost as low a degree as we could wish.... There is now an opportunity of seeing what a very small number of the multitude of persons of all ages, habits and constitutions, who have been inoculated in these parts, have been ill after it.” Comparing it with the method which he had practised before, he says that he never knew ten or twelve inoculated together “in the old way” but one or more had the distemper in a pretty severe manner; on the other hand, he had inoculated four of his children in the new way and all of them together had not so many as eighty pustules. He adds that sometimes the inoculated had not even a single pustule (besides the one at the point of insertion) or at other times not more than two or three[936].

The Suttonian practice was objected to by Bromfeild in an essay dedicated to Queen Charlotte. Tracing it to Gatti, whose manifesto had been published in England two years before, he said that it was mere credulity “to have given credit to a man who should assert, that he would give them a disease which should not produce one single symptom that could characterize it from their usual state of health.... Inoculation, though hitherto a great blessing to our island, will in a very short time be brought into disgrace,” if it were assumed “that health and security from the disease can be equally obtained by reducing the patients so low as only to produce five to fifteen pimples[937].”

Bromfeild was not openly supported except by Dr Langton, of Salisbury, who contended that “the matter communicated is not the smallpox, because numbers have been inoculated a second, third and fourth time, that therefore it is no security against a future infection.” He cites Gatti’s case of the Duchess de Boufflers, and declares, as to the English inoculations, that not above one in ten have so many variolous symptoms as may be remarked in her case. “The old method of inoculating,” he says, “was to take the infection from a good subject where the pustules were well maturated, whereby the operation was sure of succeeding; but the present practice is to take the matter from the incision the fourth day after the incision is made [this was Sutton’s avowed practice]. By this means you have a contagious caustic water instead of laudable pus, and a slight ferment in the lymph is raised, producing a few watery blotches in the place of a perfect extrusion of the variolous matter[938].”

There was no difference of opinion as to the exact purport and upshot of the new method; it was to reduce the eruption to the lowest point or to a vanishing point. Nothing can be more emphatic than Gatti’s profession of belief that a single pustule, at the place of insertion, was as effectual as ten thousand; and it is not only likely, on the face of it, that such a mitigation as Reid’s to the thirtieth remove from natural smallpox, would produce merely the local pustule, but it is clear that Gatti saw no way of ensuring more by his method, supposing he were to gratify the prejudices of the laity in favour of more, than by puncturing the skin at twenty, thirty, or fifty separate points. It is not to be supposed, however, that the minimum result was obtained in all cases, or that all inoculators were equally adroit in procuring it; even Sutton had to admit that some of his thirteen thousand patients had more pustules on the skin than he desired.

Perhaps the most exact record of the number of pustules produced in a comparative trial of various methods is that of Sir William Watson at the Foundling Hospital in 1768[939]. Of 74 children inoculated in October and November, twelve had no eruption at all, but yet were held to have been protected by the operation. The remaining sixty-two had a very small average of pustules in addition to the local pustules, which average, small as it was, came mostly from two or three severer cases (e.g. one with 440 pustules, one with 260, and one with near 200), the most having three or four or a dozen or perhaps two dozen (e.g. three had only 7 pustules among them, or, in another batch of ten done with crude or ichorous matter, “the most that any boy had was 25, the least 4, the most that any girl had was 6, the least 3,” or, in another batch of ten, also with crude lymph, two had no eruption, seven had 35 pustules among them, and one had 30). Of the amount of smallpox upon the whole sixty-two cases which had some eruption Watson says: “Physicians daily see in one limb only of an adult person labouring under the coherent, not to say confluent smallpox, a greater quantity of variolous matter than was found in all these persons put together.”

Watson’s sole measure of “success” in inoculating was the slightness of the effect produced; and as he found that crude or watery matter from the punctured spot of a previous inoculation had the least effect, he decided to use that kind of matter always in future at the Foundling Hospital. On the other hand, Mudge, of Plymouth, raised a different issue and put it to the test of experiment on a large scale. Did crude matter infect the constitution? Did it make the patient insusceptible of the effects of a second inoculation with purulent matter? The experiment came out thus:

At Plympton, in Devonshire, in the year 1776, thirty persons were inoculated with crude or watery matter from the arm of a woman who had been inoculated five days before, and ten persons were at the same time inoculated with purulent matter from the pustules of a case of natural smallpox. The thirty done with crude matter had each “a large prominent pustule” at the place of puncture, “but not one of them had any eruptive fever or subsequent eruption on any part of the body.” Matter taken from their local pustules produced exactly the same result in the next remove, namely, a local pustule, but no eruptive fever nor eruptive pustules. The thirty were inoculated again, this time with purulent matter (five from natural smallpox, twenty-five from inoculated smallpox), and all of them had, besides the local pustule, an eruptive fever and an eruption “in the usual way of inoculated patients.” The ten who were originally inoculated with purulent matter had that result at first[940].

In the subsequent history of inoculation it would appear that the method known by the name of Sutton, of using crude or watery matter from a previous inoculated case, was the one commonly preferred. But it was not always preferred. One of the medical neighbours of the afterwards celebrated Dr Jenner took matter from the pustules and kept it in a phial; his patients inoculated therewith had somewhat active effects, even “sometimes eruptions.” But “many of them unfortunately fell victims to the contagion of smallpox, as if they had never been under the influence of this artificial disease,” so that Jenner, who had probably not heard of Mudge’s experiment, was confirmed in his preference for the crude matter (before the eruptive fever) from a previous inoculation. It was of great importance, he said, to attend to that point, as it would “prevent much subsequent mischief and confusion[941].” Of course there were many more chances of getting matter from natural smallpox than from inoculated; but it would appear that in the former also it was taken in the ichorous or unripe stage of the eruption, according to the practice of Sutton, and despite the experimental proof that Mudge gave of its merely superficial or formal effects.

Mudge’s experiment was on a large scale, and designed to test a general or scientific issue. The testing experiment usually made was merely for the sake of the particular case; the patient was inoculated a second time, shortly after the first, with the same matter as before, or a third time, or even a fourth time. Whatever the significance of this for the doctrine of inoculation in general (as in the issue raised by Mudge), the individual was both reassured and fortified so far as concerned his own safety. The experiment of the former generation that was usually cited was that of the Hon. John Yorke. On his leaving the university at the age of one and twenty it was thought prudent that he should be inoculated for smallpox before entering on the great world. He was inoculated by serjeant surgeon Hawkins, and had the local suppuration, some fever, but little or no eruption. The inoculator was satisfied, but not so the youth: he insisted upon a second inoculation, which had no effect. This was considered a leading case. When the Suttonian method came in, and the absence of eruption (barring a few pimples or bastard pustules) became the usual thing, the occasions for a second inoculation became more common, owing to the prejudice, as Gatti said, of the laity in favour of something tangible although not excessive[942].

Dimsdale inoculated many of his patients a second time, and produced the local pustule again, as at first. Of the 74 foundlings in Watson’s experiment of Oct.-Nov. 1767, there were twelve who had no eruption, of whom four were re-inoculated with no better result or with no result. Of the whole twelve he says: “Although they had no eruption, I consider them as having in all probability gone through the disease, as the punctures of almost all of them were inflamed and turgid many days.” It was so unusual for a second inoculation, in a doubtful case, to produce more than the first, that Kite, of Gravesend, communicated to the Medical Society of London two cases where that had happened, as being “anomalous.” He had never before been able to communicate the smallpox, on a second attempt, “to any patient whose arm had inflamed, and who had even a much less degree of fever” than Case 1, who had only the local pustule and “on the eighth day was quite well:” and he cites Dimsdale to the same effect[943].

Perhaps enough has been said to illustrate the subtle casuistry that had gradually arisen out of the old problem of procuring the smallpox by artifice. I make one more citation, from a Hampshire inoculator in 1786, to show how fine were the distinctions, depending, one might suppose, upon the subjective state of the practitioner, drawn between effective and non-effective inoculation:

“The incisions sometimes have a partial inflammation for a few days, which then vanishes without producing any illness; in this case the patient is certainly still liable to infection; but I believe it very rarely happens that there is any matter, or even ichor, in the present slight manner they are made, without producing the smallpox.... I have constantly remarked that when the punctured part inflames properly, and is attended with an efflorescence, rather inclining to a crimson colour, for some distance round the same, about the eleventh or twelfth day from the inoculation, although the patient should have very little illness and no eruption, yet that he is secure from all future infection[944].”

Extent of Inoculation in Britain to the end of the 18th Century.

From 1721 to 1727 the inoculations in all England were known with considerable accuracy to have been 857; in 1728 they declined to 37; and for the next ten or twelve years they were of no account. The southern counties led the revival in the fifth decade of the century, so that before long some two thousand had been inoculated in Surrey, Kent, Sussex and Hampshire. Frewen, however, who could point to 350 cases done by himself in Sussex previous to 1749, says that it “gained but little credit among the common sort of people, who began to dispute about the lawfulness of propagating diseases, and whether or no the smallpox produced by inoculation would be a certain security against taking it by infection,” etc.

In London, after the revival under Kirkpatrick’s influence in 1743, inoculation became a lucrative branch of surgical practice, and was done by the heads of the profession--Ranby, Hawkins, Middleton and others, and almost exclusively among the well-to-do. In 1747 Ranby had inoculated 827 without losing one; in 1754 his total, still without a death, had reached 1200. In 1754 Middleton had done 800 inoculations, with one death. The operation was by no means so simple as it looked. It required the combined wits of a physician, a surgeon, and an apothecary; while the preparation of the patient to receive the matter was an affair of weeks and of much physicking and regimen. Thus inoculation was for a long time the privilege of those who could pay for it. As late as 1781, when a movement was started for giving the poor of Liverpool the benefits of inoculation, it was stated in the programme of the charity that, “as the matter now stands, inoculation in Liverpool is confined almost exclusively to the higher ranks,” the wealthier inhabitants having generally availed themselves of it for many years[945].

The first project in London for gratuitous inoculation took shape, along with the plan of a smallpox hospital, at a meeting held in February, 1746, in the vestry-room of St Paul’s, Covent Garden[946]. The original house of the charity, called the Middlesex County Hospital for Smallpox, was opened in July, 1746, in Windmill Street, Tottenham Court Road, but was shortly removed to Mortimer Street, and again, to Lower Street, Islington. The charity opened also a smallpox hospital in Bethnal Green, which eventually contained forty-four beds. The Inoculation Hospital proper, used for the tedious preparation of subjects, was a house in Old Street, St Luke’s, with accommodation for fifteen persons. Besides the smallpox hospital at Islington, the charity had, in 1750, a neighbouring house in Frog Lane, for the reception of patients after they had been inoculated in the Old Street house. Down to the middle of 1750 there had been admitted 620 patients in the natural smallpox, while only 34 had gone through the process of inoculation. The latter involved a month’s preparation, and about a fortnight’s detention after the operation was done; so that a new batch of subjects was inoculated but once in seven weeks. In 1752 the governors of the charity purchased a large building in Coldbath Fields, which they fitted with one hundred and thirty beds, as a hospital both for cases of the natural smallpox and for preparing subjects to undergo inoculation (the Old Street house being still retained for the latter purpose). The next important change was in 1768, when a large new hospital was opened at St Pancras, to be solely a house of preparation, the old hospital in Coldbath Fields being now turned to the double purpose of receiving the patients from St Pancras after their inoculation and of receiving patients in the natural smallpox. Thus the inoculation business of the charity, which had begun with being subordinate to the treatment of those sick of the natural smallpox, gradually encroached upon the latter and became paramount. The inoculations, which had been only 112 in the year 1752, reached the total of 1084 in the year 1768, while the admissions for smallpox “in the natural way” from 24 March, 1767, to 24 March, 1768, were 700.

In the year 1762-63, the admissions for natural smallpox had been 844, and for inoculations 439. One reason of the great increase of patients received for inoculation after that date was the rise of the Suttonian practice, which had vogue enough to attract numbers, and at the same time was so much simplified in the matter of preparation and in its results that many more could go through the hospitals in a given time. The inoculations by the Smallpox Charity were done in batches, men and boys at one time, women and girls at another, on some eight or twelve occasions in the year, of which public notice was given.

The following table is taken from the annual report of the Smallpox and Inoculation Hospitals for the year 1868.

Period Inoculations

Previous to Oct. 1749 17 Oct. 1749-Oct. 1750 29 Oct. 1750-Oct. 1751 85 1752 112 1753 129 1754 135 1755 217 1756 281 1757 247 1758 } 446 1759 } 1760 372 1761 429 1762 496 1763 439 1764 383 1765 394 1766 633 1767 653 1768 1084

These charitable efforts to keep down smallpox in London hardly touched the mass of the people, and did not touch at all the infants and young children among whom nearly all the cases occurred. The charity admitted no subjects for inoculation under the age of seven years. It aimed at giving to a certain number of the working class, or of the domestics or other dependents of the rich, the same individual protection that their betters paid for. Meanwhile there were on an average about twelve thousand cases of smallpox in London from year to year, mostly in infants and young children. The first proposal to apply inoculation to these came in 1767, from Dr Maty, in a paper on “The Advantages of Early Inoculation.” This physician, distinguished in letters and now become a librarian, sought to recommend inoculation for infants by glorifying the purity of their juices and the natural vigour of their constitutions, which was something of a paradox at a time when half the infants born in London were dying before the end of their third year. He saw as in a vision how smallpox would be extinguished by making inoculation universal:

“When once all the adults susceptible of the infection should either have received it or be dead without suffering from it, the very want of the variolous matter would put a stop to both the natural and artificial smallpox. Inoculation then would cease to be necessary, and therefore be laid aside[947].”

Eight years after, in 1775, Dr Lettsom seriously took up the project of inoculating infants in London[948]. He started a Society for Inoculation at the Homes of the People, which effected nothing besides some inoculations done by Lettsom himself during an epidemic “in confined streets and courts.” In 1779 he launched another scheme for a “General Inoculation Dispensary for the benefit of the poor throughout London, Westminster and Southwark, without removing them from their own habitations[949].” That also was frustrated by the active opposition of Dimsdale[950]. The objection to it was that there was no prospect of making the practice universal, and that partial inoculations in the crowded quarters of London would merely serve to keep the contagion of smallpox more active than ever. Lettsom answered that the danger of contagion from inoculated smallpox was more theoretical than real, inasmuch as the amount of smallpox matter produced upon the inoculated was a mere trifle[951].

At Newcastle, Lettsom’s design had at least a trial, under the influence of his friend Dr John Clark[952]. The Dispensary, founded in 1777, was designed from the outset to undertake gratuitous inoculations; but it was not until 13 April, 1786, that it got to work. The “liberality of the public” enabled the managers in that year to offer premiums to parents, to cover the expense of having their children sick from inoculation--five shillings for one child, seven shillings for two, nine shillings for three, and ten shillings for four or more of a family. On the first occasion, 208 children were inoculated, and all recovered. From 1786 to 1801, the cases numbered 3268. It was the aim of Dr Clark to get the operation done in infancy; accordingly in the space of four and a half years (1786-1790), of 1056 inoculations 460 were on infants under one year, 270 from one to two, 122 from two to three, 69 from three to four, 62 from four to five, 66 from five to ten, and 7 from ten to fifteen. This was perhaps the most systematic attempt at infant inoculation from year to year. The other dispensaries at which inoculation was steadily offered to the children of the poor were at Whitehaven (1079 inoculations from 1783 to 1796), at Bath, and at Chester.

Before the society was started at Chester for the purpose, the inoculations were some fifteen or twenty in a year, and these, we may suppose, in the richer families. The society got to work in 1779, but its operations were stopped in 1780 by a singular cause--the general diffusion of smallpox in the town by a regiment of soldiers. The whole inoculations of poor children from the spring of 1780 until September, 1782, were 213, besides which 203 were done in private practice. The year 1781 was tolerably free from epidemic smallpox (8 deaths), but in January, 1782, a very mortal kind prevailed in several parts of the town.

At Liverpool the first gratuitous general inoculation was in the autumn of 1781, to the number of about 517. “The affluent,” says Currie, “being alarmed at the advertisement for this purpose, presented their children also in great numbers, and 161 passed through the disease.” There was a second gratuitous inoculation in the spring of 1782 (to which some of the above numbers may have belonged), and it was intended to continue the same at regular intervals; but there is no record of more than those two[953].

Although Dimsdale opposed “general” inoculations in the large towns, for the reasons mentioned, he was in favour of inoculating together all the susceptible subjects in a smaller place or country district; and that kind of general inoculation was not unfrequently undertaken, sometimes hurriedly at the beginning of an epidemic, at other times after an epidemic had been running its course for months, and here or there, it would seem, during a free interval and by way of general precaution.

Dimsdale himself, with the help of Ingenhousz, carried out on one occasion, in Berkhamstead and three or four other villages of Hertfordshire, a general inoculation to the number, he guesses, of some six hundred persons of all ages, including some quite old persons. In 1765 or 1766 Daniel Sutton at Maldon, Essex, inoculated in one morning 417 of all ages, who were said to be all those in the town that had not had smallpox in the natural way. Some hundreds were also inoculated by him at one time in Maidstone.

In the small Gloucestershire town of Painswick in 1786, a very violent and fatal smallpox broke out during a time of typhus and intermittent fever. In consequence of the epidemic, one surgeon inoculated 738 persons from the 26th of May to the end of June[954]. In another Gloucestershire parish, Dursley, a single surgeon in the spring of 1797 inoculated 1475 persons of all ages, “from a fortnight to seventy years.” But in certain villages near Leeds in 1786-7 a general inoculation, organised by a zealous clergyman and paid for by a nobleman, mustered only eighty. About the same time, during an epidemic of malignant smallpox at Luton, Bedfordshire, 1215 were inoculated, and thereafter about 700 more; the average number annually attacked by smallpox during a period of nine years had been about twenty-five[955].

Inoculation was tried first in Scotland in 1726 by Maitland, during a visit to his native Aberdeenshire, but was not persevered with owing to one or two fatalities among the half-dozen cases. About 1733 it was begun at Dumfries by Gilchrist, who practised it during the next thirty years upon 560 persons, most of them, doubtless, paying patients. The returns made to Professor Monro, of Edinburgh, showed in the chief medical practices 5554 inoculations down to 1765; of which 703 were in Edinburgh and Leith, 950 in Glasgow, 208 in Stirling, 260 in Irvine, 157 in Aberdeen, 310 in Banff, 243 in Thurso, and 560 in Dumfries as above[956]. Seventy-two deaths are put down to the practice. When the Statistical Account of the 938 parishes was compiled in the last decade of the century, a few of the parish ministers made reference to inoculation.

Thus, in Applecross, Ross-shire, and three neighbouring parishes, an uneducated man is said to have inoculated 700 after a very fatal epidemic in 1789; it happened, however, that the pestilence reappeared, whereupon inoculation was “generally adopted[957].” Applecross may have been populous then; now there is not a smoke to be seen in it for miles. Again, the practice is said to have become “universal” in Skye from about 1780[958]. In Durness parish, which the tourist may now traverse for thirteen miles to Cape Wrath without seeing anyone but a shepherd, inoculation was rendered “general” about 1780 by the benevolence of a gentleman belonging to the parish[959]. From October, 1796, to July, 1797, a surgeon of Thurso inoculated 645 in that town and in country parishes of Caithness during a very severe epidemic[960]. In the parish of Jedburgh the cost of an inoculation was defrayed by the heritors, in that of Kirkwall by the kirk session, in another by the commissioners of annexed estates, in Earlstown, Berwickshire (on 70 children) by the chief proprietor. The ministers who mention it at all were mostly strong advocates of it, but they usually imply that the common people were (or had been) apathetic or prejudiced. It was sometimes recommended from the pulpit, and actually done by the ministers; it was even recommended that students of divinity should be instructed in the art. Statements that it had become “general” or “universal” are made for several parishes, mostly in the Highlands or Islands. The very full and trustworthy account of the parish of Banff says that “inoculation is by no means become general among the lower ranks[961];” which is perhaps about the truth for the country at large.

At the end of an epidemic at Leeds, in 1781, which had attacked 462 and killed 130 during six months, “in the next six months there were inoculated 385, of whom four died” (two by contagious smallpox). A second general inoculation was carried out in Leeds sometime previous to 1788. Lucas, writing in that year, says: “The result of two general inoculations in Leeds has been that the smallpox has since been less frequent and less fatal[962].” This will be a convenient opportunity of considering the gross effects of inoculation upon the prevalence of smallpox.

The first and most obvious consideration is that it usually came too late. “Most born in London,” said Lettsom quite correctly, “have smallpox before they are seven”--i.e. before the age for admission to the inoculation hospital. He might have added that, if they had run the gauntlet of smallpox in London until they were seven, they were little likely to take it at all. The inoculations in London were therefore done upon a very select class (they were, in fact, a very small number), who may be assumed to have escaped the perils of smallpox in London in their childhood, or to have come to London (as many did) from country places where smallpox broke out as an epidemic only at long intervals. In other large towns as well as the capital the inoculated must have been a residual class. At Leeds, with a population of 17,117, “the number of those who were still uninfected was found on a survey to be 700” at the end of an epidemic, of whom 385 were inoculated. If a general inoculation had been tried at Chester after the epidemic of 1774, there would have been only 1060, in a population of 14,713, to try it on. How many of these, above the age of childhood, were constitutionally proof against smallpox? The case of Ware, in Hertfordshire, after the epidemic in the summer of 1777, is so related by Lettsom as to bring out the ambiguity of much that was claimed for inoculation. “After about eighty had been carried off by it, a general inoculation was proposed, to prevent those who had not yet been attacked, and whose number was still considerable, from sharing the same fate. The alarm which had been excited induced most of the survivors to adopt this proposition, after which not one died, and the infection was wholly eradicated.” Eighty deaths in one epidemic is a large mortality for such a place as Ware in any circumstances; the smallpox for once had done its worst. But, says Lettsom, there were a few families of those hitherto untouched by the epidemic who did not submit to inoculation. Not one of them caught the disease--from their inoculated neighbours (Lettsom is arguing that there was no danger in that way), nor, of course, from the epidemic contagion. It cannot but appear strange to us that the natural cessation or exhaustion of an epidemic should not have been thought of. Dr Currie, of Liverpool, records that in the first general inoculation there in 1781 there were 417 inoculated gratuitously and about 100 more in private practice, and that “about three or four thousand liable to the disease were scattered in the same manner [as the inoculated], not one of whom caught the infection.” For a few weeks there was not a case of smallpox known in Liverpool, so that no matter could be got for inoculation. He adds, in the most ingenuous manner: “An important

## particular has been recalled to my mind by Mr Park; that previous to this

first general inoculation, which extinguished the smallpox in so extraordinary a way, the disease raged in town with much violence and was very fatal[963].”

The general inoculations were often carried out in so haphazard a manner as to make them valueless for a scientific as well as for a practical purpose. A Bath surgeon of long experience wrote in 1800: “Whenever the inoculating rage once takes place whole parishes are doomed, without the least attention to age, sex, or temperament--no previous preparation, no after treatment or concern.... Are not scores and hundreds seized upon at once, for the incisions, scratchings, puncturings and threadings, without even a possibility of their being properly attended to? and whether they may or may not receive the infection is just as little known or cared about[964].” It must have been equally little known or cared about whether they had had smallpox in the natural way before. What Dimsdale found to obtain at St Petersburg would have been the rule elsewhere: “The general method was to search for marks, and, if none were found, it was concluded the party had not had the disease[965].”

Thus in any attempt to estimate the gross advantages of inoculation in the 18th century we are met on every hand by sources of fallacy. Whatever its theoretical correctness, it does not follow that the inoculation of smallpox was a practical success to the extent of its trial; and even its theoretical correctness will be thought by some, and was so thought at the time, to have gone by the board when the artificial disease was brought down to a pustule at the point of puncture, with or without a few bastard pocks on the skin near. I have found two instances in the 18th century history in which there are data for a rough practical judgment, although not for a precise statistical one. The first is the town of Blandford, in Dorset; the other is the Foundling Hospital in London.

During the smallpox year 1766, smallpox of a very malignant type broke out at Blandford in the first week of April[966]. It was estimated that 700 persons in the town (population 2110 in 1773) had not had the natural smallpox, and a general inoculation was resolved upon on the 13th April. “A perfect rage for inoculation,” says Dr Pulteney[967], “seized the whole town,” and in the week following the 16th April some 300 were inoculated, the total rising to 384 before the panic ceased; of these, 150 were paid for by the parish. There were thirteen deaths among the inoculated, but most of these confluent or haemorrhagic cases, seem to have been due to the epidemic contagious smallpox, which had been peculiarly fatal, with haemorrhagic symptoms, to the few that were seized before the inoculation began, and continued to be fatal to many. The mortality from smallpox for the year in the parish register was 44, and from all causes 104, or more than twice the normal[967]. The last epidemic of smallpox in Blandford had been in 1753, when 40 died of it, the deaths from all causes being 96. In that year also there had been a general inoculation to the number of 309. The parish register gives the deaths in an earlier epidemic, in 1741, which was a year of great distress and typhus fever all over England: 76 deaths are ascribed to smallpox (102 to all causes), which is a larger total from smallpox than in either of the subsequent occasions when general inoculations were tried. Comparing these three epidemics in a Table, with the associated circumstances, we get the following:

_Statistics of Blandford in three Smallpox Years (Population in 1773, 2110)._

| | | | Annual Averages of Year of |Deaths| Deaths |Inoculations| eight previous years Epidemic| from | from | |----------------------- | all |Smallpox| | | | |causes| | |Marriages|Births|Deaths --------|------|--------|------------|---------|------|------ 1741 | 102 | 76 | --- | 24·87 |63·37 | 49·25 1753 | 96 | 40 | 309 | 19·37 |50·62 | 49·62 1766 | 104 | 44 | 384 | 20·62 |54·12 | 49·12

It will be seen that the higher mortality from smallpox in 1741 was associated with other things besides the absence of inoculation. The annual average of deaths for eight years preceding each of the three epidemics is almost the same. But the marriages and births for eight years preceding 1741 were much in excess of those in the periods preceding the other two epidemic years. In the former there was a much larger susceptible population of children, upon which the smallpox mainly fell; and that alone would account for more deaths from smallpox in the epidemic of 1741. But the year 1741 was peculiar in another way; it was the worst year of typhus fever and general distress in the whole of the 18th century, and in the circumstances the deaths from smallpox would have been unusually numerous for the cases. Another epidemic of smallpox without inoculation, in 1731, showed how mild smallpox could be. At a time when sixty families had the disease among them, a fire broke out on 4 June, and burned down the town. It is said that 150 ill of smallpox were removed to gardens, hedgerows and the arches of bridges, and that only one of the whole number died[968]. This is usually cited to show the benefits of fresh air; but if it be true, it shows more than that.

The Foundling Hospital may seem to offer all the conditions for a fair trial of the question. It had been a standing rule of the Governors, since the opening of the charity in 1749, that all children received into it should be inoculated. Sir William Watson, who states the fact, adds that he himself was “in a situation of superintending every year the inoculation of some hundreds.” Still, the rule may not have been uniformly carried out; and even in this community of children, it was not always possible to learn on their admission whether they had had smallpox before in the natural way[969].

The lists of the inoculated are longer in the later periods than in the earlier: thus, from March, 1759 to May, 1766, the annual average is something under a hundred, the inmates having been 312 in 1763; but from May, 1766 to July, 1769, the annual average is some two hundred and fifty, the inmates in 1768 having been 438. Sir William Watson, in his essay upon the inoculations at the Foundling, breathes no hint that such a thing as natural smallpox ever happened there[970]; but in another context he does casually mention that there was an epidemic of sixty cases, with four deaths, in the end of 1762, and another epidemic in the following summer, of “many” cases, nineteen of which, with eleven fatalities, occurred in children who had lately been through the measles and were weakened in consequence[971]. Another epidemic, as I find by the apothecary’s book of weekly admissions to the infirmary, happened in the winter of 1765-66, twenty-six names being entered as admitted for “natural smallpox.” After that date all the great epidemics appear to have been of measles, whooping-cough, influenza or scarlatina; but almost every year smaller groups of “natural smallpox” occur, of which the following have been collected from the available records:

_Foundling Hospital, London._

Natural Year Smallpox

1766 8 1767 2 1768 8 1769 7 1770 1 1771 2 1772 3 1773 1 1774 4 1775 3 1783 1 1784 0 1785 8 (or 16?) 1786 0 1787 5 1788 4

The occurrence of one or more cases seems to have been the signal for a general inoculation; or, again, it may be that the few cases of natural smallpox in the infirmary at one time had followed a general inoculation. Thus, in June-July, 1767, one case is entered on the second day from the inoculation (of a large number), and another on the fourth day. Again, in Nov.-Dec., 1768, one of the four cases of natural smallpox is marked “soon after his inoculation.”

The received cases in which inoculation failed to save individuals from the natural smallpox are few. Besides those already given for the first period of the practice, and the case from Heberden, there are six fully detailed by Kite of Gravesend, in two groups of three each, all in the spring of 1790[972]. Apart from exact records, there are various testimonies more or less trustworthy. The Marquis of Hertford is said to have told Dr Jenner that his father, having been inoculated by Caesar Hawkins, the serjeant surgeon, and thereafter attended by him during a tour abroad, caught smallpox at Rheims and died[973]. Bromfeild, surgeon to Queen Charlotte, is said to have “abandoned the practice of inoculation in consequence of its failure[974].” Jenner and his friends made a collection of cases in which inoculation had failed, to the number of “more than one thousand, and fortunately seventeen of them in families of the nobility[975].” A Bath surgeon said he had heard of “innumerable” cases of attacks of natural smallpox long after inoculation, and had himself professionally seen “not a few[976].” A surgeon of Frampton on Severn knew of four cases, out of five inoculated together in 1784, that took smallpox afterwards in the natural way, of whom one died[977]. In an epidemic of smallpox at Enmore Green, a suburb of Shaftesbury, in 1808, a surgeon from Shaston found that “nearly twenty” of the victims had been inoculated “by the late Mr John White” about ten years before, and were supposed to have had it “very fine[978].” Dr John Forbes learned that some nineteen cases of natural smallpox in and around Chichester in 1821-22 were of inoculated persons[979]. It would be incorrect to say that such cases could be multiplied indefinitely; on the contrary, they are hard to find. Whether that shows that inoculation was on the whole a success, to the extent that it was tried, or that its failures are in part unrecorded, I am not competent to decide. But it cannot be doubted that the usual estimates of the saving of life by inoculation were extravagant and fallacious. La Condamine, a mathematician, counted up the saving to the slave-owner in an ideal plantation of three hundred negroes[980]. Watson, with the epidemics in the Foundling fresh in his memory, estimated that inoculation might have saved 23,000 out of the 23,308 who had died of smallpox in London in ten years, 1758-68[981]. Haygarth[982] reckoned that 351 might have been saved by inoculation of the 378 children who died of smallpox at Chester from 1772 to 1777. Woodville, who wrote the history of inoculation down to the advent of Sutton, declared in 1796 that the art of inoculation, originally a fortuitous discovery, “is capable of saving more lives than the whole _materia medica_[983].” Arnot, the historian of Edinburgh (1779), asserted inoculation to be “a remedy so compleat that we hesitate not in the least to pronounce those parents, who will not inoculate their children for the smallpox, accessory to their death[984].” The College of Physicians, in a formal minute of 1754, pronounced it “highly salutary to the human race.”

Despite all those academic pronouncements, inoculation was somehow not a practical success. It cannot be maintained that it failed because the people were averse to it; for it continued to be in popular request far into the 19th century, until it was at length suppressed by statute. For the present we may return to the proper subject of epidemic smallpox, premising, on the ground of what has been said, that inoculation made but little difference to the epidemiological history.

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._

Percentage Locality of the Deaths of Epidemic Period Authority Cases Fatalities

Halifax[987] winter of 1721 Nettleton, 276 43 15·9 to April 1722 _Phil. Trans._ XXXII. 51 Rochdale[988] " " 177 38 21·4 Leeds[989] " " 792 189 23·8 Halifax parish 1722 _Ibid._ p. 221 297 59 19·9 towards Bradford Halifax parish, " " 268 28 10·4 another part 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 Whitaker, 994 168 16·9 (to 15 Oct.) _Ibid._ p. 223 Haverfordwest 1722 Perrot Williams, 227 52 22·9 _Ibid._ Barstand, Ripponden, " Nettleton, in 230 38 16·5 Sorby, and part of Jurin’s _Acct._ Halifax parish for 1723, p. 7 4 miles from the town Bolton 1723? Jurin’s _Acct._ 406 89 21·6 for 1723, p. 8 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 660 100 15·1 1724, p. 12 Dedham, near " " 339 106 31·3 Colchester Plymouth " " 188 32 17·2 Aynho, near 27 Sept. 1723 Rev. Mr Wasse, 133 25 18·8 Banbury to 29 Dec. 1724 rector, _Ibid._ for 1725, p. 55 Stratford on Avon " Dr Letherland, 562 89 15·8 _Ibid._ Bolton le Moors " Dr Dixon, _Ibid._ 341 64 18·8 Cobham " Sir Hans Sloane, 105 20 19·0 _Ibid._ Dover 29 Sept. 1725 Dr Lynch of 503 61 12·1 to 25 Dec. 1726 Canterbury, in Jurin’s _Acct._ for 1726, p. 17 Deal 25 Dec. 1725 " 362 33 9·1 to 29 Nov. 1726 Kemsey, " Dr Beard, in 73 15 20·5 near Jurin, _Ibid._ Worcester Uxbridge[992] 1727 Dr Thorold, in 140 51 36·4 Scheuchzer’s _Acct._ for 1727 and 1728 Hastings 1729-30 Dr Frewen, 705 97 13·7 _Phil. Trans._ XXXVII. 108

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]:

above Ages 0-1 -2 -3 -4 -5 -10 -15 -20 -25 -30 -40 -50 -60 -70 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._

All Dead of Year Burials Smallpox

1744 1345 167 1745 1463 141 1746 1712 128 1747 1200 71 1748 1286 167 1749 1132 192 1750 1038 64 1751 1241 109 1752 1187 147 1753 1105 70 ----- ---- 12709 1256 or 1 in 9·6

1754 1215 104 1755 1187 89 1756 1316 126 1757 1267 113 1758 1001 52 1759 1136 232 1760 1123 66 1761 903 6 1762 1305 274 1763 1160 123 ----- ---- 11613 1185 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._

Percentage Parish Cases Deaths 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 15·3 or 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._

Died by Year Baptised Buried 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._

Died by Year Baptised Buried 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 Under One to Two to Three to Four to Five to Above Age not ages One Two Three Four Five Six Six 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].

Smallpox in London in the middle of the 18th century.

There is hardly any epidemic malady in London of which so few particular records remain as of smallpox, except in the bills of mortality. The monthly notes in the _Gentleman’s Magazine_ from 1751 to 1755 by Dr Fothergill, who practised at that time in White Hart Court, Lombard Street (having afterwards removed westward to Harpur Street, Red Lion Square), contain the following references to it:

1751, May. Smallpox uncommonly mild in general, few dying of it in comparison of what happens in most years.

1751, December. Smallpox began to make their appearance more frequently than they had done of late, and became epidemical 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.

1752, January. A distinct benign kind of smallpox continued to be the epidemic of this month.... A few confluent cases, but rarely. February--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 fatality, of this distemper.

1752, April. Smallpox continued to be the principal epidemic, as in the preceding months; during which time it attacked most of those who had not hitherto had the distemper, and it is now spread into the suburbs and the neighbouring villages, but still in a favourable way in general. Some have the confluent, a few the bleeding kind, but these are not very common.

1752, June. Smallpox still continues, not many escaping who have not had it before.

1752, July. Smallpox inclined to become malignant, but the constitution on the whole remarkably mild. Children from one to three years old have, I believe, suffered more from the distemper during this constitution than those of any other ages; at least it has so fallen out under the writer’s observation.

1753, December. Smallpox of a bad type.

1754, August. Smallpox frequent in many parts of the City, and eastern suburbs especially. In general the kind was mild, distinct and favourable. Out of sixteen who had the disease in a certain district, of different ages, one only died. In some it was very virulent, with livid petechiae.

1754, December. Smallpox not unfrequent. Many had the worst kind seen for years.

1755, January. Smallpox more favourable.

Fothergill, who pointed out the defects of the London bills of mortality and made a serious attempt to get them reformed[1013], was disposed to take their figures of smallpox deaths as on the whole trustworthy: “The smallpox, of all diseases mentioned in the weekly bills, is perhaps the only one of which we have any tolerably exact account, it being a disease which the most ignorant cannot easily mistake for another.” Reserving this opinion for some critical remarks in the sequel, we may now resume the London statistics from the year last given.

_Smallpox Mortality in London, 1721-60._

Deaths Deaths from from Year smallpox all causes

1721 2,375 26,142 1722 2,167 25,750 1723 3,271 29,197 1724 1,227 25,952 1725 3,188 25,523 1726 1,569 29,647 1727 2,379 28,418 1728 2,105 27,810 1729 2,849 29,722 1730 1,914 26,761 1731 2,640 25,262 1732 1,197 23,358 1733 1,370 29,233 1734 2,688 26,062 1735 1,594 23,538 1736 3,014 27,581 1737 2,084 27,823 1738 1,590 25,825 1739 1,690 25,432 1740 2,725 30,811 1741 1,977 32,169 1742 1,429 27,483 1743 2,029 25,200 1744 1,633 20,606 1745 1,206 21,296 1746 3,236 28,157 1747 1,380 25,494 1748 1,789 23,069 1749 2,625 25,516 1750 1,229 23,727 1751 998 21,028 1752 3,538 20,485 1753 774 19,276 1754 2,359 22,696 1755 1,988 21,917 1756 1,608 20,872 1757 3,296 21,313 1758 1,273 17,576 1759 2,596 19,604 1760 2,181 19,830

The year 1752, to which Fothergill refers most fully in the notes cited, had the highest total of deaths from smallpox in the period 1721-60, namely, 3538, and was exceeded by only two years in the latter part of the century, 1772, with 3992 deaths and 1796 with 3548. Fothergill says twice that the disease in 1752 was on the whole mild, but so universal that not many escaped it who had not had it before; and that children from one to three years suffered most from it. As the year was not an unhealthy one in general, this epidemic of smallpox may be chosen to show its effect upon the weekly mortalities, of children in particular.

_London Weekly Mortalities: Smallpox Epidemic of 1752._

Under Two Five Convulsions Week All two to to Smallpox deaths Ending deaths years five ten deaths

March 3 438 162 54 19 64 113 10 441 165 40 16 63 116 17 477 177 56 15 76 110 24 456 161 61 19 87 111 31 471 169 62 8 96 117 April 7 500 185 58 14 87 129 14 431 144 52 27 76 99 21 397 145 37 18 77 106 28 458 161 47 25 94 98 May 5 421 133 52 17 81 85 12 414 140 62 24 93 101 19 461 235 52 20 119 104 26 456 157 66 24 120 92 June 2 452 159 65 28 125 98 9 415 172 51 17 113 87 16 421 165 56 20 120 98 23 380 160 57 15 102 82 30 353 127 52 19 92 74 July 7 390 142 68 19 107 87 14 339 142 44 12 79 98 21 351 144 38 23 73 97 28 368 168 53 14 92 93 Aug. 4 316 141 37 13 72 90 11 350 155 44 13 58 99 18 297 145 26 9 43 98 25 371 168 46 12 57 109

The weeks with highest smallpox mortalities have not always the highest deaths from all causes; but they correspond to a marked rise of the deaths from two to five years. If the table were continued to the end of the year, to show the decline of smallpox to a fourth or fifth of its highest weekly figures, the decline in the deaths from two to five, as well as from five to ten, would be seen to correspond more strikingly[1014]. The other notable suggestion of the figures is that the article “convulsions,” which included at that time nearly the whole of infantile diarrhoea, is not so high as usual when the article smallpox rises most. The highest weekly deaths from convulsions are in the first months of the year, when the smallpox epidemic was beginning, and in September and October, the season of infantile diarrhoea, when the smallpox epidemic was nearly spent.

The ages at which persons died in the several diseases were not given in the Bills, although they were recorded in the books of Parish Clerks’ Hall; so that the incidence of smallpox mortality upon infants and young children cannot be proved for the capital as it can for other great towns in the 18th century. Not only can it not be proved, but it was not the fact that the disease was so exclusively an affair of childhood as it was in the populous provincial centres. The London population was peculiar in receiving a constant recruit direct from the country. Many of them came from parishes where, as Lettsom says, “the smallpox seldom appears”; they must often have passed their childhood without meeting with it, to encounter the risk when they came to London[1015]. Many of the class of domestic servants were in that position; and it was especially for them that the London Smallpox Hospital existed, the admission to it being by subscribers’ letters, as in the voluntarily supported hospitals at present.

Its small accommodation was given up to some extent also to persons in exceptionally distressed circumstances[1016]. From its opening on 26 September, 1746, to 24 March, 1759, it had admitted 3946 cases, of which 1030 had died; these are stated in the annual reports to have been “mostly adults, in many cases admitted after great irregularities and when there was little hope of a cure”; so that the practice of this hospital alone may be taken as evidence of several hundreds of adult cases of smallpox in the year in London (the whole annual cases averaging perhaps twelve thousand).

The exact statistics which we shall come to in a later period of the century, for Manchester, Chester, Warrington and Carlisle, show that nearly all the deaths by smallpox were under five years; and it can hardly be doubted that the bulk of them in London also, with all its influx of country people, were at the same age-period. “Most born in London,” said Lettsom, “have smallpox before they are seven.” It is singular, therefore, that smallpox should have caused a much smaller proportion of the deaths from all causes in London than in the populous provincial cities. The annual average for London was one smallpox death to about ten or twelve other deaths; in other large towns it was one in about six or seven. Lettsom held that the proportion in London would have come out nearly the same if the classification of deaths in the London bills had been correct, the generic article “convulsions” having swallowed up, in his opinion, a large number of the smallpox deaths of infants. An assertion such as that is more easily made than refuted. Everyone agreed that there was no difficulty in recognising smallpox[1017]. Whoever had seen confluent smallpox all over an infant’s body was not likely to have set down its death under any other name, for there is hardly anything more distinctive or more loathsome. It is possible, however, that many infants with mild smallpox had died of complications, such as autumnal diarrhoea. Sydenham, indeed, says as much under the year 1667, blaming the nurses for killing the infants by trying to check the diarrhoea. The truly incredible sacrifice of infant life in London in the 17th and 18th centuries by summer diarrhoea, as shown in another chapter, may have caused a certain number of deaths of infants to be classed under “griping in the guts” in the earlier period, and under “convulsions” in the later, which were primarily cases of smallpox. But the true probability of the matter--and it is wholly for us a question of probability--is that London’s smaller ratio of smallpox deaths and greater ratio of infantile deaths from other causes, was not artificially made by transferring deaths from the one to the other, but was actual, owing to a really greater liability of the London infants to die of other more or less nondescript maladies before smallpox could catch them[1018].

The Epidemiology continued to the end of the 18th century.

The London bills, which are the only continuous series of figures, show the following annual mortalities by smallpox from 1761 to the end of the century:

_Smallpox Mortality in London, 1761-1800._

Smallpox All Year deaths deaths

1761 1,525 21,063 1762 2,743 26,326 1763 3,582 26,148 1764 2,382 23,202 1765 2,498 23,230 1766 2,334 23,911 1767 2,188 22,612 1768 3,028 23,639 1769 1,968 21,847 1770 1,986 22,434 1771 1,660 21,780 1772 3,992 26,053 1773 1,039 21,656 1774 2,479 20,884 1775 2,669 20,514 1776 1,728 19,048 1777 2,567 23,334 1778 1,425 20,399 1779 2,493 20,420 1780 871 20,517 1781 3,500 20,709 1782 636 17,918 1783 1,550 19,029 1784 1,759 17,828 1785 1,999 18,919 1786 1,210 20,454 1787 2,418 19,349 1788 1,101 19,697 1789 2,077 20,749 1790 1,617 18,038 1791 1,747 18,760 1792 1,568 20,213 1793 2,382 21,749 1794 1,913 19,241 1795 1,040 21,179 1796 3,548 19,288 1797 522 17,014 1798 2,237 18,155 1799 1,111 18,134 1800 2,409 23,068

The last twenty years of the century show a decrease in the annual averages of smallpox deaths, along with a decrease of deaths from all causes. The health of the capital had undoubtedly improved since the reign of George II., especially in the saving of infant life. But it is not worth while instituting a statistical comparison, for the reason that some large parishes, containing poor and unwholesome quarters, had become populous in the latter part of the century, but were not included in the bills, while some of the old parishes, including those of the City, were probably become less populous owing to the conversion of dwelling-houses into business premises of various kinds. The decrease of fever-deaths in the bills is closely parallel with the decrease of smallpox, and it is probable that both were real; but as there is an element of uncertainty in the data it would be unprofitable to abstract statistical ratios from them, or to aim at demonstrating numerically what can only be in a measure probable. Perhaps the safest generality from these London figures is that smallpox once more fluctuates a good deal from year to year, seldom, indeed, falling below a thousand deaths, but showing a considerable drop for several years after some greater epidemic, as in the earlier history. This becomes most obvious by exhibiting the mortality in a graphic tracing.

Manchester, which was a healthier place than the capital, having an excess of births over deaths, had a smallpox mortality for six successive years, 1769-1774, as follows, the population, exclusive of Salford, having been 22,481 by a careful survey in 1773[1019]:

_Smallpox Deaths in Manchester._

Year All deaths Smallpox deaths

1769 549 74 1770 689 41 1771 678 182 1772 608 66 1773 648 139 1774 635 87 ----- ---- 3,807 589

Between a seventh and a sixth part of all the deaths in Manchester (15·3 per cent.) were from smallpox. All but one were under the age of ten years:

All deaths Under One to Two to Three to Five to Ten to by smallpox One year Two Three Five Ten Twenty

589 140 216 110 93 29 1

Manchester was one of the towns that had smallpox continuously from year to year at this period. It had a rapidly growing population, and an excess of births over deaths which was in great part due to the very large number of new families settling in it. It was probably this rapid increase of children that explained the great height of the smallpox mortality in 1781, namely, 344, rising from three deaths in January and falling to thirteen in December, the maximum being in the third quarter of the year[1020].

Liverpool, like Manchester, had smallpox among its infants and children steadily from year to year, and a higher rate of fatality from that cause than Manchester. With a population half as great again as that of Manchester, namely, 34,407 in 1773, it had the following deaths from smallpox, according to the figures taken from the registers by Dobson and supplied to Haygarth[1021]:

_Smallpox Deaths in Liverpool._

Dead of Year Baptisms Burials smallpox

1772 1160 1085 219 1773 1192 1129 200 1774 1207 1420 243

The smallpox deaths were 1 in 5½ of all deaths. The figures also mean that nearly all the infants born in Liverpool, who survived the first months, must have gone through the smallpox.

Warrington, with a population (about 9000) one-fourth that of Liverpool, had a great periodic outbreak of smallpox in 1773, which caused about the same number of deaths that Liverpool had steadily in three successive years. The deaths were 207, with an incidence upon infants as remarkable as at Manchester. I reserve the figures for another section. Whether Warrington had much or any smallpox in the years between, it is known to have had fifty deaths in 1781, most of them in the first half of the year. Chester, in 1774, with a population half as great again as Warrington, namely, 14,713, had 1385 cases of smallpox, with 202 deaths, or 1 in 6·85, all the deaths being of children under five except 22, and those of children from five to ten. At the end of the epidemic a census showed that there were only 1060 persons in Chester who had not had smallpox. It was one of the healthier towns, which had a great smallpox mortality only in certain years; in 1772 it had 16 deaths, in 1773, only one death; the next great mortality after 1774 falling in 1777, when the deaths were 136, of which only 7 were in children above the age of seven years. In 1781 it had 7 deaths.

In the year 1781, when smallpox was so fatal to Manchester, Leeds also had an epidemic, 462 cases, with no fewer than 130 deaths, the population (in 1775) being 17,111, of whom only some seven hundred (or eleven hundred) at the end of the epidemic had not been through the natural smallpox.

At Carlisle, where the conditions of a greatly increased population (4158 in 1763 increased to 6299 in 1780) and weaving industries were the same as at Leeds, the smallpox deaths in a series of years were as follows[1022]:

_Deaths by Smallpox at Carlisle, 1779-87._

Under Over Five Five Total years Years

1779 90 } 1780 4 }136 7 1781 19 } 1782 30 } 1783 19 17 2 1784 10 9 1 1785 38 39 0 1786 -- -- -- 1787 30 28 2 --- --- -- 241 229 12

The smallpox deaths were 13·37 per cent, of the deaths from all causes. The deaths from all causes under five years were 44·13 per cent.

Whitehaven, which had, like Liverpool, a large part of its labouring population housed in cellars, suffered severely from smallpox in 1783: “incredible numbers,” says Heysham, of Carlisle, were attacked, of whom “scarcely one in three survived.” The annual reports of its dispensary, which begin from that year, show a small number of calls to smallpox cases in most years; but it must have happened there, as Clark found it in Newcastle, that medical aid was not often sought for the children of the poor in smallpox unless they were dying. Smallpox was perhaps not peculiar among infantile troubles in that respect; but it is remarkable that it should have fallen so little under the notice of practitioners considering how important its aggregate effects were on the death-rate. In 1753 the readers of the _Gentleman’s Magazine_ took some interest in the question whether smallpox required the aid of a physician or an apothecary, or whether a nurse were not sufficient: instances were adduced in support of the latter view, while the serious claims of smallpox to regular medical attendance were elaborately urged in a letter several columns long. At Newcastle, at all events, the prevalence and fatality of smallpox were actually unknown to Dr Clark, for all his zeal and statistical accuracy. Assuming from the experience of some other populous industrial towns, that it made a sixth part of the deaths from all causes, he estimated its annual mortality at 130.

Smallpox in Glasgow towards the end of the 18th century appears to have been more mortal to children than anywhere else in Britain. The figures are not known previous to 1783, from which year the laborious researches of Dr Robert Watt in the burial registers begin; but it is probable that the conditions were as favourable to smallpox at an earlier period[1023]. In the year 1755 its mortality is given thus: “buried, men 273, women 206, children 584, total 963[1024].”

The following table shows the Glasgow deaths from smallpox, and from all causes at all ages and at three age-periods under ten:

_Glasgow Mortality by Smallpox and all causes, 1783-1800._

Smallpox All deaths All deaths All deaths Year All deaths deaths under Two 2-5 5-10

1783 1413 155 479 174 66 1784 1623 425 671 161 45 1785 1552 218 576 126 42 1786 1622 348 706 179 56 1787 1802 410 746 205 65 1788 1982 399 770 221 68 1789 1753 366 794 188 76 1790 1866 336 903 247 86 1791 2146 607 984 320 63 1792 1848 202 664 184 54 1793 2045 389 807 239 80 1794 1445 235 553 144 62 1795 1901 402 761 225 62 1796 1369 177 562 181 54 1797 1662 354 586 241 57 1798 1603 309 642 181 41 1799 1906 370 783 244 78 1800 1550 257 545 148 53

Dividing the period into three of six years each, and abstracting the ratios, Watt got the following result[1025], by which it appears that smallpox made between a fifth and a sixth of the whole mortality, and presumably a full third of all the deaths under five years:

Ratio under Ratio of Ratio of five years, Six-years period All deaths fevers smallpox all deaths

1783 to 1788 9994 12·65 19·55 50·06 1789 to 1794 11103 8·43 18·22 53·28 1795 to 1800 9991 8·24 18·70 51·03

The Glasgow figures bear out the rule that the greater the mortality of children from all causes, the greater the mortality from smallpox. The ratio of infantile deaths (under two) was actually higher in Glasgow in the end of the 18th century than in London during the very worst period of its history, the time of excessive drunkenness in the second quarter of the 18th century: the London deaths under two years were 38·6, and from two to five 11·37 per cent. of the annual average deaths from 1728 to 1737, while the Glasgow maxima were 42·38 and 11·90.

The examples last given are all of crowded industrial towns, the sanitary condition of which has been referred to in the chapter on Typhus. The market towns and the villages doubtless had the same relatively favourable experiences of smallpox which have been shown for them in the first half of the 18th century. It happens that the figures for Boston, Lincolnshire, of which a twenty-years series has been given already, are complete to the end of the century.

_Smallpox Deaths in Boston, Lincolnshire, 1769-1800._

All Smallpox Year Births deaths deaths

1769 159 120 3 1770 140 166 78 1771 150 133 2 1772 138 130 6 1773 157 143 27 1774 160 112 -- 1775 162 186 55 1776 165 176 7 1777 165 131 6 1778 166 174 18 1779 173 195 3 1780 137 247[1026] -- 1781 136 193 19 1782 133 177 -- 1783 162 149 -- 1784 147 202 58 1785 168 124 4 1786 152 114 -- 1787 168 130 -- 1788 181 145 -- 1789 184 185 27 1790 204 126 -- 1791 218 93 2 1792 219 152 -- 1793 195 141 1 1794 197 148 -- 1795 217 161 1 1796 214 205 64 1797 240 166 -- 1798 227 112 -- 1799 229 133 -- 1800[1027] 225 147 1

The second division of the table covers the same years as the Glasgow table, but tells a very different tale. It shows a great excess of births over deaths, and smallpox coming at the same long and regular intervals as in the twenty-years period before 1769, but now causing only a fifteenth part of the whole annual average deaths, or about one-third as many of them as in Glasgow. Whether the other market towns and villages of England had improved equally cannot be proved, owing to the almost total absence of smallpox statistics from the country south of the Trent. It was partly an accident that the best statistics of smallpox all came from the northern half of the country, where population and industries were growing most; but it was in part also because there was more epidemic disease there than elsewhere in England.

Some particulars or generalities were recorded for the parishes of Scotland in the last ten years of the 18th century by parish ministers writing for the _Statistical Account_:

Some of the Highland parishes suffered greatly from time to time by epidemics of contagious fever and by smallpox. Kiltearn, in Eastern Ross, a parish in which “the greatest number of cottages are built of earth, and are usually razed to the ground once in five or seven years, when they are added to the dunghill,” was visited at intervals by infectious fever which spread from cottage to cottage, and by smallpox so disastrously in two successive years, 1777 and 1778, that above thirty children died in the first and no fewer than forty-seven in the second, owing, the minister thought, in part to improper management (_Statistical Account of Scotland_, I. 262). Something similar, although the numbers are not given, had happened in 1789 in the Western Ross parish of Applecross, which is now one vast deer-forest with two or three poor fishing hamlets. Of Kilmuir, in the extreme north-west of Skye, it is said, “In former times the smallpox prevailed to a very great extent, and sometimes almost depopulated the country.”

In the parish of Holywood, Dumfriesshire, the yearly average marriages were 5, the baptisms 16, and the burials 11; but in 1782, the burials rose to 20, “owing to an infectious fever in the west part of the parish” (said elsewhere to be “chiefly owing to poor living and bad accommodation during the winter season”); and in 1786 “the large number of deaths”--namely fourteen all told--“was owing to the ravages of the natural smallpox” (I. 22).

In Galston parish, Ayrshire, “smallpox makes frequent ravages.” In Eaglesham parish, near Glasgow, most of the infectious deaths are by fever, but smallpox also carries off great numbers (II. 118).

In the parish of Largs, Ayrshire, the number of deaths varied in different years “according as the smallpox or any species of dangerous fever prevailed”; in such cases the number of deaths were above forty, but in ordinary years between twenty and thirty, the mean annual average of births being about thirty. (II. 362.) But in Dunoon “we have commonly no sickness or fatal distemper except from old age and the complaints peculiar to children; and even these last are not in general fatal.” (II. 390.) In Forbes and Kearn, Aberdeenshire, “some children are lost by the smallpox, measles, and hooping-cough. But as the people in a great measure have got over their prejudices against inoculation, very few now die of the smallpox,” (IX. 193).

In Monquhitter, in the same county: “the chincough, measles and smallpox return periodically; but the virulence of these disorders is now greatly lessened by judicious management” (VI. 122). In Grange, Banffshire, “of late neither the smallpox nor any inflammatory disorders have been very prevalent or mortal; the complaints are principally nervous” (IX. 563). In Fyvie, Aberdeenshire, “there has been no prevalent distemper for some time except the putrid sore-throat” (IX. 461). But, in Dron, Perthshire, smallpox owing to the prejudice against inoculation, continues to carry off a great number of children; the hot regimen, and the keeping of the patients too long in their foul linen and clothes, are bad for the disease (IX. 468). In Fordyce, the ravages of the smallpox are very much abated by the practice of inoculation; the most prevalent distemper is fever (III. 48). In the sea-board parish of Rathen, smallpox occurred among the fishers (VI. 16). The fullest account is under the head of Thurso (XX. 502), supplied by John Williamson, surgeon: In December, 1796, the confluent smallpox became highly epidemic and fatal in the county of Caithness. In Thurso, more particularly, the epidemic was almost general, “and by my calculation one in four fell a victim.” The mortality became so general that a general inoculation was proposed, and more or less carried out in most parishes except Latheron.

The most exact record is for the parish of Torthorwald Dumfriesshire; in two ten-year periods and one of seven years the mortality was as follows (II. 12):

Infants under All one, cause deaths Smallpox Measles Chincough Fevers unknown

1764-73 100 2 1 1 10 9 1774-83 100 5 0 3 7 14 1784-90 80 7 0 0 8 6

Ages at deaths from all diseases.

All Under One to Two to Five to Ten to Forty to Above deaths One Two Five Ten Forty Seventy Seventy

1764-73 100 9 2 1 2 19 28 39 1774-83 100 16 7 2 2 8 34 31 1784-90 80 8 2 1 4 12 23 30

Twelve of the fourteen smallpox deaths occurred after the introduction of inoculation in 1776, and were ascribed by the parish minister to that source. Again, in the parish of Whittinghame, among the Lammermuir hills, “it is not remembered that this parish has ever been visited with any epidemical distemper”--its vital statistics for ten years, 1781-90, being (II. 352):

Marriages Baptisms Burials

54 189 81

On the other hand another Berwickshire parish, Dunse, much more populous and occupied with weaving, had an epidemic of smallpox in 1781, which brought the annual deaths up to 85, the births for the year being 54.

Authentic accounts of smallpox in Ireland in the 18th century are not easy to find, but it is clear from such notices of it as do exist that it could be widely prevalent and malignant in type. Rogers gives it a bad name in Cork in the first third of the century. During the great famine and fever of 1740-41 the deaths by smallpox are said to have been twice or thrice as many in Dublin as the deaths by fever[1028]. The smallpox mortality, being chiefly of infants and children, attracted no special notice, just as the smallpox deaths in the famine of 1817-18, although more than those by fever, are all but unmentioned in the various accounts for those years. Rutty, of Dublin, under the year 1745, says: “The smallpox was brought to us by a conflux of beggars from the north, occasioned by the late scarcity there; whose children, full of the smallpox, were frequently exposed in our streets.” His next mention of smallpox is in the winter of 1757-58, when the disease “kept pace in malignity,” with the prevalent spotted or typhus fever. Amidst numerous entries of fevers of all kinds (typhus, agues, miliary fevers), as well as scarlatina and angina, these are the only two references to smallpox in Rutty’s Dublin annals from 1726 to 1766. The annals kept by Sims of Tyrone overlap those of Rutty by a few years; and his first reference to smallpox is under the year 1766, which was a year of almost universal smallpox in England. Towards the close of 1766 and in the spring of 1767 the smallpox caused unheard-of havoc, scarcely one-half of all that were attacked escaping death. The disease had appeared the year before along the eastern coast, and proceeded slowly westward with so even a pace that a curious person might with ease have computed the rate of its progress. It had not visited the country for some years, and was not seen again until 1770, when it was less severe than in 1766-7[1029].

Little is heard of smallpox in the army and navy in the 18th century. Pringle says, “We have never known it of any consequence in the field.” On board ships of war it is mentioned occasionally, but very rarely in comparison with fever. Lind says that it prevailed in 1758 in the ‘Royal George,’ among a ship’s company of 880 men: “it destroyed four or five persons and left nearly a hundred unattacked[1030].” Trotter has an occasional reference to it in his naval annals from 1794 to 1797[1031]. One reason, and doubtless the chief reason, for its rarity in the services was that comparatively few escaped having it in childhood. The surgeon to the Cheshire Militia told Haygarth in 1781 that he found the whole regiment of six hundred to have had smallpox, except thirty[1032]. It does not appear that so great a ratio of sailors or marines were protected by a previous attack; for Trotter counted 70 in a 74-gun ship of war who had not had it, and based a calculation thereon that there were about 6000 men in the navy in the like case. It was comparatively rare, also, in the gaols, doubtless for the same reason that has been suggested for the army and navy. Howard mentions it in only three of the prisons visited by him[1033].

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 2_d._ a day. It is then bleached, which is done by men, who earn 10_s._ a week; after bleaching, it is wound by women, whose earnings are 2_s._ 6_d._ a week; next it is warped by men, who earn 7_s._ a week; and then starched, the earnings 10_s._ 6_d._ a week. The last operation is the weaving in which the men earn 9_s._, the women 5_s._, the boys 3_s._ 6_d._ a week. The spinners (women) in the sacking branch earn 6_s._ a week. Then it is wound on bobbins by women and children, whose earnings are 4_d._ 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._

Warrington. Chester. Warrington Pop. 9,501 Pop. 14,173 raised to the Ages at death in 1781 in 1774 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. Deaths. Warrington, Chester, 1773 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 Chester (pop. in 1781, 9501) (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.

Cowpox.

Much has been said, in previous sections of this chapter, as to the efforts of inoculators to reduce the effects of inoculated virus “to as low a degree as we could wish.” What kind of matter do you use? one inoculator would ask of another. The comparative trials of Watson had shown that serous or watery matter from an unripe pustule of smallpox, preferably from the unripe pustule of a previous inoculation on the arm, was most “successful,” the success being measured by the slightness of the effect produced at the time. The comparative trials of Mudge had confirmed that, but had gone a little farther in showing that these slight effects of crude or unripe matter left the constitution still open to the same effects by the same means, or to more severe effects by more severe means. What kind of matter to use was, accordingly, still an open question, which offered some scope for originality and ingenuity. Among other sources of crude or watery matter with bland properties was the glassy or watery variety of eruption called swinepox, which, like its congener chickenpox, was peculiar to man; and among those who tried that source of non-purulent matter for inoculation was Jenner, of Berkeley. It was in 1789 that he inoculated his child, aged eighteen months, with matter from the so-called swinepox of man. There was still another pox bearing the name of a brute animal, which was, however, a true affection of brutes--the cowpox or pap-pox. A farmer at Yetminster, Dorset, named Benjamin Jesty, had used matter from that source for the inoculation of his wife and two young children in 1774, with the result that the arm of the former was much inflamed and had to be treated by a surgeon. There seemed to be no good reason for preferring matter of such dangerous tendency, and the experiment was not repeated. A few years after, an apothecary of Lyme, in Dorset, is said to have heard of another case of the domestic use of cowpox matter for inoculation by the mistress of a farm house, and to have pressed this fact upon the attention of Sir George Baker; who, although a supporter of the mild or Suttonian inoculations with crude lymph, and by his own avowal a friend of experiments, did not favour the trial of matter from the pap-pox of cows, probably for the reason that he should have been departing from the ground-principle of inoculating for the smallpox if he were to go outside the class of variolous disease for his matter. The true virtuoso, however, has no antecedent objection to experimenting with anything. Sometime after Jenner had used the swinepox matter, he began to talk among his medical neighbours of using cowpox matter. But it was known that cowpox matter had properties and effects of its own, and that it would be a radical innovation to use it, a departure _toto coelo_ from every modification hitherto tried in the inoculation procedure. Although it was also a pox by name, and although cowpox to the apprehension of a man of words or notions might seem to be in the same class as swinepox, glasspox, hornpox, waterpox or chickenpox, yet those who had ever seen it on the chapped hands of milkers would hardly admit that matter from such a source could serve for inoculation purposes unless upon wholly independent and original proof of efficacy. Jenner’s colleagues are reported to have denied that cowpoxed milkers escaped natural smallpox any more than their fellows[1071]. About the year 1794 Jenner began to press the subject upon the attention of his friends. His clerical neighbour, Worthington, mentioned it in one of his letters to Haygarth, of Chester, who replied, on 15 April, 1794:

“Your account of the cowpox is indeed very marvellous, being so strange a history, and so contradictory to all past observations on this subject, very clear and full evidence will be required to render it credible. You say that this whole rare phenomenon is soon to be published, but do not mention whether by yourself or some other medical friend. In either case I trust that no reliance will be placed upon vulgar stories. The author should admit nothing but what he has proved by his own personal observation, both in the brute and human species. It would be useless to specify the doubts that must be satisfied upon this subject before rational belief can be obtained. If a physician should adopt such a doctrine, and much more if he should publish it upon inadequate evidence, his character would materially suffer in the public opinion of his knowledge and discernment[1072].”

It is clear that Haygarth, who was well acquainted with epidemic smallpox and with inoculation, saw in this Gloucestershire idea something quite new as well as antecedently improbable. What the real novelty was will appear from the next historical reference to cowpox in an original work upon Morbid Poisons by Joseph Adams, a writer of the Hunterian school. All that Adams knew of the nature of cowpox previous to March, 1795, came from Cline, surgeon to St Thomas’s Hospital, who had been a fellow student of Jenner’s five and twenty years before, and kept up some correspondence with him. Adams is writing on the peculiar danger of ulceration and sloughing, or phagedaena, from transferring animal matters from one body to another, his last illustration having been the notorious phagedaenic ulceration of the gums, with rashes of the skin and constitutional effects so severe as to be fatal, which followed the transplantation of fresh teeth from one person to another in a number of cases about the year 1790 and led to the speedy abandonment of that unnatural practice[1073]. He proceeds to say, “Thus far we have only traced the poisonous effects of matter applied from one animal to another of the same class,” and then he brings in the illustration of cowpox to finish the chapter:

“The cowpox is a disease well known to the dairy-farmers in Gloucestershire. The only appearance on the animal is a phagedaenic ulcer on the teat, with apparent inflammation. When communicated to the human subject, it produces, besides ulceration on the hand, a considerable tumour of the arm, with symptomatic fever, both which gradually subside. What is still more extraordinary, as far as facts have been hitherto ascertained, the person who has been infected is rendered insensible to the variolous poison[1074].”

Jenner’s own essay on the cowpox, when it appeared at length in 1798, confirmed these statements as to the phagedaenic or corroding ulcerous character of the milkers’ sores, in his brief accounts of several cases, of which it will suffice to mention these two: William Stinchcomb, farm servant, had his left hand severely affected with several corroding ulcers, and a tumour of considerable size appeared in the axilla of that side; his right hand had only one small sore. A poor girl, unnamed, “produced an ulceration on her lip by frequently holding her finger to her mouth to cool the raging of a cowpox sore by blowing upon it[1075].” Inquiries made by Dr George Pearson in various other dairy counties of England brought out the same character of cowpox in milkers: the painful sores might be as large as a sixpenny piece, and might last a month or two, causing the milker to give up his work[1076].

As to the pap-pox itself, or cowpox in the cow, the most circumstantial account was obtained, a few months after Jenner’s first essay, by interrogating a veterinary surgeon or cow-doctor, one Clayton, who attended at most of the farms within ten miles of Gloucester:

“That the chief diseases of the cow are the lough, swellings of the udder, and cowpox; that the two former are the most common, the latter being rarely seen except in spring and summer.

That cowpox begins with white specks upon the cow’s teats, which, in process of time, ulcerate; and, if not stopped, extend over the whole surface of the teats, giving the cow excruciating pain.

That, if this disease is suffered to continue for some time, it degenerates into ulcers, exuding a malignant and highly corrosive matter; but this generally arises from neglect in the incipient stage of the disease, or from some other cause he cannot explain.

That this disease may arise from any cause irritating or excoriating the teats; but that the teats are often chapped without the cowpox succeeding. In chaps of the teats, they generally swell; but in the cowpox, the teats seldom swell at all, but are gradually destroyed by ulceration.

That this disease first breaks out upon one cow, and is communicated by the milker to the whole herd; but if one person was confined to strip the cow having this disease, it would go no farther.

That the cowpox is a local disease, and is invariably cured by local remedies.

That he never knew this disease extend itself in the highest degree to the udder, unless mortification had ensued; and that he can at all times cure the cowpox in eight or nine days[1077].”

No account of cowpox in the cow has ever been given which differs materially from that of this experienced Gloucester cow-doctor in 1798[1078]. Cowpox is not only a local disease, but it is peculiar to certain individuals of the species, namely cows in milk; in them it occurs on the teats, so that it was correctly known in Norfolk by the name of pap-pox. The common observation has been that one cow starts it, and that an infection is rubbed into the teats of others by the fingers of the milkers. The cow which develops this ulceration of the paps is usually either a heifer in her first milk, from which the calf has been taken away, or a cow in milk which has been bought in a market, with the udder “overstocked” or left distended for appearance sake, but as yet with no blemish of the paps. The cause of cowpox is the rough handling of a highly sensitive part, which was originally adapted only for the lips and tongue of the calf. Ceely, a correct observer in the Vale of Aylesbury, uses no exaggerated phrase when he speaks of “the merciless manipulations of the milkers.” Men milkers are well known to lack the delicate tact of women; and cowpox has been most common in the great dairying districts where men-milkers are employed. But in some animals cowpox may be produced even under gentler handling or with slighter provocation, of which I give a recent case from my notebook, taken during a visit to the country:

27 April, 1891. Case of cowpox. A maid in the service of Mr J. R. has on the ulnar side of the fore finger of the right hand, over the joint of the first and second phalanges, a collapsed bleb the size of a sixpenny piece, pearly white round the margin, bluish towards the centre, which is brown. The forefinger, as well as the wrist and hand generally, bears traces of recent inflammation, and was said to have been greatly swollen and painful, the pain extending up the arm. There is a symmetrical rash of bright red papules on both arms as high as the elbows, more copious and bright on the right arm but abundant on the left also. The papules are elevated and pointed, with a small zone of bright redness of the skin round the base of each. The history is as follows: A cow was bought four or five weeks ago to supplement the supply of milk from the three ordinarily kept. The new comer proved “tough” to milk, so that the maid was obliged, contrary to usual practice, to take the paps in the cleft of the fore and middle fingers; under this mode of “stripping,” the animal would hardly stand quiet to be milked. After a time it was found that one of the paps had a black crust upon it, which might have covered originally a chap of the skin. The crust would have been displaced in the milking, and would have grown again; the sore beneath soon healed. Only one pap was affected. None of the other cows was infected. The “tough” cow was at length sold as an unsatisfactory milker, and had been sent to a distance on the morning of the day on which these notes were made. The maid’s finger began to be affected after two or three weeks of milking the cow, the beginning of the large and tumid bluish-white vaccine vesicle having been like a small wart.

Jenner’s opinion that cowpox was a specific disease “coeval with the brute creation,” and that it had been the parent of the great historical smallpox of mankind, is not now received as correct. His other opinion, that cowpox was derived from the hocks of horses affected with “grease,” which held a central place in his original essay, especially in connexion with his doctrine of “true” and “spurious” cowpox, was rejected by most of his contemporaries, and is perhaps unsupported by anyone at the present time[1079].

In the title-page of his first essay, Dr Jenner called this singular malady of the cow’s paps by a new name--_variolae vaccinae_, or smallpox of the cow. Pearson, the earliest and most ardent of Jenner’s original supporters, and for several years thereafter a convinced vaccinist, at once took exception to the name _variolae vaccinae_ “for the sake of precision of language and justness in thinking.” It is a palpable catachresis, says he, to designate what is called the cowpox by the denomination variolae vaccinae, because the cowpox is a specifically different distemper from the smallpox in essential particulars, namely, in the nature of its morbific poison and in its symptoms[1080].

That the term _variolae vaccinae_ in Jenner’s title-page is used tropically can hardly be doubted; but it is not so easy to say which of the great classical tropes it is. It may be objected that “catachresis” is too general for the misuse of a word when that word is a scientific one and occurs in the leading title of a scientific book. Here we have the somewhat specific and purposeful use of a word in an unwonted sense, which, if it fall under any of the scholastic figures of speech, ought to be a figure more specifically defined than mere catachresis. In a matter so important as this one should find the exact figure if possible; but at the outset a difficulty arises, namely whether we should look for it in the usage of the rhetors, as Isocrates teaches, or in the usage of the logicians, as Aristotle lays down the definitions of tropes. If among the former class, the nearest is perhaps the hypocorisma, or attractive, agreeable name for something that is not so nice in itself. If among the latter, we shall hardly find a better than the metalepsis, which is a change more of mood than of meaning, namely the transition without proof from a supposition to an assertion. But in truth no single figure of the ancient teachers suits this modern instance. We require at least two. Metalepsis carries us so far, but synecdoche must supplement it. The term _variolae vaccinae_ is a synecdoche in that it names the cause from the effect; it is a metalepsis in that it passes abruptly from the hypothetical mood to the categorical; and in respect that it does both at a stroke it is probably unique, and without precedent among the examples known to the ancients. Or again, leaving the graver figures, and translating the Latin name of Jenner’s title-page, one may try the figurative conversion of cowpox into smallpox by the standard of pure and legitimate paronomasia, of which there is a familiar English example in the conversion of a plant into an animal by the verbal play of horse-chestnut and chestnut horse in the minor premiss.

Some in more recent times, mistaking the figurative or rhetorical intention of Jenner, have understood his Latin name of cowpox as if there really were a smallpox of the cow (although not of the bull, nor of the steer, the maiden heifer or the calf of either sex). Not being able to find a smallpox of the cow in the natural way, they have thought to satisfy the legitimate requirements of proof by manufacturing it. Certain Germans of the Lower Rhine, where the cows ordinarily wear blankets, have wrapped the blankets taken from smallpox beds round the bodies of cows, after clipping the hair close; nothing was found to ensue in these interesting experiments except an occasional pimple which had probably been caused by the shears in the preliminary clipping. Others in England, France, America and India, have succeeded in raising a smallpox pustule at the point of puncture in the epidermis of the cow or in the more delicate transitional epithelium, the matter from which has produced smallpox in its turn[1081]. But these are academic exercises. The natural cowpox of the cow has been likened by none to the natural smallpox of man in a sustained comparison of all the anatomical and epidemiological particulars of each; nor, I am persuaded, will anyone ever attempt to draw out such a comparison. _Variolae vaccinae_ as a name for cowpox was a figure of speech, and it is to misunderstand its original use to treat it as anything else.

The proof that cowpox had some power over smallpox consisted in trying to inoculate with the latter those who had been previously inoculated with the former. The accepted mode of testing the power of inoculated smallpox itself was to inoculate it again; at first the test for cowpox was to inoculate with smallpox, but after a few years the testing inoculation was done with cowpox itself. The effects of Suttonian inoculation with smallpox, as we have seen, were nearly always slight, and sometimes invisible (as in Watson’s practice at the Foundling Hospital). A previous inoculation with cowpox made them slighter still; but even with cowpox in the system, the pustules of smallpox rose where the matter had been inserted on the arm. It may be thought that there were only fine shades of difference between the effects of inoculation after cowpoxing and the effects of the same in a virgin soil; but some difference must have been perceived, for it was upon that, and upon nothing else, that the authority in favour of cowpox as a substitute for smallpox in inoculation was promptly established. The relationship between cowpox and smallpox was admitted by all to be in the nature of things “extraordinary,” as Jenner said, or a mystery, as others said; but as an empirical fact many believed it to be true, because the cowpoxed had less to show for the effects of inoculation with smallpox than if they had not been cowpoxed. Jenner himself is known to have made only two variolous tests. He used crude or watery matter from the local pustule of inoculated smallpox, and advised all his readers to do the same. In one of his two trials, a child Mary James had nearly the same effects from inoculation after cowpox that her mother and another child had from it without having been cowpoxed, namely the pustule or confluent group of pustules at the place of puncture, and the eruptive fever at the ninth day[1082].

In the earliest tests made independently of Jenner, five at Stonehouse[1083], near Stroud, and five at Stroud[1084], in the first months of 1799, the cowpoxed received smallpox afterwards by inoculation “in the usual slight manner.” In the practice at the Smallpox and Inoculation Hospital, London, in the spring and summer of 1799, many of the cowpoxed took smallpox by contagion from the atmosphere of the hospital, so that Woodville, after a period of perplexity, at length concluded that cowpox, while it was still active upon the arm, did not shut out the action of the smallpox virus in the constitution[1085].

The antecedent objections to cowpox, arising out of its non-variolous nature, were met by appealing to the results of experiments. The authority in favour of cowpox was speedily established on that ground, and has been continuous to the present time. The experimenters had to decide very nice points both in the way of observation and of reasoning. They had to appraise the margin of difference between the effects of Suttonian inoculation where cowpox had preceded and where it had not preceded. They had to allow for the first virus causing a swelling in the absorbent glands, which would obstruct the entrance of the second testing virus into the blood. They had to average the varying effects of Suttonian inoculation for its own sake, and the equally varying effects of it as the variolous test, and to find a broad difference between the two averages. Having decided that preceding cowpox infection did make a real and appreciable difference to the number of pustules resulting, at the spot or elsewhere, from the insertion of inoculated smallpox matter, or to the amount of fever, they had next to consider whether that degree of resistance by a cowpoxed person to inoculation were a good measure of his power to resist contagion reaching his vitals in the natural way. Their diligence and acumen may or may not have been equal to these things--it was a slack tide in medical science. Also they received little or no help from Dr Jenner himself, whose inventive genius was of the kind that is apt to leave the practical value, and even the theoretical probability, of the project to be tried by others. The inventor made interest with great personages--with the king, the duke of York, and the aristocracy of his county. His priority, and the merits of his project, were referred in 1802 to a Committee of the House of Commons, with Admiral Berkeley as chairman, which entered on its labours with a strong recommendation from the king, endorsed by Addington, the prime minister. They decided in favour of Dr Jenner’s claim for remuneration on all the issues, and on 2 June, 1802, the Committee of the whole House unanimously voted: “That it is the opinion of the Committee that a sum not exceeding £10,000 be granted to his Majesty to be paid as a remuneration to Dr Edward Jenner for promulgating the discovery of the Vaccine Inoculation, by which mode that dreadful malady the smallpox was prevented[1086].” On 29 July, 1807, a farther sum of £20,000 was voted to him; and on 8 June, 1808, a National Vaccine Establishment was appointed, at an annual cost of about £5,000.

Chronology of epidemics resumed from 1801.

In resuming the history of smallpox from the beginning of the present century, we come first to the deaths in the London Bills of Mortality, which are the only continuous figures. The bills of Parish Clerks’ Hall had failed, before they ceased, to include more than two-thirds, perhaps not much more than a half, of all the deaths in the capital. The great parishes of St Pancras and St Marylebone, which returned a somewhat excessive share of the deaths both from smallpox and from fever in the first two or three years of the Registration Act (1837-39), as well as the parishes of Chelsea and Kensington, were never included within the Bills; also much of the suburban extension on the other sides of London was never taken in. Meanwhile the area of the old Bills had actually become less populous owing to the displacement of dwelling houses by warehouses, workshops, counting houses, and the like, in the City, the Liberties and in certain out-parishes such as those bordering the Thames at the east end.

Still, the bills of mortality may be taken as showing on the whole fairly the proportion of smallpox deaths to other deaths, and the years of its greater outbursts.

_Smallpox in the London Bills of Mortality, 1801-37._

Smallpox All deaths deaths

1801 1461 19,374 1802 1579 19,379 1803 1202 19,582 1804 622 17,034 1805 1685 17,565 1806 1158 17,938 1807 1297 18,334 1808 1169 19,954 1809 1163 16,680 1810 1198 19,983 1811 751 17,043 1812 1287 18,295 1813 898 17,322 1814 638 19,283 1815 725 19,560 1816 653 20,316 1817 1051 19,968 1818 421 19,705 1819 712 19,928 1820 722 19,348 1821 508 18,451 1822 604 18,865 1823 774 20,587 1824 725 20,237 1825 1299 21,026 1826 503 20,758 1827 616 22,292 1828 598 21,709 1829 736 23,524 1830 627 21,645 1831 563 25,337 1832 771 28,606 1833 574 26,577 1834 334 21,679 1835 863 21,415 1836 536 18,229 1837 217 21,063

The 18th century had ended with a severe epidemic of smallpox (2409 deaths) in the year 1800; and excepting in the year 1804, the deaths kept at a somewhat high level for ten years longer. The rise at the end of the last century corresponded to a time of distress and a severe epidemic of typhus fever. The fever declined after 1803, and remained for a dozen years at so low a level that Bateman, in his quarterly reports on the practice of the Carey Street Dispensary, expresses surprise that there should have been so little of it. The same writer, however, has occasion to remark upon the fatality of smallpox; twice he mentions large mortalities from it in courts adjoining Shoe Lane[1087]. According to the figures, also, smallpox declined less than fever. This means that, in the same circumstances, adult lives fared better than infancy and childhood. But, on the whole, smallpox shared with fever the advantageous conditions for health which obtained in all parts of the kingdom (in Ireland as well as in Britain) from the decline of the epidemics of 1799-1803 until the rise of the next epidemics in 1816-19. This period of comparative freedom from smallpox and fever corresponded to the second period of the great French War from its resumption after the failure of the Peace of Amiens until its termination with the Peace of Paris. It may seem surprising that this should have been a time of comparatively good public health in Great Britain and Ireland, inasmuch as it was a time of dear food and heavy taxes. The amount of typhus or relapsing fever is the best test; and those diseases, by all accounts, were at a lower level in all parts of the United Kingdom from 1804 to 1817 than they had been for many years before or than they were for many years after. Again, if precedents count for anything, the same kind of lull in smallpox and fever together is shown in the London bills during the war of the Allies against Louis XIV., and during the Seven Years War.

In Glasgow the decline of smallpox deaths for a few years in the 19th century was perhaps more marked than elsewhere because it was a decline from an excessively high level in the end of the 18th century.

_Glasgow Mortalities, 1801-12._

Smallpox Measles All Year deaths deaths deaths

1801 245 8 1434 1802 156 168 1770 1803 194 45 1860 1804 213 52 1670 1805 56 90 1671 1806 28 56 1629 1807 97 16 1806 1808 51 787 2623 1809 159 44 2124 1810 28 19 2111 1811 109 267 2342 1812 78 304 2348

Here it is not until 1805 that a marked fall in the smallpox deaths takes place. In Norwich there was a clear interval from the last severe period in the end of the 18th century, until the year 1805, when smallpox, “after being for a time almost extinct,” became prevalent again. At the Whitehaven Dispensary, the contrast between the last years of the 18th century and first years of the 19th is not striking[1088]:

_Smallpox at Whitehaven Dispensary._

Cases Deaths

1795 8 0 1796 41 5 1797 (no table) 1798 51 3 1799 7 1 1800 120 11 1801 9 3 1802 (no table) 1803 67 16 1804 1 0

Carlisle, which used to share in smallpox as much as Whitehaven, seems to have been almost wholly free from it in the first twelve years of the century: at least Dr Heysham, who was no longer statistical, “had reason to believe” that no person died there of smallpox from the autumn of 1800 (when cowpox inoculation was introduced) until November, 1812[1089].

The Newcastle Dispensary, like that of Whitehaven, treated a small fraction of all the cases of smallpox in the town; but it continued to have a fair average of cases and deaths after the century was turned:

_Smallpox cases attended from Newcastle Dispensary._

Cases Deaths

1795 7 1 1796 19 3 1797 12 0 1798 15 3 1799 -- -- 1800 -- -- 1801 14 4 1802 -- -- 1803 7 4 1804 0 0 1805 7 0 1806 16 6

Most places continued to have their periodical epidemics of smallpox as before, although both measles and scarlatina were becoming more and more its rivals. Boston, Lincolnshire, had its sexennial epidemic in 1802 with thirty-three deaths. Besides the year 1805, there were two periods in which smallpox was somewhat general, 1807-9 and 1811-13. At Norwich from 1807 to the end of 1809 the bills of mortality showed 203 deaths from smallpox[1090]. In 1808 we happen to hear of it also at Sherborne, in Dorset, at Ringwood, in Hampshire, at Cheltenham, at Cambridge and at Edinburgh, although the great epidemic malady of children in that year was measles[1091]. Lettsom wrote on 25 January, 1808: “The smallpox (infanticides) and measles have been prevalent and fatal. The coffins for the parish poor in England for the smallpox deaths alone have cost £10,000[1092].”

In 1811 it began to be somewhat general again, and rose in London to a considerable epidemic in 1812, the deaths in summer rising to sixty in a week[1093]. A village epidemic of 46 cases and 7 deaths is reported from North Queensferry, near Edinburgh, from 14 December, 1811 to 7 March, 1812[1094]. At Norwich from 10 February to 3 September, 1813, there were 65 deaths[1095]. The rise from 1811 to 1813 coincided with an increase of fever, the winter of 1811-12 having been a time of dearth and depressed trade, especially in the manufacturing districts. After that came a notable lull both in fever and smallpox, which was at length broken by the epidemics of each in 1817 in Ireland, Scotland and England, coincidently with the depression of trade and dislocation of commerce that began everywhere as soon as the great war was over.

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._

Under Total 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]:

Deaths from Deaths from 1819 smallpox 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.

Extent of Inoculation with Cowpox or Smallpox, 1801-1825.

Twenty-five years had now passed since cowpox became the rival or substitute of the old matter of inoculation. The history at this point requires some notice of the extent to which each of those methods was practised. Professional opinion, or that part of it which found expression, was for the most part in favour of cowpox. The Smallpox and Inoculation Hospital of London took the lead, under Woodville, in substituting cowpox for smallpox, and other public institutions, such as the Newcastle and Whitehaven Dispensaries, quickly followed. The new mode was practised upon larger numbers than the old. At the Newcastle Dispensary the inoculations of smallpox from 1786 to 1801 had been 3268; the inoculations of cowpox from 1801 to 1825 were 20,264. At the Whitehaven Dispensary 173 children were inoculated with smallpox in 1796, the total inoculations before that having been 906. To the end of 1803 the total vaccinations were 490, of which many were done during the severe outbreak of smallpox in 1803.

In Glasgow, where the old inoculation was either little practised or of little use, the Jennerian mode was received with favour, and was offered to the children of the working classes gratuitously at the Hall of the Faculty of Physicians and Surgeons. From the 15th of May, 1801, to the 31st of December, 1811, these public vaccinations numbered 14,500, an average of about 1400 in the year. In the next seven years they declined as follows:

1812 950 1813 1162 1814 875 1815 926 1816 980 1817 820 1818 650

On the revival of smallpox the Glasgow Cowpock Institution was opened on 28 August, 1818, and vaccinated 146 to the 1st of January, 1819. The smaller demand for even gratuitous vaccination of infants after 1812 was owing to the very small amount of smallpox in Glasgow in those years; in the six years, 1813-19, there were said (by Cleland) to have been only 236 deaths from smallpox in a total of 22,060 deaths from all causes, or 1·07 per cent. of all deaths[1115]. Not more than a fourth part of all the infants born in Glasgow had been vaccinated in the years 1812 to 1818, and that was the time when smallpox was at its lowest point among the infantile causes of death. In some of those years when smallpox was in abeyance measles was most destructive. It was currently said in Glasgow that vaccination, if it discouraged smallpox, predisposed to measles, an opinion of the populace which Malthus shared from the _à priori_ point of view. But in a survey of the individual cases in their practice the Glasgow doctors did not find that those were the relevant circumstances, whatever the truly relevant things may have been. Thus, Dr Robert Watt, a good observer and cautious reasoner, who became president of the Glasgow faculty, wrote: “The only family within my knowledge where three died of the measles in 1808 was one where none of the children had been either vaccinated or had had the smallpox. I met with another family where two died in the same circumstances”--that is to say, five children, in two families, escaped smallpox to die of measles, no artificial interference having been attempted[1116].

Manchester was another populous district where vaccination had been freely offered to the poorer classes. Roberton, writing in 1827, says that it had been on the decline for several years, and gives the following figures for the earlier period, May, 1815, to May, 1823[1117]: At the Manchester Lying-in Charity the annual average of deliveries was 2667, while the number of infants brought back for vaccination averaged 1392 in a year. During the same eight years public vaccinations at the Manchester Infirmary averaged 1700 annually. Great numbers of infants were said, also, to have been vaccinated gratuitously by druggists. The decline in the number of vaccinations, which had perhaps begun some time before (as at Glasgow), was shown conclusively by the returns for the two years May, 1824--May, 1826. The births at the Lying-in Charity averaged 3285 per annum; but the vaccinations in the infants brought back to the charity, together with those brought to the Manchester Infirmary, averaged only 1309 per annum.

Newcastle, Glasgow and Manchester were probably favourable instances of the extent of public vaccinations in the first quarter of the century. In London the proportion of vaccinations to births is known to have been smaller, although there was more money going and at one time four public charities--the Vaccine Pock Institution, the Royal Jennerian Society, Walker’s offshoot from the latter, and the Inoculation Hospital. The following were the vaccinations at the Inoculation Hospital in four periods of five years each from 1806[1118]:

1806-10 7,004 1811-15 9,339 1816-20 13,348 1821-25 16,666 ------ 46,357

Annual average 2317.

At Norwich, Dr Rigby succeeded in 1812 in persuading the Board of Guardians to offer half-a-crown premium to parents for each child brought to be vaccinated. The premiums paid were as follows:

1812 (12 Aug.-31 Dec.) 1066 1813 511 1814 47 1815 11 1816 348 1817 49 1818 64

--the annual births being from a thousand to twelve hundred[1119].

At the Canterbury Hospital the applications for free vaccinations fluctuated as follows:

1818 52 1819 249 1820 263 1821 47 1822 35 1823 50 1824 (Jan.-July) 588

The sudden rise in 1819-20 and again in 1824 was owing to smallpox being epidemic in the city. During the severe epidemic of 1824 there were 250 vaccinations at the Dispensary, besides the 588 at the hospital[1120]. At Kendal the following is the Dispensary record of vaccinations for three years, the annual average of births being 390[1121]:

1819 221 1820 102 1821 73

These are examples of the spasmodic demand for vaccination in the towns. The following is an instance of general vaccination in a village during an epidemic:

The village of North Queensferry, near Edinburgh, had a population of 390. There was an epidemic of smallpox from 14 December, 1811, to 7 March, 1812, during which time 46 children, from one to fifteen years, were attacked, and seven died, the same number that had died in the last epidemic, in 1797. When the epidemic was over there were only nine persons in the village, most of them aged, who had neither had smallpox nor cowpox. Those who had been vaccinated numbered 132; while of those “formerly vaccinated” only two were included among the 46 children who caught smallpox in 1811-12. The adult population must have nearly all gone through smallpox in former epidemics[1122]. These general vaccinations during or towards the end of an epidemic were exactly comparable to the general inoculations by the old method. At Norwich, where a premium of half-a-crown was given to parents for each vaccination, the epidemic of smallpox in 1819 stimulated the practice somewhat, the increase in July and August having followed a public meeting of the inhabitants and a combined effort of the doctors:

Progress of Progress of premium the mortality vaccinations

January 3 26 February 0 51 March 2 101 April 15 226 May 73 226 June 156 92 July 142 301 August 84 359 September 42 14 October 10 4 November 2 2 December 1 0

Cross estimated that a fifth part of the population of Norwich (50,000) were vaccinated--8000 before the epidemic of 1819, and 2000 during the epidemic. Many of the adults had been through the smallpox in the ordinary way in former epidemics. The state of vaccination throughout Norfolk and Suffolk was indicated in the answers made by ninety-one practitioners to the circular of queries sent out by Cross. Twenty-six had done 13,313 vaccinations during the epidemic of 1819. The whole number in the practice of those ninety-one from first to last had been 120,000, two of the practitioners having vaccinated none.

To sum up, as well as the records enable us to do, the extent of the new practice in the first quarter of the century, it was systematically carried out from year to year among the infants of large towns, such as Glasgow, Newcastle, Manchester and London, and in these the maximum of gratuitous vaccinations in proportion to the births may have been one-half. In smaller towns and in country parishes the inoculations of cowpox, like those of smallpox, appear to have been irregular or by fits and starts, the alarm of smallpox being the occasion for them. But after the epidemic of 1817-19, which was the most general since cowpox had been tried, it was not mere negligence or procrastination that kept parents back, it was distrust of the new practice and preference for the old.

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.”

## CHAPTER V.

MEASLES.

In the earliest English writings on medicine, measles is the inseparable companion of smallpox; so closely are they joined in pathology and treatment that even the statements as to the pustules and scars of the eruption are in some compends made to apply to both without distinction. This singular conjunction of two diseases came originally from the Arabian teaching, which was everywhere authoritative in the medieval period, and especially authoritative in all that related to smallpox. In the Latin compends based upon Avicenna or other Arabic writers, the two names were _variolae_ and _morbilli_, the former being as it were the _morbus_ proper and the latter its diminutive. It can hardly be doubted that we owe the English name of measles as the equivalent of _morbilli_ to John of Gaddesden. Originally the English word meant the leprous, first in the Latin form _miselli_ and _misellae_ (diminutive of _miser_), as in the histories of Matthew Paris, and later in the Norman-French form of _mesles_, as in the Acts of Parliament of Edward I. and in the ‘Vision of Piers the Ploughman.’ In the 15th century the leper-houses in the suburbs of London were called the “lazarcotes” or “meselcotes.”

Gaddesden, by some unaccountable stretch of similarity, coupled the sores or tubercular nodules on the legs of “pauperes vel consumptivi,” who were called “_anglicé_ mesles,” with the spotted rash of the Arabian “morbilli”; and it was doubtless this haphazard bracketting of two unlike diseases that led in course of time to the name of mesles being disjoined from its original sense of the leprous and restricted to the second member of Gaddesden’s strangely assorted couple. In the time of Henry VIII. smallpox and mezils are familiarly named together just as _variolae et morbilli_ are an inseparable pair in the treatises of the Arabistic writers. A still more singular usurpation by “mezils” or “maysilles” or “measles” is met with in the Elizabethan period. In the vocabulary of Levins, a schoolmaster who was also a medical graduate of Oxford, the word _variolae_ is rendered by “ye maysilles,” while _morbilli_ is omitted altogether among the Latin names and smallpox among the English; and in the English translation of Latin aphorisms appended to one of the works of William Clowes, surgeon to St Bartholomew’s Hospital, _variolae_ is in like manner translated “measles” on every occasion. In the English dictionary by Baret, belonging to the same period, measles is defined as “a disease with many reddish spottes or speckles in the face and bodie, much like freckles in colour”--which seems to exclude the possibility of a pustular disease having been part of the Elizabethan notion of measles.

Notwithstanding this singular usage of the vocabularies and dictionaries, the name of smallpox occurs by itself in letters or other memorials of the Elizabethan period, having been doubtless correctly applied to the true pustular _variola_. In the short essay on smallpox by Kellwaye, appended to his book on the plague (1593), measles and smallpox are distinguished on the whole clearly, according to the definitions of Fracastori or other foreign writers of the 16th century. The association between measles and smallpox that survived longest was a peculiar and somewhat uncommon one; certain cases of smallpox, in which the pustules were wholly or partially represented by, or changed into, broad spots level with the skin, red or livid in colour, and in which haemorrhages occurred from the nose, lungs, bowels or kidneys, that is to say, cases of haemorrhagic smallpox, were apt to be called, from the time of James I. until as late as the case of Queen Mary in 1694, by the name of “smallpox and measles mingled.”

From the date of the annual bills of mortality by the Parish Clerks of London, the year 1629, it is improbable that there was any real confusion between smallpox and measles; there was certainly some ambiguity in the entry of measles long after, but that later confusion, especially in the second half of the 18th century, was with scarlatina[1184]. The entry of measles is in the bills from the first, apart from that of “flox and smallpox:”

Measles Smallpox Year deaths deaths

1629 42 72 1630 2 40 1631 3 58 1632 80 531 1633 21 72 1634 33 1354 1635 27 293 1636 12 127 1647 5 139 1648 92 401 1649 3 1190 1650 33 184 1651 33 525 1652 62 1279 1653 8 139 1654 52 832 1655 11 1294 1656 153 823 1657 15 835 1658 80 409 1659 6 1523 1660 74 354

In the great epidemic of smallpox in 1628, the year before the bills begin, Thomas Alured wrote to Sir John Coke that his house in London had been visited “once with the measles and twice with the smallpox, though I thank God we are now free; and I know not how many households have run the same hazard[1185].” In the year 1656, which has the highest total in the above table, two cases of measles are mentioned in a letter of 31st May: “Young Sir Charles Sedley is at this time very sick of a feaver and the meazells, of which Sir William dyed”--Charles Sedley being then in his seventeenth year[1186]. An instance parallel to that of 1628, of measles and smallpox co-existing in the same household, occurred in the royal palace at Whitehall in December, 1660. The princess of Orange, sister of the king, died of smallpox on the 23rd; on that day, or a day or two before, her sister the princess Henrietta, who had come from France on a visit with the queen-mother, Henrietta Maria, removed from Whitehall to St James’s, “for fear of infection.” After a few days she embarked on board the ‘London’ at Portsmouth to return to France, but the ship had to come to anchor again owing to the princess being attacked with “the measles.” Her illness, which delayed the sailing of the vessel until the 24th of January, 1661, is uniformly spoken of as the measles in the various letters which make mention of it[1187]. In that year, and in several of the next ten years, the measles deaths in London reached a considerable total:

Measles Year deaths

1661 188 1662 20 1663 42 1664 311 1665 7 1666 3 1667 83 1668 200 1669 15 1670 295

The epidemic of 1670 is the subject of a description by Sydenham, the diagnostic points of which were doubtless those current at the time.

Sydenham’s description of Measles in London, 1670 and 1674.

Sydenham’s account of the epidemic of 1670 is full enough to leave no doubt that it was measles of the ordinary kind; the details, indeed, are as minute for all essential points as they would be in a modern text-book[1188]:

Measles, he says, is a disease mainly of young children (_infantes_), and is apt to run through all that are under one roof. It begins with a rigor, followed by heats and chills during the first day. On the second day there is fever, with intense malaise, thirst, loss of appetite, white tongue (not actually dry), slight cough, heaviness of the head and eyes, and constant drowsiness. In most cases a humour distils from the nose and eyes, the effusion or suffusion of tears being the most certain sign of sickening for measles, more certain indeed than the exanthem. The child sneezes as if it had taken cold, the eyelids swell, there may be vomiting, more usually there are loose green stools (especially during dentition), and there is excessive fretfulness. On the fourth or fifth day small red maculae, like fleabites, begin to appear on the forehead and the rest of the face, which coalesce, as they continue to come out in increasing numbers, so as to form racemose clusters. These maculae will be found by the touch to be slightly elevated, although they seem level to the eye. On the trunk and limbs, to which they gradually extend, they are not elevated. About the sixth day the maculae begin to roughen and scale, from the face downwards, and by the eighth day are scarcely discernible anywhere. On the ninth day the whole body is as if dusted with bran. The common people say that the spots had “turned inwards,” by which they mean that, if it had been smallpox, they would have remained out longer, and have proceeded to suppuration or maturation. The rash having thus “gone in,” there is an access of fever, attended with laboured breathing and cough, the latter being so incessant as to keep the children from sleep day or night. If they had been treated by the heating regimen, they are apt to have the chest troubles pass into peripneumonia, by which complication measles becomes more destructive than smallpox itself, although there is no danger in it if it be rightly treated. When peripneumonia threatens, the patient should be bled, even if it be a tender infant. Diarrhoea, which sometimes continues for weeks after an attack of measles, may be cut short by blood-letting, and so also may whooping-cough.

This epidemic, says Sydenham, began in January, and was almost ended in July, which agrees exactly with the rise and decline of measles deaths in the weekly bills of the Parish Clerks.

His account of the epidemic of 1674 is still more important to be set beside the figures in the bills; for the type, according to Sydenham, was anomalous, and the total of deaths entered by the Parish Clerks (795) is exceptionally large. Like the epidemic four years before, it began in January, came to a height about the vernal equinox, and was nearly over at the summer solstice[1189].

_Weekly Deaths in London in the first six months of 1674. (Epidemic of Measles.)_

1674

Week Griping in Convulsions Consumption All ending Fever Smallpox the guts Measles Teeth causes

Jan. 6 35 13 35 0 37 15 78 332 13 35 19 32 1 32 22 65 369 20 37 12 29 0 39 18 65 327 27 34 15 38 0 38 17 68 354 Feb. 3 32 23 39 7 45 26 75 418 10 47 18 35 4 48 35 86 430 17 55 21 46 15 70 38 98 537 24 62 17 45 28 54 44 97 510 March 3 58 31 28 59 48 49 87 547 10 55 22 31 87 85 58 122 688 17 63 15 46 95 79 57 113 695 24 59 23 44 65 57 39 96 568 31 51 19 49 60 77 51 105 622 April 7 44 13 40 43 65 48 118 547 14 53 20 32 31 60 50 98 535 21 40 17 43 38 55 42 106 517 28 50 17 44 53 67 34 87 520 May 5 51 31 28 30 56 24 75 452 12 38 26 47 30 54 37 79 479 19 50 35 33 26 47 28 82 461 26 67 27 33 13 45 28 63 415 June 2 48 24 28 14 41 26 77 365 9 35 26 38 15 48 27 66 369 16 64 34 38 19 38 22 70 419 23 34 33 34 9 52 15 71 368 30 37 39 30 9 30 21 59 343

It will be seen that the highest weekly mortality from measles is only 95, in the week ending 17th May. But in that week the deaths from all causes reached the enormous total of 695, which was nearly three hundred above the weekly average of the time. This appears to have been the epidemic of measles which Morton declares to have destroyed three hundred in a week, a mode of reckoning which would claim for measles, directly or indirectly, the excess of mortality from all causes during the height of the epidemic[1190].

These high weekly mortalities in February, March, April and May are remarkable for the season of the year. Usually when the weekly figures reach six or seven hundred, it is in a hot autumn, and the cause is infantile diarrhoea, represented in the bills by the excessive number of deaths from “griping in the guts” and “convulsions;” more rarely, and then only for three or four weeks, correspondingly high figures are reached in a season of influenza. But in this case the epidemic measles is the only relevant thing. The measles deaths by themselves do by no means account for the enormous weekly totals; but two of the three columns of figures which help them, and indeed keep pace with the rise of the measles deaths, namely, “convulsions” and “teeth,” are infantile deaths obviously related to the prevailing epidemic; while the third column, “consumption,” which contributes most of all, did not in the London bills mean pulmonary consumption exclusively, but also the wasting or marasmus which followed or attended acute fevers in general, and was specially apt to follow or attend measles[1191].

Sydenham gives no indication that the spring of 1674 was unusually productive of pneumonia or pleurisy among adults; the winter, he says, was unusually warm, the weather in spring turning colder. But, as to the measles, he does say that the epidemic was anomalous or irregular; while both he and Morton refer the fatalities more especially to the sequelae of measles,--to the “suffocation” of infants and children by the bronchitis or peripneumonia, or to “angina,” as Morton says, meaning perhaps the same as in Scotland was understood by “closing” in infants. Measles itself was a milder disease than smallpox, according to the experience of all times; and yet, by its sequelae (bronchitis, capillary bronchitis and pneumonia, including what Morton calls “angina,” and excluding, for the present, whooping-cough), it raised the weekly mortalities of February, March, April and May, 1674, to far above the average. Sydenham said, with reference to the much milder epidemic of 1670, that these after-effects of measles “destroyed more than even smallpox itself” (_quae_ [_peripneumonia_] _plures jugulat quam aut variolae ipsae_). We shall not correctly understand the part played by measles among the infective maladies of children unless we keep that grand character of it in mind--that its effects upon the mortality of infancy and childhood are only in part expressed by the deaths actually appearing under its name.

The London bills for 1674 afford us the opportunity of testing Sydenham’s paradox that measles, by its after-effects, destroyed more than smallpox itself. The epidemic of measles was nearly over in June; and immediately thereafter an epidemic of smallpox began (not of course from zero but from the usual level of the disease), which reached a maximum of 122 deaths in the week ending 20th October. The second half of the year was thus marked by a sharp outburst of smallpox, as the first half was marked by a sharp outburst of measles; and those two diseases were the only epidemic maladies that gave character to the respective seasons, each being in its proper season, according to Sydenham--measles in the spring, smallpox in the autumn. Although the measles deaths were only 795 for the whole year, the smallpox deaths being 2507, yet the former epidemic was attended by so great an excess of deaths under various other heads that the half of the year in which it fell was far more unhealthy than the succeeding half in which the smallpox mainly fell, the weekly average of the first six months having been 468 deaths, and of the second six months 349 deaths. The following table shows the weekly mortalities for the second half of the year; it will be observed that no column of figures keeps pace with the rise of the smallpox deaths, as three columns had kept pace with the rise of the measles deaths in the first six months of the year.

_Weekly Deaths in London in the last six months of 1674. (Epidemic of Smallpox.)_

1674

Week Griping in Convulsions Consumption All ending Fever Smallpox the guts Measles Teeth causes

July 7 31 44 35 9 44 24 69 351 14 38 55 34 5 37 17 54 353 21 40 71 47 6 42 25 56 395 28 43 71 37 3 49 18 48 367 Aug. 4 38 68 39 6 31 23 47 347 11 33 66 48 -- 18 8 45 324 18 49 86 41 1 26 20 48 374 25 35 85 23 3 32 10 46 328 Sept. 1 60 96 41 -- 32 18 57 414 8 32 99 48 3 22 16 32 374 15 28 102 38 2 30 19 55 362 22 27 72 32 3 29 11 57 327 29 39 81 34 2 41 9 53 358 Oct. 6 37 98 29 -- 34 10 63 391 13 36 75 25 -- 35 17 49 311 20 42 122 35 1 34 10 68 402 27 24 75 36 -- 38 15 45 294 Nov. 3 34 83 21 -- 30 11 41 322 10 30 81 15 -- 31 12 49 321 17 31 70 16 -- 24 10 58 304 24 35 70 28 -- 38 14 57 344 Dec. 1 33 85 29 -- 32 14 68 378 8 33 66 28 -- 36 11 53 327 15 29 61 26 -- 39 16 49 339 22 34 68 21 -- 32 11 52 335 29 41 41 19 -- 33 7 74 337

The total of deaths by smallpox for the year, 2507 was the highest since the bills began, and remained the highest until 1681. It is open to us to suppose that it would not have been so high but for the epidemic of measles preceding. The measles not only made the first half of the year far more deadly than the second, within which most of the smallpox fell, but its effects may have aided the high mortality of smallpox itself, according to the experience of later times that infants and young children recovering from measles in a greatly weakened condition fell an easier prey to smallpox coming after[1192].

Morton passes from the fatal epidemic of 1674 (or, as he says, 1672), with the remark that the malady had not been epidemic again in London from that time until the date of his writing, 1692-94, a period of nearly twenty years; and that is on the whole borne out by the London bills and by Sydenham’s records so far as they extend. From 1687 to 1700, inclusive, the London bills grouped the measles deaths along with the deaths from smallpox, under the heading, “Flox, Smallpox and Measles”; in 1701 the total of measles, 4 deaths, is given as a separate item in the same bracket with smallpox; and in 1702 the heading of “Measles,” is restored to the place in the alphabetical list which it had held, except for that unaccountable break, from the beginning of the published bills in 1629. The following are the annual totals from and including the great epidemic of 1674:

Death from Year measles

1674 795 1675 1 1676 83 1677 87 1678 93 1679 117 1680 49 1681 121 1682 50 1683 39 1684 6 1685 197 1686 25

Thus for a good many years after the general prevalence of measles in 1674 the deaths from it in London averaged only about one and a half in the week, while in no year until 1705-6 is there an epidemic comparable to that of 1674. It is clear that the severe epidemics of measles came at first at very long intervals, and that the years between had a very moderate mortality from that disease.

Measles in the 18th century.

There is hardly a reference to be found to measles in medical or other writings until the annual accounts of the public health at Ripon, York, Plymouth, etc. in the third decade of the 18th century. The annual deaths from it in London, according to the bills, were as follows, from 1701, when the disease was restored to its separate place in the classification:

Year Measles deaths

1701 4 1702 27 1703 51 1704 12 1705 319 1706 361 1707 37 1708 126 1709 89 1710 181 1711 97 1712 77 1713 61 1714 139 1715 30 1716 270 1717 35 1718 492 1719 243 1720 213 1721 238 1722 114 1723 231 1724 118 1725 70 1726 256 1727 72 1728 82 1729 41 1730 311 1731 102 1732 30 1733 605 1734 20 1735 10 1736 169 1737 127 1738 216 1739 326 1740 46

The high mortalities of 1705 and 1706 belonged to one continuous epidemic from October, 1705, to April, 1706 (Sir David Hamilton says that smallpox was common in London in July, 1705, but the deaths in the bills are not excessive). The epidemic followed a great prevalence of the autumnal diarrhoea of infants, so that it is probable the high mortality was due as much to a greater fatality of cases from the antecedent weakening, as to an unusual number of cases[1193]. The following were the weekly deaths in a population about one-sixth that of London now:

1705-1706

Week Measles ending deaths

Oct. 16 9 23 9 30 12 Nov. 6 10 13 30 20 34 27 29 Dec. 4 37 11 46 18 44 25 22 Jan. 1 35 8 33 15 28 22 20 29 18 Feb. 5 27 12 11 19 26 26 28 Mar. 5 10 12 10 19 9 26 13 Apr. 2 9 9 9

The unusually large mortalities from measles in 1718-19 and in 1733 were again associated with a “constitution” otherwise sickly. The epidemic in the latter year, from the middle of March to the end of July, which had a maximum of 47 deaths in each of the two middle weeks of May, followed close upon a severe influenza. Like the epidemic of 1674, it was attended by a high mortality from other causes, especially “convulsions” and “consumption”; and, as the bills had now begun to give the ages at death, it is no longer doubtful, or merely conjectural, that the great excess of deaths under these and other heads was really among infants, or that a rise in “consumption” at that time of the year meant an increase in the wasting diseases of infancy. This was a period when any epidemic malady among London children was sure to go hard with many of them, the period, namely, when spirit drinking, besides ruining the health of the parents, rendered them, in the opinion of the College of Physicians, “too often the cause of weak, feeble and distempered children[1194].”

The intervals between epidemics of measles in London having been so considerable as the table shows, it is not surprising to find but casual mention of the disease in the chronicles of Wintringham, Hillary, and Huxham for England, of Rogers, O’Connell and Rutty for Ireland, and of the Edinburgh annalists. Wintringham, of York, whose annals extend from 1715 to 1730, records an epidemic of measles in 1721, which began in April and lasted all the summer, being for the most part of a bad type, attended with continual cough and inflammation of the lungs. Hillary, of Ripon, enters measles in 1726, “very common but mild,” autumn and winter being the season of it. Wintringham briefly mentions the same epidemic. Huxham of Plymouth has an entry of measles in the first year of his annals, 1727, in the month of July, followed by whooping-cough in December. Wintringham again enters measles at York in 1730 in the company of smallpox. In the annual accounts of the disease at Edinburgh, for a series of years beginning with 1731, measles is first mentioned in 1735[1195]. The epidemic began in June and became universal in December: “The progress of these measles along the west road of England towards Edinburgh was very remarkable, for they could be traced from village to village; and it was singular that the first person in Edinburgh who was seized with them was a lady in childbed, who saw nobody but her nurse and a friend who lived in the house with her”--an argument, apparently, for the doctrine of an epidemic “morbillous” constitution of the air. Five years after, we obtain the mortality statistics of Edinburgh, in the two great years of scarcity, typhus fever and sicknesses of all kinds, the years 1740 and 1741: in those two years measles must have been as general as smallpox if it were half as mortal, for the deaths set down to it in each year are 110 and 112, as compared with 274 and 206 from the more usual infantile infection. In like manner the second year of the disastrous epidemic of typhus in 1741-42, had the highest total of measles deaths in London until the great epidemic of 1808. While the high mortality of that year was due to special causes, it is at the same time clear from the following table that measles had not yet become a steady or perennial cause of death to the infancy of the capital:

Year Measles deaths

1741 42 1742 981 1743 17 1744 5 1745 14 1746 250 1747 81 1748 10 1749 106 1750 321 1751 21 1752 111 1753 253 1754 12 1755 423 1756 156 1757 24 1758 696 1759 316 1760 175 1761 394 1762 122 1763 610 1764 65 1765 54 1766 482 1767 80 1768 409 1769 90 1770 325 1771 115 1772 211 1773 199 1774 121 1775 283 1776 153 1777 145 1778 388 1779 99 1780 272 1781 201 1782 170 1783 185 1784 29 1785 20 1786 793[1196] 1787 84 1788 55 1789 534 1790 119 1791 156 1792 450 1793 248 1794 172 1795 328 1796 307 1797 222 1798 196 1799 223 1800 395

The considerable epidemic of 1755 is thus referred to by Fothergill in his monthly notes:

_May_: the measles more common than for some years, adults, who had not before had it, rarely escaping. _June_: measles common, smallpox rare. _September and October_: no epidemic disease but measles; few perished in proportion to all who took it[1197]. The epidemic of 1758 was more fatal, but Fothergill’s notes are not continued to that year. The elder Heberden says that measles was remarkably epidemical (in London) in 1753, which year has only 253 deaths in the bills, whereas the year 1755 has 423 deaths and the year 1758 has 696; but, as he implies that the type was mild, there would have been a multitude of cases to produce that number of deaths. It was a peculiarity of that epidemic, he says, that the cough preceded the outbreak of measles by seven or eight days, whereas it was usually but two or three days in advance of the eruption[1198].

At that period there would have been an epidemic of measles in London every other year, or once in three years, with a fatality from the direct effects seldom more than a sixth part that of an epidemic of smallpox. A London writer some twenty years after said that few escaped measles in infancy or childhood, while the deaths put down to it were only a tenth part of those due to smallpox on an average of years[1199]. The proportion of measles deaths to smallpox deaths was nearly the same in Manchester for twenty years from 1754 to 1774, according to Percival’s table of the burials in the register of the Collegiate Church where most of the poorer class were buried[1200]:

_Annual averages of Burials from Measles etc. at the Collegiate Church, Manchester._

All deaths Deaths at Period Measles Smallpox under two all ages Baptisms

1754-58 21 64 209 651 678 1759-63[1201] 10·6 95 213 639 731 1764-69 9·6 98 229 659 827 1770-74 21·6 102 242 651 1062

The ages of those who died of measles “in six years from 1768 to 1774,” to the number of 91, were as follows:

Total 3 mo. -6 mo. -12 mo. -2 years -3 -4 -5 -10 -20 -30

91 2 3 10 31 25 7 9 2 1 1

Fifty were males, forty-one females--a preponderance of males which is according to rule. Of the whole ninety-one, no fewer than fifty-one died in June of the several years.

In the smaller and more healthy towns, such as Northampton, the epidemics of measles came at long intervals and caused but few deaths:

_Infantile Causes of Death, All Saints, Northampton_[1202].

Year Measles Whooping-cough Convulsions Teething

1742 3 1 10 8 1743 -- -- 21 2 1744 -- 3 14 4 1745 -- -- 22 7 1746 -- 3 19 3 1747 7 -- 29 -- 1748 -- -- 24 4 1749 -- 6 15 4 1750 1 -- 17 1 1751 -- -- 14 6 1752 -- 1 13 6 1753} not published 1754} 1755 -- 1 8 1 1756 -- 2 10 2 1757 1 1 28 4

In the parish of Holy Cross, a suburb of Shrewsbury, there were 4 deaths from measles in the ten years 1750-60, and 15 in the ten years 1760-70, the smallpox deaths having been respectively 33 and 46. Ackworth, in Yorkshire, may represent the country parishes. It had no deaths from measles from 1747 to 1757, two deaths from 1757 to 1767. At Kilmarnock during thirty-six years from 1728 to 1764, there were 93 deaths from measles, 52 of them in the period 1747-52, and only 11 in the next twelve years. Sims, of Tyrone, having described an epidemic of smallpox which desolated the close of 1766 and spring of 1767 with unheard of havoc (it had been out of the country for some years), mentions farther that an epidemic of measles followed immediately: “Before the close of the summer solstice the measles sprang up with a most luxuriant growth,” and was followed in harvest by whooping-cough.

Wherever we have the means of comparison by figures, it appears that measles caused by its direct fatality not more than a sixth part of the deaths by smallpox in Britain generally. But in the colonies, where an epidemic of smallpox was a rare event of the great seaports, and as much an affair of adults as of children, measles seems to have been more fatal, dividing with diphtheria or scarlatina the great bulk of the infectious mortality of childhood. Thus Webster enters under 1772: “In this year the measles appeared in all parts of America with unusual mortality. In Charleston died 800 or 900 children”; and under 1773: “In America the measles finished its course and was followed by disorders in the throat”--especially in 1775[1203]. It is only among the children of public institutions in England that we find in the corresponding period a similar predominance of measles and scarlatina over smallpox. In the Infirmary Books of the Foundling Hospital the more general outbreaks of smallpox cease after 1765, while epidemics of measles, extending to perhaps a third or more of the inmates, as well as great epidemics of scarlatina, begin after that date to be common[1204].

In the Infirmary Book from which the following extracts are taken, the number of deaths is not stated. The number of children in the Hospital was 312 in 1763, 368 in 1766 and 438 in 1768.

1763. Before the date of the Infirmary Book, Watson records an epidemic of putrid measles from 21 April to 9 June, 1763, which attacked 180 and caused 19 immediate deaths.

Nov. 19. Nine in the infirmary with “morbillous fever”; many cases of “fever” until the 17th December.

1766. May to July. Many entries in the book; Watson says: “Seventy-four had benign measles, and all recovered.”

1768. Great epidemic, May to July; one hundred and twelve in the infirmary with measles on June 4th; Watson gives the total cases at 139, of which 6 were fatal.

1773. Nov. and Dec. Great epidemic: maximum of 130 cases of measles in the infirmary on 27th November. Next week there were 40 with measles, and 90 convalescing therefrom.

1774. May. A slight outbreak (8 cases at one time).

(_Records from 1776-1782 not seen._)

1783. March and April. Great epidemic: maximum number of cases in the infirmary with measles 94, on March 22nd.

1784. June. Eleven cases of measles at once.

1786. March and April. Maximum on April 5th--measles 47, recovering from measles 19.

The records from 1789 to 1805 have not been seen, but Willan gives the following dates and numbers, on the information of Dr Stanger, physician to the charity[1205].

1794. 28 had measles, all recovered.

1798. 69 had measles, 6 girls died.

1800. 66 had measles, 4 boys died.

1802. 8 had measles, one died.

The general testimony in the last quarter of the 18th century is that measles, if a common affection, was not usually a severe one. Heysham, of Carlisle, says that measles came thither in 1786 from the south-west of Northumberland, “where, I am informed, they proved very fatal”; the epidemic began at Carlisle in August, and continued very general until January, 1787, but extremely mild and favourable, only 28 having died (26 under five years, 2 from five to ten), out of “some six or seven hundred, I suppose.” The previous epidemic of measles at Carlisle in 1780 (mortality not stated), had followed a most fatal epidemic of smallpox in 1779; and although the epidemic of mild measles in 1786 did not follow a great epidemic of smallpox, it followed a high and steady annual average of deaths of infants and young children from that cause year after year[1206]. In both years of the measles at Carlisle, there were no deaths from smallpox. In like manner at Leeds, in 1790, measles followed smallpox, and was extremely mild; Lucas wrote of it, “I have not seen one instance of a fatal termination[1207].” This was the time (1785) when Heberden said of the disease in London, just as Willis, Harris and others had said of it and of smallpox together a century before: “The measles being usually attended with very little danger, it is not often that a physician is employed in this distemper.”

Increasing mortality from Measles at the end of the 18th century.

There were epidemics of measles with high mortality in the 17th and 18th centuries, occurring in special circumstances of time and place, of which instances have been given. But in general the position of measles was not then so high among the causes of death in infancy and childhood as it afterwards became. It is not easy to demonstrate the exact proportions by figures, even for London; the bills of the Parish Clerks are less trustworthy for measles than for smallpox, for the reason that deaths from scarlatina were probably included among the former (see under Scarlatina). For example, the ratio of 1·10 per cent. measles deaths for the ten years 1781-90 in the following table should be only 0·70 if the 793 deaths in 1786, supposed scarlatinal, be left out. But, taking the bills as they stand, they show an increasing ratio of measles (as well as of whooping-cough) among the deaths from all causes towards the end of the 18th century.

_Percentage of Measles and Whooping-cough in all London deaths, 1731-1830._

Ten-year Share of Share of periods measles whooping-cough

1731-40 0·70 0·41 1741-50 0·68 0·40 1751-60 1·15 1·03 1761-70 1·11 1·12 1771-80 0·93 1·66 1781-90 1·10 1·32 1791-1800 1·34 1·97 1801-10 3·11 3·14 1811-20 3·52 3·49 1821-30 3·17 3·13

During the same period, the ratio of deaths from all causes under two years of age had decreased, while the ratio of deaths from two to five, and at all ages above five, had increased as in the following table, also compiled from the London bills beginning with the year 1728 when the ages at death were first published.

_Ratios of Deaths from all causes under two years, from two to five, and above five, London, 1728-1830._

Ratio Ratio Ratio of Total under from all ages Period deaths Two years Two to Five above Five

1728-30 (3 yrs.) 84,293 36·7 8·7 54·6 1731-40 246,925 38·6 8·9 52·5 1741-50 254,717 33·6 7·9 58·5 1751-60 204,617 30·9 9·3 59·8 1761-70 234,412 34·1 9·1 56·8 1771-80 214,605 34·4 9·6 56·0 1781-90 192,690 32·5 9·5 58·0 1791-1800 196,801 31·8 10·9 57·3 1801-10 185,823 29·3 11·5 59·2 1811-20 190,768 27·7 9·8 62·5 1821-30 209,094 28·0 9·7 62·3

Thus, while measles (with whooping-cough) was usurping, so to speak, a larger share of all the deaths, the two first years of life were claiming a smaller share of the deaths from all causes as the probability of life was improving. The saving of infant life was due to various things, but especially due to the decline of smallpox, as described in another chapter. We may now turn to consider, by a less abstract method, the increase of measles mortality from the last years of the 18th century.

In Willan’s periodical reports of the prevailing diseases of London[1208], scarlatina declined in 1795 and became sporadic, after having been extremely fatal for a long period, while measles and smallpox began to extend about the end of that year, the former being for the most part mild in its symptoms and favourable in its termination, the latter often confluent, and fatal to children. The report for March and April, 1796, is that measles had become more severe, and had been followed by obstinate coughs; for May, that “smallpox and measles have prevailed more during this spring than has been known for many years past.” However, it was smallpox that occasioned the larger share of the deaths among infants and children. The next general view that Willan gives us of the relative importance of measles among the infectious diseases is under Oct.-Nov. 1799: “The measles, though extensively diffused, have continued mild and moderate. The scarlet fever has increased, since the last report, both in extent and in the violence of its symptoms; but the contagious malignant fever [typhus] has been the most frequent, as well as the most fatal, of all acute diseases.” There is little sign of fatal measles in the London bills during the years of distress, 1799-1801; but we hear of it in Scotland and Ireland, where there was probably less scarlatina. An Edinburgh observer of the prevailing diseases says that “several hundreds” died of measles there in the winter of 1799[1209]. In the Irish emigration to America, which took one of its periodic starts owing to the repressive measures following the rebellion of 1798 and the union with England, measles appears to have been the fatal form of infection among the children on board ship. A medical letter from Philadelphia, 10 December, 1801, says that measles had been imported to Newcastle and Wilmington in the summer of 1801 by some vessels from Ireland, on board which a great many children died during the voyage; the epidemic at length reached Philadelphia and had become general throughout the city[1210]. At Whitehaven large numbers of infants were attended in measles from the Dispensary in 1796 and 1799, but the deaths (2 in 202 cases, and 2 in 266 cases) are probably only a few that came to the knowledge of the visiting physician. An epidemic at Uxbridge, Middlesex, in the winter of 1801-2 was certainly malignant or fatal more than ordinary, whatever its anomalous type may have meant.

The epidemic began in September, and was at first of so mild a type as to need no medical assistance. Towards November the cases increased in number and severity, but still, says the narrator, “I believe every case terminated favourably, not in my practice only, but in that of other gentlemen also.” Towards the middle of November, the attacks were more sudden and more violent while they lasted, and were soon over either in death or recovery. In some the eyes became all at once as red as blood, the pulse full, quick and hard, the cough incessant, with a rattling noise in the throat and quick laboured breathing, the skin hot and parched. “Another peculiarity in this epidemic was that the cuticle in many children did not separate after the disappearance of the eruption, and in several others that I particularly noticed, it came off in large flakes instead of branny scales; and the appearance of the rash in others assumed so striking a resemblance to the scarlet fever that, had it not been for the violent cough and other measly symptoms, many such cases occurring singly might, upon a superficial view, have been considered and treated as that disorder.” The various forms occurred in the same family; thus, of four children, one had typical measles, ending in a branny scurf, two others had the sneezing and the watery inflamed eyes, but the eruption in the form of an universal red fiery rash, after which the skin peeled in large flakes, while the fourth had the disease of a low typhoid type and recovered with difficulty. The epidemic “continued its destructive career” through December and January, after which the type became as mild as it had been at first. If the author had not discussed the diagnosis as between measles and scarlatina, deciding in favour of the former, one might have suspected that there were cases of both. But even the sphacelation that followed the application of blisters, the pemphigus-like eruption turning gangrenous, and the petechiae, were signs of malignancy in more than one of the exanthematous fevers. The sequelae of this epidemic of measles were as anomalous as the symptoms themselves; instead of the inflamed eyes, and the distressing cough (sometimes ending in consumption) there were aphthous fever and dysenteric purging[1211].

The deaths in the London bills for the first twelve years of the century will be found in the table on p. 655. We find the measles deaths for the first time equalling the smallpox deaths in 1804, and in 1808 surpassing them, and we may take it that the deaths so entered were almost wholly of measles proper. The epidemic of measles in 1807-8 was, in fact, a great and clearly defined event in British epidemiology, the first of a series of epidemics in which that disease established not only its equality with smallpox as a cause of infantile deaths but even its supremacy over the latter. It would appear, also, to have been more malignant than the scarlatina that coexisted with it. Thus, Bateman, of London, at the outset of the great measles epidemic of 1807-8, says: “The most prominent acute disorders have been eruptive fevers and particularly the measles, which during October and November have been very prevalent, and, when occurring in young children, have proved very fatal by terminating in violent inflammation of the organs of respiration.... The scarlatina was generally mild, presenting the eruption with a slight sore-throat[1212].”

Other accounts of the epidemic in London show it to have been of the type which Sydenham, in 1674, called anomalous or malignant.

The epidemic began in October-November, 1807, and was remarked as unusually fatal[1213].

Several children in the same family had fallen victims to it. Some cases were fatal in a few days, either from the intensity of the fever or from pneumonic complication. “But when these symptoms have been less violent, and the patient has passed without much alarm through the different stages of the disorder, and even after all apprehension of danger in the mind of parents or friends has been dismissed, a continuance or recurrence of pneumonic symptoms has laid a foundation for phthisis pulmonalis.” In some cases attended from the Westminster Dispensary, death followed from effusion into the chest or from membranous inflammation of the trachea. Numbers who recovered from the measles were afterwards affected with debility, cough, emaciation and oedematous swellings of the face and extremities which proved very difficult to remove. These particulars are given mostly for the end of 1807, but it is under the year 1808 that the great rise in the measles deaths appears in the London bills of mortality.

Besides these accounts for London, we have some details of the same epidemic at Edinburgh and Aberdeen and exact figures for Glasgow. It began at Edinburgh in the winter of 1807, and at Aberdeen (as at Glasgow) in the spring of 1808. At both places it was remarked as unusually fatal, chiefly from a complication of bowel complaint in children and from pulmonary affections in adults.

The Aberdeen observer says that in town (the disease being milder in the country) there were troublesome symptoms in almost every case--a violent pain in the belly, frequently accompanied with diarrhoea (and even with vomiting), and with the dysenteric symptoms of tenesmus and mucus in the stools. This bowel complaint usually lasted three or four days, and wasted the patients remarkably. There was also the usual catarrh with violent tickling cough, and, after the acute attack, a tendency to sudden dyspnoea and “fatal coughs.” In some the convalescence was lingering and very distressing to the patient: “it consists in a slow kind of fever, with evening exacerbations[1214].”

The observers at Edinburgh and Aberdeen agree that the epidemic was the worst that had been seen for many years. Says the former[1215]: “I believe that the present epidemic has been more general in this place and its vicinity than ever happened within the remembrance of any medical man at present living, and I am sorry to say it has been very fatal.” The Aberdeen chronicler says the mortality was “greater than we have witnessed for a long period,” and that the epidemic was general throughout the whole of England and Scotland. But, besides this direct testimony, there is a not less indirectly significant fact of the epidemic. It affected many adults--“persons of all ages, who had never had them,” says the Aberdeen writer: few persons escaped, says the Edinburgh observer, “who had been previously unaffected by this disease.” The deaths from pulmonic complaints did not often happen among children, but among people somewhat advanced in life. Significant also was the outbreak in the Invernessshire Militia, which marched into Edinburgh in March while the epidemic was raging. Fifty men, all young recruits newly joined, were attacked in the course of a few days, the others escaping the disease though equally exposed to it; in some of those who died in the regiment there were found, on opening the thorax, fibrinous pleurisy and pericarditis, with effusion of fluid, as well as evidences of bronchial catarrh[1216]. The Aberdeen writer says: “I always observed that in full-grown persons the eruptions were more numerous, quicker in appearing, and longer in going off than in young subjects.... Many full-grown persons were very ill, yet the measles were more fatal to the young.” The implication of so many adults in the severe epidemic of 1808 would of itself show that measles had not been for some time before a steady and universal affection of infancy and childhood[1217].

Measles in Glasgow in 1808 and 1811-12: Researches of Watt.

The measles epidemic of 1808, which appears to have been somewhat general in England and Scotland, made an extraordinary impression in Glasgow. That disease had never before been nearly so mortal there, nor had any infection since the time of the plague, not even smallpox itself, engrossed the burial registers so much as measles did in the months of May and June, 1808. Glasgow had been the worst city in the kingdom for smallpox; by a somewhat sudden transition the infancy of the city died for a few months in larger numbers by the new disease than by the old. The highest monthly mortalities from smallpox had been 114 in October and 113 in November, 1791, the population being 66,578; but in 1808, the population having increased to 100,749 by the census of 1811, measles carried off 259 children in May and 260 in June, and in the months before and after as follows:

_Measles in Glasgow, 1808._

Month Deaths

Jan. 2 Feb. 2 March 5 April 71 May 259 June 260 July 118 Aug. 32 Sept. 22 Oct. 10 Nov. 4 Dec. 2

The figures were not known at the time; but every doctor in Glasgow, as well as the whole populace, knew that measles was cutting off the infants, while smallpox had fallen to insignificance. So dramatic was this turn in the public health that the common people set it down to the new practice of inoculating children with cowpox: ready to believe anything of vaccination, they concluded that, if it kept off smallpox, it brought on measles. Dr Robert Watt took the trouble to refute this singular notion; he found in his own practice that three children in one family, and in another two, had died of measles who had neither been vaccinated nor had smallpox before. Another great epidemic of measles arose in Glasgow three years after, in the winter of 1811-12:

Measles 1811 deaths

October 12 November 76 December 161

1812

January 130 February 61 March 30 April 19 May 15 June 18

Those two great epidemics of measles in Glasgow, in 1808 and 1811-12, were the occasion of one of the earliest and most memorable inquiries in vital statistics in this country, the research by Dr Robert Watt on “the Relative Mortality of the Principal Diseases of Children, and the numbers who have died under ten years of age in Glasgow during the last thirty years[1218].” Having begun with a search of the principal Glasgow burial-registers for deaths by whooping-cough, he extended it to sixteen folio volumes of the registers of all the burial-grounds, old and new, and included the mortalities from all causes with the ages at death, and from fevers and the principal diseases of infancy and childhood. The increase of population from 1783, when his figures begin, to 1812, the date of his writing, was known to him; but as the numbers living at the respective periods of life were not known, he was obliged to state the change in the mortalities at the various ages, and from the various diseases, in ratios of the annual deaths from all causes,--a perfectly scientific comparison so long as the nature of the ratios compared was clearly stated. It would have been more satisfactory, of course, if the comparison could have been made in terms of the annual death-rate, which was much lower (for reasons already explained), in the second half of his period than in the first; but, in the circumstances, that was impracticable, and Watt did the next best thing. The following is the principal part of his table of ratios in five successive periods of six years each:

_Vital Statistics of Glasgow in sexennial periods, 1783-1812._ (_Watt._)

Per Per Per cent. cent. Per Per Sum cent. from from cent. cent. of all under Two to Five of of Period deaths Two Five to Ten Smallpox Measles

1783-88 9994 39·40 10·66 3·42 19·55 0·93 1789-94 11103 42·38 11·90 3·79 18·22 1·17 1795-1800 9991 38·82 12·21 3·45 18·70 2·10 1801-06 10304 33·50 13·43 5·10 8·90 3·92 1807-12 13354 35·89 14·22 5·58 3·90 10·76

Per cent. of Per cent. of Period Whooping-cough “Bowel-hive”

1783-88 4·51 6·72 1789-94 5·13 6·43 1795-1800 5·36 6·47 1801-06 6·12 7·27 1807-12 5·57 9·26

The actual deaths from smallpox, measles and whooping-cough are shown in the next table, which includes for comparison the corresponding figures from the London bills of mortality:

_Smallpox, Measles and Whooping-cough in London and Glasgow, 1783-1812._

London /----------------------------------\ Year Smallpox Measles Whooping-cough

1783 1550 185 268 1784 1759 29 457 1785 1999 20 194 1786 1210 793 200 1787 2418 84 228 1788 1101 55 298 1789 2077 534 374 1790 1617 119 391 1791 1747 156 279 1792 1568 450 311 1793 2382 248 352 1794 1913 172 469 1795 1040 328 311 1796 3548 307 536 1797 522 222 567 1798 2237 196 418 1799 1111 223 451 1800 2409 395 380 1801 1461 136 428 1802 1579 559 1004 1803 1202 438 586 1804 622 619 697 1805 1685 523 703 1806 1158 530 623 1807 1297 452 439 1808 1169 1386 326 1809 1163 106 591 1810 1198 1031 449 1811 751 235 486 1812 1287 427 508

Glasgow /----------------------------------\ Year Smallpox Measles Whooping-cough

1783 155 66 153 1784 425 1 41 1785 218 0 34 1786 348 2 173 1787 410 23 57 1788 399 1 17 1789 366 23 45 1790 336 33 177 1791 607 4 117 1792 202 58 68 1793 389 5 112 1794 235 7 51 1795 402 46 180 1796 177 92 60 1797 354 5 76 1798 309 3 98 1799 370 43 95 1800 257 21 27 1801 245 8 125 1802 156 168 90 1803 194 45 60 1804 213 27 52 1805 56 90 129 1806 28 56 162 1807 97 16 85 1808 51 787 92 1809 159 44 259 1810 28 19 147 1811 109 267 62 1812 78 304 103

The ratio of deaths under the age of two had decreased greatly in Glasgow, while the ratios from two to five and from five to ten had increased. At the same time smallpox had almost ceased (but only temporarily, as it appeared) to be the great infectious scourge of infancy, while measles had come in its place. “Now that the smallpox are in great measure expelled,” (Watt believed that cowpox inoculation had done this), “the measles are gradually coming to occupy the same ground which they formerly occupied. I am sorry to make this statement, but the facts, at least with regard to Glasgow, are too strong to admit of doubt.”

In order to explain the enormous increase of deaths by measles, he had recourse to the following argument. Formerly nearly all children, say nine-tenths, had both smallpox and measles, the attack of smallpox in most cases coming first. Children who had survived smallpox were fortified by that ordeal, not merely as selected lives, but positively fortified, so that measles, when it assailed them in due time afterwards, was taken mildly or was “modified,” not one in a hundred cases proving fatal. But now (1813), when so few children have been through the smallpox, measles has become ten times more fatal to them, although it could hardly be more common than it used to be. Having found it necessary to assume that children in former times took smallpox before they took measles, nine-tenths of them taking both, he qualifies this in another passage: “Still, however, as the measles came round now and then, as a very general epidemic, they must occasionally have had the precedence, and it was perhaps chiefly among such patients that the disease proved fatal.”

The measles which came round now and then as a general epidemic was nearly the whole of it; even in London there were intervals of several years with only a few annual deaths, and in smaller towns or country districts the clear intervals were longer. The prevalence of measles on the great scale being more casual than that of smallpox, it is likely that most children had taken smallpox before they incurred measles. But it is clear from such instances as the London epidemic of 1674, and the epidemic in the Foundling Hospital in 1763, that measles might attack children just before smallpox, and by its weakening effects, increase the number of victims of the latter. As to the fatality of measles itself in the 17th and 18th centuries, the statement of Watt that it did not amount to one death in a hundred attacks, while it can neither be proved nor disproved by an array of figures, can be shown to be inconsistent with the language of annalists. The epidemics of measles varied in severity then as afterwards: that of 1670 in London was regular and mild, that of 1674 in the very same months of the year was anomalous and fatal; Huxham characterizes the measles at Plymouth in the winter of 1749-50 as “maximé epidemici, imo et saepe pestiferi”; at Kidderminster, in 1756, after fevers had been very fatal to adults, the measles went through the town so that an immense number of children “died tabid”; in the West of England about 1760 a disease called measles made “a melancholy carnage amongst children.”

While Watt’s theory of the working of this principle of substitution is open to criticism on some points of detail, the law itself, as enunciated by him, remains to the present time one of the soundest and most instructive generalities in epidemiology. He based it upon a laborious search of the burial registers, such as no one before him in this country had undertaken. Next he saw correctly that a great rise in the deaths of infants by such a disease as measles could only be accounted for by a great increase in the rate of fatality. Thirdly, he connected the loss from measles with the saving from smallpox. Adopting an old opinion, which may be discovered in Willis[1219], he argued that smallpox, when taken first, served to fortify children so that they passed easily through the measles afterwards; but in the following passage he indicated a better reason why the absence of smallpox gave measles the chance of proving more fatal: “In this point of view we are not to consider the smallpox as so peculiarly fatal in their nature. They perhaps prove so fatal merely by having the start of other diseases. The measles, the chincough, the croup, the scarlet fever, and perhaps many others, would have proved equally fatal had they occurred first.” The principle is true to this extent, that a certain proportion of weakly infants, or children of poor stamina, will succumb to almost any disease--if not to smallpox, then to measles, and if not to measles directly, then to the sequelae of measles. This was perceived in the form of a necessary truth by Haygarth in 1793: “A considerable number of those who now die of the smallpox would die in childhood of other diseases if this distemper were exterminated[1220].” It was commonly believed that smallpox had at length found its real artificial check, not in the inoculation of itself, but in the inoculation of cowpox. At all events it had declined greatly in Glasgow. During the three years before the measles epidemic of 1808, there could hardly have been more than a thousand children attacked by smallpox, or not one in ten of all the children born. During several years the infancy of the city had been spared any great ordeal of infectious disease; the first epidemic that came along happened to be measles, so that it fell to that infection to take off the weaklings. In the economy of nature it is impossible to rear all the young of a species, nor would it be good for the species if it were possible. It is among the birds that the principle of population, or of the survival of the fittest, is seen working in the most admirable way: the annual migration of many species to breed in a remote country brings with it an ordeal for the birds of the year in finding their way to the winter feeding-grounds--an ordeal which only the strongest come through. For some unexplained reason, the young of the human species are peculiarly tried by infectious diseases, which multitudes pass through safely, while many of poor stamina or of ill tending are cut off.

Dr Watt’s teaching, as to the displacement of one infectious cause of death by another was resisted at the time as being of “evil tendency” for the pretensions of vaccination, although Watt believed as firmly in the virtues of cowpox as Jenner himself did. Writing to James Moore on 6 Dec. 1813, Jenner says of Watt’s essay (Baron, II. 392): “There is nothing in its title that developes its purport or _evil tendency_.... Is not this very shocking? Here is a new and unexpected twig shot forth for the sinking anti-vaccinist to cling to.” Sir Gilbert Blane, who was then president of the Medical and Chirurgical Society, having a natural fondness for ideas of all kinds expressed in a paper to that society rather more approval of Watt’s view than was thought prudent: “An ingenious friend of mine has remarked to me in conversation that some light is thrown on this subject by considering that whichever of the epidemic maladies attack children first, it will be the most fatal, inasmuch as all feeble constitutions will fall in its way while the stronger will be left to encounter the attacks of the others; and that the smallpox, owing probably to the greater abundance and rankness of their effluvia, are generally caught in a casual way before measles, hooping cough and scarlet fever, and are therefore reckoned more fatal than any of these. But, a new field of research being opened,” etc. Efforts were made to correct the effect of this, by showing that measles in some parts of the country had not been more fatal than usual. Holland, of Knutsford, attributed the fatality of the epidemic in 1808 to a change of the wind to the east. Writers in the _Edinburgh Med. and Surg. Journal_, pointed out that Watt had compared the absolute deaths by smallpox at one time and by measles at another without taking account of the increase of population, and the rates of mortality from each disease. The best criticism of Watt was by Roberton in his _Mortality of Children_, 1827, p. 49. He offers the following considerations, without seeming to know that they were really to be found in Watt’s own essay: Smallpox used to be caught first; it swept off the feeble and sickly, leaving the strong and vigorous _only_ to encounter the attacks of other diseases. “That infectious febrile disease to which in early infancy there is the strongest predisposition will of course in general make the first attack and prove the most fatal of any.” There were reasons why measles used to have comparatively few victims, “and why, when they now prevail epidemically, they, as was the case with smallpox, are caught at an earlier age than other diseases in general and prove so very fatal: which happens not more from their priority in attack than from being in their nature what they were ever considered--a severe and dangerous disease. We are to recollect, however, that measles do not in general attack at so early an age as smallpox; nor ever, like the latter, destroy eight or nine-tenths of all the children that die in the place where they happen to prevail, as was the case in the variolous epidemics of Chester and Warrington [this is an error, _vide supra_, p. 554]; consequently we have reason to hope that neither measles nor any other infantile disease will, as Dr Watt imagined, ‘come to occupy the place which smallpox once occupied,’” (p. 58). A feeble echo of Roberton’s criticism, with all its scientific candour left out and its points against Watt emphasized in a spirit of paltry cavilling, was heard next year in the Goulstonian Lectures of Bisset Hawkins on _Elements of Medical Statistics_, 1829.

Many years after, when the enormous increase of deaths by scarlatina was illustrating the doctrine of displacement in a new way, Dr Farr gave a full analysis of Watt’s essay in his annual Letter to the Registrar-General for the year 1867, and endorsed the Glasgow teaching of 1813 with more heartiness than it had hitherto received. Although Farr did not take the Malthusian view that the loss of weakly children by one means or another was inevitable, yet he could not help seeing, in his work upon the registration returns from 1837 onwards, that one infection had been taking what another spared. He recurred to Watt’s doctrine time after time in his annual reports, and in that of 1872 (p. 224), expressed his belief thus plainly: “The zymotic diseases replace each other; and when one is rooted out, it is apt to be replaced by others which ravage the human race indifferently whenever the conditions of healthy life are wanting. They have this property in common with weeds and other forms of life: as one species recedes, another advances.”

Two remarks remain to be made under the doctrine of displacement. The first is that the substitution of measles for smallpox was one of a series of such changes in the public health of Britain. The great infective scourge of medieval and early modern periods had been plague, which destroyed at times immense numbers of the valuable or mature lives. Its successor was typhus fever, which also cut off the parents more than the children, but did not retard population as the plague had done. The saving of life by the extinction of plague was in great part balanced by the loss from smallpox, which fell, however, more and more upon the earliest years of life until at length it was almost confined to them. The first great decline of smallpox itself corresponded to a great decline of typhus fever during the second half of the French war; but while there was no great infectious disease in those years to thin the ranks of the adults, measles took the place of the more loathsome smallpox in cutting off a certain number of young lives. While the older types of infection have disappeared, the incidence has shifted from mature lives to children, so much so that at the present time enteric fever, and occasional choleras and influenzas, are almost the only infections that correspond to the old plague and to typhus fever in their age-incidence.

The other remark is that the greater prevalence or fatality of measles, as if in lieu of smallpox, meant a good deal more for the bills of mortality than actually appeared under the name of measles. Smallpox was not an infection that did much constitutional damage to those that came through it, although it sometimes destroyed the vision and spoiled the beauty of the face. On the contrary, it was held by many that the general health was better after an attack of smallpox than before; and, if personal experience can justify an opinion, that ought to be my own view of the matter[1221]. But measles is an infection peculiarly apt to leave mischief behind. The bronchial catarrh, which is an integral part of the malady, and is often the cause of death in the second stage of the attack, may so affect weakly children that the respiratory organs are permanently damaged. Tuberculosis of the lungs is apt to follow measles. Some children, again, fall into mesenteric disease after measles, and die tabid, the intestinal catarrh being as dangerous in one way as the bronchial is in another. Another large proportion of the subjects of measles take whooping-cough[1222]. While smallpox did its work summarily, the full effects of measles were longer in being realized. This may in part explain the fact brought out by Watt, that while fewer children died under two years of age, measles being the dominant epidemic disease, there was an increase in the ratio of deaths from all causes between the years of two and five and from five to ten.

Measles in the Period of Statistics.

The history of measles for nearly a generation after the great epidemics of 1808 and 1811-12 is little known. No one in Glasgow continued Watt’s laborious tabulation of the causes of deaths in the numerous burial registers[1223]; nor was any regular account kept elsewhere except by the Parish Clerks of London. The following deaths by measles in their bills from 1813 to 1837, when the modern registration began, were probably no more than from a third to a half of the deaths in all London:

Measles Year deaths

1813 550 1814 817 1815 711 1816 1106 1817 725 1818 728 1819 695 1820 720 1821 547 1822 712 1823 573 1824 966 1825 743 1826 774 1827 525 1828 736 1829 578 1830 479 1831 750 1832 675 1833 524 1834 528 1835 734 1836 404 1837 577

The inadequacy of these figures to the whole of London will appear from the fact that the registration returns under the new Act gave for the last six months of 1837 the measles deaths at 1354, while the bills of the Parish Clerks gave them at 577 for the whole year. But the old bills enable us to compare the deaths from different diseases within the same area and under the same system of collection, and to compare the deaths “within the bills” in a series of years since the last of the new parishes were taken in about the middle of the 18th century. Using the bills so far legitimately, we find that measles at length came to be of equal importance with smallpox itself as a cause of death in childhood, and that it had become a larger and steadier total from year to year.

So far as concerns Glasgow, the high mortality from 1807 to 1812, making 10·76 on an annual average of the deaths from all causes, was not maintained. When the tabulation of the causes of death was resumed from 1835, the annual average of measles for the five years ending 1839 was found to be only 6 per cent. of the deaths from all causes, the average of smallpox having come back to 5·3 per cent. During that unwholesome period, in which there was much distress among the working class and a great epidemic of typhus, measles and smallpox were dividing the infectious mortality of childhood somewhat equally, the age-incidence of measles being only a little lower than that of smallpox:

_Ages of the Fatal Cases of Measles in Glasgow, 1835-39_[1224].

Under one 1-2 2-5 5-10 10-20 20-30 30-40 40-50 Total

1835 116 141 121 34 10 4 - - 426 1836 86 209 183 38 1 1 - - 518 1837 77 133 122 16 2 1 350 1838 76 124 161 39 3 1 1 405 1839 165 259 275 73 7 2 1 783 -------------------------------------------------------- 520 866 863 200 23 9 1 1 2482

In Limerick, which may stand for a typically unhealthy Irish city in the worst period of over-population, there were many more deaths from smallpox among children than from measles, the age-incidence being nearly the same, according to the following dispensary statistics for a number of years before 1840[1225]:

_Limerick Dispensary Deaths._

Age 0-5 5-10 10-15 15-20 Total

Smallpox 333 55 5 0 393 Measles 187 32 6 1 226 Scarlatina 8 2 10

Although it is impossible to prove it, yet the indications all point to measles having kept for a whole generation after 1808 the leading place among infantile causes of death which it then for the first time definitely took[1226]. Almost the only direct references to the subject were made by way of controverting the doctrine of Watt; but these are too meagre, or too general in their terms, to be of any use[1227]. The epidemics of measles seem to have travelled then, as they do now, from county to county in successive years. Thus in 1818, while most parts of England were or had recently been suffering from smallpox, the Eastern counties were suffering from measles “very frequent and fatal.” Smallpox at length reached Norwich in 1819, and became the reigning epidemic in the place of measles, which was “hardly met with” so long as the enormous mortality of the other disease proceeded[1228]. At Exeter in the spring of 1824 measles became epidemic after a long interval; many susceptible children had accumulated, and of these few escaped. The mortality was very great, and was caused by severe pulmonary inflammation, the catarrhal symptoms being mild. In one day seventeen children were buried in one of the five parish churchyards of the city; but that high mortality, according to the parochial surgeon, did not on an average stand for more than four deaths in one hundred cases[1229].

When the curtain rises, in the summer of 1837, upon the prevalence and distribution of diseases in England, as ascertained by the new system of registration of the causes of death, measles is found in the first place among the infectious maladies of childhood, thereafter yielding its place to smallpox for a year or more, and taking the lead again until it was passed by scarlatina.

_Deaths by Measles and Smallpox in London, 1837-39._

1837 1838 1839 3rd Qr. 4th Qr. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. (four quarters)

Measles 822 532 173 96 94 225 2036 Smallpox 257 506 753 1145 1061 858 634

The epidemic of smallpox hardly touched the Eastern counties until 1839; so that while the home counties in that year had far more deaths by measles than by smallpox, Norfolk had only 72 deaths by the former against 820 deaths by the latter. In the same year measles took the lead in four out of six great English towns, scarlatina being the dominant infection in one (Sheffield), and smallpox in one (Bradford):

_Deaths in 1839 by the three chief infections of Childhood._

Liverpool Manchester Leeds Birmingham Sheffield Bradford

Measles 401 773 383 170 33 70 Scarlatina 374 264 35 133 419 7 Smallpox 259 237 171 56 16 208

In all England and Wales during fully half-a-century of registration, measles has fluctuated somewhat from year to year but has not experienced a notable decline among the causes of infantile mortality (see the table at p. 614). In the decennial period 1871-80, its annual average death-rate was 377 per million living; in the next decennium it rose to 441, the previously high rates of scarlatina having fallen greatly. Among the highest rates for the ten years 1871-80, were those of Plymouth, 1·13 per 1000, East Stonehouse 1·79, and Devonport 1·19 (owing to a great epidemic in 1879-80), Exeter, 0·82, Liverpool ·91, Bedwelty (Tredegar and Aberystruth collieries) 0·88, Wigan 0·74, Whitehaven 0·71, Alverstoke 0·81. In the most recent period there have been some very high death-rates; thus at Jarrow the annual rate, which was only ·27 per 1000 from 1871 to 1880, rose in the nine years 1881 to 1889 to an annual average of ·94, having been made up almost wholly by great epidemics every other year--in 1883 (2·9), 1885 (2·4), 1887 (1·4), and 1889 (·9)[1230]. In the year 1888, an epidemic at Stoke-on-Trent, Hanley, &c. with 342 deaths, made a rate of 2·8 for the year; in Wolstanton, Burslem, &c., 221 deaths were equivalent to a rate of 2·6.

The latest reports of the Registrar-General have traced a progression of the epidemic of measles from county to county or from district to district in successive years, such as was remarked, both for smallpox and measles, by some of the 18th century epidemiologists in England, Scotland and Ireland.

Thus in 1890, measles was epidemic in Cheshire, South Lancashire and North Staffordshire; in 1891 it ceased in these, but became epidemic in North Lancashire, South Staffordshire and the West Riding; in 1892 it ceased in its last-mentioned area, and became epidemic in Warwickshire, Leicestershire, Derbyshire, the East and North Ridings, Westmoreland and Durham. During the same three years a similar progression or cycle was observable (on looking over the tables) in the South-west of England. The epidemic year of measles in Devonshire was 1889. It ceased there, and became epidemic in 1890 in Cornwall on the one side and in Somerset on the other, sparing Dorset. In 1891 it ceased to be epidemic in those parts of Cornwall and Somerset which it occupied in 1890, and became prevalent in the extreme west of Cornwall, in parts of Somerset, in Wiltshire and in Gloucestershire. In 1892 it ceased in all the last-mentioned excepting Gloucestershire, and became epidemic in Dorset, where there had been no severe prevalence of measles since 1888[1231].

Measles has no such decided preference for a season of the year as scarlatina and enteric fever have for autumn or infantile diarrhoea has for summer. But it often happens that most deaths are recorded from May to July, owing, doubtless, to the greater number of attacks in summer and not to any excessive fatality of that season. In London and the great industrial towns the deaths are spread somewhat uniformly over the year; or, in the language of statisticians, the maxima do not rise far above the mean of the year. In a tabulation of the weekly deaths in London from 1845 to 1874[1232], it appears that they touch a higher point in mid-winter (Nov.-Jan.) than in summer, a fact which may be readily accounted for by the injurious effects of the London air in winter upon a disease which is largely a trouble of the respiratory organs. In the great industrial populations of Lancashire, which resemble London in their high death-rate from measles, the rise of the deaths in mid-winter is almost the same as the summer increase[1233].

Most of the deaths from measles fall at present upon the ages from six months to three years, just as they did when the deaths were comparatively few, as at Manchester from 1768 to 1774. Deaths of adults, which were not altogether rare in the first great epidemic of modern times in 1808, are seldom heard of at present, for the same reason that adult deaths used to be uncommon in smallpox, namely, that the disease is passed by almost everyone in infancy or childhood. Although the deaths from measles sometimes reach large totals--in London during the spring of 1894 they were in some weeks as high as one hundred and fifty--yet it is the common experience of practitioners that a strong or healthy child rarely dies of measles, that the fatalities occur among the infants of weakly constitution, and especially in the numerous families of the working class in the most populous centres of mining, manufactures and shipping.

To bring these various characteristics of measles together in a concrete instance, I shall give briefly the facts of a recent epidemic in a town in Scotland of some twelve thousand inhabitants. There had been only five deaths from measles for two years. There had not been a case of smallpox for at least ten years. The measles epidemic, when its triennial opportunity came, reached a height in July, on a certain day of which month there were seven or eight burials from measles or its direct sequelae. Nearly all the children in the place who had not been through the measles in the corresponding epidemics of 1889 or 1887 suffered from it on this occasion, excepting the class of very young infants. The deaths in the whole epidemic numbered about fifty, which would not all be registered, however, as from measles. Yet this high mortality was not due to any unusual malignancy of the disease, but to the feeble stamina of a certain number of infants, or to the indifferent housing and tending of the poorer class. One did not hear of a death in the well-to-do families (probably there was none), although they had their full share of attacks. The frequency of the burials for a short time, and the effects of the epidemic on the mortality from first to last, must have been very nearly the same as in an epidemic of smallpox a century before, when the population was only a third or fourth part as large. But in the period when smallpox was in the ascendant, having few rivals among the infective causes of death in childhood, the general conditions of health in this town were altogether different. One or two specimens of the thatched huts of the poorer class had been left standing into the era of photography, so that we could compare past with present, in externals at least; also, of the houses of the richer class some still remained, perhaps turned into tenement-houses, with small windows, low doorways, and crow steps on their gables; and it was on record by the parish minister at the end of the 18th century, that within the memory of that generation there had been peat stacks and dunghills before the doors on the High Street of the burgh.

## CHAPTER VI.

WHOOPING-COUGH.

It is singular that a malady so distinctively marked as whooping-cough is should figure so little in the records of disease from former times. Astruc could find no traces of it in the medical writings of antiquity or of the Arabian period. In modern times the first known account of an epidemic of it is under the year 1578, when Baillou of Paris included a prevalent convulsive cough as part of the epidemic constitution of that year, remarking in the same context that he knew of no author who had hitherto written of the malady[1234]. Yet, if whooping-cough had been as common in former times as it has been in quite recent times, it deserved a high place among the causes of infantile mortality. Doubtless it occurred in former times in the same circumstances in which it occurs now. Baillou in 1578 speaks of it as a familiar thing; and it can be shown from an English prescription-book of the medieval period that remedies were in request for a malady called “the kink,” a name which survives in Scotland (like other obsolete English words of the 15th century) in the form of “kink host[1235].”

In Phaer’s _Booke of Children_ (1553) chincough is not named. It is perhaps more singular that the disease should be omitted from the list in Sir Thomas Elyot’s _Castel of Health_ (1541), of maladies proper to three periods of childhood; for that list has every appearance of being an exhaustive enumeration[1236]. Still, it would be erroneous to suppose that the convulsive cough of children which is so common an epidemic incident in our time, and in some impressionable subjects is the almost necessary sequel of a coryza or catarrh, did not then occur in the same circumstances as now. When Willis, in his _Pharmaceutice Rationalis_ of 1674, remarks that pertussis was left to the management of old women and empirics, he suggests the real reason why so little is said of it in the medical compends. Sydenham mentions it twice, and on both occasions in a significant context. Under the name of pertussis, “quem nostrates vocant _Hooping Cough_,” he brings it in at the end of his account of the measles epidemic of 1670, without actually saying that it was a sequel of the measles. His other reference to it, under the name of the convulsive cough of children, comes in his account of the influenza of 1679. In both contexts it is adduced as an instance of a malady much more amenable to bloodletting than to pectoral remedies, the depletion being a sure means of cutting short an attack that was else very apt to be protracted, if not altogether uncontrollable[1237]. One glimpse of it we get among the children of a squire’s family in Rutlandshire in the summer of 1661. On the 26th of May the mother of the children writes to her husband then on a visit to London[1238]:

“I am in a sad condition for my pore children, who are all so trobled with the chincofe that I am afraid it will kill them. There is many dy out in this town, and many abroad that we heare of. I am fane to have a candell stand by me to goo in too them when the fitt comes.” On 2 June, the children are still “all sadly trobeled with the chincofe. Moll is much the worst. They have such fits that it stopes theare wind, and puts me to such frits and feares that I am not myselfe.” In a third letter, the children “are getting over the chincofe. I desire a paper of lozenges for them”; and on 30 June, the children are better, but the smallpox is still in the village. It was probably from the latter disease that many were dying.

In Dr Walter Harris’s _Acute Diseases of Infants_[1239], the convulsive or suffocative coughs are mentioned in one place without being identified as chincough, while in two or three other places the malady is briefly referred to under its name. Thus, “corpulent and fat infants troubled with defluxions, and having an open mould, are most subject to the rickets, chincough, king’s evil, and almost incurable thrushes.” Again, chincough of infants is one of the inflammatory diseases that are “not altogether free from contagion”; and again: “Albeit that any notable translation of the subject matter of the fever into the lungs, and chincoughs, do advise bloodletting for the youngest infants, yet it is most evident that it is not a remedy naturally convenient for them.... And therefore its help is not to be invoked for all the diseases of infants except in the chincough or any other coughs that do attend and are concomitants of fevers that do suddenly begin”--showing his deference to Sydenham, his master.

Probably the “any other coughs” are those that he thus describes in another place (p. 26):

“Moreover he is often troubled with a slight, dry cough, though sometimes it is strangling and suffocative: with a dry cough because of the sharpness and acrimony of the humours that continually prickle the most sensible branches of the windpipe; but the choaking doth proceed from the abundance of serous and watry humours that so fill up and burden the small vesicles of the lungs that it cannot be cast off and discharged. But also they being endued with a great debility and weakness of nerves, and a superlative softness and delicacy of constitution, they are not able to subsist with that violent trouble of coughing, but do succumb under that unnatural and excessive motion of their breast, and their face is blackish as that of strangled people.”

These were cases of whooping-cough, although they are not so called. Among his eleven cases, Harris gives two in infants of the Marquis of Worcester; one had been “very often troubled with an acute fever,” and was found to be much weakened by a chincough when the physician was called to him; the other, an infant of eleven months, had at the same time an acute fever “and a cough almost convulsive.”

This inclusion, under the generic name of cough, of cases that had all the signs of whooping-cough, namely, the paroxysmal seizures, choking fits, and blackness of the face, is found also in the London bills of mortality. Although “coughs” are entered as the cause of a not very large number of deaths in the earlier annual bills, with an occasional special mention of whooping-cough among them, it is not until 1701 that “hooping cough and chincough” becomes a separate item, with six deaths in the year; next year the entry is “hooping cough” alone, with a single death, and so on for a number of years in which the deaths are counted by units; in 1716 they rise to eleven, and continue to be counted by tens until 1730, when 152 deaths are set down to “cough, chincough, and whooping-cough.” It would be a mistake to suppose that these figures during the first thirty years of the 18th century are anything like a correct measure of the number of infants in London who suffered from whooping-cough, or are at all near the number who might have reasonably been returned as dying from it. It was in that generation that the entries of the Parish Clerks became most indefinite as to the causes of death in infants, five-sixths of the enormous total of deaths under two years being entered under the generic head of “convulsions” and “teeth,” while the item “chrysoms” received the deaths under one month old.

The increase of whooping-cough in the following table, from units to tens, from tens to hundreds, and thereafter to a somewhat steady total of hundreds year after year, can hardly be explained except on the hypothesis of more exact classification of infantile deaths, corresponding to the actual decline of the article “convulsions” in the second half of the century.

Years Whooping-cough

1701 6 1702 1 1703 5 1704 0 1705 0 1706 2 1707 3 1708 3 1709 1 1710 5 1711 7 1712 3 1713 6 1714 6 1715 7 1716 11 1717 15 1718 24 1719 17 1720 33 1721 20 1722 21 1723 38 1724 25 1725 53 1726 37 1727 67 1728 21 1729 35 1730 152 1731 33 1732 65 1733 97 1734 139 1735 81 1736 130 1737 160 1738 69 1739 72 1740 280 1741 109 1742 122 1743 92 1744 46 1745 135 1746 95 1747 151 1748 150 1749 82 1750 55 1751 275 1752 188 1753 65 1754 336 1755 93 1756 199 1757 239 1758 84 1759 227 1760 414 1761 197 1762 300 1763 291 1764 251 1765 225 1766 213 1767 364 1768 262 1769 318 1770 218 1771 249 1772 385 1773 235 1774 554 1775 206 1776 181 1777 529 1778 379 1779 268 1780 573 1781 165 1782 78

(Continued in the table of measles deaths, p. 655)

It is not without significance that the vital statistics of Sweden were the first to give whooping-cough something like its rightful place among infantile causes of death: from 1749 to 1764 the deaths set down to that cause were 42,393, or an annual average of 2600, the epidemic year 1755 having 5832. In this we should find merely the influence of systematic nomenclature. Nosology, or the scientific classification of diseases, may be said to have begun under Linnaeus, who was for many years professor of medicine at Upsala before he became professor of botany, and was teaching a somewhat rudimentary nosology to the Swedish students of medicine before the great work of his friend and correspondent Sauvages made classifications general.

Concerning the year 1751, which has 275 deaths from whooping-cough in the London bills, Fothergill writes in May: “Great numbers of children had the hooping cough, both in London and several adjacent villages, in a violent degree. Strong, sanguine, healthy children seemed to suffer most by it; and to some of them it proved fatal where it was neglected or improperly managed”--the deaths having become more numerous towards the end of the year[1240]. At Edinburgh, during the second year of high mortalities in the famine-period 1740-41, whooping-cough has 101 deaths to 112 from measles, having had only a fourth part as many the year before (see p. 523). In the Kilmarnock register from 1728 to 1763, “kinkhost” is credited with a total of 116 deaths, about 3 on an annual average, measles having a total of 93 during the same thirty-six years. In Holy Cross parish, a suburb of Shrewsbury, chincough has 9 deaths in the ten years 1750-60, and 6 in the next ten years, measles having 4 and 15 in the respective periods, and convulsions 9 and 31. In Ackworth parish, chincough has no deaths in the ten years 1747-57, and 2 in the next ten years, “infancy” having 13 in each decade, “convulsions” and measles none in the first, 6 and 2 respectively in the second. Warrington, in the disastrous smallpox year, 1773, had 16 deaths from chincough and 34 from convulsions. In the two years 1772 and 1773, Chester had 33 and 10 deaths from chincough, 70 and 69 from convulsions, 17 and 13 from “weakness of infancy.”

Watt’s researches in the registers of all the Glasgow burial-grounds brought out the fact that whooping-cough during a period of thirty years, 1783 to 1812, had been a common and somewhat steady cause of death among infants, having made 4·51 per cent. of the annual total of deaths at all ages in the first six years of the period, and 5·57 per cent. in the last six years[1241]. This was a higher annual average ratio than in the London bills for the same period (see the tables at p. 647 and p. 655), and was probably the maximum in Britain, inasmuch as the Glasgow death-rate of infants was the worst from all causes.

Whooping-Cough in Modern Times.

When the causes of death began to be registered, in July, 1837, whooping-cough was found to have the following relative place among the principal maladies of children during the latter six months of the year in London and in all England and Wales.

_Mortality by diseases of Children, last six months of 1837._

London England and Wales

Convulsions 1717 10729 Measles 1354 4732 Whooping-Cough 1066 3044 Smallpox 763 5811 Scarlatina 418 2550

Throughout the whole registration period, whooping-cough has kept its place steadily among the chief causes of infant mortality, neither decreasing nor increasing notably in the successive periods from 1837 to the present time. Its mortality has varied a good deal from year to year, owing to occasional great epidemic years such as 1866 and 1878; but on the mean annual average of decennial periods, it has varied little:

_Annual Deaths by Whooping-cough per million living at all ages._

Males Females Both sexes

1851-60 460 545 503 1861-70 487 566 527 1871-80 474 547 512 1881-90 -- -- 451

No other epidemic malady has shown the same excess of female deaths in proportion to the numbers of the sex living, diphtheria being the only other that shows an excess at all.

The excess of deaths by whooping-cough among female infants was roughly shown by Watt in 1813, viz. 975 females to 842 males in the registers of the Glasgow High Church, College Church and the North-Western Cemetery, the relative numbers of the sexes living at the respective ages being then unknown. In all Scotland in 1889 the ratio was 1043 male deaths to 1225 female. The singular difference between the sexes in this respect is almost certainly related to the corresponding differences in the formation and development of the larynx, the organ which gives character, at least, to the convulsive cough of children. The expansion of the larynx in boys, which becomes so obvious at puberty and remains so distinctive of the male sex, is one of those secondary sexual characters which begin to differentiate quite early in life, and are probably congenital to some extent. It is not known whether female children are more often attacked than males; but it is probable that they are predisposed both to acquire coughs of the convulsive suffocative kind and to have their lives shattered by the attack--for the same anatomical and physiological reasons, namely, the imperfect development of the posterior space of the glottis with the spasmodic closure by reflex action[1242]. The deaths have been nearly all under the age of five.

_Deaths by Whooping-cough per million living at the respective age-periods._

0-5 5-10

1851-60 3624 174 1861-70 3766 152 1871-80 3652 135

These proportions are almost the same as those given by Watt in 1813 from three of the Glasgow registers.

Deaths by Period whooping-cough Under five Five to ten Above ten

1783-1812 1817 1713 98 3

Most of the deaths are in the first year, and in a rapidly declining ratio until the fifth, according to the following rates per million of male children living at each age-period (these figures are for a single year, 1882):

Under one One to two Two to three Three to four Four to five

3039 2115 826 433 248

The mortality from whooping-cough falls very unequally on town and country. Thus, in Scotland in 1889, it caused 2268 deaths, being 3·13 per cent. of the deaths from all causes, and equivalent to a rate of ·58 per 1000 living. The death-rate varied as follows: ·91 in the eight principal towns, ·46 in the group of large towns, ·45 in the group of small towns, ·25 in the mainland rural districts, and ·08 in the insular rural districts. In England, the capital has more than its share of deaths from whooping-cough, Lancashire coming next, while the death-rates of Monmouthshire, Cornwall and Warwickshire are also a good deal above the mean of the whole country. The lowest death-rates are found in the purely agricultural counties.

During the last half-century there has been a decline in the death-rate from all causes, including the infectious diseases as a group; but it can hardly be said that whooping-cough has had a due share in this decline. Notably in Ireland, where the decline of infectious disease has been most marked, it has been, as it were, pushed to the front of its class by the shrinkage of the other items. In Scotland it is now decidedly at the head of the list, and in England it has shared the first place with measles since the great diminution of scarlatina deaths.

_Annual average Death-rates per 100,000 living._

Whooping-cough Measles Scarlatina

England { 1871-80 51·2 37·7 71·6 { 1881-90 45·1 44·1 33·8

Scotland { 1871-80 63·1 37·0 79·5 { 1881-90 60·7 38·3 28·8

Ireland { 1871-80 34·8 21·0 43·5 { 1881-90 28·5 19·2 20·8

There is a small decrease in the death-rate of whooping-cough within the last decennial period, whereas in that of measles there is a slight increase (except in Ireland). The comparative steadiness of whooping-cough among the causes of death is doubtless owing to the fact that the bulk of its fatalities are among infants, and that there appears to be an irreducible minimum of the deaths from all causes at that age-period.

Whooping-Cough as a Sequel of other Maladies.

Although it is convenient to group whooping-cough among the infectious diseases, and although it is a clear case of a malady that comes in epidemics, yet its pathology is peculiar. It seems to be more a sequel of other diseases than an independent or primary affection. The whoop of the breath, from which it is named, is really proper to any convulsive cough of some infants or children. Adults, having undergone the change in the form and relative size of the larynx at puberty, have the convulsive cough usually without the whoop if they have it at all. After the successive influenzas of recent years (1889-92), many adults suffered from convulsive paroxysmal cough which was whooping-cough in all respects but the whoop, the choking fits, the blackness of the face, and the vomiting being, of course, all kept in subjection by the greater control of adults over their reflex actions.

It has been often remarked that the ordinary whooping-cough of children has followed epidemics of influenza, or widely prevalent catarrhs. Thus, Hillary records in July, 1753, an epidemic of whooping-cough, or “the fertussis,” all over the island of Barbados following the epidemic catarrh which was at a height in January of the same year. Whooping-cough had not been known in the island for many years past, “neither could I find by the strictest inquiry that I could make that any child or elder person did bring it hither[1243].” Willan, in his corresponding records of the succession of diseases at the Carey Street Dispensary, London, from 1796 to 1800, has the following:

“There was also among infants and children during the month of January [1796], an epidemic catarrh attended with a watery discharge from the eyes and nostrils, a frequent though slight cough, a shortness of breath, or rather panting, a flushing of the cheeks, great languor with disposition to sleep, and a quick small irregular pulse.... It was succeeded in February by the hooping cough.”

Measles, which is usually a catarrhal malady, has undoubtedly been followed by whooping-cough in many individual cases and in epidemics as a whole; and it may be that there is a closer association of whooping-cough with measles than with any other infectious disease. In the table on p. 647, the deaths by whooping cough in London from 1731 to 1830 have been reduced to ratios per cent. of the deaths from all causes, in a parallel column with the ratios of measles; it will be seen that the increase of both is equally remarkable towards the end of the table. But the Glasgow ratios abstracted by Watt show no such decided increase of whooping-cough from 1783 to 1812, side by side with the astonishing increase of measles; while his annual bills for the same period show that there were many deaths from whooping-cough in Glasgow for years before measles began to replace smallpox or to divide the mortality with it. The first high monthly mortalities from whooping-cough in Watt’s bills were from November, 1785, to the end of 1786; but there had been so little measles for twenty-four months before that epidemic began, that only one death from it is recorded all the time. Again, the great measles epidemic of 1808 in Glasgow was indeed followed by many deaths from whooping-cough in 1809; but, while the height of the measles epidemic was in May and June, 1808, it was not until April, 1809, that whooping-cough began to cause many deaths.

_Glasgow: Deaths by measles and whooping-cough._

Whooping-cough Measles

1807 Nov. 18 2 Dec. 18 1

1808 Jan. 10 2 Feb. 20 2 March 12 5 April 18 71 May 9 259 June 9 260 July 2 118 Aug. 2 32 Sept. 2 22 Oct. 2 10 Nov. 4 4 Dec. 2 2

1809 Jan. 7 4 Feb. 6 4 March 7 2 April 16 1 May 22 4 June 25 4 July 22 6 Aug. 15 2 Sept. 35 4 Oct. 23 1 Nov. 36 2 Dec. 45 10

1810 Jan. 33 4 Feb. 32 4 March 19 3

Whatever correspondence or relation there may be between measles and whooping-cough, (and it has been remarked by many in the ordinary way of experience), it eludes the method of statistics[1244]. As for the catarrhs of infants and children other than those which are part of the actual attack of measles or influenza, they are so common from year to year, and even from month to month, (perhaps coincident with teething, or with chicken-pox or other slight febrile disturbance), that a statistical study of whooping-cough in relation to them could lead only to an empirical, and possibly bewildering, result. It may be more useful to consider the antecedent probability of some such relationship, arising out of the pathology of the convulsive cough.

Whooping-cough is not only a paroxysmal cough coming on in convulsive fits at intervals, but the paroxysms, as they recur for many weeks, or, as they say in Japan, “for a hundred days,” have none of the obvious occasions of coughing, such as catarrh of the mucous membrane, congestion of the lungs from hot or close air, irritation of the bronchial tubes from dusty

## particles or vapours, or the presence of tubercles in the substance of the

lungs. Such irritants can, indeed, produce whooping-cough, as in the following instance of “artificial chincough” related by Watt:

Two children having quarelled in their play, one of them thrust a handful of sawdust into the mouth of the other. Some of the sawdust passed into the windpipe. After a short time the child began to have violent convulsive fits of coughing, in which the whoop was very distinctly formed. Expectoration in the course of a few hours removed all the irritation, and the coughing thereupon ceased.

But in natural or ordinary whooping-cough there is no mechanical irritation, there is nothing to cough up, the reflex action, violent and paroxysmal though it be, has apparently no motive. I have, in another work, offered an original explanation of the paroxysmal cough of children as being the deferred reaction, the postponed liability, the stored-up memory, of some past catarrhal or otherwise irritated state of the respiratory organs, to which I refer without attempting to summarize it here[1245].

The epidemicity of whooping-cough presents no more difficulty if the malady be viewed as the sequel or dregs of something else than if it be taken for an independent primary affection. The many infants and children that suffer from it together may have equally been suffering together from one or other of the various things of which it is assumed to be the sequel--influenza, measles, sore-throat, the bronchitis of rickets, simple bronchial catarrh of the winter, simple coryza. Again, it may be a secondary or residual affection with many, but a communicable disease to others. Much of the whooping-cough of an epidemic is believed by good authorities, such as Bouchut and Struges[1246], to be simply mimetic, or a habit of coughing acquired by hearing other children coughing in a

## particular way, just as chorea is sometimes acquired in schools or

hospital-wards through the mere spectacle of it. But it may be doubted whether much of the whooping-cough which swells the bills of mortality is acquired in that way. The children that die of it are probably most of them such as had only escaped dying of the measles or other infective disease, or of the non-specific catarrh, which had preceded the whooping-cough.

## CHAPTER VII.

SCARLATINA AND DIPHTHERIA.

Scarlatina and diphtheria have to be taken together in a historical work for the reason that certain important epidemics of the 18th century, both in Britain and in the American colonies, which were indeed the first of the kind in modern English experience, cannot now be placed definitely under the one head or the other, nor divided between the two. It may be that this ambiguity lies actually in the complex or undifferentiated nature of the throat-distemper at that time, or that it arises out of the contemporary manner of making and recording observations upon the prevalent maladies of seasons. The older or Hippocratic method was not unlike the mason’s rule of lead, said to have been in use in the island of Lesbos for measuring uneven stones; it took account of gradations, modifications, affinities, being careless of symmetry, of definitions or clean-cut nosological ideas, or the dividing lines of a classification. Sydenham was the great English exponent of this method; but, in one of his more discursive passages, he sketched out another method of describing diseases as if they were species or natural kinds[1247]. He did no more than indicate this analogy, at the same time declining to put it in practice; so that Sauvages correctly described his great Nosology of 1763 as being constructed “juxta Sydenhami mentem et Botanicorum ordinem.” The identification of scarlatina in its modern sense, including scarlatina simplex and scarlatina anginosa, falls really in the time of the nosologies in the generation following the work of Sauvages, although both the name and definition in the modern sense were used in England as early as 1749. On the other hand, the name and definition of diphtheria were little known until about the years 1856-59, when the form of throat-distemper which is now quite definitely joined to that name became suddenly common, having been almost unheard of for at least two generations before. The only English writer who has attempted to unravel the accounts of the 18th century epidemics of throat-disease was Dr Willan in his unfinished work on Cutaneous Diseases, 1808; he swept the whole of those epidemic types into the species of scarlatina, to which also he reduced the great Spanish epidemics of “garrotillo” in the 16th and 17th centuries. Whether he would have used so summary a method if he had seen the sudden return of diphtheria in 1856, may well be doubted; at all events the German writers who brought their erudition to bear upon the question of identity some thirty years ago have discovered true diphtheria among the 18th century throat-distempers, although no two of them agree as to which of these should be called diphtheria and which scarlatina anginosa. It is one advantage of a historical method that the complexities of things may be stated just as they are, with due criticism, naturally, of the matters of fact and of the relative credit of observers. The result is more an impression than a logical conclusion,--an impression which will take a colour from the pre-existing views or theoretical preferences of individual readers on such points as fixity of type or the incompetence of the earlier observers. An author who has puzzled over these difficulties in detail can hardly help having a tolerably definite impression of the real state of the case; and I do not seek to conceal mine, namely, that scarlatina anginosa and diphtheria were not in nature so sharply differentiated in the 18th century as they have been since 1856.

The significant name of _pestis gutturuosa_ or plague of the throat is given by the St Albans chronicler to the great pestilence, or some part of it, in 1315-16, during one of the worst periods of famine and murrain in the whole English history. But those two words being all that we have to base upon, there is no use speculating whether the disease was scarlatina anginosa, or diphtheria, or something different from either. This is perhaps the only reference to an epidemic throat-distemper in England for several centuries in which bubo-plague was the grand infection. In the popular medical handbooks of the Tudor period one naturally looks for scarlatina among the diseases of children. In Elyot’s _Castel of Health_ (1541), “the purpyles” is mentioned among children’s maladies in company with smallpox and measles, and the same name is in the London bills of mortality from their beginning in 1629, although it does not appear whether the deaths assigned to it were of children or adults. Perhaps the most common use of purples in the 17th and 18th centuries was for a form of childbed fever often attended with discoloured miliary vesicles. In Scotland, according to Sibbald (1684), “the fevers called purple” were any fevers, even measles or smallpox, in which livid or dark spots occurred as an occasional thing. Unless a few scarlatinal deaths are included under “purples” in the London bills (they could not have been many in any case), there is no other evidence of their existence until 1703, when the entry of scarlet fever appears for the first time, with seven deaths to it in the year. The heading remains in the bills until 1730 (the deaths never more than one figure), after which it is merged with fevers in general. The same indications of the insignificance of scarlatina among the causes of death in the 17th century may be got from the medical writers in London.

Sydenham introduced into the third edition (1675) of his _Observationes Medicae_ a short chapter entitled “Febris Scarlatina[1248].” It was a disease that might occur at any time of the year, but occurred mostly in the end of summer, sometimes infesting whole families, the children more than the elders. It began with a rigor, as other fevers did, the malaise being but slight. Then the whole skin became interspersed with small red spots, more numerous, broader, redder and less uniform than in measles; they persisted for two or three days and then vanished, and, as the cuticle returned to its natural state, there were successive desquamations of fine branny scales, which he compares elsewhere to those following the measles of 1670. Sydenham took it to be a moderate effervescence of the blood from the heat of the summer just over, or from some such excitement. It was a mild affair, not calling for blood-letting nor cardiac remedies, and requiring no other regimen than abstinence from flesh and spirituous liquors, and that the patient should keep in doors, but not all day in bed. The disease, he says, amounted to hardly more than a name (_hoc morbi nomen, vix enim altius assurgit_); but it appears that it was sometimes fatal; and in those cases Sydenham was inclined, after his wont, to blame the fussiness of the medical attendant (_nimia medici diligentia_). If convulsions or coma preceded the eruption, a large epispastic should be applied to the back of the neck and paregoric administered. Whether Sydenham was describing true scarlatina simplex, or a “scarlatiniform variety of contagious roseola,” it is from him that we derive the name of scarlatina by continuous usage to the present time[1249].

A few years after Sydenham had thus described scarlatina, Sir Robert Sibbald, physician and naturalist of Edinburgh, professed to have discovered the same as a new species of disease. “Just as the luxury of men,” he says, “increases every day, so there grow up new diseases, if not unknown to former generations, yet untreated of by them. Nor is this surprising, since new depravations of the humours arise from unwonted diets and from various mixtures of the same. Among the many diseases which owe their origin to this age, there has been most recently (_nuperrime_) observed a fever which is called _Scarlatina_, from the carmine colour (named by our people in the vernacular _scarlet_) with which almost the whole skin is tinged. Of this disease the observations are not so many that an accurate theory can be delivered or a method of cure constructed.” He proceeds to append one case--a child of eight, daughter of one of the senators of the College of Justice, who fell ill with redness of the face (thought at first to indicate smallpox coming on), became delirious and restless, then had the redness all over, which disappeared and left the child well about the fifth day. He had heard from some of his colleagues that the scarlet rash was sometimes interspersed with vesicles--perhaps the _miliaria_ so much in evidence a generation or two later. In adults, Sibbald had seen the cuticle fall from nearly the whole body. But extremely few (_paucissimi_) had died of this fever. Like Sydenham, he omits to mention sore-throat and dropsy[1250].

Another 17th century reference is by Morton, who practised in London, in Newgate Street, from about 1667 to the end of the century, and was frequently called to consult with apothecaries or other physicians in cases of sickness in middle-class families. In the second volume of his _Pyretologia_, published in 1694, he has a chapter “De Morbillis et Febre Scarlatina,” and a separate chapter “De Febre Scarlatina.” His position towards scarlet fever is peculiar. He uses the name, he says, in deference to the common consent of physicians, but, for his own part, he thinks scarlatina different from measles only in the form of the rash, so-called scarlatina being confluent measles just as there is a confluent smallpox. Except in that sense he sees no reason for retaining scarlatina in the catalogue of diseases. Both arise from the same cause, both have hacking cough, heaviness of the brain, sneezing, diarrhoea; the single difference is that in scarlatina the rash is continuous. He gives eleven cases, most of which are clearly enough cases of measles; but the fourth case, that of his own daughter, Marcia, aged seven, in 1689, “in quo febris dicta Scarlatina, tempore praesertim aestivo, quadantenus publice grassabatur,” had no cough, nor redness of the eyes, nor diarrhoea, nor any other catarrhal symptoms (such as her sister had in 1685), but on the fourth day a continuous scarlet rash over the whole skin, which ended, not in a desquamation of fine branny scales, but in parchment-like peeling. The eleventh instance is complex enough to show that Morton had some reason, at that early stage in the history of scarlatina, for hesitating to make the disease a distinct type under a name of its own.

About midsummer, 1689, he was called to the house of his friend Mr Hook, merchant, of Pye Alley, Fenchurch Street, and found the whole household, three young girls, one little boy, and their aunt Mrs Barnardiston, a matron aged seventy, all suffering from the effects of some infection of as deleterious a kind as synochus, the symptoms being hacking cough, coma, delirium, and other signs of malignity. But on the 4th, 5th, or 6th day, each had a scarlatinal rash all over the skin, which lasted until the 7th, 8th or 10th day. Two of the girls, and the boy, had “on the 4th or 5th day of the efflorescence” extensive parotid swellings, difficulty of swallowing, vibrating arteries, and other urgent symptoms, for which they were blooded. The parotid abscesses burst, and discharged a copious acrid, corrosive pus by the nostrils, ears and throat, for the space of thirty days, during which the patients gradually got well. The third girl had, on the 3rd or 4th day of the rash, a painful swelling in the left armpit, not unlike a bubo; she also was blooded, and recovered completely, the swelling having broken and discharged pus for many days. The case of the aunt, aged seventy, was somewhat different; she neglected her medicines, acquired a “carcinoma” or slough over the pubes, which became gangrenous, recovered with difficulty, and lived three years longer.

Morton calls these cases a veritable _pestis_ or plague; and he goes on in the same context to say: “what swellings have I seen of the uvula, fauces, nares, and how protracted! At other times, what turgid lips, covered with sordid crusts and ulcerated!”--instancing the child of Mr Blaney, who had these symptoms long after the efflorescence, together with fever and coma[1251]. These cases, all given under the eleventh history illustrating the chapter on Scarlatina, are perhaps not different from those which Huxham, next in order, described in 1735, but not under the same name. It would appear from a reference in Hamilton’s essay on Miliary Fever, published in 1710, that scarlet fever continued to be seen in London: “If, in a scarlet fever, miliary pustules should arise, dying away with a red colour, they promise safety[1252].”

Several of the annalists of epidemic constitutions agree as to fatal anginas in the year 1727, with an exanthem of the miliary kind. Wintringham, of York, mentions the two things apart--in one place a putrid fever with cutaneous eruptions of a fuscous colour, sometimes dry, sometimes filled with a clear serum; in another place, “about this time many anginas were prevalent, attended with extreme suffocation, which proved fatal unless they were speedily relieved.” He mentions the same putrid fever in the summer of 1728, and again anginae. Hillary, who was then at Ripon, gives the same fever in 1727 (or perhaps in 1726) with miliary eruption, and chronicles “a fatal suffocative quinsey” in the winter of 1727-28, of which many died, especially those that had been reduced by the fever. Huxham’s account of an epidemic malady of the throat and neck at Plymouth in January and February, 1728, might relate to mumps (which Hillary and an Edinburgh observer describe clearly enough under 1731); and under October, 1728, he describes an erysipelatous and petechial fever, often relieved by an eruption of red miliary vesicles accompanied by sweats, the same miliary fever being again common in the autumn of 1729. This association of “putrid” fever with sore-throat became still more notable in the period 1750-60.

These anginas of 1727-28 are unimportant compared with the outbreak a few years later. We hear first from Edinburgh in June, 1733, of scarlet fever and sore throats frequent in several parts of the country near the city, and continuing all through the summer into the winter and spring of 1734[1253]. Then in April, 1734, begins a series of important notes by Huxham at Plymouth[1254]. In that month, he says, there began a certain anginose fever (“for so I shall call it”), raging more and more every day. It mostly affected children and young people. Among other symptoms were vomiting and diarrhoea, pain and swelling of the fauces, languor, anxiety, delirium or stupor, a favourable issue being attended with sweats and red pustules. In May it was raging worse, with more severe angina and most troublesome “aphthae.” In June it was now miliary-pustular, and not seldom erysipelatous, while the throat was “less oppressed.” On the 6th or 7th day the cuticle looked rough and broken as if thickly sprinkled with bran; at length the whole desquamated--sometimes the entire skin of the sole of the foot coming off. The more copious the rash, the better the chance for life. It was contagious, affecting several in the same house. In July it cut off several within six days of the onset. Huxham’s references to this putrid miliary fever in Devon and Cornwall go on for some time, without farther mention of the throat complication. In April, 1735, “raro nunc adest strangulans faucium dolor, paucaeque nunc erumpunt pustulae.” But, in September, 1736, he enters again, “febres miliares, scarlatinae, pustulosae,” often attended with swelling of the parotid glands and of the fauces, and with profuse sweats.

The most important scene of fatal angina with rash in the same period (1734-35) was the North American colonies. Before coming to that remarkable outburst, I shall mention one curious coincident outbreak in the island of Barbados. Dr Warren, who occupies his pen chiefly with yellow fever, says[1255]: “In this space of time [1734 to 1738], there arose here a few other diseases, that were really epidemical and of the contagious kind too, few escaping them in families where they had once got a footing. The first was an obstinate and ill-favour’d erysipelatous quinsey. The second a very anomalous scarlet fever, in which almost all the skin, even of the hands and feet, peeled off,”--just as Huxham described for Devonshire.

It is beyond our purpose to include the evidence from foreign countries; but it may be noted in this context that Le Cat, in tracing the antecedents of the great Rouen fever in his paper of 1754, refers to many fatal anginas in that city about twenty years before[1256]. Thus we find about the year 1735 evidence of the beginning of a remarkable “constitution” of throat-disease both in the old world and in the new. But the facts in America stand out with peculiar prominence, and shall be given on the threshold of the subject as fully as possible.

The Throat-distemper of New England, 1735-36.

The accounts of the great wave of “throat-distemper” that spread over the towns and villages of New England in 1735 are singularly clear and even numerically precise. The arrival of this sickness is one of the most definite incidents in the whole history of epidemics; it was hardly possible for the common belief, whether popular or professional, to have been mistaken about it. Just a hundred years had passed since the first settlement of the Puritans on Massachusetts Bay and along the Connecticut river; Boston had grown to a town of some 12,000 inhabitants, and many small towns and townships had sprung up along the coast and in the interior. The population was still sparse, although it was growing rapidly from within; it is difficult to believe that even the largest towns could then have deserved the strictures which Noah Webster passed upon them two generations later[1257].

In the mother country at that time, smallpox was the great infectious malady of infancy and childhood. It was not unknown in the colonies, Boston having had epidemics in 1721, 1730 and 1752, and Charleston an epidemic in 1738 after an almost free interval of thirty years. Even in the chief cities of the colonies such epidemics were only occasional, affecting adults and adolescents perhaps more than infants and as much as children; while in such a town as Hampton, for which the register was well kept from 1735, it is known that there were no smallpox deaths in the twenty years following, or until the period 1755-63, when four died of the disease, and that only one death from it occurred in the next recorded period of ten years, 1767 to 1776. It was in these circumstances of a growing population, almost untouched, at least in the inland towns, by the great infantile infectious malady of the old country, that the throat-distemper broke out and raged in the manner now to be described.

The disease “did emerge,” as Douglass says, on the 20th of May, 1735, at Kingston township, some fifty miles to the east of Boston[1258]. The first child seized died in three days; in about a week after three children in a family some four miles distant were successively seized, and all died on the third day; it continued to spread through the township, and Douglass was informed that of the first forty cases none recovered. It was vulgarly called the “throat illness” or “plague in the throat.” Some died quickly as if from prostration, but most had “a symptomatic affection of the fauces or neck: that is, a sphacelation or corrosive ulceration in the fauces, or an infiltration and tumefaction in the chops and forepart of the neck, so turgid as to bring all upon a level between the chin and sternum, occasioning a strangulation of the patient in a very short time.” In August it was at Exeter, a town six miles distant, but it did not appear at Chester, six miles to the westward, until October. After the first fatal outburst in Kingston township it became somewhat milder; but in the country districts of New Hampshire it was fatal to 1 in 3, or 1 in 4 of the sick, and in scarce any place to less than 1 in 6. This average was made up by its excessive fatality in some families; Boynton of Newbury Falls lost his eight children; at Hampton Falls twenty-seven died in five families. The following table, compiled by Fitch, minister of Portsmouth, shows the deaths from it in various towns and townships of New Hampshire during fourteen months from May, 1735, to 26 July, 1736, with the ages[1259]:

_Deaths from the throat-distemper in 14 months, 1735-36_ (Fitch).

Under Ten to Twenty Thirty Above ten years twenty to thirty to forty forty Total

Portsmouth 81 15 1 -- 2 99 Dover 77 8 3 -- -- 88 Hampton 37 8 8 1 1 55 Hampton Falls 160 40 9 1 -- 220 Exeter 105 18 4 -- -- 127 Newcastle 11 -- -- -- -- 11 Gosport 34 2 -- -- 1 37 Rye 34 10 -- -- -- 44 Greenland 13 2 3 -- -- 18 Newington 16 5 -- -- -- 21 Newmarket 20 1 -- 1 -- 22 Stretham 18 -- -- -- -- 18 Kingston 96 15 1 1 -- 113 Durham 79 15 6 -- -- 100 Chester 21 -- -- -- -- 21 --- --- --- --- --- --- 802 139 35 4 4 984

The meaning of these figures in the townships of New Hampshire will appear from the case of Hampton. In the year 1736 its burials from all causes were 69, and its baptisms 50; while the throat-distemper alone, during fourteen months of that and the previous year, cut off 55. As we have seen, Hampton had no smallpox to ravage its children; but the throat-disease of 1735-36 had almost the same effect as the occasional disastrous epidemics of smallpox had upon English towns of a corresponding population or annual average of births.

This plague in the throat attacked the children of the most sequestered houses, especially those situated near rivers or lakes. It was least fatal to those who lived well, both Douglass and Colden assigning the salt diet, and other things likely to produce _psora_, as the reason of its greater severity. In the country districts or townships, in which the fatalities were most numerous, it would appear that an eruption, scarlet or other, was not only not the rule but even something of a rarity. Douglass, who was familiar with the exanthem in the Boston cases, assigns its absence in the country to a mistaken evacuant treatment, by which “the laudable and salutary cuticular eruption has been so perverted as to be noticeable only in a few, and in these it was called a scarlet fever.”

When the disease broke out in due course at Boston it proved much less malignant than in the country. The first case, on the 20th August, had white specks in the throat and an efflorescence of the skin. A few more soon followed in the same locality, of which none were fatal; they had soreness in the throat, the tonsils swelled and speckt, the uvula relaxed, a slight fever, a flush in the face and an erysipelas-like efflorescence on the neck and extremities. The first death was not until October, the disease becoming more frequent and more fatal in November, and reaching its worst in the second week of March, when the burials from all causes rose to 24, the average per week in an ordinary season being 10. The fatalities in Boston were so few for the enormous number of cases that many could scarce be persuaded that it was the same disease as in the Townships. In the corresponding weeks (1 Oct. to 11 May) of eight ordinary years preceding, the average deaths were 268, whites and slaves; during this sickness they were 382, or an excess of 114, which were probably all due to the throat-distemper, as many as 76 fatal cases having come to the knowledge of Douglass himself. He estimates the whole number of attacks at 4000, giving a ratio of one death in thirty-five cases; but it is clear that very slight cases of sore-throat were counted in.

The fatal cases in Boston seem to have shown a great range of malignant symptoms: “We have anatomically inspected persons who died of it with so intense a foetor from the violence of the disease that some practitioners could not continue in the room.” Among the bad symptoms were the coming and going of the miliary eruption, dark livid colour of the same, the vesicles large, distinct and pale, like crystalline smallpox; an ichorous discharge from the nose; many mucous linings expectorated, resembling the cuticle raised by blisters; pus brought up where no sloughs could be seen in the fauces; extension to the bronchi, with symptoms of a New England quinsey (? croup); in some children, spreading ulcers behind the ears; the tongue throwing off a complete slough with marks of the papillae. Among the after-effects in severe cases were anasarca or dropsy of the skin, haemorrhages, urtications, serpiginous eruptions chiefly in the face, purulent pustules, boils, or imposthumations in the groins, armpits and other parts of the body, indurations of the front of the neck (the same by which many in the country were suffocated, and a few in Boston), hysteric symptoms in women, and epileptic fits.

Douglass gives special attention to the eruption, which he calls miliary in his title-page. Some had a sore-throat without any eruption, and a very few had an eruption with no affection of the throat beyond the tonsils and uvula swollen. In some the eruption preceded the soreness of the throat, in some the two came together, but in the general case the eruption was a little later than the affection in the throat. The ordinary course was a chill and shivering, spasmodic wandering pains, vomiting or at least nausea, pain, swelling and redness of the tonsils and uvula, with some white specks: then followed a flush in the face, with some miliary eruptions, attended by a benign mild fever; soon after, the miliary efflorescence appears on the neck, chest and extremities; on the third or fourth day the rash is at its height and well defined, with fair intervals; the flushing goes off gradually with a general itching, and in a day or two more the cuticle scales or peels off, especially in the extremities. At the same time the cream-coloured sloughs or specks on the fauces become loose and are cast off, and the swelling goes down. Where the miliary eruptions were considerable the extremities peeled in scraps or strips like _exuviae_; in one or two, the nails of the fingers and toes were shed. Some who had little or no obvious eruption underwent a scaling or peeling of the cuticle.

The epidemic having spent its force upon the New England towns from the autumn of 1735 until the summer of 1736, gradually travelled westward, and was two years in reaching the Hudson River, distant only two hundred miles in a straight line from Kingston, where it first appeared in May, 1735. It continued its progress, with some interruptions, until it spread over the colonies from Pemaquid in 44°N. latitude to Carolina; and as Douglass, writing in 1736, had heard that “it is in our West India Islands,” it was probably the same disease that Warren recorded for Barbados in the same years under the names of “an obstinate and ill-favour’d erysipelatous quinsey,” and “a very anomalous scarlet fever”; and the same as the epidemic “sore-throats” that another records for the Virgin Islands in 1737[1260].

Although it usually attacked several children in the same house, it did not seem to be communicable, like smallpox, from person to person or by the medium of infected clothes. The Boston physicians held a consultation on the point, and published their opinion that it proceeded entirely from “some occult quality of the air.”

* * * * *

This was the first appearance of sore-throat with efflorescence of the skin among the English colonists of North America. For at least two generations after, the disease remained in the country, breaking out unaccountably from time to time at one place or another and often cutting off many children, but never so malignantly as at first[1261]. Colden, writing from near New York in 1753, says:[1262]

“Ever since I came into this part of the country where I live (now about fourteen years), it frequently breaks out in different families and places, without any previous observable cause, but does not spread as it did at first. Sometimes a few only have it in a considerable neighbourhood. It seems as if some seeds or leaven or secret cause remains wherever it goes; for I hear of the like observations in other parts of the country. Several have been observed to have it more than once.... In different years and different persons the symptoms are various. In some seasons it has been accompanied with miliary eruptions all over the skin; and at such times the symptoms about the throat have been mild and the disease generally without danger if not ill treated. Some have had sores, like those on the tonsils, with a corrosive humour behind their ears, on the private and other parts of the body, sometimes without any ulceration in the throat” (case given of a child of ten with sores on the pudenda).

It was in 1754, the very next year after Colden wrote as above, that the second great epidemic of throat-distemper arose in New Hampshire and the neighbouring parts of Massachusetts. The figures of its mortality which have been preserved for the town of Hampton, New Hampshire, may serve as a sample of its prevalence subsequent to the original explosion of 1735-36. In the first epidemic, 1735-36, there died at Hampton of the throat-distemper, 55 persons, mostly children. In the second, from January 1754 to July 1755, there died of it 51 persons. The deaths from all causes in those two years were 85, and the births 70.

The following table shows the proportion of deaths from throat-distemper to the deaths from all causes in Hampton from 1735 to 1791[1263].

Deaths from Deaths from Period throat-distemper all causes

1735-44 91 216 1745-54 60 221 1755-63 30 187 1764-66 -- -- 1767-76 3 115 1777-86 7 99 1787-91 0 46

It was once more described, for New York city, by Dr Samuel Bard in 1771[1264]. He identifies it with the disease described by Douglass in 1735, and gives an account of it on the whole like Colden’s.

It was “uncommon and very dangerous,” mostly a malady of children under ten. They drooped for several days, had a watery eye, then a bloated livid countenance, and a few red eruptions here and there on the face. This went on for three or four days, the throat meanwhile showing white specks on the tonsils. Sudden and great prostration ensued, with a peculiar hollow cough and tone of voice, or loss of voice, constant fever, especially nocturnal, and a degree of drowsiness. In fatal cases there was great restlessness and tossing of the limbs towards the end. In one family all the seven children took it one after another; three died out of the four elder; the three younger recovered, having had ulceration behind the ears, which continued for several weeks and rendered an acrid, corrosive ichor. Many other children had these ulcerations behind the ears, sometimes with swelling of the parotid and sublingual glands. The same ulcerations might occur also “in different parts of the body.” Sloughs of the fauces and epiglottis extended as a membranous exudation into the trachea. Two cases occurred in women, one of them having assisted to lay out two children dead of the distemper.

The last time of its general spreading (within the period covered by Belknap’s _History of New Hampshire_, 1791) was in 1784-85-86 and -87. It was first seen at Sandford in the county of York, and thence diffused itself very slowly through most of the towns of New England; but its virulence and the mortality which it caused were comparatively small[1265].

Angina maligna in England from 1739.

Although there had been an extensive prevalence of angina with miliary or scarlet or erysipelatous rash in Devon and Cornwall in 1734 and following years, a slight amount of sore-throat with scarlet fever in and near Edinburgh in 1733, a great prevalence of throat-distemper with scarlet or miliary rash in the North American colonies in 1735-37, and an ill-favoured erysipelatous quinsy as well as an anomalous scarlet fever in Barbados, St Christopher, &c., during the same period, yet it was not until the end of the year 1739 that cases more or less similar occurred in London. The incident that first drew attention to the throat-distemper in the capital was the death of the two sons of Henry Pelham, the colleague of his relative the Duke of Newcastle in the premiership[1266]. Horace Walpole, writing twenty years after concerning similar calamities in the family of the Earl of Bessborough, says that not only Mr Pelham’s two sons, but also two daughters and a daughter of the Duke of Rutland all died together. Chandler, writing in 1761, says that he well remembered the disease at the end of 1739. Early in 1740 he had in his own practice as an apothecary two cases of children sick in one family; the first died, and as he was at a loss to account for the death, there being “something in the whole of the case quite new and unknown to me,” he called in Dr Letherland to see the other, who declared that the child would die also, as it did. Letherland then spoke to Chandler of the death of the two Pelhams shortly before, “of the alarm it caused all over this great city, both from its novelty and fatality,” and of his own care and pains in turning over ancient and modern writers to see if he could trace any footsteps of this remarkable and terrible disease: at last, after long search, he had been so happy as to discover the identical disease circumstantially described in the Spanish writers[1267].

The identification of the English throat-distemper of the 18th century with the _garrotillo_ of Spain in the 16th and 17th centuries was thus undoubtedly due to Letherland, so far as English learning was concerned, and he received due credit for it in the Harveian Oration at the College of Physicians on the first occasion after his death[1268].

Chandler thus described the state of the disease at its first breaking out in 1739:

“The first and common appearances are feverishness, sickness, vomiting or purging; the proper and diagnostic signs which follow are an ulcerous slough in some part of the fauces, discharging a fœtid matter.... The nostrils are glandered.... From the absorption of the fœtid pus, the blood is contaminated; crimson efflorescences and small putrid pustules break out on the skin of the neck and breast, a quick depressed pulse, with a tendency rather to stupor than violent perturbations accompanying all, and, if not relieved, terminate in delirium, languor, clammy sweats and death.”

Fothergill, whose name is so closely associated with the outbreak of gangrenous sore-throat a few years after, makes little of the earlier epidemic in London; besides the cases in the Pelham family and some others in the same part of the town, there were, he says, very few observed, so that “the disease and the remembrance of it”--including Letherland’s priority--“seemed to vanish altogether.” The winter of 1739-40, in which these cases had occurred, was one of intense frost and the beginning of a two years’ sickly period in which typhus in Britain, dysentery and typhus in Ireland, reached a height unprecedented in the 18th century.

An epidemic of Throat-disease in Ireland, 1743.

In Ireland the dysenteries, typhus and relapsing fevers, attendant on and following the famine, were hardly over when the plague of the throat began among the children. It was seen first in the summer of 1743 (an influenza having preceded in May and June), it raged through the autumn and winter, and was not extinct for many years after. There were but few instances of it in Dublin, but it was prevalent in the adjoining counties, and exceedingly so in Wicklow, Carlow, Queen’s County, Kilkenny, Cavan, Roscommon, Leitrim, Sligo “and perhaps many others, carrying off incredible numbers, and sweeping away the children of whole villages in a few days.” The country doctors, who knew most of it, were not apt to record their experiences; so that the following account, which Rutty extracted from Dr Molloy, is all the record that remains of an epidemic concerning which one would wish to have known more[1269]:

“It is peculiar to children, and those chiefly of from a month to three, four, five, six, eight or nine years old. They commonly for a day or two, or more, had a little hoarseness, sometimes a little cough; then in an instant they were seized with a great suffocation lasting a minute or two, and their face became livid; they have frequent returns of these fits of suffocation like asthmatic persons. The said suffocation is ever followed by one symptom which continues till they die, viz. a prodigious rattling in the upper part of the aspera arteria [windpipe] resembling that sound which attends colds when there is phlegm that cannot be got up. It is scarce sensible when they are awake but very great when they are asleep.”

While there is little in this account to suggest the malignant sore-throat, and no mention of a miliary or scarlet rash, yet Rutty made no doubt that it was the malignant angina, comparing it rather to that described by Starr for Cornwall in 1748 than to that of Fothergill’s description. He adds, from some other source of information, that children had generally clammy sweats upon them, with foetor of the breath. Many died in twenty-four hours; none lived above five days. Some had tumours behind the ears, which mortified. Many had a prodigious weeping behind the ears, which was very corrosive. A case is given of a child recovering after a profuse sweat, which suggested diaphoretic treatment by warm baths and sack-whey. Swellings of the tonsils and uvula were not observed.

It will be convenient to give here what remains to be said of the 18th century history of sore-throat in Ireland. In 1744 Rutty enters “mortal anginas” in Dublin. In March, 1751, tumours of the face, jaws, and throat, following an epidemic among horses in December, 1750. In the spring of 1752 “the pestilential angina” made great havoc among children. In the spring of 1755, “the gangrenous sore-throat” (same as in 1743) was fatal to some children. In the winter of 1759-60 he records “scarlet fever,” and a singular form of the same in May, 1762, noticed under Influenza (p. 356). This must serve for the Irish experiences, although it is far from satisfactory. But it should be added that Dr James Sims, of Tyrone, who came to London afterwards and there wrote on the Scarlatina Anginosa (1786), says in an account of his Irish practice: “During all my practice here I have not seen one instance of the malignant ulcerous sore-throat as described by authors” (_op. cit._ 1773, p. 86).

Malignant Sore-throat in Cornwall, 1748.

Dr Starr, of Liskeard, calls the Cornish throat-disease the Morbus Strangulatorius. Writing in January, 1750, he said it had raged in several parts of Cornwall “within a few years,” with great severity[1270]: “Many parishes have felt its cruelty, and whole families of children been swept off: few, very few, have escaped.” Cases given by himself belong to the year 1748; and Huxham, who did not meet with it at Plymouth until 1750-51, says that it had been raging with great fatality for a year or two before in and about Lostwithiel, St Austel, Fowey and Liskeard. In the account of the Cornish epidemic the emphasis falls upon the affection of the larynx and trachea; while there are so many other symptoms enumerated, including eruptions and brawny swelling of the neck, that it is clearly impossible to distinguish between exanthematous fever with sore-throat and laryngeal diphtheria pure and simple. Starr says: “Dr Fothergill’s sore-throat with ulcers and Dr Cotton’s St Albans scarlet fever are, in my opinion, but its shadows.”

The symptoms generally pointed to the glottis.

Agonized breathing for a time was followed by the spitting up of jelly-like, glairy and somewhat transparent matter, mixed with white opaque thready matter, which might resemble more or less a rotten body or slough. The paroxysm returned, and the patient either died suddenly or sank away gradually, and died worn out, with or without convulsions. A plate is given of a whitish membrane loosened from the velum by means of hydrochloric acid on a silver probe; it was not a slough, but a strong tenacious membrane which would bear handling and stretching without breaking. In the same case, the child’s father afterwards pulled from the mouth a complete cast of the trachea including the bifurcation of the bronchi, of which a figure is given: “what sweated from it was as sticking as bird-lime”; he lived twenty-one hours after this second cast was drawn from him and died somewhat suddenly in his perfect senses. Such formations Starr clearly believed to be the essence of the disease; but he gives many variations of it. The train of symptoms was not the same in every subject: “Some, I am informed, have had corrosive pustules in the groin and about the anus, eating quick and deep, and threatening a mortification even in the beginning [as Colden described for the sore-throat in New York State]. Others after a few days’ illness have had numbers of the worst and deepest petechiae break out in various parts of their body: such I have not seen.” But he gives cases of his own at Liskeard in 1748: “A child here and there had red pustules which broke out in the nape of the neck and threw off a surprising quantity of thin transparent ichor”; these pustules sloughed when poulticed; in another case sloughs followed where blisters had been applied to the neck and arm. Many had swelling of the tonsils, parotids, submaxillary and sublingual glands. A few had oedema from the chin to the thyroid, and up the side of the face. In one case, a tumour of the fauces broke and yielded some ounces of coffee-coloured foetid matter, to the patient’s relief and ultimate recovery. Not a few had gangrenous sloughs in the mouth, which formed quickly. Some had foetor of the breath as an early symptom, but others had it not. Some were merely feverish and hoarse.

When Huxham came to describe the disease at Plymouth a year or two later, he laid the emphasis on other symptoms than those mostly dwelt upon by Starr, describing really a sloughing sore-throat with rash. But he has this also: “The windpipe itself was sometimes much corroded by it, and pieces of its internal membrane were spit up, with much blood and corruption; and the patients lingered on for a considerable time, and at length died tabid.”

Fothergill’s Sore-throat with Ulcers, 1746-48.

Meanwhile we have to overtake Fothergill’s history of the ulcerous sore-throat in or near London[1271]. It broke out at Bromley, near Bow, Middlesex, in the winter of 1746 (Short says that it was in Sheffield in 1745). So many children died suddenly, some losing all and others the greater part of their families, that people were reminded of the plague.

It began with a chill and rigor, followed by heat. The throat became sore, and there were nausea, vomiting and purging. The face turned red and swollen, the eyes were inflamed and watery, the patient was restless, anxious and prostrated. The seizure was often in the forenoon, and in all cases the symptoms became much worse towards night, to be relieved by a sweat in the morning, as in an intermittent fever. The uvula, tonsils, velum, inside of the cheeks, and the pharynx, were florid red, with a broad spot or patch, irregular in figure, of pale white colour like the blanched appearance of the gums when they have been pressed by the finger. Usually on the second day of the disease, the face, neck, breast and hands to the tips of the fingers became of a deep erysipelatous colour with perceptible swelling, the fingers in particular being often of so characteristic a tint as at once to suggest an examination of the throat. A great number of small pimples, of a deeper red than the skin around them, appear on the arms and other parts; they are larger and more prominent in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and lower extremities. With the coming out of this rash, the sickness, vomiting and purging cease. The white spot or spots on the throat are now seen to be sloughs; they come first usually in the angles above the tonsils. They are not formed of any foreign matter covering the parts but are real mortifications of substance leaving an ulcer with corrosive discharge behind. The nocturnal exacerbation now takes the form of delirium and incoherent talking. The parotids are commonly swelled and painful; and if the disease be violent, the neck and throat are surrounded with a large oedematous tumour threatening suffocation. The pulse is 120, perhaps hard and small. The urine is at first crude and pale like whey; afterwards it is more yellow, as if from bile; and towards recovery it is turbid and deposits a “farinaceous” sediment. The initial purging having ceased, the bowels become irregular. The disease had no crisis, but in general, if the patient were to recover, the amendment began on the third, fourth or fifth day, when the redness disappeared and the sloughs in the throat were cast off.

Such is the main outline; the following symptoms have less general value.

At the outset, the patient complained of a putrid smell in the throat and nostrils, which caused nausea. The nostrils were often inflamed, yielding a sanies, and the inside of the lips covered with vesicles filled with an excoriating ichor. Some had the parts about the anus excoriated. Fothergill was inclined to think that either the excoriations or the ichor from them extended down the whole intestinal tract, and accounted for the purging, with other bowel symptoms, which sometimes remained for weeks after the primary disease and caused death by emaciation[1272]. In some there was bleeding at the nose, or mouth, which might be fatal; in one case there was a like accident from the ear. Several cases are given in which there were no sloughs of the throat, but a dry glossy redness or lividity; in these cases, there was a general brawny swelling of the neck, a coldness of the hands and feet, involuntary evacuations, a glassy eye and certain death. Three of Fothergill’s five briefly reported cases are of that variety. In one of them, a boy of 14 years, he says there was “deep redness of the face, hands and arms, with a plentiful eruption of small pimples, which induced those about him to apprehend it was a scarlet fever.”

That is the only reference to a possible diagnosis of scarlet fever in the whole essay. In the New England throat-distemper of 1735, “scarlet fever” was in like manner the name given by the laity, and disapproved by the profession. Fothergill, adopting the erudition of Letherland, identified the ulcerous or gangrenous sore-throat of London in 1746-48 with the _garrotillo_ of Spain in the 16th and 17th centuries, the famous throat-plague of Naples and other places in Italy and Sicily from 1618 onwards, and the “plague in the throat” mentioned by a traveller, Tournefort, in 1701 as occurring among children in the island of Milo, (Douglass having already identified the Levantine plague in the throat with the throat-distemper of New England in 1735.)

After the outbreak at Bromley and Bow in the winter of 1746, the ulcerous, or putrid or gangrenous angina continued in London and the villages near until the date of Fothergill’s writing (1748). By credible accounts, he says, it was also “in several other parts of this nation.” Short, of Rotherham, a professed epidemiologist, says that the malignant angina “never left Sheffield entirely since the year 1745[1273].” Fothergill himself, in his monthly accounts of the weather and diseases of London from 1751 to 1755, refers to the sore-throat once or twice; thus, in October, 1751: “epidemic sore-throat, in both children and adults”; and again, in July, 1755: “The ulcerated sore-throat likewise appears in many families, with the greatest part of its usual symptoms, but gives way without much difficulty, if no improper evacuations have been made, to the method heretofore recommended (XXI. 497)[1274].”

“Scarlet Fever” at St Albans, 1748.

The same disease that Fothergill described for London and villages near was seen at St Albans in the autumn of 1748, and described as “a

## particular kind of scarlet fever,” by Dr Nathaniel Cotton, who kept a

madhouse there. Among his friends were the poet Cowper (at one time his patient), and Young, of the ‘Night Thoughts.’ Cotton himself had the same melancholy cast of mind, and found the same solace in making verses, which have probably served more to keep his memory green than his essay in medicine[1275]. He professes to describe “a particular kind of scarlet fever” in his title-page; and in the text he has this remark: “From this diversity of symptoms, I have found some practitioners inclined to think that this disease could not with propriety be called a scarlet fever. But I imagine that such disputes are about words only.” It is, indeed, difficult to find any real difference between his particular kind of scarlet fever and the “sore-throat with ulcers” which Fothergill wrote upon a few months before, or, again, between his scarlet fever and that of Withering thirty years after.

The sickness began about the end of September, 1748, in St Albans and some towns adjacent. At first it attacked children only, afterwards also adults. The symptoms given are just those detailed by Fothergill, as well as by Douglass for New England:

Sickness with purging at the outset, rapid swelling of the tonsils and (or) the parotids and maxillary glands, whitish sloughs on the tonsils, small ulcers up and down the fauces, the eyelids puffed as in measles, swelling of the neck, arms and hands in many, in some swelling of the body also, intense red efflorescence, coming on either suddenly or tardily, with thick spots as if dipped in blood. On the face, neck and breast, the rash was even with the surface, elsewhere it was miliary or shagreen. Some were restless or anxious, and delirious, others so drowsy that when awakened to receive a draught or the like, they relapsed at once into stupor. The attack, if not violent, ended on the fourth or fifth day; there were few in whom the fever did not return on one, two or more evenings thereafter, so going off gradually. In one or two, the parotids swelled after the fever was gone, continuing hard for a fortnight and then suppurating. In nearly all, the cuticle peeled off “as in other scarlet fevers.” In some the nervous system was much shaken; in particular they dreaded the approach of evening with an unusual kind of horror, and started at the shadows of the candles on the wall. In convalescence some complained of universal soreness. The spots where blisters had been applied continued to discharge in some cases eight or ten days or more.

Besides the reference to swelling of the neck, arms or body among the early symptoms, there is no reference to oedema, while the pallid dropsy of convalescence, which Withering described in 1779, is not mentioned. It is noteworthy that Cotton, who lays the emphasis on the scarlatina, and not on the throat-disease, was of opinion that the copiousness of the eruption was not a measure of the security of the patient, although that was clearly the opinion of Huxham and others, who laid the emphasis on the sore-throat.

Epidemics of Sore-throat with Scarlet rash in the period between Fothergill and Withering.

The years 1751-52, and indeed the whole of that decade, saw a good deal of the same diseases, after which little is heard of them until 1778. Huxham’s accounts for Plymouth, which are of the first importance, begin with 1751[1276]. They are of importance because his memory went back to the anginose fever of 1734, in which the miliary eruptions, with sweats, were critical or relieving to the throat, and because he could not clearly distinguish between them and the sore-throats of 1751-52, although he follows Fothergill in identifying the latter with the Spanish _garrotillo_. The throat affection began in the end of 1751, and became most severe in October, November and December, 1752, in Plymouth and at the Dock and all around, carrying off a great many adults as well as children. It ceased in May, 1753. He describes the sloughing patches in the throat, the excoriated nostrils with acrid dripping discharge, the swelling of the parotids and sometimes of the whole neck, just as other writers had done; and gives the account of laryngeal or tracheal membranes already cited (p. 695). It is perhaps more important to dwell upon his account of the rash. Most commonly the angina came on before the efflorescence, but in many instances the cuticular eruption appeared before the sore-throat. “A very severe angina seized some patients that had no manner of eruption, and yet even in these a very great itching and desquamation of the skin sometimes ensued; but this was chiefly in grown persons, very rarely in children.” Commonly there was a rash, general or

## partial, on the second, third or fourth day.

“Sometimes it was of an erysipelatous kind, sometimes more pustular; the pustules were frequently very eminent, and of a deep fiery-red colour, particularly in the breast and arms, but oftentimes they were very small and might be better felt than seen, and gave a very odd kind of roughness to the skin. The colour of the efflorescence was commonly of a crimson hue, or as if the skin had been smeared over with the juice of raspberries, and this even to the fingers’ ends; and the skin appeared inflamed and swollen, as it were; the arms, hands and fingers were often evidently so, and very stiff and somewhat painful. This crimson colour of the skin seemed indeed peculiar to this disease.” The eruption seldom failed to give relief; but there were also cases of an universal fiery exanthem which proved fatal. An early and kindly eruption, when succeeded by a very copious desquamation of the cuticle, was one of the most favourable symptoms.

Comparing it with the _febris anginosa_ which he had entered in his annals under the year 1734, at a time when the ulcerous or malignant sore-throat was still unheard of, he says that the earlier type differed from the later in being more inflammatory, and less putrid; the sore-throat of 1751-52 might seem to be a disease _sui generis_, but it differed from the anginose fever of 1734 only in the above respect: “In a word, the high inflammatory smallpox differs as much, or more, from the low malignant kind, as the _febris anginosa_ from the pestilential ulcerous sore-throat.” In the latter he found the remarkable evidences of putridity already cited in connexion with putrid fevers[1277]. He gives the case of a boy of twelve whose tongue, fauces and tonsils were as black as ink; he swallowed with difficulty, and continually spat off immense quantities of a black, sanious and very foetid matter for at least eight or ten days; about the seventh day, his fever being abated, he fell into a bloody dysentery, but recovered eventually. In a few the face before death became bloated, sallow, shining and as if greasy, and the whole neck swollen. Even the whole body might be oedematous in some degree, retaining the impression of the finger.

Perhaps it may be said that Huxham had really to do with two diseases; and he does in one place say: “The anginose fever still continued, and we had several of the malignant sore-throats in September, many more in October, &c.”--as if the two were not the same. But he generalized the “epidemic constitution” of 1751-52, in another way: “In all sorts of fevers there was a surprising disposition to eruptions of some kind or other, to sweats, soreness of the throat and aphthae. The smallpox were more fatal in August, and sometimes attended with a very dangerous ulceration in the throat and difficulty of swallowing. Indeed the malignant ulcerous sore-throat was now also frequent, probably sometimes complicated with the smallpox.” Even pleuritic and peripneumonic disorders were attended during this constitution with a sore-throat, aphthae, and some kind of cuticular eruption.

Some facts about the throat-disease at Kidderminster and other places in Worcestershire will complete this part of the somewhat perplexing history. Dr Wall says it appeared about the beginning of 1748 chiefly in low situations[1278]: “It then went generally under the name of scarlet fever, the complaint in the throat not being much attended to, or at least looked upon only as an accidental symptom.” His first cases were at Stratford-on-Avon--a young lady who recovered with difficulty, and then two sisters who died, all three having been treated by blood-letting and the cooling regimen. By these cases Wall was convinced that the disease was more putrid than inflammatory, that it was infectious, that the antiphlogistic treatment was a mistake, that bark was the grand remedy, that the throat was the principal seat, and that the scarlet efflorescence was rather an accidental symptom than essential to the disease, some having petechiae and purple spots. He adopts Mead’s name of _angina gangraenosa_. The malady had been rife in the city of Worcester, and most of all at Kidderminster, where it was in a manner epidemical. He was told that nine or ten poor persons had died of it there one after another. Having been called to the child of a respectable tradesman, he treated the case with bark and the cordial regimen. He persuaded the Kidderminster surgeons and apothecaries to adopt the same method, which they did with such success that, as he found afterwards in the books of one of them, there were only 7 deaths in 242 cases of the disease, while Dr Cameron did not fail once, and Wall himself had fifty recoveries and only two deaths. It is said, however, on the authority of the parish register, that a hundred persons died at Kidderminster of the malignant sore-throat in 1750, “in the months of October and November only[1279].” Dr Wall goes on to say that the “Kidderminster sore-throat” had a vast variety of symptoms, the only certain ones being aphthous ulcers and sloughs on the tonsils and parts about the pharynx. “Very few here [which may mean Worcester] have had the scarlet efflorescence on the skin.” Dr Johnstone, senior, confirms this in a measure for Kidderminster[1280]: “The anginous fever was not always, though often, attended with cutaneous eruptions; and these, for the most part red, were sometimes also of the christalline miliary kind.” And in writing again in 1779, when Withering’s scarlet fever was dominant in place of Fothergill’s sore-throat, Dr Johnstone said: “A scarlet eruption was a much more frequent symptom of this disease than it used to be when I first became acquainted with it nearly thirty years ago.” But, as it is known that the rash of true scarlet fever is far less constant in adults than in children, and as many of the attacks referred to by Wall and Johnstone were in adults, the so-called Kidderminster sore-throat may have been a fairly uniform scarlatina. Still, it is clear that all the leading writers, excepting Cotton, of St Albans, distinguished between sore-throat (gangrenous, malignant, or ulcerous) and scarlatina, identifying the former with the old _garrotillo_ of Spain and Italy[1281]. The distinction may have been really between scarlatina simplex and scarlatina anginosa, as Willan believed; but whether the disease were malignant scarlatina, or diphtheria, or a mixture of the two (as in Cornwall), or an undifferentiated type with the characters of both, it was certainly new as a whole to British experience in that generation, and, if we except the reference by Morton to certain cases which may have been sporadic, it was a disease hitherto unheard of in England since systematic medical writings began. We may realize the impression which it made, both in the American colonies and in England in the middle third of the 18th century, by recalling the sudden appearance of diphtheria some thirty-five years ago; but, whereas the diphtheria of 1856-58 came upon a generation of practitioners who had seen much of the very worst kinds of scarlatina for twenty years or more, the contemporaries of Huxham, Letherland, Fothergill, Johnstone and Wall in England, or of Douglass, Colden and Bard in America, knew no scarlet fever but scarlatina simplex. The outbreaks of the 18th century throat-distemper in certain families were of the same tragic kind as diphtherial outbreaks in our own time. Instances of whole families swept away have been cited from the New Hampshire epidemic of 1735. Horace Walpole gives the following instance of a noble family in London:

“There is a horrid scene of distress in the family of Cavendish; the Duke’s sister, Lady Bessborough, died this morning of the same fever and sore throat of which she lost four children four years ago. It looks as if it was a plague fixed in the walls of their house; it broke out again among their servants, and carried off two a year and a half after the children. About ten days ago Lord Bessborough was seized with it and escaped with difficulty; then the eldest daughter had it, though slightly: my lady attending them is dead of it in three days. It is the same sore throat which carried off Mr Pelham’s two only sons.... The physicians, I think, don’t know what to make of it[1282].”

The medical accounts of the sore-throat of those years are none the easier to interpret in a modern sense owing to the frequent use of the term “miliary” to describe the rash. Douglass had used this term in the title of his Boston essay in 1736. Bisset applies it to a Yorkshire epidemic some twenty years after[1283]. The disease began among adults at Whitby in September and October, 1759, and spread over the country between the coast and Guisborough in the spring of 1760, as well as in some places to the westward of the latter; afterwards it became epidemic in all the western parts of Cleveland in August and September of 1760, the summer months having been almost a clear interval. It was remarkable, he says, that some persons in the eastern parts of Cleveland who had escaped it when it was epidemical in the spring, were attacked by it in the autumn after it “had got a good way to the westward of them.” This epidemic progression is spoken of as of a single but composite disease,--“the epidemic throat-distemper and miliary fever that appeared in the Duchy of Cleveland in 1760.” In adults it was mostly an affection of the throat, few having the miliary eruption, and only one adult dying “within the circle of my observations.” But in children the fever with miliary rash was predominant, and of it the fatality is put at one death in every thirty cases. There is no discussion as between the names of scarlet fever and miliary fever; but the following on the peeling of the skin is significant: “From the ninth to the thirteenth day the scarf-skin begins to peel off in cases that were attended by a copious rash; and that of the hands and feet sometimes came off almost entire.” Soreness of throat often happened in this fever of children; and, to repeat, the sore-throat of adults and the miliary fever of children are described as parts of one and the same epidemic[1284]. An account which probably relates to the same disease comes from Rotherham or Sheffield in a letter by Dr Short, the epidemiologist, to Rutty, of Dublin. It was very violent, he says, in July, 1759, and cut off whole families of children. The attack was attended with diarrhoea, swelled tonsils, oedema of the face, an eruption like measles all over the body, and a discharge of sanious humour from the nostrils. “In some there was an efflorescence on the skin like the scarlet fever, and these recovered[1285].”

Another complication arises owing to the prevalence, in the same period, of putrid or miliary fevers, which had sometimes an anginous or “throaty” character. This source of perplexity extends from near the beginning to near the end of the 18th century, but it is greatest in the middle period, when the “constitution” was most decidedly “putrid[1286].” The relationship was most definitely expressed by Johnstone, of Kidderminster: “This malignant fever (_vide supra_, p. 123) was very often, though not constantly, complicated with, and in general had great analogy with the malignant sore-throat which at this time prevailed in many parts of England.” An Oxford practitioner, in 1766, actually wrote a dissertation to distinguish the “putrid sore-throat” which attended the “putrid” continued fever of the time, from the “gangrenous sore-throat” of Fothergill, Huxham and others: in the former, the aphthae and sloughs of the tonsils and uvula, as well as of the mouth, were only symptomatic of the putrid fever, and late in showing themselves; in the latter, the throat affection was the primary and dominant one, present from the beginning of the illness[1287].

The last complication of the highly complex circumstances in which scarlatina first became a great disease in England is with “putrid” or malignant measles. In the same years as the epidemic described above for Yorkshire, namely, 1759 and 1760, there occurred an “anomalous malignant measles,” which for some months had made a melancholy carnage amongst children in the west of England. The symptoms were difficult breathing, an amazingly rapid pulse, white or brown tongue, and “some red eruptions which run in irregular groups and splatches on the surface of the skin.” The attack was apt to be attended by colliquative diarrhoea. A fatal issue was indicated by a sunken and very quick pulse, the abatement of the dyspnoea, and the eruption coming and going. Some rapid cases in infants ended in convulsions on the third day. Children from one to six years were attacked most[1288]. Perhaps the only reason for not including this among epidemics of measles is the author’s remark: “I look upon the poison of the disease to be a good deal akin to that of the ulcerated sore-throat so very rife and fatal some years since,” although he does not allege throat-complications in the malady which he describes.

Three years later, in 1763, there was an epidemic at the Foundling Hospital, London, which Watson, the physician to the charity, described in a special essay as one of “putrid measles.” Willan, writing in 1808, challenged the diagnosis on the ground both of the symptoms as given by Watson, and of the names given to the malady in the Infirmary Book at the time. The first entry in the apothecary’s book is on 23 April, 1763, a case of “fever with a rash,” the next on 30 April, a case of “scarlet fever,” then on 7 May, ten cases of “eruptive fever,” and, for the rest of May and all June, very long lists of “eruptive fever,” the name of measles not occurring at all in that outbreak, while the names of “morbillous fever” and “fever” are given to a smaller but still considerable outbreak in November of the same year. Among the symptoms, Watson mentions that the fauces were of a deep red colour, that the rash came out on the second day, and that there was no cough. The most remarkable character of the epidemic as a whole was a tendency to sloughing in various parts:

“Of those who died some sank under laborious respiration: more from dysenteric purging, the disease having attacked the bowels; and of these one died of mortification in the rectum. Besides this, six others died sphacelated in some one or more parts of the body. The girls who died most usually became mortified in the pudendum. Two had ulcers in their mouth and cheek, which last was so covered by them that the cheek, from the ulcers within, sphacelated externally before they died. Of these one had the gums and jawbone corroded to so great a degree that most of the teeth on one side came out before she died. The lips and mouth of many who recovered were ulcerated, and continued so for a long time.” The anatomical examination of those who died showed the bronchitic affection, in one case pleurisy, and in some a gangrenous condition of the lungs. One died of emaciation six weeks after the attack. Eleven others succumbed shortly after to smallpox, out of eighteen who caught the latter during recovery from the preceding epidemic disease[1289].

Long after, in 1808, when the diagnosis between measles and scarlatina was fixed, Dr James Clarke saw at Nottingham in several cases of measles “a great tendency to gangrene,” the sites of blisters having mortified in two (as in scarlet fever) and two having gangrene of the cheek and mortification of the upper jaw[1290]. Huxham, he says, saw such cases, Willan never; and that was one of the reasons why Willan claimed the Foundling cases as scarlatina. The diagnosis is important; for, in the same year, 1763, the bills of mortality record 610 deaths from measles in London, and Watson expressly includes the 19 deaths in the Foundling Hospital (in 180 attacks) as part of the general epidemic in London.

The confusion between measles and scarlatina is farther shown by the entries in the Infirmary Book of the Foundling Hospital from the beginning to the end of an extensive epidemic in 1770: On 31 March, 23 children are in the infirmary with “measles,” and on 7 April, 37 children still with “measles”; on 12 May the long list is headed “measles and ulcerated sore-throat,” on 19 May, “putrid fever,” and on 26 May, “fever and ulcerated sore-throat[1291].”

Whether or not we agree with Willan in taking the Foundling epidemic of 1763 (and perhaps with it the general epidemic in London) for one of scarlatina, it can hardly be doubted that the Foundling epidemic of 1770 was the latter disease, the names of “measles with ulcerated sore-throat,” “putrid fever,” and “fever and ulcerated sore-throat” clearly indicating scarlatina anginosa. Grant also records the prevalence of epidemic sore-throat in London in 1770[1292], and Dr William Fordyce, writing in 1773, dealt with the “ulcerated and malignant sore-throat” as a question of the day[1293].

It was not until forty years ago, he says, that they had become acquainted in England with ulcerated and malignant sore-throat, while “both kinds” are now very common. His aim is to separate the ulcerated from the malignant, and he instances an outbreak in a gentleman’s house at Islington, where the worst symptoms of the malignant occurred in the children, while only the ulcerous prevailed among the servant maids. In 1769 it was reported to be seldom fatal in London and Westminster, and in the villages around; but within these last twelve months (1773) it had appeared of a bad type in high situations such as Harrow, in the months of June and July. In a later note, he adds that “it still continues to make a havock so considerable as to keep up the alarm about it both in the metropolis and all over England,” his own last experience of it having been two fatal cases in a noble family a few miles to the west of London. Fordyce identified this disease with Fothergill’s sore-throat, and described the eruption as “the general erysipelatous colour that comes about the second day on the face, neck, breast and hands to the finger ends, which last are tinged in so remarkable a manner that the seeing of them only is sufficiently pathognomonic of the malady [this is a repetition of Huxham and Fothergill]; and finally a great number of small pimples, of a colour more intense than that which surrounds them, appearing in the arms and other parts of the body.” He gives the following as a case of the malignant sore-throat in a young gentleman five or six years old: “Every part of the body that bore its own weight was gangrened, as well as the orifices where he had been blooded twice before I saw him (which was three days after the seizure); the parotid glands were very much swelled, the whole body was more or less oedematous, and the skin throughout of an erysipelatous purple; he died the third day after I saw him.”

Although Fordyce, and probably most others, still adhered to Fothergill’s view of the sore-throat with ulcers as a disease apart, yet there appear to have been at this date some who followed the line taken with regard to it by Dr Cotton in 1749. Sometime about the end of 1771 or beginning of 1772, a physician at Ipswich sent to a London physician, who sent it to the _Gentleman’s Magazine_, an account of a “Successful Method of treating the Ulcerated Sore Throat and Scarlet Fever,” by tartar emetic, calomel &c.[1294] He begins: “The ulcerated sore-throat and scarlet fever has been very rife in this place and the neighbourhood for some months past, and has been in a considerable number of instances fatal. It has in every respect answered the description given of it by Dr Fothergill”--so much so that he does not give the symptoms, but only the treatment, which, in his own hands, had been singularly successful: “I have had considerably more than one hundred patients, and have not buried one,” his cases, between the writing and printing of the paper (3 June) having “increased to near three hundred with the same success.” This must have been an interval of mild scarlatina, during which the prevalence of the malady, however extensive, had attracted little notice. The outburst in 1777-78, from which the diagnosis and naming of scarlatina anginosa properly date, was obviously an interruption of a quiet time of the disease.

Scarlatina anginosa in its modern form, 1777-78.

Dr Levison[1295], who was physician to a London charity called the General Medical Asylum located at No. 4, Tottenham Court-road (afterwards in Welbeck Street), observed the outbreak, on 15 July, 1777, of a malignant sore-throat, “nearly such as described by Dr Fothergill and Dr Huxham (only without the efflorescence and attended with costiveness),” among children from three to seven years, by which many were cut off in the space of six to eight days, some by suffocation and others by vomiting of blood. It became more general in August, and in some was very malignant, being joined with an erysipelatous inflammation and a diarrhoea. It raged with great fury in Kentish Town, and at Enfield Chase it swept away many in twenty-four hours. But on the high ground about London, as at Hampstead and Highgate, it was of a benign type. It was worse in the villages round than in the capital itself.

In the milder form, there was only a superficial whiteness of the uvula, tonsils and velum; in the more severe, the same parts were beset with thick ulcerations, running very deep in the fauces. Both in the milder and in the more severe cases the neck became swollen on the second or third day. The commencement was usually with shivering and nausea, followed by heat, and an efflorescence over the breast, the limbs, and often the whole body, of a crimson red. “Some were spread over with a kind of little millets, similar to that in the miliary fevers, and which scaled off the skin the sixth or seventh day; in which cases the ulcerations were very slight, as also all other symptoms of malignancy.” The mouth was apt to be full of sloughs, the teeth covered with black crusts. The urine was scanty, high-coloured, with a thin suspended cloud. Some bled from the nose. The nostrils were apt to be stuffed with greenish sanies, which dropped out continually. The efflorescence and sore-throat were often met with separately. Most had cough throughout, great dejection of spirits, and oppressed breathing. The disease had no regular progress and no crisis; the whole of the symptoms would often cease suddenly about the eighth or ninth day. In one case there was recovery after three weeks’ illness. Several cases had suppuration of the glands of the neck. In one fatal case, a tumour behind the right tonsil was found to contain three ounces of fœtid pus.

Oedema was frequent after recovery--the lips, nose and face bloated, sallow, shining and greasy; the belly also might be swollen. This, says Levison, was a peculiar kind of dropsy; and as he adds that it had not been remarked by Huxham he intends to distinguish it from the bloated greasy appearance which Huxham did remark. Some died of it a month after the fever; many recovered from it by the aid of calomel, rhubarb and diuretics--the treatment for the scarlatinal dropsy--and full doses of bark. In the acute disease blisters were sometimes tried, in compliance with custom; but they did no good, and occasioned a great discharge of thick matter. Bleeding and antiphlogistics were seldom called for. This outbreak, which began in July 1777, abated in November. Next year it came back about the middle of March, but in a benign form, and unattended with either the efflorescence or the diarrhoea, and so continued until the date of writing, the 11th May, 1778. Levison distinguishes two or three types--a malignant sore-throat at the outset early in summer, 1777, to which in autumn two other epidemics were joined, namely, on the one hand, scarlet fever (or miliary fever), and on the other hand, a purging like autumnal dysentery.

The second season of the epidemic in London[1296], the spring and summer of 1778, saw the outbreak of malignant sore-throat, with rash, in the Midlands. It appeared in Birmingham about the middle of May, and in June it was frequent in many of the towns and villages in the neighbourhood. It continued to the end of October, and revived a little during mild weather after the middle of November. It seems to have reached Worcestershire in the autumn, cases having been seen first at Stourbridge and afterwards at Kidderminster and Cleobury. According to Johnstone, the younger, it broke out first in schools, and spread very rapidly among children, attacking adults sometimes. The summer of 1778 was remarkable for heat, which is described as West Indian in its intensity.

The account of this epidemic which has attracted most attention (and deservedly) is that of Withering, of Birmingham, who had written his thesis at Edinburgh twelve years before (1766) on _angina gangraenosa_. He calls it definitely by the name of “scarlet fever and sore-throat, or _scarlatina anginosa_,” explaining that it was “preceded by some cases of the true ulcerated sore-throat,” by which he meant the disease described by Fothergill in 1748. The elder Johnstone, then of Worcester, who had described the Kidderminster sore-throat of 1750-51, declared that the scarlet eruption was a more common symptom of this 1778 disease than it used to be when he first became acquainted with it near thirty years before; and dealing with the same epidemic as Withering, he makes out three varieties:--namely, first the scarlatina simplex of Sydenham, with no sore-throat, second, the scarlatina anginosa, and third, the ulcerated sore-throat[1297]. His son, who also wrote upon the epidemic of 1778 as he saw it at Worcester, having written his Edinburgh thesis upon malignant sore-throat several years before, says: “The disease which now prevails is the ulcerous malignant sore-throat, combined with the scarlet fever of Sydenham[1298].” Saunders, a retired East Indian surgeon, described the corresponding epidemic in the north of Scotland as one of sore-throat and fever[1299].

Withering’s account of the symptoms differs little from that given by Levison the year before, and is chiefly noteworthy for confirming that writer as to the occurrence of scanty urine and oedema[1300]:

The rash came out on the third day, continued scarlet, the colour of a boiled lobster, for two or three days, then turned to brown colour, and desquamated in small branny scales. He had been told of three instances in which the desquamation was so complete that even the nails separated from the fingers. In the colder weather of October the scarlet colour was less frequent and less permanent. Many had no appearance of it at all; while others, especially adults, had on tender parts of the skin a very few minute red pimples crowned with white pellucid heads. The worst cases fell into delirium at the outset, had the scarlet rash on the first or second day, and might die as early as the second day; if they survived, the rash turned to brown, and they would lie prostrate for several days, nothing seeming to afford them any relief. “At length a clear amber-coloured matter discharges in great quantities from the nostrils, or the ears, or both, and continues so to discharge for many days. Sometimes this discharge has more the appearance of pus mixed with mucus. Under these circumstances, when the patients do recover, it is very slowly; but they generally linger for a month or six weeks from the first attack, and die at length of extreme debility.” These discharges, compared by a writer a generation before to glandered secretions, are not to be confused, says Withering, with the matter from abscesses on both sides of the neck, under the ears, which “heal in a few days without much trouble.” The submaxillary glands were generally enlarged. Adults usually had a ferretty look of the eyes, and sometimes small circular livid spots about the breast, knees and elbows. Some had a succession of boils. One man had “lock-jaw.” Most patients had the fauces,

## particularly the tonsils, covered with sloughs, which separated and

left the parts raw, as if divested of their outer membrane. The most troublesome symptom was exulcerations at the sides and towards the root of the tongue; these were painful and made it impossible to swallow solid food. Some threw out several white ash-coloured sloughs, though no such sloughs were visible upon inspecting the throat.

With reference to the diagnosis between scarlatina anginosa and angina gangraenosa (of Fothergill) Withering says: “They are both epidemic, they are both contagious; the mode of seizure, the first appearances in the throat, are nearly the same in both; a red efflorescence upon the skin, a great tendency to delirium and a frequent small unsteady pulse are likewise common to both. With features so strikingly alike, and these, too, of the most obvious kind, is it to be wondered that many practitioners considered them the same disease?” And again: “But perhaps he will never be able precisely to draw the line where the light begins and where the penumbra ends[1301].”

The extent of the epidemic of scarlatinal sore-throat, of which we have

## particulars from Middlesex, Warwickshire and Worcestershire in 1778,

cannot be ascertained. It is heard of, as we saw, in the north of Scotland in 1777. According to Barker, of Coleshill, the scarlet fever which “in a manner raged in the neighbouring town of Birmingham,” occurred in only a few cases in his own parish, and these mild[1302]. It appears to have been in Carlisle the year after, 1779, under which date Heysham says that “two epidemics swept off a great number of children--smallpox and a species of scarlet fever[1303].” Nothing more is heard of it in Carlisle for the next eight years, during which Heysham kept an account of the diseases. The epidemic of 1778-9 fell also upon Newcastle:

From the month of June, 1778, until the 1st September, 1779, there were treated 146 cases of “ulcerated sore-throat,” of which 18 were fatal. The epidemic was at its height in September and October. The ages were: under ten years, 98, ten to twenty, 25, twenty to thirty, 18, above thirty, 5. Dropsy followed in 23; 75 were mild scarlatina and sore-throat, 33 were angina maligna. During the ten years following, until 1789, only 57 more cases were treated from the Newcastle Dispensary, of which 8 were fatal[1304].

History of Scarlatina after the Epidemic of 1778.

In London, according to Dr James Sims, scarlatina with sore-throat occasioned a great mortality in the latter half of 1786. The bills of mortality assign only 19 deaths to sore-throat, while they give 793 for the year to measles. But Sims says that “measles were not present in London during the whole year; at least I saw none, and I saw about two thousand cases in private and at the General Dispensary.”

The deaths from scarlet fever, he thinks, had been given under measles and also under “fevers,” which were a large total for the year. The epidemic was very virulent, going through families; many lost two children, some a larger number; many adults fell victims to it who were supposed to die of common fever.

Sims’ first case was of a youth at Camberwell, in March, with scarlet rash and sloughs of the throat. He saw no more cases for several weeks, and then, on 1 May, he was called to a case of sore-throat in a school at Hampstead; the illness was slight, and there was no efflorescence; but in June there occurred in the same school an explosion of scarlatina, twenty of the girls being seized within a short time. It was in other suburban villages in the summer, but did not enter London until August, after which Sims saw three hundred cases of it; of some two hundred treated by him in a certain way, only two died. The symptoms of the epidemic were the usual ones of scarlet fever with ulcerated or sloughing throat. In November and December, swelling attacked the face and extremities, which were painful but not oedematous. The parotids were swollen. Several had the angina without the rash; others the rash without the angina[1305].

The same epidemic in London was one of the early medical experiences of Dr Robert Willan, who gave some account of it in the volume ‘On Cutaneous Diseases’ which he published in 1808, shortly before his death[1306]. It began in the autumn of 1785, was superseded by measles for a time, and revived again in 1786, to last into 1787. It was most malignant in the narrow courts, alleys and close crowded streets of London, but existed also in the villages near. While admitting the existence of measles in the winter of 1785-86, he confirms Sims in saying that it was not measles (as in the Bills) but scarlatina that caused the high mortality in 1786: “The cases of scarlatina during the year 1786 exceeded in number the sum of all other febrile diseases within the same period.” The deaths were mostly between the seventh and eighteenth day of the fever. The following is his classification of over two hundred cases seen by himself:

1786

Scarlatina Scarlatina Scarlatina Sore-throat simplex anginosa maligna without eruption

April -- 3 -- -- May 6 10 2 -- June 4 12 1 4 July 2 11 1 3 August 1 17 4 4 Sept. 2 29 9 12 Oct. 3 24 5 7 Nov. 0 38 12 10 Dec. 0 8 5 2 -- --- -- -- 18 152 39 42

The infirmary book of the Foundling Hospital has long lists of patients sick of “scarlet fever with sore-throat” in August and September, 1787, as many as 76 being under treatment in one week, the next week 39 sick of scarlet fever, besides 45 recovering from it. This is the first unambiguous entry of an epidemic of scarlet fever in the Foundling Hospital records[1307]. Under the same year, 1787, Barker, of Coleshill, records “scarlet fever, smallpox, and chincough” in a neighbouring city, as well as pestilential sore-throats “epidemical everywhere in the terrible foul weather of winter.” His next entry of “scarlet fever and sore-throat” is under the year 1791[1308].

An account by Dr Denman, of London, dated 28 November, 1790, of “a disease lately observed in infants,” but otherwise unnamed, appears to relate to diphtheria. Eight cases in young infants were seen, one per month from April to October, of which six proved fatal. The signs were “thrush in the nose,” fulness of the throat and neck, the tonsils red, swelled, and covered by ash-coloured sloughs or extensive ulcerations. The skin sloughed at places where blisters were applied. Nothing is said of a scarlet rash[1309].

Scarlatina (1788) and Diphtheria (1793-94) described by the same observer.

One good observer at the end of the 18th century, Rumsey, a surgeon at Chesham, in Bucks, has left full accounts of two epidemics in his district, one in 1788, which he calls “epidemic sore-throat[1310]” and the other in 1793-94, which he calls “the croup[1311].” The one corresponds to scarlet fever, the other to diphtheria. The author does not think it necessary to enlarge on the distinction between the “epidemic sore-throat” and “the croup” as it was so obvious; yet the former was “Fothergill’s sore-throat,” which some English writers of the present time assume to have been diphtheria; while the disease which Rumsey calls “the croup” corresponds with laryngeal and tracheal diphtheria, not unmixed with diphtheritis of the tonsils, uvula and velum. There is hardly anything in the history of scarlatina and diphtheria more instructive than the juxtaposition of those two excellent descriptions by Rumsey, who grudged the name of scarlatina to the former epidemic because the rash was not invariable, and called the latter by the name of croup although it was not confined to the larynx and trachea, and was epidemic in the summer months.

The epidemic of “sore-throat” in 1788 began in April and lasted until November, attacking those of every age except the very old, but especially children, and mostly women among adults.

The throat was slightly sore for twelve or twenty-four hours; it then became fiery red, the uvula and tonsils being much swelled. About the second or third day there were whitish or yellowish sloughs on the tonsils and uvula, which in many cases left deep, ragged ulcers. It was many days before the sloughs were all exfoliated. Some spat up an astonishing quantity of mucus; in young children there was apt to be a discharge of mucus from the nostrils, and in a few cases from the eyes. The parotid and submaxillary glands were often enlarged, sometimes suppurating or sloughing. A white crust separated from the tongue on the third or fourth day, leaving it raw and red. In some cases there was sickness with vomiting, in some diarrhoea. In many cases there was a scarlet eruption over the whole body, usually on the second or third day. The fatal cases had all a very red eruption, and the skin burning to the touch. In some the eruption was so rough as to be plainly felt. In a few cases, after the efflorescence broke out, a number of little pustules made their appearance about the breast, arms, &c., of about the size of millet seeds, which died away in twenty-four or thirty-six hours. This was not common; but in one family the mother and three of the four ailing children had pustules. One young man had large white vesicles on the sixth day; another young man, in November, had vesicles on the arms, thighs and legs as large as a half-crown piece, filled with yellow serous fluid, or gelatinous substance, with a good deal of erysipelas round them. The red efflorescence was always followed by peeling. Many had the throat-disease without rash, but none had the efflorescence without the sore-throat.

Rumsey decides against two distinct types of disease; it was the same contagion acting on different constitutions; yet he could not help thinking that scarlatina anginosa was an improper term for it, inasmuch as the rash was not constant. It was a less putrid disease than that described by Fordyce in 1773 (_supra_, p. 707), and carried off but few considering the great numbers who were affected by it. Two of the fatalities in children were from the anasarca of the whole body, with scanty urine, which came on a week or two after. He bled only once, applied leeches to the temples in several, and saw many recoveries with no treatment but topical applications.

The epidemic five or six years after in the same town in a valley of Buckinghamshire and on the hills for some six miles round was something unusual. Rumsey had about forty cases of “the croup” from March, 1793, until January, 1794; whereas his father, who had practised there above forty years, could not recall more than eight or ten cases of “croup” in all his experience. The cases were all in children from one to fourteen years; there were sometimes three attacked in one family; most of the fatal cases occurred in summer; the epidemic was distributed impartially in the valley where Chesham stands and upon the hills enclosing it. Rumsey gives full details of seventeen cases, eight that died and nine that recovered, with post-mortem notes for some.

His first case was in March, 1793; then came a succession of cases about June and July, of which four that proved fatal were in children just recovered from measles. All those earlier cases had the disease coming on insidiously, then the peculiar cough and tone of voice, if any voice remained, paroxysms of choking, expectoration of shreds of membrane, giving relief to the distress, and the trachea found after death lined with a coagulated matter[1312]. Among these summer cases were three children in one family, of whom two died, both being just out of the measles. The later series of cases in the winter of 1793-94 were less often fatal; the epidemic constitution, he says, became less severe towards the end; he also used mercurials freely on the later cases; but it is farther noteworthy that “most of the cases which occurred in November and afterwards, were attended with inflammation and swelling of the tonsils, uvula and velum pendulum palati, and frequently large films of a whitish substance were found on the tonsils”--so that the disease was in its extension more than cynanche trachealis, or croup, even if it had not been also an epidemic infection.

In only one case, the eighth recorded, does he seem to have hesitated between “the croup” and sore-throat: “ulcerated sore-throats being at this time [6 Sept. 1793] somewhat prevalent, induced me to inspect the fauces, and I observed a swelling and no inconsiderable ulcer on the left tonsil.” It was in the autumn and winter that these throat complications of “the croup” mostly appeared; and it was because he found “so much disease about the tonsils” in the tracheal and laryngeal cases that he forebore to bleed, and used mercurials. Also in the same season when “the croup” was joined to disease of the tonsils, uvula and velum, there was a certain epidemic constitution prevalent: “In the autumn, likewise, and winter, many children suffered by erysipelatous inflammation behind the ears, in the groins, on the labia of girls, or wherever the skin folded, attended with a very acrid discharge”--precisely the complication of the “throat-distemper” of America described by Douglass and Colden as well as by Bard, also of the Irish throat-epidemic in 1743 mentioned by Rutty, of the morbus strangulatorius in Cornwall described by Starr, and of the sore-throat described by Fothergill. In systematic nosology, do the corrosive pustules behind the ears, in the groins, labia, &c., belong to scarlatina or to diphtheria?

* * * * *

It is perhaps the same juxtaposition, or intermixture of scarlatina anginosa and diphtheria, that we find in the north of Scotland about the same time of the 18th century. Various parish ministers who contributed to the first edition of the _Statistical Account_ make mention of “the putrid sore-throat” about 1790 and 1791, without any reference to fever or scarlet rash. The following relates to three localities in Aberdeenshire:

New Deer: “In the autumn of 1791, a putrid kind of sore-throat, which first made its appearance about the coast side, found its way into this parish. Since that, it has continued to rage in different places with great virulence and little intermission, and is peculiarly fatal to the young and people of a full constitution[1313].” Crimond, a coast parish: “The putrid sore-throat raged with great violence two or three years ago [1790 or 1791] in most parishes in the neighbourhood, and carried off great numbers: but though a few were seized with it in Crimond, none died of that disorder[1314].” Fyvie, an upland parish:--“There has been no prevalent distemper for some time except the putrid sore-throat, which raged about two years ago [probably 1791] and proved fatal to several people. It has appeared this winter, but is not so violent as formerly[1315].”

From Aberdeen the epidemic is reported in a letter by one of the physicians, in May, 1790, in such terms as not to imply that it was scarlatina: “The malignant sore-throat has been most prevalent and very fatal, no period of life being exempted.” In children from six months to three years there was observed a livid appearance behind the ears which, in seven or eight cases, spread over the external ear, causing the latter on one or both sides to drop off by sloughing before death[1316].

The scarlet fever, with sore-throat, which reappeared in London about 1786-87 (and at Chesham in 1788) is said to have been somewhat steady until 1794. Willan, who began his exact records in 1796, says retrospectively that the scarlet fever with an ulcerated sore-throat had been prevalent every autumn from the year 1785 to 1794, “and proved extremely fatal[1317].” Lettsom gave a particular account of it in the spring of 1793[1318]; it was seen first in the higher villages about London, gradually descended into lower situations, and visited the metropolis pretty generally about the end of February. “It has been remarked for many years that this disease appears in the vicinity of London before it visits the metropolis,” beginning often among the numerous boarding-schools in the suburbs, to be carried thence by the dispersion of pupils to their homes. In some villages private families suffered greatly; in a few Lettsom heard of half the children dying, as well as of deaths among the domestics and other adults. The same epidemic of 1793 also called forth one of the numerous essays of Dr Rowley, who had written on the “malignant ulcerated sore-throat” in 1788[1319].

Scarlatinal Epidemics, 1796-1805.

The history of scarlatina in London, as of most epidemic maladies, is enriched for a few years by Willan’s monthly or quarterly accounts of the cases treated at the Carey Street Dispensary. From the beginning of 1796 to the end of 1800, scarlet fever is hardly ever wanting, and is occasionally the principal epidemic. It is only now and then, however, that a death from it appears in the Parish Clerks’ bills of mortality. Willan remarks that they gave only one death from that cause between the 8th and 29th November, 1796, “a period during which there occurred many fatal cases of that disease.” The bills have only three deaths from it in the quarter 27 Sept.-27 Dec. 1796. The Parish Clerks did not adopt scarlet fever fully into their classification until 1830; long after it had become an important factor in the mortality, they placed the deaths from it under “fevers” or under “measles.” According to Willan’s experience, it must have been as common as measles from 1796 to 1801. It was, he says, always most virulent and dangerous in the month of October and November, but generally ceased on the first appearance of frost. He records a spring epidemic as an exceptional thing in 1797: “Since the beginning of May, the scarlatina anginosa has become more frequent than any other contagious disease, both in town and in many parts of the country; the disease has generally occurred in its malignant and fatal form, which, at this season of the year, is very unusual.” The bills give only one death from 18th April to 18th May. Willan says that it was rife again in the autumn of 1797 and of 1798. Dr James Sims, who had described the scarlatina of London in 1786, found the epidemic in the end of 1798 so different from the former, and attended with so great fatality, that he made it the subject of a second paper[1320]. It was preceded in the winter and spring of 1797-98 by a remarkable epidemic among the cats of London (an angina, with sanious discharge from the nostrils and running at the eyes), which killed “myriads” of them[1321]. In Sept.-Oct. 1798, he heard that a scarlet fever had been fatal to some adults about South Lambeth, and afterwards to several children there, five dying in one family and three in another. The swellings on each side under the jaw were so great as to force the chin up into the horizontal; there was much acrid foetid discharge from the nostrils, the pulse sank about the seventh day, and the scarlet eruption remained out until near death, which took place usually about the ninth or tenth day. Along with this malignant type, a mild or simple scarlatina was also prevalent. Sims wrote when the epidemic seemed to be “in its infancy,” and so it proved; for Willan describes it as prevailing to the end of 1798 and rising still higher in the first months of 1799, his report for February and March being: “Scarlatina anginosa in its malignant form has been very prevalent, and has proved in many instances fatal; and in those who recovered, it produced after the cessation of the fever, anasarca, swelling of the abdomen, swelling of the lips and parotid glands, strumous ophthalmia, with an eruption of the favus, and hectical symptoms of long duration. The disease spread from London to the adjacent villages, and was almost universal in Somers Town during the month of February.” It continued throughout the year, and into 1800, being second in importance among the epidemic maladies only to typhus, which, in that time of distress, was the grand trouble of the poorer classes in London. Willan’s reports cease with the year 1800; but it appears from other sources that a very malignant scarlet fever and sore-throat prevailed in London in the summers and autumns of 1801 and 1802, becoming milder in 1803[1322], and in various parts of England during the same three years. The provincial accounts for those years give the impression that this was the first general outbreak for some time, perhaps since the one described by Withering and others in 1778; and that is also suggested by the statistics of the Newcastle Dispensary: in the two first years of its practice, from 1 October, 1777, it treated 146 cases, with 18 deaths; in the next ten years 1779-1789, it treated only 57 cases, with 8 deaths; and from 1790 to 1802, it treated 152 cases, with 7 deaths[1323]. Accounts of very general scarlatina come from various parts of England. In the summer and autumn of 1801 it ran through many parishes of Cornwall, sparing others. In the parish of Manaccan, twelve out of the twenty-five burials in the year 1801 were from scarlatina--the malignant or putrid form, which was often fatal before the third day. In many other cases, the first untoward symptom was the dropsical swelling which came on as the fever went off. Three years after, in 1804, there was much scarlatina in and around Falmouth[1324]. In 1805 it caused 12 in a total of 20 deaths in Revelstoke parish, South Devon.

In Northamptonshire in 1801 it was observed “in a form similar to the epidemic described by Dr Withering[1325].” At Cheltenham in 1802 it was also compared to the epidemic described by Withering: “in consequence of the number of persons who have gone through the disease, it has for this month past (20th December) been gradually on the decline[1326].” At Derby, in 1802, it had been the prevailing complaint in the last eight months of the year[1327]. In the district of Framlingham, Suffolk, in 1802-3, it had proved very malignant and fatal in many families[1328]. It is heard of also from Lancaster[1329], and from various other parts of England, being casually mentioned in reports on the influenza of 1803.

To this period also belong several incidents of a kind that had attended scarlatina from its first appearance, namely, school epidemics of it. One of these was an outbreak in the Quaker boarding-school for boys and girls at Ackworth, in Yorkshire, in 1803. Although many of the children dispersed, yet no fewer than 171, in a total of 298 on the roll, were attacked with scarlatina in the course of four months, of whom seven died[1330]. In the same year Dr Blackburne published a treatise on the preventive aspect of the disease, with directions for checking the spread of it “in schools and families[1331].” It broke out in 1804 among the boys in Heriot’s Hospital, Edinburgh, and in the city generally in 1805[1332]. Ferriar makes mention of a “destructive epidemic of scarlet fever” in Manchester in 1805, which he supposed to have been introduced from Liverpool[1333].

The general prevalence of malignant scarlet fever in the first years of the 19th century is farther shown by the accounts from Ireland, which were recalled by Graves in a clinical lecture of the session 1834-35, during the prevalence of a scarlet fever as malignant as that of thirty years before[1334].

“In the year 1801,” he says, “in the months of September, October, November and December, scarlet fever committed great ravages in Dublin, and continued its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character; and although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution. The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death (as appears by the notes of Dr Percival kindly communicated to me) so early as the second day. It thinned many families in the middle and upper classes of society, and even left not a few parents childless. Its characters seem to have answered to the definition of the scarlatina maligna of authors.”

The long immunity from malignant scarlatina which Graves asserts for Ireland after 1804, is made probable also for England and Scotland after 1805, by the fewness of the references to it in medical writings. Bateman in 1804 resumed the regular reports on the prevalent diseases of London, which Willan had left off at the end of 1800, and continued them until 1816[1335]; but he makes very few references to scarlatina compared with his predecessor. The two occasions when it is said to have been somewhat common were in 1807-8, during the severe epidemic of measles (and then it was “generally mild, presenting the eruption with a slight sore-throat”), and in 1814 when it was “very prevalent” along with measles. In Scotland during the same epidemic of malignant measles, in 1808, scarlatina was only occasional, and mild. It is heard of in its old malignant form from two localities of England, during the time of distress and typhus fever in 1810-11. At Nottingham it was “very prevalent, passing through whole families,” in September, 1810, and in October became more violent and often fatal[1336]. In the district around Debenham, in Suffolk, where it was last reported by the same observer in 1803, it made its appearance in February, 1810, in its very worst forms, causing deaths of children and adults in many houses, and destroying some children within forty-eight hours from the first attack. “All the surgeons for ten miles round have had to attend to scarlatina maligna in a variety of cases in all ages, from infants to fifty and sixty years.” It was still raging in October, 1810, and was breaking out “in different spots around this country, that appear to have had no communication with the afflicted[1337].”

It is not until 1831 that we begin to hear much of malignant scarlatina again. But it is clear that scarlet fever was common enough all through that interval, probably in its milder form. It was now the usual epidemic trouble of schools. In September and October, 1814, there were fifty-five cases, mostly mild, in children and two in adults in the Asylum for Female Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal Military College at Marlow, having been followed by anasarca in only one instance[1339]. Heysham, whose exact records of epidemics at Carlisle were made twenty or thirty years earlier, mentions casually in 1814 that scarlet fever had been “more frequent of late,” but that it did not spread as formerly[1340]. Other references to it in this interval are to show how seldom fatal it was under the cold water treatment or the lowering regimen[1341]. At the Newcastle Dispensary fully twice as many cases of scarlatina were attended in the twenty-five years 1803-27 (795 cases) as in the twenty-five years 1777-1802 (355 cases); but in the larger total, which an increasing population might account for, there were actually fewer fatalities (30) than in the smaller (33); the highest number in any one year was 71 in 1824, of which every one is entered as having recovered. This is the impression derived from various sources--that the scarlatina from about 1803 until about 1830 may have been frequent, but that it was mild, or easily treated, or not often fatal. Macmichael, writing in 1822, not only testified that the “scarlatina of last summer was very mild,” but argued that the malady in general was taken by many in those years in so mild a form that it was not recognized as scarlatina, “a name that sounds so fearfully in the ears of mothers,” and a rare disease in families compared with measles or even with smallpox. His point is that scarlet fever was in fact as nearly universal as measles, but that, as it was often extremely slight, it passed for rose rash or the like; at the same time he identified these slighter forms with true scarlatina by simply pointing to the oedema which might follow them[1342].

The testimony of Graves, of Dublin, who occupies many pages of his ‘Clinical Medicine’ with the disastrous scarlatina in various parts of Ireland about 1834, is conclusive that the severe type was new in the experience of that generation:

“I have already mentioned that the disease called scarlet fever assumed a very benign type in Dublin soon after the year 1804, and continued to be seldom attended with danger until the year 1831, when we began to perceive a notable alteration in its character, and remarked that the usual undisguised and inflammatory nature of the attack was replaced by a concealed and insidious form of fever, attended with great debility. We now began occasionally to hear of cases which proved unexpectedly fatal, and of families in which several children were carried off; still, it was not until the year 1834 that the disease spread far and wide, assuming the form of a destructive epidemic[1343].... Many parents lost three of their children, some four, and in one instance which came to my knowledge, five very fine children were carried off.” The severe cases were mixed with others of scarlatina simplex. The violence of the attack lay in the throat-affection, the congestion of the brain, or the irritability of the stomach and bowels, nausea, vomiting and diarrhoea being early symptoms, as in the malignant sore-throat with rash a century before.

Graves proceeds, with much candour, to show how mistaken had been the reasons assigned equally for the mild type of scarlatina between 1804 and 1831 and for the severe type of it previous to 1804:

“The long continuance of the period during which the character of scarlet fever was either so mild as to require little care, or so purely inflammatory as to yield readily to the judicious employment of antiphlogistic treatment, led many to believe that the fatality of the former epidemic was chiefly, if not altogether, owing to the erroneous method of cure then resorted to by the physicians of Dublin, who counted among their numbers not a few disciples of the Brunonian school; indeed, this opinion was so prevalent, that all those whose medical education commenced at a much later period, were taught to believe that the diminished mortality of scarlet fever was entirely attributable to the cooling regimen and to the timely use of the lancet and aperients, remedies interdicted by our predecessors. This was taught in the schools, and scarlet fever was every day quoted as exhibiting one of the most triumphant examples of the efficacy of the new doctrines. This I myself learned--this I taught: how erroneously will appear from the sequel. It was argued, that had the cases which proved fatal in 1801-2 been treated by copious depletion in their very commencement, the fatal debility would never have set in, for we all regarded this debility as a mere consequence of previous excessive reaction. The experience derived from the present [1834-35] epidemic has completely refuted this reasoning, and has proved that, in spite of our boasted improvements, we have not been more successful in 1834-5 than were our predecessors in 1801-2.”

From 1829 to 1833 there are numerous references to the scarlatina maligna in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in 1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346] in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348] in 1832-1833. It is in 1830 that scarlet fever begins to have a line to itself in the old and inadequate bills of the Parish Clerks of London, the deaths that year being 94; in the next seven years they are 143, 388, 481, 523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths from it in Glasgow[1349] for five years, during which they fell much below the deaths from either measles or smallpox.

_Deaths from Scarlatina in Glasgow._

Under one 1-2 2-5 5-10 10-20 20-30 30-40 40 and up. Total

1835 27 50 89 73 23 7 2 2 273 1836 34 57 136 86 25 9 5 3 355 1837 4 9 34 22 5 3 1 1 79 1838 3 15 42 17 7 1 1 1 87 1839 29 45 104 74 10 -- -- -- 262

The two first years of this period, which had the most scarlatina deaths, correspond to the years of the Dublin epidemic, and were also the years when it was common in Edinburgh[1350]. Probably the smaller mortality of Glasgow in 1837 and 1838 was general; for, when registration of the causes of death began in England and Wales in the latter half of 1837, it found the scarlatina mortality at a much lower figure than it reached in 1839 and continued to keep thereafter.

Scarlatina since the beginning of Registration, 1837.

The first returns of the causes of death under the new Registration Act happened to correspond with a great epidemic of typhus fever, and with an equally great epidemic of smallpox which took its victims in largest part among infants and young children. The deaths from scarlatina were also considerable during those two years and a half; but in 1840 scarlatina nearly doubled its mortality, and continued year after year for a whole generation to be the leading cause of death among the infectious maladies of childhood. The figures for England and Wales are given in a table at p. 614, in comparison with the annual deaths by smallpox, measles, and diphtheria. The enormous number of deaths from scarlatina during some thirty or forty years in the middle of the 19th century will appear in the history as one of the most remarkable things in our epidemiology. There can be no reasonable doubt that this scarlatinal period was preceded by a whole generation with moderate or small mortality from that disease, just as it is now being followed by annual death-rates which are less than a half, perhaps not more than a third, of the average during forty years before 1880.

The first great epidemic all over England was in 1840 (it had reached a maximum in London the year before), another came in 1844, a third in 1848 (in which the London death-rate was 2·12 per thousand living). In the next decennial period, 1851-60, the worst years for scarlatina were 1858-59, which were also the years of the return of diphtheria; in the period 1861-70, the great scarlatinal years were 1863-64 and 1868-70; in the period 1871-80, the year 1874 was the epidemic year. The annual average death-rates per million inhabitants in all England and Wales were as follows in four decennial periods:

1851-60 832 1861-70 972 1871-80 716 1881-90 338

In the greatest epidemic years since 1863 the death-rates per million for the whole country have been:

1863 1498 1864 1443 1868 1020 1869 1275 1870 1461 1874 1062

In those years scarlatina made from four to six and a half per cent. of the deaths from all causes.

While no county of England has been free from this infection, the bulk of the deaths have fallen upon the capital, the great Lancashire and West Riding towns, the Black Country of Staffordshire with Warwickshire, the mining districts of Durham and South Wales, and, in the earlier part of the period, upon the south-western counties.

_Highest Mortalities by Scarlatina in three Epidemics._

/-----------\ /-----------------\ 1863 1864 1868 1869 1870 1874

England and Wales 30475 29700 21912 27641 32543 24922 ------------------------------------------------------------------- London 4955 3244 2916 5841 6040 2648 Lancashire 4580 4854 4445 4890 3702 6404 West Riding 2218 3135 1676 2870 3718 3779 Durham 1216 403 2678 1512 983 1941 South Wales 501 1990 285 804 1370 1388 Staffordshire 1147 1134 943 1198 1064 1270 Devonshire 778 1054 60 155 646 72 Cornwall 995 572 254 161 587 50 Somerset 773 1013 55 154 584 173

In Lancashire and South Staffordshire there has been less fluctuation of the mortality from year to year than elsewhere. The stress of an epidemic has not fallen equally on all the principal centres in the same year or years: thus Durham has had the epidemic in advance of other centres, while South Wales has had it in arrear. The decline of the south-western counties from their leading position in 1863-64 has been remarkable. Plymouth, Devonport and Stonehouse, which had contributed most to the high scarlatinal death-rate of Devonshire in 1863-64, were found on the average of the next decennial period to have low rates from scarlatina, but death-rates from measles which were unapproached in any other region of England. In the following table four Devonshire towns are compared with certain Staffordshire registration districts in which the scarlatinal death-rate has remained high.

_Annual average Death-rates per 1000 living, 1871-80._

All causes Scarlatina Measles

{Plymouth 22·63 ·25 1·13 {E. Stonehouse 28·23 ·33 1·79 {Stoke Damerel 20·42 ·37 1·19 {Exeter 24·99 ·50 ·82

{Stoke-on-Trent 25·80 1·22 ·49 {Wolverhampton 22·78 1·05 ·35 {Walsall 22·82 1·21 ·30 {Dudley 24·24 1·18 ·59

This looks like a correlation between measles and scarlatina. The excessive death-rate from measles in Plymouth, Stonehouse and Devonport was due to a disastrous epidemic in the last two years of the decennium, 1879 and 1880 (338 deaths at Plymouth, 121 at Stonehouse, and 235 at Devonport). Measles remained high in Plymouth all through the next decennium, scarlatina still continuing low until the very end of it, when in 1889 there was a mortality of 270, equal to a death-rate of 3·39 per 1000 living. In like manner Stoke-on-Trent had its great epidemic of measles in 1888, causing 342 deaths, or a rate of 2·8. The high Plymouth death-rate, after nearly twenty years with extremely little scarlet fever, was surpassed in 1882 by an epidemic of 346 deaths in the colliery townships of Aberystruth and Tredegar, Monmouthshire, equal to a death-rate of 6·1 per 1000. Other high death-rates for single years were at Wakefield and Swansea in 1889 and at Neath in 1890. The highest death-rates from scarlatina on an average of ten years, 1871-80, were at Durham 1·70, Todmorden 1·64, Auckland 1·63, Gateshead 1·60, Sheffield 1·49, Leigh 1·41, Wigan 1·30, Newcastle 1·28. The purely agricultural counties have the lowest death-rates[1351].

As to age-incidence, the proportion of deaths under five has been almost exactly two-thirds steadily for the last four decennial periods (supra p. 625). The following table by Dr Ogle, the Superintendent of Statistics, shows both age and sex of the scarlatina mortality[1352]:

_Mean annual Mortality from Scarlet Fever per million living at successive age-periods 1859-85. England and Wales._

Age Males Females

0-1 1664 1384 1-2 4170 3874 2-3 4676 4491 3-4 4484 4332 4-5 3642 3556 0-5 3681 3482 5-10 1667 1613 10-15 346 381 15-20 111 113 20-25 59 77 25-35 36 58 35 and upwards 13 15 All ages 778 717

From certain hospital statistics on a large scale, and some figures of cases and deaths at Christiania, it was also found that the attacks of scarlatina were much more fatal in the first years of life, the fatality decreasing rapidly after five. This was only to be expected. But it was somewhat surprising to find that more girls were attacked than boys, while the fatalities among boys were more than among an equal number of girls at all ages until womanhood, when the few females attacked by scarlatina had more fatalities among them than the somewhat fewer males of the same ages. A slight excess of fatality in the female sex over the male between the ages of ten and twenty years, is shown also for smallpox by the table at p. 618. Recent notifications of infectious diseases to medical officers of health have enabled a comparison to be made between the number of cases of scarlatina notified, with age and sex, and the number of deaths certified in the corresponding time and place to the Registrar-General; from which the above generalities as to the proportions of fatal cases in the several age-periods of either sex have been confirmed[1353].

The enormous mortalities of some years may be taken to have depended in part upon an increased prevalence of the disease, but still more upon an increased fatality among the subjects of it. Since the establishment of the Metropolitan Fever Hospitals in 1870 the percentage of deaths to cases has ranged from 15·3 in 1879 to 6·6 in 1873 and 6·7 in 1891. Among the smaller totals of the London Fever Hospital the percentage of deaths has ranged even more widely from year to year[1354]. What is thus statistically proved is also a matter of common experience; there have been whole epidemics, extending perhaps over two or three years, marked by high malignancy, and epidemics just as uniformly marked by mildness of type. The severe type has usually been made by the sloughing in the neck or throat; but there has also been a class of cases tending to a fatal issue early in the attack by a sunken pulse and with few external manifestations. The cause of these variations in the severity of scarlatina is the old problem of epidemic constitutions: sometimes the constitution is “putrid” or “pestilential” or malignant, sometimes it is mild or benign.

Graves, in the passage above cited, has sufficiently exposed the fallacy of attributing changes of type to modes of treatment. On the other hand there is reason to think that the percentage of deaths (by which the “type” is usually judged) is higher in children carried off to hospitals than in those treated at home. As the same fact has been uniformly observed in epidemics of Asiatic cholera, when the ambulances have been almost as busy as those of the Metropolitan Asylums Board during an ordinary autumnal rise of scarlatina, it is probable that the reasons which used to be given in the former case hold good also in the latter.

_Scarlet Fever in London, 1890 and 1891._

All Cases Treated Treated in Fatalities Fatalities in Year Notified at Home Hospital at Home Hospital

1890 15330 8793 6537 348 510 or 3·95% or 7·8%

1891 11398 6136 5267 232 357 or 3·8% or 6·8%

This is a comparison of two parts of the same epidemic, which had a very moderate fatality in any case. The real problem of malignity or severity of type arises over such epidemics as those of 1840, 1848, 1858-59, 1868-70 and 1874, in which the doubling of the deaths, for one year, or for two or even three consecutive years, had depended less upon an increased number of seizures than upon a higher ratio of fatalities. An explanation for each occasion will have to be sought either in the condition of the patients, or in the inherent properties or external favouring circumstances of the virus. As to the former, the most fatal epidemic years of scarlet fever have not been marked in any such uniform way as the great seasons of typhus or relapsing fever; nor is scarlatina an infection that keeps mainly within the poorer classes. Among factors of the external kind, a rainfall below the average has been thought a relevant thing: thus in the three years 1862-64, the annual average rainfall at Greenwich was only 20·6 inches, the scarlatina death-rate in London for the same years reaching the high figure of 1·33 per 1000 inhabitants; in the next three years, 1865-67, the death-rate fell to ·56 (it would have fallen in any case), while the rainfall reached the very high average of 29 inches; in the three years following, 1868-70, the death-rate reached the excessive annual average of 1·5 per 1000 in London, the rainfall of the same period averaging only 22·3 inches. Thereafter for a number of years the rainfall was moderate and the scarlatina death-rate low; but in the years 1883-87, they were both low together, the scarlatina death-rate of ·26 being lower than it had ever been since registration began[1355].

Although an empirical correspondence between the great scarlatina periods and a series of dry years has not been made out without important exceptions, hitherto unexplained, yet there is a very obvious correspondence between the great rise of scarlatina deaths in London every year and the season of late autumn, which is the season when the ground-water touches its lowest level or begins to rise therefrom to the high water-mark of spring. Of all the curves of seasonal rise and fall constructed by Buchan and Mitchell from the weekly bills of mortality in London from 1845 to 1874, that of scarlatina is the most decided next to that of infantile diarrhoea, the deaths rising in October and November far above the mean line of the year, and falling farthest below the mean in spring and early summer[1356]. This was an old observation--by Sydenham for the scarlatina simplex of that age, by Willan in the end of the 18th century (one or two spring epidemics being remarked upon as exceptional). It is a very curious fact, and one that is as certain (for London at least) as it is curious. Sydenham explained it by the doctrine of his time, that the favouring things were in the human body, namely, some susceptibility of the humours owing to the heat of the preceding summer; but, according to modern views, it should bring scarlatina into the same class with the soil-poisons of enteric fever, yellow fever and cholera, which are believed to become more rife owing to the greater activity of their respective miasmatic viruses when the pores of the ground are occupied to the greatest depth with air in place of water.

It would be singular indeed if, after all, we should have to include scarlatina among the miasmatic diseases; for it is an exquisite instance of an infection which is passed from person to person, or by the agency of volatile contagion, or by fomites in clothes, bed-linen, house-furnishings and the like. The controversy which has raged so keenly in the past between contagionists and non-contagionists over the instances of plague, yellow fever and Asiatic cholera, would become still more keen over scarlatina--and be still more confused if it were not stated in more correct terms at the outset. What we all find so hard to learn is, that the one way of infection does not exclude the other. Plague was for the most part a miasmatic infection in the air of a plague-stricken town; but it could be conveyed in clothes or bales, while it was prudent to remain not too long in the company of a plague-patient. In like manner contagion from the person was, as Rush said and Blane confirmed, a “contingency” in yellow fever; and there are some authentic cases of Asiatic cholera which cannot well be explained except on the hypothesis of contact with the persons of those sick or dead of the disease. Scarlatina is more contagious than any of these, because it shows so much on the surface of the body and scatters its infective matter into the atmosphere of a room with the fine scales or dust of desquamation. Still, there are conditions for the contagiousness of scarlatina, just as there are for the rarer event of contagion from the persons of the sick in the plague, yellow fever and cholera. It is a remarkable fact that scarlet fever should ever be sporadic, or that a single case should appear in the midst of a crowded population (as I have seen in a coast town filled with strangers during the herring fishery to the extent of one-half more than its usual numbers), and no other cases follow for months after, although there had been not the smallest attempt at isolation. Every medical practitioner knows, if some laymen and legislators do not, that scarlatina is sometimes highly contagious, and sometimes hardly contagious at all; and who can say whether the mechanical routine of “stamping out” contagion, which certain persons pursue with more zeal than knowledge, may not be the means of turning a mere potency into an actuality? The tact of individuals rather than the grinding machinery of an Act of Parliament is needed in dealing with vagaries such as Willan thus describes:

“I have seen in numerous families one child have scarlatina without communicating it to any of the rest; yet, perhaps, in the succeeding autumn, several of them were infected by only passing near a patient recovering from the disease, or by touching those who had a little time before visited some persons affected with it[1357].”

There are two special forms of epidemic scarlatina which may prove to be finger-post instances for the general pathology. It happens from time to time in the surgical wards of hospitals for children, where many cases of suppurating diseases (especially of the bones or joints) are aggregated and kept together perhaps for months, that groups of the patients acquire a scarlet rash, or an erysipelatous rash, or a hybrid form of rash, along with the constitutional symptoms of scarlatina. Whether it be from the suppuration, or from the blood of operations, this disease must be reckoned a product of so-called “hospitalism.” It is not without significance that there may be an element of erysipelas in such cases. They are probably cases of “blood poisoning,” in a double meaning of the term--poisoning of the living blood by dead blood or by pus which is closely allied to blood[1358].

The other special kind of epidemic scarlatina is that which has broken out among the inmates of houses supplied with milk from a common source. There have been many such outbreaks, including one most remarkable instance in which a large number of guests at an evening party, who had partaken of cream with strawberries, were shortly thereafter attacked by scarlet fever at their widely scattered homes. There can be no question that milk, or cream, has been the vehicle of scarlatinal infection. The first hypothesis tried was that of scarlatina on the dairyman’s premises; the effluvia of a scarlatinal patient might have become mixed with the milk. In some instances, it was actually shown that there had been a case or cases of scarlet fever among the dairyman’s children; but there were other instances in which that could not be shown, and it was, of course, possible to refer the cases, where they did occur, to a common cause in the milk used at the dairy and in the milk distributed from it. As more and more outbreaks of the kind came to be investigated, it was indeed made probable that the infection had got into the milk from the cow[1359]. Someone threw out the suggestion that the cow suffered from scarlet fever, the sign of it being soreness of the paps. Without taking seriously so random a hypothesis as that, we find much agreement as to the fact that the cows, to which the contaminated milk has been traced, were affected, one or more of them, with sore paps. In some cases the disease of the teats had been admitted to be the same as cowpox; in other cases that has been denied; in a third variety, a cow has had cowpox on one teat and something else on another. It matters little what name be given to the affection of the cow’s paps. All soreness of the skin of the teats has the same effect so far as concerns the purity of the milk. Unless the milk be drawn off by a catheter (according to a German practice), the paps are necessarily made to bleed by being “stripped”; it has been admitted by milkers that the blood, pus, and scabs are apt to become mixed with the milk; and the discharges from the sore paps have actually been seen, by a scientific witness, to trickle over the fingers of the milkers into the milk-pail[1360]. The contamination of the milk which produces scarlatina in those who use it is neither more nor less specific than that. The disease is blood poisoning in the double sense of the term--poisoning of the living blood by dead blood. Blood is a peculiar fluid, and so is milk. When the two come together the result is peculiar. Both are animal fluids that curdle by some peculiar ferment-change in their constituents. Again, milk is peculiar in its property of taking up organic effluvia; thus the milk standing in shallow vessels has been known to acquire the taste and odour of tar from a tarpaulin in the adjoining farmyard. With such properties of the milk, a small quantity of blood or pus in it will go a long way.

The one thing that connects the scarlatina of surgical wards in children’s hospitals and the scarlatina of the milk-pail is putrefying blood or pus: the disease is a septic effect of blood, just as a scarlet rash is known to be a toxic effect of very various drugs in peculiarly susceptible subjects. The obviously septic varieties of scarlatina make but an insignificant part of the whole; but they may be finger-post instances. Thus, if we assume that the infection may be miasmatic from the ground as well as contagious from the person, there are certain facts, or suspicions, that will fit the hypothesis of putrefying blood. A theory of scarlatina was put forward in 1871, on the basis of observations near Croydon, that its virus came from the blood and offal of slaughter-houses collected at particular spots to be used as manure[1361]. The first death in a recent small epidemic within the writer’s knowledge was of a school-girl who lived just across the road from a slaughter-house. The septic hypothesis of scarlatina might be made to include other corrupting animal matters. Some practitioners have a suspicion that scarlet fever is bred in the atmosphere of a horse-mews. On the greater scale, others have traced a connexion between the more signal outbreaks of angina maligna and preceding murrains of cattle[1362]. The animal matters which may become toxic to man, in miasmatic or other form, are indeed many. If scarlatinal drug-eruptions are any clue to the mystery of scarlet fever, we need not be surprised to find a somewhat uniform disease-effect produced by a variety of septic agents[1363]. But, in that hypothesis, the refuse of the shambles will merit most attention. This was thought the one great nuisance of London in the sanitary ordinances of Edward III., Richard II. and Henry VII.; it was then considered a danger to health in the measure of its offensiveness to sight and smell, but there may still be dangers from it which are subtle and unperceived.

Reappearance of Diphtheria in 1856-59.

The memorable outburst of epidemic throat-disease in Britain about the years 1858-59 was part of a sudden uprising of the malady all over the globe--in Europe, America, North Africa, India, China, and the Pacific[1364]. It was only in some parts of France, and of Norway and Denmark, that “diphtheria” had been epidemic in the generation before. Of its novelty to nearly the whole British profession in 1858, familiar as they were with the angina of scarlet fever, there can be no question. Its appearance among diseases coincided with the publication of Darwin’s hypothesis of the origin of species by natural selection; and it was in the terms of that hypothesis that Farr, of the Registration Department, spoke of the phenomenon of diphtheria. New diseases, he said, “are only recognized as distinct species when they have existed for some time. Diphtheria is an example. It obtains a distinct line in the Tables of this year [1859] for the first time”--with a total of 9587 deaths. For four years before that, it had been in a “provisional table” under the names of “diphtheria” and “cynanche maligna”; but in the general table, the deaths under these names had been merged with the scarlatinal deaths. This inclusion for a time of diphtheria under scarlatina could not have been because practitioners had any difficulty in diagnosing the one from the other, but probably because scarlatina anginosa seemed the nearest affinity in the nosological system. Diphtheria in 1858 had no scarlet rash, and yet it was supposed to be the same disease that had made so much commotion in England about the middle of the 18th century: “In Fothergill’s account,” says Farr, “the symptoms are confused by the introduction of the eruption of scarlatina into his description”--as if his description had been a patchwork of his fancy, with some characters taken from “diphtheria” and some from scarlet fever. The greatest of our nosologists, Cullen, had long before that separated “cynanche maligna” from “scarlatina anginosa,” but the separation was not made on the ground of absent or present rash. Both had the rash, the cynanche having, besides a general exanthem, very distinctively the peculiar scarlet redness, with swelling and stiffness, of the fingers which Fothergill described, while the scarlatina rash was “commonly more considerable and universal.” Both also might have a discharge from the nose; but when the coryza did occur in scarlatina, “it is less acrid, and has not the foetid smell which it has in the other disease.” It was really on the ground of malignancy or fatality that Cullen separated them. In forty years he had seen scarlatina anginosa six or seven times prevailing as an epidemic in Scotland, and he had seen two or three epidemics of cynanche maligna. He had seen mild cases in the latter, as well as in the former; but whereas there would be only one or two malignant cases in a hundred of scarlatina anginosa, the malignant or putrid cases in an epidemic of cynanche were four-fifths of the whole[1365]. On the other hand Willan, writing just fifty years before the modern diphtheria made its appearance, maintained that “no British author has yet described any epidemical and contagious sore-throat except that which attends the scarlet fever,” not even Starr, whose “morbus strangulatorius” he held to be “the most virulent form of scarlatina[1366].”

The name diphtheria, which appeared for the first time among the classified causes of death in England in the report for the year 1855 (published two years after), had been given originally in 1826, with the termination _itis_ according to the then Broussaisian fashion, by Bretonneau in his account of epidemics at Tours in 1818-21 and at La Ferrière in 1824-25[1367]. It was in January, 1855, or just before the disease became general in Europe, that he changed the termination to _diphtherie_[1368]. This name was taken from διφθέρα, a prepared skin or hide, suggesting in strict correctness, a certain toughness and texture which were actually found in only a small proportion of all the diphtheritic deposits or exudations or sloughing infiltrations in the first great epidemic and subsequently.

The interval between 1793-94, the date of Rumsey’s diphtheria or “croup” at Chesham, and the outbreak of diphtheria in England in 1856-59, affords several instances of the disease, some of which were contemporaneous with Bretonneau’s in France, but were still called “croup” in this country. These I shall merely enumerate in a note, passing at once to the beginnings of the great outbreak[1369].

The first public notice of the reappearance of a fatal throat epidemic in England appears to have been in the Registrar-General’s third quarterly report of the year 1857, when attention was drawn to the remarks by various local registrars (Thame, Billericay, Maldon, Liskeard, Truro and Chesterfield) as to fatalities from “inflammation of the throat,” “putrid sore throat,” “malignant sore throat,” “disease in the throat,” and “throat-fever.” About this time it was also called the “Boulogne sore throat.” There had been an epidemic at Launceston from 30 September, 1855, which had come to a height in August, 1856; several deaths had occurred near Spalding, in Lincolnshire, in July, 1856, and the disease had been seen at Ash, in Kent, in November, 1856. When the registered causes of death during the year 1855 were classified (in 1857), “diphtheria” was credited with 186 deaths, in the Supplementary Table then first introduced, “cynanche maligna” having 199 deaths. The following shows the progress of the epidemic during the four first years, and the mode of entry:

Scarlatina (inclusive Cynanche of columns 1 and 2 in Year maligna Diphtheria the general table)

1855 199 186 17,314 1856 374 229 14,160 1857 1273 310 14,229 1858 1770 4836 30,317

In 1857 and 1858 the deaths from croup were above the average, and probably included some of the new disease.

Accounts of the epidemic began to come into the medical journals[1370] from various localities in the course of 1858,--from Lincolnshire, Essex, Kent, Sussex, etc. A systematic inquiry, conducted by Greenhow and Sanderson for the Medical Department, under the direction of Simon, gave an exact picture of the several degrees of throat-distemper that constituted the epidemic in the year 1858, in certain of the more severely visited centres of Lincolnshire, South Staffordshire, Cornwall, Kent, and other counties[1371]. The numerous cases of throat disease occurred often in the midst of scarlatina, but sometimes also where there was no scarlatina. One of the worst centres was in and around Spalding, a market town situated in a flat grazing country within the fen district of Lincolnshire. A thousand cases were counted in and near Spalding, many of them mild, a small ratio of them gangrenous and mortal; one practitioner had 200 cases with 5 deaths, another 200 cases with 2 deaths, another 160 cases with 17 deaths (of 65 tabulated with 9 deaths, which occurred in 35 houses, the first four all died from gangrene in June, 1858). The doctor at Pinchbeck, in the same district, had some 500 cases of which 300 occurred in the space of about six weeks; most of the 19 deaths in his extensive series happened in the first cases (this was observed also in the New Hampshire epidemic of 1735). At Launceston, in Cornwall, there were about a thousand cases known, the height of the epidemic having been in the summer and autumn of 1856; among 126 taken as they came in 98 families, 18 died. The mildest and the most severe cases were equally parts of the epidemic constitution, and occurred side by side in the same households; many of them were quinsies, ulcerated sore-throats, or the like, others were gangrenous. In this great variety, only a part could be reckoned “true diphtheria.” From the first, the remarkable sequel of paralysis, not only of deglutition but of the motor powers generally, was remarked here and there. Sometimes an eruption of the skin was seen, but desquamation did not occur[1372]. Albumen in the urine was somewhat constant. It is noteworthy, the more so that the coincidence was not remarked at the time, that the true diphtheritic pellicle,--tough, leathery, elastic,--was found most distinctively, if not exclusively, where it was found in 1748, namely in Cornwall[1373].

Although the epidemic was not confined to low and damp situations, yet there was no mistaking the severity of it in Lincolnshire; and although it fell upon both clean and filthy houses, yet it is probable that the cases with most pronounced gangrene or foetor happened amidst the most unwholesome surroundings. The disease was very general in England in 1858. When the deaths from it in 1859 (9587) were tabulated for the first time according to counties, it was found that they came from every part of England and Wales. The highest death-rate was in Lincolnshire, 1·2 per 1000 on the annual average of 1859 and 1860 (995 deaths in the two years). Sussex, Kent, Essex and Norfolk had also high death-rates, the agricultural counties in general having somewhat more than their usual share of an infective mortality as compared with the industrial centres. But it would be erroneous to suppose that diphtheria was at all specially a country disease. The mining districts of Staffordshire, Durham and South Wales had considerable mortalities, and so had Lancashire and the West Riding. But the North Riding and East Riding had their full share or even more than their share; whereas, if it had been scarlatina or enteric fever, they would have been far behind the great industrial division of Yorkshire in ratio of their populations. In the more recent prevalence of diphtheria the country districts have lost their preeminence, according to the following table of death-rates per million living in registration districts classified roughly as sparse, dense and medium[1374]:

_Diphtheria Death-rates per million, according to density of population._

Period Dense Medium Sparse 1855-60 123 182 248 1861-70 163 164 223 1871-80 114 125 132

In Scotland, also, the incidence was the same: e.g. in 1862, of 997 deaths, 360 were in the towns, 617 in the mainland rural and 20 in the insular districts[1375].

The law of incidence of diphtheria upon town and country respectively has become a good deal confused by the extraordinary severity with which diphtheria has fallen in the last two or three years upon most parts of London and upon the adjoining municipal boroughs of Croydon and West Ham. The following table compares the annual death-rates per million in all England and Wales and in London from the year of the first recognition of diphtheria to the present time.

_Death-rates from Diphtheria per million, in all England and in London._

Year England London

1855 20 -- 1856 32 -- 1857 82 -- 1858 339 -- 1859 517 284 1860 261 174 1861 225 239 1862 241 288 1863 315 275 1864 261 207 1865 126 144 1866 140 152 1867 120 145 1868 137 155 1869 47 107 1870 120 104 1871 111 105 1872 93 80 1873 108 95 1874 150 122 1875 142 167 1876 129 109 1877 111 88 1878 140 155 1879 120 155 1880 109 144 1881 121 171 1882 151 220 1883 158 241 1884 185 236 1885 163 221 1886 147 205 1887 157 226 1888 168 305 1889 185 371 1890 179 330 1891 173 340 1892 222 460 1893 302 740

The deaths in London in 1893 were 3196, having been 1962 the year before, but never more than half the latter total in any year previous to 1888. Besides Croydon and West Ham, Cardiff is the great town which has come nearest the London rate, having had O·68 deaths from diphtheria per 1000 living in 1892, while Swansea had only 0·05, Wolverhampton (including Bilston and Willenhall) only 0·06, Huddersfield 0·03 and Blackburn 0·02. In London the very high death-rate of 1893 was distributed not unequally over all the divisions, the highest mortality corresponding to the highest fecundity.

_Diphtheria in London in 1893._

Death-rate Diphtheria District from all causes Birth-rate death-rate

Eastern 25·1 37·3 1·00 Central 26·6 29·0 0·82 Southern 19·9 31·7 0·73 Northern 20·0 29·3 0·73 Western 18·7 26·4 0·52

Diphtheria shows no such decided preference for the late autumnal or early winter season as scarlatina, but the winter is on the whole its most fatal season, according to the following annual averages of the quarters of the year for twenty years from 1870 to 1889 (total of 67,676 deaths in England and Wales).

_Annual average of Diphtheria deaths in the quarters of the year._

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

903 713 730 1025

According to some recent returns under the Notification Act, which are of doubtful value owing to the laxity of diagnosis (greater perhaps in throat-disorders than in any other class of diseases), the second and third quarters of the year have also the lowest mortality in proportion to the number of attacks[1376]. As to the ages at which diphtheria proves fatal, they are somewhat similar to those of fatal scarlatina, but slightly higher all over; thus, while two-thirds of the deaths from scarlatina are of infants and children under five years, only one-half of the deaths from diphtheria are under that age. In the first epidemic period, 1855-61, Farr reckoned that 1553 adults had died of diphtheria above the age of twenty-five, while the deaths under that age had been 28,216. In its age-incidence diphtheria is very different from croup, which attacks chiefly children of one, two, and three years of age, the boys dying in greater numbers than the girls[1377]. But in all comparisons between diphtheria and croup, as regards sex and age, it should be kept in mind that many cases of angina of the throat, which end in death by extension to the larynx and trachea, are registered as croup, even in epidemics. Diphtheria is the only epidemic disease besides whooping-cough which is more fatal to female children than to males in proportion to the numbers of each sex living. The following annual average death-rates per million for the period 1855-80 show the higher death-rates of females at certain age periods[1378]:

All ages 0- 1- 2- 3- 4- 5- 10- 15-20

Males 157 490 724 617 667 589 325 107 50 Females 168 377 673 668 746 694 413 159 57

It is not until the third year that female children begin to die of diphtheria in excess of males; which means that the usually greater risk to male infants holds good also in this disease for the two first years, while some difference between the sexes becomes thereafter so marked as to turn the balance of fatality to the side of the females. Something of the same kind happens in whooping-cough; and it is probable that in both maladies the cause lies in the earlier acquisition by the male of secondary sexual characters in the throat and larynx, as suggested in the chapter on whooping-cough.

Conditions Favouring Diphtheria.

The circumstances of the great and sudden explosion of diphtheria in 1858 and 1859 are as likely as any to throw light on the causes or determining conditions of the disease. Those two years were remarkable for the Thames running so low in summer as to give out a stench, which was thought to forebode much fever[1379]. The expected epidemic of fever did not come; on the contrary the fever deaths in London were much lower than usual in 1858 and 1859, and, to judge from the few admissions of each kind to the London Fever Hospital, enteric fever declined as well as typhus[1380]. It was diphtheria that came. The lowness of the rivers was due to a succession of years with rainfall below the average:

Low rainfall High rainfall

1855 21·1 inches 1865 29·0 inches 1856 22·2 " 1866 30·7 " 1857 21·4 " 1867 28·4 " 1858 17·8 " 1868 25·2 " 1859 25·9 " 1869 24·0 " ---- ---- Average 21·7 " Average 27·4 "

The low state of the rivers was an index of a low level of the ground-water. If diphtheria is to be included among the infections that have the habitat of their virus in the soil, it will probably be found to be affected by irregularities in the movements of the subsoil water. A series of observations have been made which seem to favour that hypothesis.

At Maidstone in each of the three years 1885, 1886 and 1887, the ground-water rose with the greatest regularity and steadiness to its highest point towards the end of the first quarter of the year, and fell with equal steadiness to its lowest point in the autumn. During two of the years there was little diphtheria, and in one of them none. But, in the next two years, 1888 and 1889, “the levels of the ground-water oscillated to and fro with unwonted frequence,” having several maxima in 1888, and a somewhat uniform high level all through 1889; and during those two years there was a severe outbreak of diphtheria, as well as an excessive number of deaths registered as “croup[1381].”

The relationship with the ground-water, if any, will probably be found to be more than ordinarily complex; but some connexion is indicated by the remarkable selection of the Fen country of Lincolnshire in 1858. Among the 18th century observations, it was remarked in New England in 1735-36 that the throat distemper was worst near lakes or rivers, as at Newbury Falls, Hampton Falls, and the like. The ill-reputed “Kidderminster sore throat,” was associated with the low situation of weavers’ houses in the valley of the Stour, subject to inundations. Practitioners in many parts of England and Scotland have suspected an association with water, even if it were only a mill dam, in the more recent prevalence of diphtheria[1382].

Diphtheria has affinities in its pathological nature with enteric fever on the one hand and with scarlatina on the other. The process in the throat and pharynx is comparable to the typhoid process in the ileum, which is often a truly diphtheritic process in the second half of the fever[1383]. The affinities to scarlatina are shown best of all in the real ambiguity of diagnosis in some whole epidemics of the 18th century, if not also in the great epidemics of _garrotillo_ in the 16th and 17th centuries. Another singular affinity both to scarlatina and to enteric fever lies in the fact that diphtheria, as well as each of these, has been distributed in milk from some particular dairy, and that contamination of the milk by the products of disease upon the cows’ teats has been found to be the relevant thing both for the scarlatina and the diphtheria[1384]. Again, whatever suspicion pertains to slaughter-houses or animal offal for the production of a scarlatinal miasm, pertains to them also for the diphtherial. With such more or less real affinities in the pathology and etiology, it may be made a question whether the recent increase of the death-rate by diphtheria in London and some other places has depended, as if in the way of correlation, upon the decrease in the death-rates of scarlatina and of enteric fever[1385]. Diphtheria is perhaps the most obscure and complex of all the infective diseases in its causes and favouring conditions. A certain explanation may seem to suit one outbreak and be wholly irrelevant for another. More particularly there have been innumerable cases for which insanitary surroundings cannot be alleged in any ordinary meaning of the term.

## CHAPTER VIII.

INFANTILE DIARRHOEA, CHOLERA NOSTRAS, AND DYSENTERY.

Infantile diarrhoea and the cholera nostras of adults are closely allied in symptoms and pathology, but they are so unlike in their fatality that they are best considered apart. Dysentery is sufficiently distinguished from choleraic disorders even in nosological respects; and except in Ireland, where its history (already given) has been somewhat special, it might have been made the subject of a separate chapter in British epidemiology. But, for the same reason as in the case of influenzas and epidemic agues and of scarlatina and diphtheria, it is necessary in a historical review to include infantile diarrhoea, cholera nostras of adults, and dysentery in one chapter, the reason being, that they are not clearly separated in the earlier records. So little are they separated in the London bills of mortality that the younger Heberden, in his fragment upon ‘The Increase and Decrease of Diseases[1386],’ has understood the name of “griping in the guts,” under which enormous totals of deaths are entered in the bills for many years of the earlier period, to mean dysentery alone: having assigned that meaning to the name, and having observed, as everyone must, the very palpable fact that “griping in the guts” steadily declined in the bills from the end of the 17th century until it had almost disappeared from them in his own time, he has elaborately proved from the figures that dysentery was at one time among the most important causes of death in London, that it declined in the most regular way, and at length became all but extinct. This illustration of the increase or decrease of diseases has seemed so apt, the statistical demonstration so complete, that it has become a favourite example of those broad contrasts between the public health of past and present times which are not less pleasing in rhetoric than they are on the whole true in fact[1387]. But it happens that the particular instance is wholly fallacious and erroneous. It was not dysentery that the article “griping in the guts” meant for the most part, it was infantile diarrhoea; which has not only not ceased in our own time, but is commonly believed to be distinctively a product of the industrial town life of the present age. I shall show that it was one of the most important causes of London mortality from the Restoration onwards, and that although it is still one of the great causes of death in infants, yet that it had weekly mortalities in some of the hot summers of former times which were far higher in ratio of the numbers living than the diarrhoeal death-rates of our own time. So far as concerns dysentery itself, it is indeed now rare in England and Scotland, and not common in Ireland; but the real history of its decrease has been altogether different, both in the period of it and in the extent of it, from what Heberden supposed. There are two reasons for the fallacy and error of that writer: the first, that he overlooked the question of age-incidence in “griping in the guts”; the second, that he failed to observe that enormous annual totals of deaths under that head had been gradually transferred in the bills of the Parish Clerks to the head of “convulsions,” until there were only a few of the old name left[1388].

Summer Diarrhoea of Infants in London, 17th century.

In the period of twenty-five years which Sydenham’s epidemic constitutions cover (1661-1686), the first distinctively choleraic season was the late summer and autumn of 1669. It was the first of a series of such seasons, in one or more of which there occurred dysentery, cholera morbus and bilious colic. In the context of the bilious colic of the years 1670-72, Sydenham remarks that this was a disease which attacked chiefly the young of a hot and bilious temperament, and was most rife in the summer season[1389]. It is in connexion with the smallpox of 1667-69 that he speaks of diarrhoea in infants; in that malady, he says, diarrhoea is as natural to infants as salivation to adults, and he blames the imprudent efforts of nurses to check the diarrhoea for the deaths of “many thousands of infants[1390].” This is perhaps all that can be found in Sydenham to show that infants did in fact suffer from diarrhoea, and that it was fatal to them in large numbers. Equally indirect is the testimony of Willis. Speaking of convulsions, he says they occur at two special periods of life,--within one month of birth (the “fits of the mother” of 18th century writers), and during teething; and with reference to the cause he says: “As often as the cause of the convulsive distemper seems to be in the viscera, either worms or sharp humours, stirring up to torments of the belly, are understood to be at fault[1391].” It may be thought singular that Sydenham and Willis should not have enlarged upon the infantile age at which the summer diarrhoea of London mostly proved fatal, or that Sydenham should not have elucidated by some comment the enormous weekly totals of deaths by “griping in the guts” in the Parish Clerks’ bills during many of the summers and autumns that came within the period of his epidemic constitutions.

It should be kept in mind, however, that it was from the populous liberties and outparishes occupied by the working class,--from Cripplegate, Shoreditch, Spitalfields, Whitechapel, St Olave’s, Southwark, Newington and Lambeth,--that the largest totals in the bills came. Sydenham in Pall Mall, Willis in St Martin’s Lane, and Morton in Newgate Street, were not likely to see much of the maladies of the poorest class, least of all the infantile part of these; and the fact that their illustrative cases of choleraic disease are mostly of adults should not mean that the age of infancy did not then furnish most of the deaths, as it certainly did in later times.

Whatever may have been the reason of their saying so little of infantile diarrhoea, its great frequency or fatality in London in the end of the 17th century rests upon the explicit testimony of Doctor Walter Harris, in his book on the Acute Diseases of Infants, written in 1689[1392]: “From the middle of July to the middle of September these epidemic gripes of infants are so common (being the annual heat of the season doth entirely exhaust their strength) that more infants, affected with these, do die in one month than in other three that are gentle.” It was probably this remarkable fatality of the summer diarrhoea of infants that led Sydenham to say that the cholera morbus of August differed _toto caelo_ from the disease with the same symptoms at any other time of the year[1393].

The summer of 1669 was excessively hot; it was a season of enormous mortality from fevers in Holland, of a type very difficult to understand, and in New England it was remarkable for fluxes, agues and other fevers. In that summer, as well as in the following, Sydenham lays stress upon the amount of choleraic and dysenteric sickness, without saying that it was specially fatal to children. The following Tables, compiled from the weekly bills of the Parish Clerks for each of the two summers, show the enormous rise of the total deaths in August and September, “griping in the guts” accounting for almost the whole of the increase.

_Weekly Mortalities supposed of Infantile Diarrhoea in London._

Summer and Autumn of 1669

Week Convulsions Griping in All ending the guts causes

June 29 30 42 283 July 6 49 74 365 13 48 105 391 20 53 119 389 27 36 122 368 Aug. 3 28 96 340 10 22 129 437 17 43 173 510 24 31 182 482 31 42 269 665 Sept. 7 45 318 707 14 34 277 619 21 33 231 524 28 29 232 570 Oct. 5 38 185 553 12 30 172 518 19 25 156 473 26 16 146 421 Nov. 2 14 89 372

Summer and Autumn of 1670

Week Convulsions Griping in All ending the guts causes

July 5 37 41 318 12 40 51 320 19 43 76 351 26 40 77 372 Aug. 2 49 113 470 9 38 160 485 16 44 189 555 23 47 222 629 30 42 250 629 Sept. 6 31 253 617 13 24 239 586 20 38 225 575 27 27 150 474 Oct. 4 16 130 401 11 13 104 376 18 17 78 325 25 15 75 336 Nov. 1 19 46 283

These are the characteristic London bills of a hot autumn; they recur sometimes two or three years in succession, and on an average perhaps once or twice in a decennium. Any year with an unusually high total of deaths from all causes is almost certain to show a large part of its excess of deaths in the weekly bills of summer and autumn. The proof that these enormous weekly totals under the head of “griping in the guts” were infantile deaths lies in the fact that they were gradually transferred to “convulsions,” as will appear in the tables of future autumnal epidemics showing the transference half made and wholly made. The transference to “convulsions” was almost complete before the year 1728, when the ages at deaths from all causes were first published in the weekly bills. After that year it is obvious that any excessive mortality of the six or eight hot weeks of late summer or autumn corresponds to a great increase of the deaths under two years, which is also the increase of deaths from convulsions. But those were the “convulsions” of a particular season, occupying exactly the place which “griping in the guts” held in the weekly bills of certain years in the earlier period. As most of the deaths from infantile diarrhoea are really from convulsions, it is easy to see that high weekly totals of deaths under that generic name must have been from infantile diarrhoea--when they began to rise in August far above the ordinary level of convulsions to fall to the level again in October. It is by precisely the same reading between the lines that we discover, under the head of “diarrhoea and dysentery” in the modern registration returns, that there is hardly any fatal dysentery, not much fatal diarrhoea of adults, but an enormous fatality from the diarrhoea of infants, especially in summer.

The sickness of the latter half of 1669, and of the years following to 1672, which we know from Sydenham and Morton to have been choleraic and dysenteric, was not special to London. The following abstracts of the burial registers of country parishes,

_Deaths in Country Parishes of England._

Registers With excess of Baptisms Burials Years examined burials over baptisms in these in these

1669 118 33 685 878 1670 119 53 781 1403 1671 121 36 668 1051 1672 121 28 555 741 1673 124 16 365 487

by Short, show an excessive mortality in those years, which would have been in part caused by bowel complaints, as in the general “choleric lasks” of the 16th century.

In the summers of 1671 and 1672 the article of “griping in the guts” continues high in the London bills. It rises again decidedly in the summer of 1675, reaching a maximum of 129 deaths in the week ending 24 August, the deaths from all causes being 460. In the summer of 1676 it almost equals the high mortality of 1669 and 1670, reaching a maximum of 238 deaths in the week ending 22 August, the deaths from all causes being 607. In 1678 and 1679 there were epidemic agues, complicated with choleraic flux and gripes, which undoubtedly affected many adults[1394]. The deaths from “griping in the guts” continue high in the summers of 1680 and 1681. But by that time the article “convulsions” had steadily increased in the bills; and in the next great season of bowel complaint, the excessively hot and dry summer of 1684, the high mortality of the season is divided more equally between “griping in the guts” and “convulsions,” a sufficient indication of the age-incidence of the former:

_London Weekly Mortalities._

1684

Griping in Week ending the guts Convulsions All deaths

July 1 56 98 454 8 71 92 404 15 65 79 364 22 74 89 420 29 116 84 503 Aug. 5 154 180 720 12 -- -- -- 19 186 100 609 26 -- -- -- Sept. 2 171 95 585 9 144 82 564 16 103 58 471 23 91 59 464

The summers and autumns of 1688 and 1689 were again characteristic seasons of infantile diarrhoea. The deaths rose in August and September almost as in 1669 and 1670; but now the article of convulsions has actually more of the mortality of the season assigned to it than the original article of “griping in the guts.”

_London Weekly Mortalities._

Summer and Autumn of 1688

Week Convulsions Griping in All ending the guts causes

July 10 84 28 353 17 94 35 388 24 90 80 491 31 108 86 510 Aug. 7 122 119 557 14 141 136 630 21 130 113 518 28 120 90 483 Sept. 4 109 98 532 11 112 119 547 18 90 102 474 25 102 76 476 Oct. 2 71 65 380 9 67 43 362

Summer and Autumn of 1689

July 16 108 60 486 23 109 65 463 30 121 69 504 Aug. 6 147 102 576 13 121 130 631 20 140 150 662 27 150 190 726 Sept. 3 150 170 733 10 108 156 693 17 110 117 630 24 95 90 558 Oct. 1 104 89 540 9 76 78 486

The following table from the annual bills will serve to show the summers most fatal to infants in London, and at the same time the gradual usurpation of the place of “griping in the guts” by “convulsions.”

_Annual deaths from Infantile Diarrhoea, etc., in London._

Griping in Convulsions the guts

1667 2108 1210 1668 2415 1417 1669 4385 1730 1670 3690 1695 1671 2537 1650 1672 2645 1965 1673 2624 1761 1674 1777 2256 1675 3231 1961 1676 2083 2363 1677 2602 2357 1678 3150 2525 1679 2996 2837 1680 3271 3055 1681 2827 3270 1682 2631 3404 1683 2438 3235 1684 2981 3772 1685 2203 3420 1686 2605 3731 1687 2542 3967 1688 2393 4438 1689 2804 4452 1690 2269 3830 1691 2511 4132 1692 1756 3942 1693 1871 4218 1694 1443 5024 1695 1115 4496 1696 1187 4480 1697 1136 4944 1698 1165 4480 1699 1225 4513 1700 1004 4631 1701 1136 5532 1702 1189 5639 1703 985 5493 1704 1134 5987 1705 1021 6248 1706 948 5961 1707 883 5948 1708 768 5902 1709 812 5892 1710 707 6046 1711 614 5516 1712 575 6156 1713 581 5779 1714 670 7161 1715 589 6818 1716 709 7114 1717 653 7147 1718 801 8055 1719 826 7690 1720 731 6787

Summer Diarrhoea of Infants, 18th century.

The first series of unhealthy summers in the 18th century is from 1717 to 1729 (the summer of 1715 having had also high “convulsions”). In the week ending 17th September, 1717, the article of “convulsions” rises to 187, while that of griping in the guts is only 13, the deaths from all causes being 522. For the next two years, the highest mortalities of the autumn were these:

_London Weekly Mortalities._

Griping in Week ending the guts Convulsions All deaths Births

1718

Aug. 12 34 226 653 355 19 23 239 645 383 26 25 256 693 347 Sept. 2 28 265 668 350 9 27 245 725 388 16 26 221 653 336 23 27 213 639 367 30 24 182 632 361

1719

Aug. 11 32 215 688 354 18 29 243 670 342 25 28 245 755 371 Sept. 1 27 233 726 362 8 17 229 735 393 15 22 218 728 379 22 14 202 663 360 29 17 161 639 372

If these two tables be compared with the tables already given for the summers and autumns of 1669 and 1670, it will be found that the figures under “griping in the guts” and under “convulsions” have exactly changed places, the hundreds of the former in 1669-70 becoming tens in 1718-19, and the tens of the latter in 1669-70 becoming hundreds in 1718-19.

In those two years the article of fever was very high, contributing largely to the weekly totals of deaths from all causes, especially in the summer and autumn. In 1720 “fever” and “convulsions” again reached a maximum in September, the deaths from all causes in the week ending 20th September being 592. The winter of 1721 (February) is the first of a series when the weekly deaths of the cold season reach the enormous height of the most unwholesome summers, the causes being “fever,” “aged,” “consumption,” “dropsy,” and the like, with a due proportion of infantile deaths. The fatal winters following are 1723 (January), 1726 (Jan.-March), 1728 (Feb.-March, the end of a great epidemic of fever), 1729 (Nov.-Dec., still fever), 1732-33 (Dec.-Feb.) and 1738 (November). This was the great period of spirit-drinking, crime, and general demoralization in London. In the week ending 30th Jan. 1733, the deaths from “dropsy” were 64: it was in the midst of an influenza.

The next characteristic weekly bills of autumn are found in the year 1723, when the following enormous mortalities occurred in three successive weeks:

1723

Griping in Week ending the guts Convulsions All deaths Births

Sept. 3 23 308 761 396 10 32 251 705 339 17 33 262 768 390

Then comes a succession of four summers and autumns, 1726-29, in which the weekly mortalities are of the same kind--high totals from all causes and high “convulsions,” while “fevers” are high in several seasons of the period, perhaps from influenzas. Strother, writing in the summer of 1728, says there was much diarrhoea in London “last autumn [1727] and this summer,” the effects of which upon the bills of mortality are nowhere visible except under the enormous weekly totals of “convulsions.”

I shall take one more example of a season fatal to infants, the autumn of 1734, by which time we find recorded the ages at death:

_London Weekly Mortalities, with the numbers under five years._

1734

All deaths Total of All deaths from deaths Week ending Convulsions under two two to five at all ages

Aug. 13 218 240 71 558 20 217 284 76 547 27 240 297 80 573 Sept. 3 260 331 59 638 10 226 283 61 593 17 209 253 43 528 24 169 225 46 515 Oct. 1 158 224 59 510 8 190 236 61 558 15 136 172 42 464

In those nine mortal weeks of 1734, it will be seen that the deaths under two years were about 45 per cent. of the deaths at all ages; they were at the same time considerably more than half the recorded births. That was the characteristic mortality of an unhealthy summer and autumn. It was chiefly caused by the same cholera infantum or summer diarrhoea which raises the weekly bills of London in our own time, and the occasions of it recurred in a series of hot summers, or at intervals, just as they do now. I shall not seek to illustrate this point for the rest of the 18th century, and down to the beginning of registration in 1837. The history of infantile diarrhoea is a continuous and uniform one, with indications of greatest severity in the first half of the 18th century. Sir William Fordyce, whose general theme is what he calls the hectic fever of children (rickets), thus reveals some reasons why that should have been the worst period of infantile diarrhoea[1395]:

“I speak within the bounds of truth when, judging from the Bills of Mortality and the numbers in such circumstances who have been brought to my door since the year 1750, I assert that there must be very near 20,000 children in London, and Westminster and the suburbs (if this be questioned, examine the public charity schools and workhouses, the purlieus of St Giles’s and Drury Lane, and satisfy yourselves) ill at this moment of the hectic fever, attended with tun-bellies, swelled wrists and ancles, or crooked limbs, owing to the impure air which they breathe, the improper food on which they live, or the improper manner in which their fond parents or nurses rear them up: for they live in hotbed chambers or nurseries, they are fed even on meat before they have got their teeth, and, what is if possible still worse, on biscuits not fermented, or buttered rolls, or tough muffins floated in oiled butter, or calves-feet jellies, or strong broths yet more calculated to load all their powers of digestion; or are totally neglected.”

Mistaken regimen among the more comfortable, total neglect among the lowest class--these general causes of infantile mortality reached their highest point in London under George I. and George II., at the time of the disastrous mania for spirit-drinking. But the broken constitutions of the parents were probably a more telling thing for the poor stamina of the children than close nurseries, injudicious food or even total neglect[1396].

While the article “Convulsions” in the London bills gradually swallowed up nearly all the deaths of infants under two years, and so far extinguished the article “griping in the guts” that the latter in the year 1739 had fallen to the merely nominal figure of 280 deaths in the year, yet it should be borne in mind that there must have been in the same period an excessive mortality from convulsions not specially related to cholera infantum. For example, the kind of convulsions in new-born infants which nurses called the “nine-day fits,” produced the following mortalities in the Lying-in Hospital of Dublin: Of 17,650 infants born alive in the hospital from 8 Dec. 1757 to 31 Dec. 1782, there died 2944 within a fortnight of birth, or 17 per cent. The disease of perhaps nineteen in twenty was “general convulsions, or what our nurses have been long in the habit of calling the nine-day fits[1397].” Corresponding deaths in London would have been included under “chrisoms and infants” in the earlier period; but as that article gradually ceased, they were naturally transferred to the article “convulsions.”

The sacrifice of infants’ lives in London by the diarrhoea of summer having been so enormous as the preceding tables show, the question arises whether the same disease was a chief factor in the mortality of provincial cities and towns. There is little positive evidence for, and there is a good deal of probability against, its having been so important anywhere as in London. In the second quarter of the 18th century, when London had 700,000 inhabitants, the larger provincial towns such as Edinburgh, Glasgow, Manchester, Newcastle had not more than 30,000 to 40,000. A Liverpool writer in 1784, by which time the population had grown much, does indeed say that young children in large towns during the hot summer months are apt to be fretful and peevish, and that they should have a change to the air of the country[1398]. But it is inconceivable that Manchester, with such vital statistics as are shown at p. 644 could have had the same death-rates from convulsions in general or from the summer-diarrhoea kind of them in particular, that London then had. Still it had at least a local predisposition, then as now, to epidemic diarrhoea. Thus Ferriar, having described certain flagrant nuisances in the town, goes on to say that the burning summer of 1794 was followed by wet warm weather, that a bilious colic raged among all ranks of the people, and that thereafter “the usual epidemic fever” became very prevalent among the poor[1399].

The bills of mortality for occasional years at Chester, Warrington, Northampton, Carlisle and Edinburgh, which have been cited before in various contexts, throw hardly any light upon this question of infantile diarrhoea. The records of the Newcastle dispensary in the end of the 18th century do show a good many cases of diarrhoea to have been attended, with a proportion of fatalities which suggests that some, at least, were in infants. Newcastle, as will appear in the sequel, was certainly much subject to dysentery and the diarrhoea of adults in the 18th century, and was as likely a place as any in England for cholera infantum. In the records of two towns of Scotland it seems probable that a good deal of infantile diarrhoea had been entered in the burial registers under the name of “bowel-hive.” At Kilmarnock, from 1728 to 1764, and at Glasgow from 1783 to 1800, the principal causes of death in infancy had the following annual average ratios per cent. of the deaths from all causes:

Kilmarnock Glasgow 1728-64 1783-1800

Smallpox 16 per cent. 18·8 per cent. Bowel-hive 7·0 " 6·5 " Chincough 3·0 " 5·0 " Closing 2·8 " 2·7 " Measles 2·4 " 1·3 " Teething 1·4 " 3·5 "

The article “bowel-hive” has a somewhat higher ratio of the deaths from all causes at Kilmarnock, with about 4000 population, than at Glasgow with some 80,000, and was probably a very comprehensive term[1400].

So far as concerns systematic medical description, an article by Dr Benjamin Rush, of Philadelphia, written in 1773, is the first expressly on the theme of cholera infantum or the summer diarrhoea of children; but, as Hirsch correctly remarks, the popular names of the disease then current in American towns, such as “disease of the season,” “summer complaint,” or “April-and-May disease” (Southern States), indicate that it was well known before the profession began to write upon it[1401]. So far as concerns London, I am disposed to infer that it was more common, relatively to the population, in the end of the 17th century and throughout the 18th than in our own time. I shall come back to that after giving the modern statistics of the malady for the capital and other English towns.

Modern Statistics of Infantile Diarrhoea.

The first six months of registration of the causes of death in England and Wales, July-December, 1837, brought to light the following highest mortalities from diarrhoea, which are mostly in manufacturing towns, and especially in those of Lancashire and Yorkshire:

1837

Deaths by Diarrhoea

3rd qr. 4th qr.

{Manchester 164 47 {Salford 26 15 {Chorlton 63 14 {Liverpool 142 49 {West Derby 53 15 Leeds 52 37 Nottingham 43 4 (besides dysentery 25 2) Dudley 45 52 Wolverhampton 37 32 Bolton 40 27 Newcastle 35 25 Sheffield 30 23 Stockport 28 23 Preston 21 20 Wakefield 22 10 Cockermouth 12 14

The returns were incomplete at first; and, for London, the figures of only three parishes are given:

3rd qr. 4th qr.

Shoreditch 73 15 Greenwich 43 19 Kensington 35 13

Apart from the imperfect machinery of registration in the first years, the figures of mortality by infantile diarrhoea are incorrect owing to many such deaths having been certified as from “convulsions,” according to the old tradition of the Parish Clerks’ bills. Doubtless this goes on still to a considerable extent; but it will appear from the following comparative table for London that it masked the real amount of infantile diarrhoea to a much greater extent at the beginning of registration than afterwards.

_London Mortalities from the beginning of Registration._

Gastritis and Years Diarrhoea Dysentery Cholera Enteritis Convulsions

1838 393 105 15 881 3419 1839 376 79 36 843 2961 1840 452 70 60 977 2983 1841 465 78 28 957 2778 1842 704 151 118 996 2773 1843 834 271 85 874 2701 1844 705 125 65 818 2736 1845 841 99 43 707 2395 1846 2152 156 228 648 2086 1847 1976 -- -- -- 2258

There is a progressive decline under “convulsions” and a progressive increase under diarrhoea. The year 1846 was undoubtedly marked by an unusual amount of choleraic disease; but the high level of the diarrhoeal deaths was maintained from that year, so that it is probable that some radical change had been made in the mode of entry. The nearly equal proportion of deaths from diarrhoea and from convulsions in London has continued since that time to the present, the former falling mostly in the third quarter of the year, the latter not unequally on all the quarters.

In all England and Wales during the first five and a half years of registration the deaths from diarrhoea were few compared with the numbers relative to population in later periods:

England and Wales

Years 1837 (6 mo.) 1838 1839 1840 1841 1842 Deaths from Diarrhoea 2755 2482 2562 3469 3240 5241

There is a break in the annual tabulations of the returns for four years from 1843 to 1846; when they are resumed in 1847, the diarrhoeal death-rate per million living is found to have apparently risen to an enormous height, at which it remained somewhat steady for a whole generation.

_Annual average Mortalities per million living from Diarrhoea (and Dysentery)._

England and Wales

1838-42 254 1847-50 900 1851-60 918 1861-70 968 1871-80 917 1881-90 662

London

1838-40 274 1841-50 782 1851-60 1030 1861-70 1040 1871-80 949 1881-90 749

From year to year the mortality has fluctuated enormously, as in the following list, the rise or fall depending for the most part on the kind of summer: e.g. that of 1893 was hot, and had an excessive mortality from infantile diarrhoea.

1866 18266 1867 20813 1868 30929 1869 20775 1870 26126 1871 24937 1872 23034 1873 22514 1874 21888 1875 24729 1876 22417 1877 15282 1878 25103 1879 11463 1880 30185 1881 14536 1882 17185 1883 15983 1884 26412 1885 13398 1886 24748 1887 20242 1888 12839 1889 18434 1890 17429 1891 13962 1892 15336 1893 28755

These large annual totals stand almost wholly for deaths of infants, according to the following table of rates per million living at the respective ages:

_Mortality from Diarrhoeal diseases per million living at the age-periods._

All ages 0-5 5-10

1851-60 1080 5263 229 1861-70 1076 5985 160 1871-80 935 5728 69

Three-fourths of the deaths are of infants in their first year. The middle period of life is comparatively free from this cause of death, but at fifty-five the ratio begins to rise again, and at seventy-five and upwards is almost as high, among the comparatively small number living in extreme age, as it was in infancy. Male infants die of it in excess of females, according to a very general rule of sex mortality. It is also according to rule that the ratio of female deaths approximates to that of males in middle life and old age.

The deaths from infantile diarrhoea fall in great excess upon the towns, and most of all upon the manufacturing towns and certain seaports. London, which almost certainly had a great pre-eminence in the 18th century in the matter of infantile deaths by summer diarrhoea, has lost it to a number of provincial towns, of which the following is a list in the order of the percentage ratios of their diarrhoeal death-rate per 1000 living under five years to their death-rates from all causes under five years (Decennial Period, 1871-80):

_Percentages of Diarrhoeal death-rate in the death-rates from all causes under five years._

Yarmouth 19·4 Leicester 19·2 Preston 16 Worcester 16 {Sculcoates 16 {Hull 14 Northampton 15 Coventry 15 Goole 14 Leeds 13·7 Birmingham 13·5 Manchester 13 Salford 13 Norwich 13 Wigan 12·7 Hartlepool 12·5 Nottingham 12·4 Sheffield 12 Hunslet 12 Bolton 11·6 Holbeck 11·6 Stoke-on-Trent 11·3 Stockport 11·2 Liverpool 11 Blackburn 10 London, St Giles’s 10 London, Whitechapel 9·6

The reasons for placing the towns in the above order will be found in the Table that follows, the significance of which will be pointed out after some other matters have been disposed of. Meanwhile it may be said that all these have diarrhoeal death-rates under five years greatly in excess of all England and of all London.

_Table of English Towns with highest death-rates from Infantile Diarrhoea._

Death-rate Death-rate from from all causes diarrhoea under five under five Deaths of per 1000 per 1000 infants Birth- Death- living living under one rate rate at the at the to 1000 per per age-period age-period births 1000 1000

Liverpool 119·29 14·13 217 35·08 33·57 Manchester (1871-73 incl. Prestwick) 103·82 18·84 207 38·97 31·46 Manchester (1874-80) 103·52 11·23 190 40·78 32·16 Preston 97·85 15·61 212 37·86 28·05 Salford 95·96 12·44 184 42·39 27·65 London, Whitechapel 95·83 19·24 181 36·42 33·03 Holbeck 94·00 10·93 196 42·63 26·64 London, St Giles’s 92·69 9·42 176 34·05 23·42 Leicester 92·52 17·81 214 41·44 24·46 Sheffield 91·22 10·96 183 42·50 27·41 Blackburn 90·33 9·02 191 39·30 25·29 Hunslet 88·35 10·75 192 44·52 25·49 Leeds 87·47 12·02 188 39·33 26·04 Wigan 87·28 11·13 172 45·70 25·77 Stoke-on-Trent 86·76 9·91 189 43·29 25·80 Birmingham 86·10 11·78 179 39·89 25·82 Stockport 80·33 9·05 182 35·79 24·73 Nottingham 79·30 9·86 184 32·58 22·55 Bolton 78·54 9·13 167 39·20 24·34 Yarmouth 75·37 14·38 199 32·45 22·94 Hartlepool 75·26 9·43 166 43·36 22·49 {Hull 77·89 11·02 178 37·88 24·52 {Sculcoates 71·53 11·64 170 39·46 21·66 Norwich 72·29 9·78 188 32·86 23·32 Northampton 71·41 10·85 173 37·48 22·65 Worcester 68·24 11·10 176 32·00 22·13 Coventry 68·09 10·06 164 35·17 21·59 Goole 64·58 9·20 166 36·47 21·39

The deaths by infantile diarrhoea have a seasonal rise more marked than that of any other malady. In the curves formed by Buchan and Mitchell of the rise and fall of the deaths by various diseases in London throughout the year, that of diarrhoea was the sharpest, rising to a high peak in the third quarter of the year (July-Sept.). “Speaking generally,” says Dr Ogle, “it appears from the returns of mortality in London that the diarrhoeal mortality becomes high when the mean weekly temperature rises to about 63°F.[1402]” The season is practically the same throughout the British Isles. But in warmer countries, such as the more southern of the United States of America, infantile diarrhoea is “the April and May disease.” It is not the fatalities only, but the cases as a whole, that fall decidedly upon the third quarter of the year[1403].

Causes of the high death-rates from Infantile Diarrhoea.

Sydenham said that the diarrhoea or bilious colic of London in the month of August differed _toto coelo_ from that of other seasons of the year; and Harris, writing in the year of Sydenham’s death (1689), said that more infants, affected with the epidemic gripes, died in one month of the hot season, from mid-July to mid-September, than in other three that are gentle. If this were taken to mean that the infantile mortality from all causes was trebled by the prevalence of diarrhoea during the eight warmest weeks of the year, it would be nearly borne out by the weekly bills of mortality, according to the examples given of them from the more fatal years. So far from the deaths of infants in London by summer diarrhoea having increased in the present century, they would appear to have diminished greatly. The two worst weeks of an unhealthy summer or autumn raised the London deaths in former times relatively as much as the whole diarrhoeal season would do now. If this great change for the better be admitted as correct, it may throw some light upon the causes of excessive infantile diarrhoeal mortality in London in former times, and in some other English towns at the present time.

The London populace in the 17th and 18th centuries were not only the single great urban community in the kingdom, but they were far more “urban” than now, in Milton’s sense of being

“long in populous city pent, Where houses thick and sewers annoy the air.”

The houses stood closer together, many of them back to back in courts and alleys. The streets were narrower. The inhabited area had few or no open spaces besides the bed of the Thames. Not only the City and Liberties, but also the out-parishes were compact, as if within a ring fence, joining on to the open country abruptly, and not as now in straggling suburbs. It was hardly possible to take children out for an airing, except in the west end. When Lettsom about 1770 applied the fresh-air treatment to convalescent cases of typhus, he had to send the patients to loiter on the bridges spanning the Thames. As Cobbett said, London was a “great wen,” in the correct sense of a shut sac which grew by distension. The soil was full of organic impurities, including the decompositions of many generations of the dead. A hot summer in former times raised effluvia from the ground such as the modern residents have no experience of. The life indoors was equally adverse to infants. Fustiness was favoured by the window-tax; a tenement-house was apt to be pervaded by the excremental effluvia from the “vault” at the bottom of the stair. The worst time of all in London was the great drunken period from about 1720 onwards. Doubtless drink was then used, as it is sometimes now, to drug the fretful infants into torpor; but it told also upon them indirectly, inasmuch as dissolute parents would have bred children with _mala stamina vitae_[1404]. In all these respects there has been so great an improvement in London that, although its population now exceeds four millions, its death-rate from infantile diarrhoea, a distinctively urban disease, exceeds only by a little the mean of all England and Wales.

While the mortality from infantile diarrhoea in London has undoubtedly decreased since the 17th and 18th centuries per head of the population, it is equally certain that there has been within the present century a great relative increase of the deaths from that cause in the country generally. The reason is that there has been an enormous increase of population and that the increase has been almost wholly urban. The rise of new manufacturing towns, with the great extension of the borders of old towns, as in Lancashire and Yorkshire, has inevitably brought to the front this distinctive fatality of town-bred infants. If the additional millions had been dispersed in village communities over the face of the country, as in Bengal, the mere density of population per square mile would have had its effect on the public health, but not the same effect. There are now two or three provincial cities comparable in size to 18th century London, and there are some twenty more large enough to be in the same group. In most of these the mortality from infantile diarrhoea has held its ground, for all the improvements in sanitation and in well-being whereby the death-rate from all causes has been considerably reduced. It is mainly owing to that disease, and to whooping-cough, that the death-rate in the first year of life, although it has ranged widely from year to year, has fallen but little in the successive decennial periods. The bad eminence of some towns in the list already given is probably due to a composition of causes, among which the situation, soil, depth of ground-water, and the like, would count. It is remarkable, however, that there are only a few of them, such as Liverpool and Hull, that have been the chosen seats of great epidemics of Asiatic cholera. On the other hand, Leicester and Birmingham never had an epidemic of that disease, while Preston and the cotton-weaving towns of Lancashire generally have had but slight outbreaks of it. Again, the deaths from diarrhoea have been more purely infantile in the group of towns which have had little or no Asiatic cholera[1405].

That which distinguishes the Lancashire and West Riding towns with highest proportions of diarrhoeal death-rates in their infantile death-rates generally, as well as such towns as Leicester, Worcester, Northampton, Coventry and Norwich, Birmingham, Nottingham and Stoke-on-Trent, is the extensive employment of women in factory work and other labour of the factory kind. The Census returns do not adequately show this for married women, who may be returned simply as of the married rank whether they be wage-earners or not; but it is well known that the female labour of industrial towns is to a large extent the labour of child-bearing women. Among the towns that stand highest for infantile diarrhoea, Preston, in the Census of 1881, had 32 per cent. of its adult female population occupied in the cotton mills; Leicester had 20 per cent. of all its women occupied in various industries, of which the chief are the hosiery and boot-making; Northampton only 13 per cent., all at boot-making; Worcester, a percentage, unknown for the city, occupied mostly at glove-making; Norwich about 10 per cent. of its women returned as employed at boot-making, silk manufacture, and various smaller industries.

One obvious result of married women engaging in factory labour, or piece labour of the same kind at home, is that they do not suckle their infants; and it has long been known that infants brought up with milk from a feeding-bottle are much more liable to diarrhoea than infants brought up at the breast. But the feeding-bottle is now too universal an appurtenance of infancy among all classes and in all places to be a sufficient explanation without something else, although there is no doubt that feeding-bottles which are not kept very carefully clean are a real danger in the particular way. Again, young children above the age for suckling or feeding by the bottle are attacked by summer diarrhoea in about the same proportions (e.g. at Leicester) as infants under one year, although they do not contribute an equal quota to the death-roll.

In the discussions upon this question it has been commonly assumed that the fault lies with the mother after the birth of her child, and all the remedial measures, such as crèches for the infants of workwomen, have that assumption underlying them[1406]. I believe that this is a very inadequate account of the cause of this great modern evil, and that the remedies proposed are mere palliatives which are destined to fail. The importance of the matter may justify me for once in making an excursus into physiology and pathology.

The problem of infantile diarrhoea is in great part the same as the problem of rickets. The peculiar summer disease of town-bred infants is especially apt to assail the rickety: probably a very large number of the infants under one who are cut off by it would have become obviously rickety if they had lived a few months longer. But even if there were not this well-known correspondence between the subjects of infantile diarrhoea and of rickets, we should find analogies in the pathology of each. Rickets is an exquisitely congenital disease, or a disease acquired by the child in the womb from the kind of intra-uterine nutrition that it receives. In recent times it has been usual to restrict the term congenital in rickets to the very few cases that have rickets developed at birth. This is a typical instance of the peculiar narrowness of view in modern pathology. All rickets is congenital, although it is rare to find the symptoms made manifest until the infant is nearly a year old. Cullen’s reasoning on this point a century ago has never been answered nor superseded. The theories of that day to explain rickets by injudicious feeding or regimen after birth seemed to him beside the mark: “Upon the whole I am of opinion that hired nurses seldom occasion this disease unless when a predisposition to it has proceeded from the parents.... I am very much persuaded that the circumstances in the rearing of children have less effect in producing rickets than has been imagined.... I doubt if any of the former [dietetic errors and the like] would produce it where there was no predisposition in the child’s original constitution.... So far as I can refer the disease of the children to the state of the parents, it has appeared to me most commonly to arise from some weakness, and pretty frequently from a scrofulous habit, in the mother,” (Cullen, _First Lines_, Part III. Bk. II. chapter 4). The chief exponent of the diathetic views on rickets in our time has been Sir William Jenner (_Med. Times and Gaz._, 1860, I. 466); but I remember at the Pathological Society on 7 Dec., 1880, how unacceptable, or perhaps unintelligible, that part of his exposition was to a younger generation who appeared to have forgotten the meaning of _mala stamina vitae_.

The congenital nature of rickets is not only an empirical fact, based upon experience, but it is a doctrine of rational pathology. The latter aspect of it rests upon the correct physiology of intra-uterine nutrition, for which I refer to my investigations on the structure and function of the placenta (_Journal of Anatomy and Physiology_, July, 1878, and January, 1879). The detailed application of the physiological facts to rickets I have attempted deductively in section 5 of the article “Pathology” in the _Encyclopaedia Britannica_, vol. XVIII., 1884. The building up of the placenta by the mother, and the due performance of function by that great and wonderful extemporised organ, require certain favouring conditions, which have been never unperceived by the common sense of mankind. Those conditions are certainly not to be found in factory labour. A woman who has to be thinking of the time-keeper at the gate and the foreman in the mill, who has ever in her ears the din of belts and wheels and mill-stones, who has dust in her lungs and weariness in her back, can hardly do justice to the child in her womb. The rearing of the child after it is born is of small consequence beside the rearing of it before it is born. The opportunity comes once (heredity apart) of giving it good stamina or bad; and in the circumstances of factory labour the wonder is that breeding women provide so well as they do for their unborn offspring. It is undoubted that they often tax themselves beyond measure to do so, in tacit obedience to the great law of maternity.

While the connexion of rickets in the child with the laborious or anxious preoccupations of the mother during gestation can be followed out in physiological or pathological detail, the connexion with the same of a disposition to summer diarrhoea remains empirical, except in so far as it is a part of the rickety constitution itself. Some congenital weakness, we may suppose, attends the functions of digestion and assimilation, and, under the relaxing influence of continued high temperature, leads to vomiting and purging, to which many infants succumb through the eventual implication of the cerebral functions.

Ballard gives a table to show that of 332 infants (in a total of 340) who died of diarrhoea at Leicester in 1881 and 1882, 141, or 42·5 per cent. were “healthy,” and 191, or 57·5 per cent. were “weakly,” and other tables to show that “our experience of these Leicester epidemics by no means supports an opinion commonly held that a summer diarrhoeal epidemic makes its first fatal swoop upon the weakliest children[1407].” If “weakly” and “healthy” were as determinate as bushels of wheat or barley, there would be some fitness in this resort to numerical precision. But, in the circumstances, common experience will come as near the truth as the statistical method can, and will assign poor stamina to a much larger proportion of the infants that die. The poor stamina may be more a matter of inference than of direct observation. Thus, the last case of a death from infantile summer diarrhoea that came under my notice was in a big-boned and well-grown infant in the country. But it was the twelfth child of an equally large-built country woman, then big with her thirteenth, whose husband, a farm labourer, earned on an average not more than ten shillings a week. The rate of fecundity has, of course, a direct influence upon the stamina of the children. Its bearing upon the death-rate from infantile diarrhoea is shown in one of the columns of the table at p. 762.

Cholera Nostras.

Thus far I have considered diarrhoea as the “disease of the season” for the age of infancy or early childhood; and undoubtedly the large totals of deaths from it in the London bills, whether under the name of “griping in the guts” or afterwards under the generic name of “convulsions” were nearly all infantile deaths, both in earlier and later times. If we had regard only to the statistics of mortality and the effects upon population, we might now pass from the subject of epidemic diarrhoea, having said all that has to be said of it in those respects. But the deaths from epidemic diarrhoea, mostly of the summer and autumn, are far from being a correct measure of its prevalence, whether in our own time or in earlier times. Adults suffered from it in a fair proportion of the numbers living at the higher ages, although few of them died of it, except among the elderly and aged. It is only for modern times that we have any figures of the number of persons attacked at the respective periods of life; and these I shall take first in order, as illustrating the probabilities or generalities that may be collected from earlier writers such as Willis and Sydenham.

The following Table of the ages attacked at Leicester during a recent series of years shows a smaller proportion of attacks in infancy than some other modern tables do; but it is not misleading for general experience, and it will serve emphatically to correct the illusion that infants, because they contribute the bulk of the deaths, are most obnoxious to the attacks[1408]:

_44,678 cases of Summer Diarrhoea at Leicester in seven epidemic seasons, 1881-87._

Age Cases Per cent.

Under one year 2,284 5·2 One year and under five 8,956 20·0 Five years and upwards 33,438 74·8 ------ ----- 44,678 100·0

On the other hand, the fatalities from diarrhoea in all England during the same seven years had the following very different incidence upon the periods of life:

Under One year and one year under five Five years and upwards

1881 9408 2476 2852 = 19·3 per cent. 1882 10680 3555 3050 = 17·6 " 1883 9962 2843 3128 = 19·6 " 1884 17854 4794 3764 = 14·2 " 1885 8821 2023 2524 = 17·9 " 1886 16514 4936 3298 = 13·3 " 1887 14101 2936 3205 = 15·8 " ---- Annual average per cent. above five 16·8

Thus, while (at Leicester) the attacks above the age of five years were 74·8 per cent. the fatalities above that age (in all England) were only 16·8 per cent. and the greater part of the deaths in that small fraction were of elderly or aged persons. This means that persons attacked by diarrhoea between the ages of five and (say) fifty nearly all recover; on the other hand a large proportion of infants in their first year succumb to the attack, and a considerable proportion of elderly or aged persons succumb to it.

If we were to judge from the direct testimony of Sydenham and Willis, we should say that the cholera nostras of London in the 17th century was chiefly a malady of the higher ages; there is little in their writings to suggest the enormous mortality of infants from that cause, which can be deduced from a close study of the bills. One reason for this, as already said, was that the ailments of infants and young children in former times came little under the notice of physicians, being left to the “mulierculae” or nurses, and that among the working class, from which most of the deaths in the bills came, there was in those times an almost total lack of the medical experiences now gained through dispensaries, hospitals and other charities or public institutions. With this proviso we may take the accounts of the older writers as giving a correct picture of the epidemic cholera nostras of a hot and close summer or autumn in former times.

The great seasons of choleraic disease in the 16th century were the years 1539-40, (which were remarkable all over Europe for dysentery as well), 1557-58, 1580-82, and probably 1596[1409]. The term commonly used in that period was a choleric lask, which meant _profluvium_. In some, if not in all, of those seasons there was unusual heat and drought. It is clear that these were only the years when cholera nostras of the summer season was exceptionally common and severe. According to a medical work of the year 1610, dealing with the indications for the use of tobacco by individuals, including the seasons of the year when it was most admissible, midsummer is characterized in general terms, and perhaps in the stock language of foreign medical treatises, as the season for “continuall and burning fevers, bleareyedness, tertian agues, vomiting of yellow choler, cholericke fluxes of the belly, paines of the eares and ulcerations of the mouth, putrefactions of the lower parts: especially when the summer, besides his heat, is enclined to overmuch moisture, and that no windes blow, and the weather bee darke, foule, close and rainie.... So that in this season, and for these remembered griefes, no man, I trust, will grant tobacco to be verie holesome[1410].” Consistently with this Sydenham says that, while the cholera morbus of August, 1669, was more general than he had ever known it, yet in every year, at the end of summer and beginning of autumn, there was some of it; and he compares its regularity to the coming of the swallow in spring or of the cuckoo in early summer. It was marked by enormous vomiting, purging, vehement pain in the bowels, inflation and distension, cardialgia, thirst, a quick pulse, sometimes small and unequal, heat and anxiety, nausea, sweats, spasms of the arms and legs, faintings, coldness of the extremities, and other symptoms, alarming to the attendants and sometimes causing death within twenty-four hours[1411]. Next year, 1670, in the corresponding season, he describes under the name of a bilious colic, a prevalent malady which, he says, should count rather among chronic diseases[1412]. It was marked by intolerable pain, the abdomen being now bound as if in a tight bandage, now bored through as if by a gimlet. These pains would remit for a time, and the paroxysm come back, the patient shrinking from the mere idea of it with misery expressed in his face and voice. This was evidently somewhat different from the cholera morbus of the summer of 1669; it was apt to end in inverted peristaltic action, with vomiting of the matters of enemata, or in iliac passion[1413]. There was also dysentery in both years, as we shall see.

Morton gives the first choleraic and dysenteric season under the year 1666, and says of its recurrence in the following autumn, that hardly any other disease was to be seen, that the whole town was seized, and that 300, 400 or 500 died of it in a week. This is obviously antedated by two years, just as Morton is two years earlier than Sydenham with the great fatality of measles (1672 instead of 1674). Willis, again, who wrote some twenty years nearer to the events than Morton did, places the great choleraic seasons in 1670 and 1671, instead of 1669 and 1670. Sydenham’s dates are undoubtedly correct, both as borne out by the bills of mortality, and as occurring in consecutive order in the annals which he kept for a period of twenty-five years. The correctness of his dates apart, Willis may be cited for the symptoms of the London cholera[1414].

The onset was sudden, with vomiting and watery purging, accompanied by prostration: “I knew a great many that, though the day before they were well enough and very hearty, yet within twelve hours were so miserably cast down by the tyranny of this disease that they seemed ready to expire, in that their pulse was weak and slender, a cold sweat came upon them and their breath was short and gasping; and indeed many of them, that wanted either fit remedies or the help of physicians, died quickly of it. This distemper raged for a whole month, but began to decrease about the middle of October, and before the first of November was almost quite gone.” The vomitings and purgings were copious, watery, almost limpid, not bilious. The sickness was peculiar to London or the country within three miles of it. It did not seem to be infectious, but to attack only those predisposed to it; for it would seize those who kept out of the way of the sick and spare those who attended them. Morton, however, declares that he was infected in two successive seasons, “dum, mense Augusto, sedes dysentericorum minus cauté inspicerem.”

These illustrations from the highly choleraic summers of 1669 and 1670 will serve to show the prevalence of cholera nostras among adults in London in former times. Its great seasons were the same as those of cholera infantum, of which numerous instances have been given from the London weekly bills of mortality. The years 1727-29 were specially noted for cholera by the annalists, such as Wintringham, of York. Hillary, of Ripon, having entered in his annals a “cholera morbus” in 1731, adds: “which disease I have observed to appear almost every year towards the latter end of summer[1415].” A letter from Darlington, 29 July, 1751, having mentioned the death of the earl of Derby by “the cholera morbus,” adds that the disease usually rages at the close of summer and towards the beginning of autumn[1416]. Newcastle was much subject to it, as well as to dysentery, Wilson, of that town, devoting an essay to dysentery in 1761 and to cholera in 1765. Lind, who went to Haslar Hospital in the very unwholesome period about 1756-58, found much aguish and choleraic sickness: “Obstinate agues, and what is called the bilious cholic, from being accompanied with vomitings and a purging of supposed bile, but especially the flux, are often at Portsmouth and Gosport in the autumnal season highly epidemical. Since I resided here, I have observed those distempers to rage among the inhabitants, strangers and troops with an uncommon degree of mortality; while, during this period of universal distress at land, ten thousand men in the ships at Spithead remained unaffected with them[1417].” At Manchester, in the burning summer of 1794, a bilious colic, says Ferriar, “raged among all ranks of people[1418].” Clarke, of Nottingham, writing in 1807 of the great prevalence of cholera nostras, calls it “the usual attendant on autumn[1419].”

The appearance of Asiatic cholera in England in the end of 1831 gave rise to much controversial writing for a few months, as to whether the epidemic were really the foreign pestilence. Every effort was made by a certain school to find native precedents for a disease equally malignant; which, if they did not prove the point in question, gave more exact particulars of cholera nostras than we might otherwise have received. The only one of these accounts that need concern us here is Thackrah’s for Leeds and its vicinity in 1825[1420].

The weather had been exceptional. In May, three-eighths more rain fell than usual, the wind being in the east the whole month. June was showery and sultry, the thermometer on the 12th marking 87°. July was sultry, with drought for several weeks to the 3rd of August, when showers fell. There had been a few cases of cholera in May, June and July, but it was not until August that the disease became rife in Leeds and still more in certain villages near it. The symptoms were purging, vomiting, cramps, prostration, coldness of the extremities, shrinking of the features, &c. At Moor Allerton, a parish three or four miles north of Leeds, with a poor scattered population occupied on the farms, there were found in 60 houses, containing 299 persons, no fewer than 114 cases of sickness in July, August and September, 81 of these from cholera, with 3 deaths. Dysentery was common, both as a sequel of the cholera and as a primary malady. At Halton, three or four miles east of Leeds, with a population better off than in the former, there were found in 60 houses, with 298 persons, 74 cases of sickness, of which 63 were choleraic. At Grawthorpe, four miles west of Wakefield, with a weaving population not poor but of filthy habits, there had been for two months before the visit of inspection more sickness than any one remembered. Twenty of all ages had died of the epidemic, there having been 7 corpses in the village on one morning. Of 70 houses inspected, only 7 had been exempt from cholera and dysentery. In one house of 9 persons 7 were ill, 2 with cholera, others with dysentery and typhus. This was one of the most unhealthy villages, supplied with water from ponds only. In Leeds the choleraic epidemic was less than in the adjoining country, and the few deaths that occurred from it were all among the poor and debilitated. The hot summer of 1825 was unusual for the amount of cholera nostras. It prevailed at South Shields that season with unusual severity, the cramps and spasms being peculiarly manifest[1421].

Dysentery in the 17th and 18th centuries.

The younger Heberden remarks, “There is scarcely any fact to be collected from the bills of mortality more worthy the attention of physicians than the gradual decline of dysentery.” I have shown the fallacy of Heberden’s proof in the first part of this chapter on Infantile Diarrhoea. It is true that dysentery did decline in London, but not on the evidence adduced by Heberden, nor within the noteworthy limits that he supposed. It was at no time one of the greater causes of death in London, and it had already by the middle of the 18th century reached as low a point as it stood at when Heberden wrote. As it is one of the diseases that have become rare in this country, there is a scientific interest in establishing the fact of its decrease, even although its prevalence had been at no time more than occasional.

Hirsch groups the outbreaks of dysentery as of four degrees of extent: (1) localized in a single town or village, or even a single house, or barrack, or prison, or ship; (2) dispersed over a few neighbouring localities; (3) dispersed over a large tract of country in the same season; (4) simultaneous in many countries, or extending over a great part of the globe, and continuing as a pandemic for several years[1422]. The last are the most curious; and of these there are at least two in which Britain had a share, the dysenteries of 1539-40 and of 1780-85. Of the next degree, there have been several in Ireland and Scotland, including those of the great Irish famines of the 18th and 19th centuries, and the “wame-ill” of Scotland in 1439. Of the two minor degrees of extent, there have been, of course, many instances in the towns, counties or provinces of Britain.

A considerable decline of dysentery in London before the end of the 17th century is made probable by various facts that can be gathered from the bills of mortality. When these began to be printed in 1629, dysentery appeared in them under the unambiguous name of bloody flux; there were 449 deaths from that cause in 1629, they had decreased to 165 in 1669 (a year remarkable for dysentery and other forms of bowel-complaint), and to 20 in the year 1690, soon after which the article of bloody flux ceased in the bills. But we are not to judge of the amount of dysentery from the entries under the name of bloody flux alone. In 1650 there began the article of “griping in the guts”; as I have shown, it was mostly infantile diarrhoea of the summer and autumn, but, so long as it lasted, it had probably included some dysentery. Besides the articles of bloody flux and griping in the guts, there was a third article for a time in the bills, namely “surfeit,” a term which came at length to mean dysentery[1423]. Thus the great plague of 1625 is said to have been preceded by a surfeit in Whitechapel; and it is clear from other uses of that word, for example as applied to slaves shipped on the West Coast of Africa for transport to the West Indies, that it meant dysentery more than any other form of bowel-complaint[1424]. Accordingly when we find in the weekly bills of mortality for London that a series of weeks in the dysenteric summer and autumn of 1669 had deaths from “surfeit” to the numbers of 9, 11, 10, 12, 9, 15, &c., we may take it that these were dysenteric rather than choleraic, the more so as the other name “bloody flux” has fewer deaths to it than we might have expected from Sydenham’s general language. These various items in the London bills cannot be used for an exact statistical purpose, but only as indications. Perhaps the most trustworthy indication is the total of 449 deaths from bloody flux in the year 1629, being a twentieth part of the mortality from all causes (8771 deaths). That was a prevalence of fatal dysentery in London far in excess of anything that is known in the 18th century, for example in the dysenteric seasons of 1762 and 1781. So long as plague lasted, dysentery seems to have been somewhat common, and probably most so in the plague years; for, besides the surfeit in Whitechapel with which the plague of 1625 is said to have begun, we find many deaths from bloody flux in the year of the Great Plague itself, 1665. As Sydenham and Willis have left good accounts of the London dysentery of 1669-72, it will be convenient to take from these sources our impressions of the disease in the 17th century.

Referring to the dysentery of 1669, Sydenham says that there had been comparatively little of it for ten years before, not including, doubtless, the plague-year of 1665, when Sydenham was out of town[1425]. Both he and Willis are clear that there was a certain amount of it every year, although it was seldom fatal in ordinary seasons. The ordinary London dysentery, says Willis, though it be horrid or dreadful by reason of its bloody stools, and is most commonly of a long continuance, yet it is not very contagious nor often mortal[1426]. Sydenham says that it was fatal more particularly to aged persons, but highly benign in children, who might be subject to it for months _sine quovis incommodo_. However, in certain seasons it became malignant and caused a good many deaths.

It began usually with chills and shiverings, to which succeeded heat of the whole body, and shortly after tormina with dejections; but sometimes the griping and stools were the first symptoms. Always there was intense suffering and “depression of the intestines,” with frequent straining at stool. The stools were mucous, not stercoraceous, and with traces of blood. The tongue might be whitish, or dry and black; the strength was prostrated and the spirits faint. After a time the streaks of blood in the motions would be replaced by pure blood, without even mucus, a change which threatened a fatal end. Sometimes the bowel became gangrenous, while aphthae would appear in the mouth and fauces. If the patient were about to recover, the symptoms would gradually be restricted to the rectum, in the form of tenesmus. Willis says that the dysentery of the autumn of 1671 was really a bloody one, and extraordinarily sharp and severe, hurrying many to their graves. At the outset blood was voided plentifully, with griping pains; there might be twenty stools in a day. Some were able to rise after a week; but the malady would go on for several weeks or even months. It was protracted also in fatal cases, the end being marked by watchfulness, roughness of the tongue, thirst and thrush in the mouth. He gives a case of a strong young man who recovered after having had not only terrible bloody stools, but also bloody vomit, which, Willis thought, might have come from ulceration of the stomach. But with good diet and treatment most of those attacked escaped death. Sometimes it became virulent and, as it were, pestilential, destroying many and diffusing its infection very largely by contagion.

It was most common, says Willis, in camps and in prisons, by reason of the stench of the places and the evil diet. From what Sydenham was told by Dr Butler, who accompanied Lord Henry Howard in his embassy to Morocco, the dysentery of North Africa was the same as that which prevailed in London, as an occasional epidemic, in 1669-70.

The dysentery of the siege of Londonderry and of the camp at Dundalk, both in the year 1689, have been described elsewhere. During the same reign, Dr William Cockburn got fame and wealth by a secret remedy for dysentery, which was tried first on board the king’s ships at Portsmouth[1427]. In 1693-99, there was dysentery in Scotland and in Wales. Of Scotland in 1698, the climax of the “seven ill years,” Fletcher of Saltoun says: “From unwholesome food diseases are so multiplied among poor people that, if some course be not taken, this famine may very probably be followed by a plague[1428].” A Welsh practitioner, who graduated at Dublin in 1697 said, in his thesis, that dysentery had raged for the space of three years in several maritime regions of South Wales so severely and had made such havock that in not a few houses there were hardly one or two left to bury the dead[1429]. Writing before the seven ill years, Sir Robert Sibbald mentions dysentery as one of the _dira morborum cohors_ that everywhere affected the Scots peasantry in the end of the 17th century, the causes of which were coarse food and excesses in spirit-drinking. In the century following we hear of dysentery in Scotland in particular years, which correspond on the whole to the unwholesome seasons in England. Thus in 1717, special mention is made of a fatal bloody flux in Lorn, Argyllshire. In 1731 there were dysenteries in Edinburgh in autumn, often tedious, rarely mortal. In 1733, during the harvest months, dysenteries were frequent and mortal in Fife, especially along the shores of the Firth of Forth. In the following autumn (1734) many in Edinburgh were seized with a dysentery, which continued more or less epidemic all the winter: “It had the ordinary symptoms of slight fever, frequent stools, for the most part bloody and mucous, violent gripes and an almost constant tenesmus”--being fatal to some and very tedious to others[1430]. This was a well-marked dysenteric period in Scotland, but just as much a rare or occasional experience as the corresponding epidemic a century after in 1827-30. It appears to have lasted in various parts of Scotland until the end of 1737. A regimental surgeon, who was stationed at Glasgow in the end of 1735 and afterwards at Edinburgh, had 190 dysenteric patients (civil and military) from December, 1735, to February, 1738[1431]. The summer and autumn of 1736 appear to have been its more severe seasons; it is heard of at St Andrews and in the country near it, at Kingsbarns and Crail (where “many of the boys” were seized), at Dalkeith, and in Glasgow and the neighbourhood, where one practitioner claims to have treated “some hundreds” with cerate of antimony[1432]. In the great period of epidemic fever shortly after, the years 1740 and 1741, flux in the Edinburgh bills of mortality has respectively 3 and 36 deaths, which would probably have meant thirty to fifty times as many cases[1433].

The English epidemiographists, Wintringham, Hillary and Huxham, mention dysentery in certain years, which were the seasons of high general mortality. Wintringham’s first entry for York is under the year 1717, his second in 1723 (autumnal), a third in 1724 (some fluxus alvi with blood), in 1726 diarrhoeas and dysenteries “called morbus cholera,” and the same for two or three weeks of September, 1727. Wintringham was one of the first in England to emphasize the seasonal connexion between dysenteries and agues. There was undoubtedly dysentery among the many forms of sickness in the disastrous years 1727-29. Huxham includes it among the fluxes which were common at Plymouth in 1734-36. A still greater dysenteric period followed the influenza epidemic of 1743, Huxham being again the chief chronicler of it[1434].

In the second half of the 18th century, two periods were specially noted for dysentery, the years about 1758-62 and 1780-82. The first of these called forth perhaps the only medical piece written by Dr Mark Akenside, physician to St Thomas’s Hospital and author of the ‘Pleasures of the Imagination[1435],’ as well as accounts by Sir G. Baker[1436] and Sir W. Watson[1437]. All three writers agree that the true epidemic prevalence occurred in London in the autumn of 1762. It is clear, however, that Akenside had been treating in St Thomas’s Hospital since 1759 many cases of true dysentery (which he defines as a bowel complaint with gripes, tenesmus and bloody or mucous evacuations). He had more than one hundred and thirty cases of it described in his ward-books in the five or six years previous to his writing (1764); he had proved the good effects of ipecacuanha on many in 1759; and he had remarked that the autumnal dysenteries of 1760, 1761 and 1762 in each case lasted the whole winter, not abating until the spring. Perhaps this may have been a special experience of the Surrey side of the Thames; for both Watson and Baker are clear that dysentery was something of a novelty to them in the early autumn of 1762. Says the former, writing to Huxham on 9 Dec. 1762: “We have had here this autumn a disease which has not been in my remembrance epidemic at London. Very few of our physicians have seen this disorder as it has appeared of late. You mention it as frequent at Plymouth in the year 1743....” And Baker begins his essay by saying that there became epidemic in London in the end of July, 1762, the disease of dysentery--“morbi genus hac in civitate novum feré, aut nuperis saltem annis inauditum[1438].”

The three observers agree that it attacked the poorer classes, children more than adults, convalescents, lying-in women and the like. Akenside says that it was mostly a slow non-febrile disease (in the autumnal outburst of 1762, the subjects of it were more fevered), and that some patients came to him who had been labouring under it for two or three months. His account agrees on the whole with Sydenham’s for the years 1669-72: some had vomiting, some had a painless flux following the dysentery, some had dropsy as a sequel. In cases about to end fatally there was a remission of the griping before the end; in some there were aphthae of the mouth, stupor, and somnolence, with cold sweats. Watson saw three children (of four or five years) die from debility a week or more after the gripings and discharges had ceased; they could keep down no food, and were greatly emaciated. In another case, a young child, the motions were pure blood, and death followed on the third day. Baker gives Hewson’s notes of the anatomy in a case that was clearly one of follicular dysentery, as well as Charlton Wollaston’s account of two other anatomies (mixed catarrhal and follicular), with plates of the dysenteric bowel.

Watson, physician to the Foundling Hospital, says that the dysentery, or dysenteric fever, was very prevalent among the children in 1762, the year of its most general prevalence[1439]. It may have been part of that dysenteric “constitution” which caused the following outbreak among the foundlings at the hospital at Westerham, Kent, a branch of the Guilford Street charity: “26 January, 1765. The apothecary visited the children at the hospital at Westerham, January 12th, 1765, and found twenty ill with dysenteries, many of whom had the whooping-cough complicated with it. Two of them are since dead, which, with six that died before he went down, make eight dead of that disease.” Two cases of dysentery were in the infirmary of the Foundling Hospital in London on the 2nd of March, 1765[1440]. These accounts of dysentery in London in the middle third of the 18th century show it to have been then a very occasional malady and a very small contributor to the bills of mortality.

Next to the capital, the town that seems to have had most dysentery in the 18th century was Newcastle, which had been also the seat of frequent and severe plagues. There was much dysentery in it and in the neighbouring places on Tyneside during the autumns of 1758 and 1759, but the disease was not epidemic in 1762, the season of the malady in London[1441]. It was prevalent among the same classes in Newcastle as in London--the poorer households, children, weakly persons. It recurred in the harvest quarter, in fine clear weather, when the days were almost as hot as at midsummer, but the evenings and mornings remarkably cold and the nights frequently foggy. The reason why the lower class of people were most liable to it seemed to be their “negligence in the article of cooling after heats by labour, exercise, &c.” But there may have been something also in the soil and situation of Newcastle which made these common risks to be followed by so special an effect.

The Newcastle dysentery of 1758-59, two or three years earlier than the London epidemic, was the occasion of the essay by Dr Andrew Wilson, a work which compares favourably with the writings of the metropolitan physicians. Among the symptoms of true autumnal dysentery he gives the following:

“Constant fever, drought, parchedness of the mouth and throat, dejection of the spirits, prostration of the strength, frequent viscid, acid or bilious vomiting, flatulency in the belly, wringing pain in the lower part of it, and often in the same region of the back; these pains sometimes constant, but always preceding stools; an almost constant pressing to stool, with great pain and irresistible tendency to it at the same time, called a tenesmus; the stools generally bloody, always slimy, and full of glary stuff, sometimes mixed with a whitish matter of less tenacity, which appears in separate little curdled-like parcels, often with blackish corrupted-like bile; the stools always odiously fetid; they are seldom natural without the assistance of purgatives, and then they are often discharged in hard, dry little lumps; dryness of the skin, except when clammy unbenign sweats are raised by the intenseness of the gripings and tenesmus; great watchfulness, their sleep, when accidentally they drop into any, being short and broken, with recurring pains which awake them unrefreshed. These are the principal symptoms which attend a true febrile dysentery. When such a disease is epidemic there are many slight appearances of it which happily do not extend to all these complaints, and which easily yield to proper applications.

The signs of danger in this disease are the violence with which all the above symptoms appear. But the signs of immediate danger are, decrease of pain, great sinking of the spirits, lowness of the pulse, beginning coldness of the extremities, parchedness and blackness of the tongue, aphthae; white scurf or ulceration of the throat and fauces, and constant hiccup. When there is a cessation of pain, intolerably fetid and involuntary stools, shiverings, with sometimes a sense of coldness in the belly, a slight delirium, and often unaccountable fits of agony, or rather anxiety; then the case is beyond remedy, and the patient hastens to dissolution. This stage of the disease is generally attended with a small obscure pulse and cold extremities, but I have seen it in some particular cases otherwise.

... When dysentery is epidemic, it is not uncommon for people who escape the dysentery itself to have their stools altered from their natural colour to sometimes a greenish hue, as if they had eaten much herbs, sometimes of a clay colour, and sometimes quite blackish, as if they had eaten a quantity of blood.... In 1759 particularly, it was very common for numbers of people who escaped the dysentery to be troubled with flatulencies, slight gripings and twitchings in the belly, which was generally attended with blackish stools. Stranguaries were likewise pretty frequent, and icteric complaints, or the jaundice. The stranguary was a very common symptom in many fevers which occurred during the prevalency of the dysentery. Another complaint which frequently occurred during the last dysenteric season was dry gripes.

The dysentery this last season [1759] differed in many respects from its appearance in the former season. In the latter season greater numbers had it in that slight degree which was attended with little fever and no danger. In many who were seized with seemingly great violence, it was unexpectedly checked when there appeared all reason to apprehend it would have run to a much greater length. It was not uncommon to find it complicated with agues, rheumatisms, &c., into the latter of which it frequently degenerated. In the former season the griping pains attending it were confined to the lower belly. In the latter they were very ordinarily felt also in the back, along, as might be supposed, the windings of the rectum and colon; yet, after the dysenteric stools were in a great measure gone, and the disease over, these pains often remained, or assumed the appearance of a lumbago or sciatic, with pains striking down the thighs.... The more the season advances, and the later in the year it is when persons are seized with this epidemic, the more chronical do the symptoms of it grow.”

The last sentence is probably the explanation of Akenside’s original point, that dysentery was as much a winter as an autumnal malady, not really abating until the spring. Wilson himself claims originality in the following point relating to the sluggishness of the bowels in dysentery, his treatment having been largely determined by that view of the pathology:

“During the increase and height of this distemper, it is very improperly called a flux. A proper flux, or diarrhoea, is a constant flow of immoderately liquid but otherwise natural stools, dissolved by too great an irritation upon, or too great a relaxation of, the vessels destined for mollifying the faeces and lubricating the passages by their humours; by which means they are disposed to dismiss a superfluous quantity of them. But in the dysentery the passage of the natural discharges is resisted, and their consistence is often increased to such a degree that, when they are urged along by the assistance of purgatives, they are excluded in unnaturally hard and dry little lumps or balls” (p. 3). The question whether scybala were an essential character of dysentery was often referred to in later writings.

Nothing more is heard of dysentery at Newcastle until the date of the opening of the dispensary there, 1 October, 1777. From that date to 1 September, 1779, when the disease was not epidemic there, 72 cases were treated from the dispensary.

Some importance, as regards priority, attaches to one of Dr Andrew Wilson’s observations of the Newcastle dysentery of 1759: “It was not uncommon to find it complicated with agues, rheumatisms, &c., into the latter of which it frequently degenerated.” The pains, he says, were not confined to the lower belly, but were felt also in the back; or, after the dysentery was gone, the muscular pains remained as a lumbago or sciatica, striking down the thighs. This curious relationship of dysentery to rheumatism, shadowed forth in the Newcastle essay of 1761 [1760], was formally stated by Akenside in his essay of 1764, being perhaps the best of his various attempted originalities. It was afterwards taken up in Germany by Stoll, Richter, Zimmermann and others in the 18th century, and was illustrated from the Dublin epidemics of the 19th century by O’Brien[1442] and Harty[1443]. The doctrine of a relationship between dysentery and acute rheumatism has been discovered in the 7th century writer, Alexander of Tralles, but erroneously. The Byzantine writer does indeed introduce into two paragraphs on bowel-complaint the word ῥευματισμός--one of them relating to the alvine profluvium attending fevers or following fevers, the other relating to “dysenteria rheumatica[1444].” But it is clear that he is merely ascribing to the diarrhoea in the one case and to the dysentery in the other a rheumy nature, on certain theoretical grounds of humoral pathology; there is no reference to joint pains or muscular pains, or to anything else connoted in the later use of the word rheumatism. The idea is originally an English one, from the middle of the 18th century, and belongs most properly to Akenside, although Wilson, a not less trained and capable observer, had recorded the empirical fact three or four years earlier. Akenside was led to regard dysentery “as a rheumatism of the intestines,” and to maintain that “the cause and the _materies_ of each disease were similar[1445].” Stoll adopted these phrases, adding that dysentery differed from rheumatism of the joints “merely in form and situation.” But for a few empirical facts, the relationship would be thought fanciful. These, however, may be finger-post instances, pointing to the true pathology of a somewhat mysterious malady. They are simple enough: e.g. cases of dysentery have “degenerated,” as Wilson said, into rheumatism; or cases of acute rheumatism, treated by purging, have developed the gripings, tenesmus and stools of dysentery; or, in a time of dysentery, cases have occurred in which the symptoms of the latter were joined to those of acute rheumatism, or cases in which the symptoms of the one disease obtained, say for twenty-four hours, to give place to the symptoms of the other. Again there are countries such as Lower Egypt where the frequency of dysentery is not more remarkable than the frequency of rheumatic fever. Harty points out that the rheumatic complications of dysentery seem to have arisen only when the latter malady was improperly treated by opium and astringents; but, howsoever the signs of affinity were called forth, they may prove to be true indications for the pathology. The circumstances of taking dysentery are those of taking rheumatic fever--exposure to chill after being heated with labour[1446]. In rheumatism the effect of the chill falls upon the great groups of voluntary muscles, pain being manifested at the surfaces where the muscular work is applied, namely the joints; while the redness, heat and swelling are as if restricted to the tissues by which the muscles become effective, namely the tendons, aponeuroses, ligaments and synovial membranes[1447]. In dysentery, it may be said, the effect of the chill falls upon the great involuntary muscle, that of the intestine, or upon a section of it, a muscle which serves, so to speak, as its own tendons and insertions, and is the seat of its own pains, while the tissues next to the muscular, the submucosa and mucosa with the lymph-follicles, become the seats of congestion, inflammation and suppuration. In acute rheumatism, the muscles generate heat without doing any work; in dysentery there is often febrile heat (although not invariably), and the work of the involuntary muscle is paroxysmal and ineffective. In some such way the parallel suggested by Akenside might be followed out.

After 1762, the next period of epidemic dysentery in England was from about 1779 to 1785, a period when agues also were epidemic, as well as workhouse fevers and typhus under its various names. In London it was prevalent in the autumns of 1779, 1780 and 1781, a strictly autumnal disease like the diarrhoea of children or the cholera nostras of adults. From the list of symptoms, the latter disease must have formed part of the dysenteric epidemic:--“profuse watery evacuations, mucous evacuations mixed with blood, gripings, tenesmus, pain in the back and loins, fever.” Some had tormina without flux. Some few old and infirm died; but usually the malady yielded to treatment[1448]. It is heard of also at Liverpool about 1784[1449], and its prevalence at Plymouth called forth an essay[1450]. It must have been a considerable disease in the dockyard towns; for a body of troops, originally numbering 2800, which arrived at Kingston, Jamaica, in the beginning of August, had been put on board the transports in March with much dysentery and putrid fever among them, so that the diseases with which they put to sea became more violent during the five months’ voyage, and caused many deaths. Arriving at Jamaica, four hundred were sent on shore sick, exhausted with flux and fever, of whom scarce the half recovered in the military hospitals[1451]. Here we have the singular fact of transports from England bringing dysentery to Jamaica. On the other hand, Clark, of Newcastle, who had seen much of tropical maladies, says that the dysentery which became epidemic there in 1781 was introduced first into a dockyard by some sailors returned from abroad ill of the complaint, and that it soon spread among the workmen, of whom several died. But it was epidemic in London the same year; and in Newcastle itself there were extensive epidemics in 1783 and 1785, for which no foreign source was sought or found. In those years it “attacked great numbers of the poor,” as well as some of the richer class, to which Clark’s eleven cases from the epidemic of 1785 mostly belong. In the Tables of diseases treated at the Dispensary, the epidemic dysentery of 1783 and 1785 is credited with 329 cases, of which 17 were fatal; but these, of course, were but a fraction of all that occurred in Newcastle and neighbourhood. Every year until 1805 there are a few cases of dysentery in the Dispensary books; but they become fewer to that year (except in 1801 when there were 23 cases), and at length disappear from the list altogether. A remarkable outbreak of dysentery, within narrow limits, occurred in a fishing village or “town” in the neighbourhood of Aberdeen during some months of the spring and summer of 1789: “It has proved fatal to numbers. As such a disease could not be admitted into our hospital, a temporary one has been fitted up for those that are worst, and the faculty here have given their attendance by rotation[1452].”

Dysentery in the 19th century.

Willan, who was practising in London as early as 1785-6, says that dysentery had not been epidemic there from the autumn of 1780, until the autumn of 1800, his position at the Public Dispensary in Carey Street enabling him to know the prevalent diseases. In the autumn of 1800 the epidemic was extensive. There were, he says, some sporadic cases every autumn, but he never saw a fatal case of it[1453]. In Bateman’s continuation of the same records from 1804, dysentery first appears in 1805 and remains sporadic every autumn. It was “very prevalent” in the autumn and winter of 1808, but not fatal; and it was not unusual among the dispensary patients every year until these records end in 1816[1454]. The years 1800-02 form one of the more distinct dysenteric periods also for Ireland and Scotland. Old Glasgow practitioners in the severe epidemic of 1827-28 recalled the fact that they had last seen the disease about 1802, and the books of the Glasgow Infirmary bore witness to its prevalence from 1800 to 1803 or 1804. In 1801-2 there was a good deal of it also at Hamilton, among a regiment of dragoons as well as among the people at large[1455]. The troops in various parts of Ireland suffered from it in the same years[1456]. In 1808, during a somewhat unwholesome season in which agues also were met with, some cases of dysentery were admitted to the General Infirmary of Nottingham[1457]. An altogether exceptional outbreak of a dysenteric nature occurred in 1823 among the prisoners in Milbank Penitentiary[1458].

The great dysenteric period of the 19th century coincided with, or followed, the two hot summers of 1825 and 1826, the latter of which was probably the hottest and driest summer of the century. Of its prevalence in and near Leeds in 1825, Thackrah says it was “before almost unknown as an epidemic to the present practitioners of this district.” In the same summer it was unusually common in Dublin, and was epidemic the next year in other parts of Ireland as well (_supra_, p. 271). In Glasgow it began about the end of July, 1827, in the flat district to the south of the Clyde, and in the course of the autumn became prevalent in all parts of the city. An outbreak of plague itself could hardly have caused more surprise, so strange was dysentery to that generation. A few deaths by it in one crowded street of the Gorbals were mentioned in a newspaper before the disease had become general, and “gave rise to that groundless fear which pervaded and distracted the public mind during the whole course of the epidemic[1459].”

The symptoms were severe and alarming, but the fatalities were few, perhaps not more than one in fifty attacks. The proper dysenteric symptoms usually lasted from ten to fourteen days, and were followed by diarrhoea, it might be, for many weeks. The morbid anatomy showed in the mucous membrane of the great intestine the three degrees of congestion, follicular ulceration and sloughing of the whole mucous coat (in the sigmoid flexure and rectum). The cases were nearly all above the age of puberty, and among the poorer classes. September and October were the worst months. The weather was remarkably close, damp and relaxing. One practitioner saw two cases of genuine ague in natives of Glasgow, having never seen a case of ague before. The ordinary cholera nostras of summer and autumn was much less frequent than for several years before, and it was the general remark that it had given place to the dysentery.

Having declined in the winter of 1827-28, it revived in May, and again reached a great height in the autumn of 1828, while cases of it (probably chronic, or renewals of old attacks) continued to the summer of 1830. The following table shows the number of cases treated by the poor’s surgeons in the several seasons, 1827-30; the 435 cases in the autumn of 1827 were nearly a third part of all the cases so treated (1462):

_Cases of Dysentery in Glasgow treated by the Surgeons to the Poor._

Quarter 1827 1828 1829 1830

Feb.-April -- 28 29 26 May-July -- 62 35 26 Aug.-Oct. 435 261 50 -- Nov.-Jan. 143 68 22 --

It extended to the villages and country districts all round Glasgow. It was believed to be somewhat general in Scotland in 1827-28, but the only answers to a circular of queries sent out by the editors of the ‘Glasgow Medical Journal’ came from Hamilton (and Bothwell), Ayr and Callander (including the flooded valley of the Teith and the Braes of Balquhiddar)[1460].

In Edinburgh the outbreak of dysentery began about the end of July, 1828, a year later than in Glasgow, just as the epidemic in that city was a year or more later than in Dublin. Attacks of it were numerous among the patients admitted to the Edinburgh Infirmary for other diseases; but it occurred at the same time throughout the city generally and in the country around; “nor has it been confined entirely to the lower orders.” In the imperfectly kept register of the Infirmary there were 42 admissions, with 11 deaths, from August to October. Christison, who treated some of these, had never seen dysentery before[1461]. The morbid anatomy was the same as at Glasgow--congestions, numerous small ulcerations especially of the transverse colon, or sloughing of considerable portions of the mucous membrane.

In the same years 1827-28 there was much dysentery in the Lunatic Asylum at Wakefield. It is well known that aged paupers in workhouses or asylums are peculiarly subject to the epidemic influences that produce diarrhoeal or choleraic sickness; and there had been much of that disease in the West Riding Asylum from its opening in 1819. Some cases of dysentery had also occurred, but it was not until after the exceptional summer of 1826 that they became common. In 1828 there were 55 cases among 375 inmates, mostly in old and incurable lunatics, the fatalities being at the very high rate of one in four. The morbid anatomy was that of true dysentery--follicular ulceration in the transverse colon, with occasional sloughing of large pieces of the mucous membrane. The whole sewage of the asylum collected in cesspools or “tanks of ordure” within a few feet of the wards[1462].

The causes of the rare and surprising outbreak of dysentery in 1827-28 were much debated. In Glasgow it was remarked that the choleraic complaints of the summer and autumn were much less frequent than usual; also that the first season of it, the year 1827, was remarkable for rain every day for some months, and for a close, oppressive, relaxing atmosphere. Brown, of Glasgow, thought the weather might account for it, the labouring class being thereby made peculiarly subject to heats and chills, which, grafted upon the usual bowel-complaints of the season, easily turned them to dysentery. Dr Andrew Buchanan was of opinion that exhalations from the soil were the chief, if not the sole, exciting cause of dysentery, reserving the question of contagiousness. Other forms of miasmatic febrile disease, formerly rare, had, he said, made their appearance of late years and become epidemic. Christison had already spoken in the same sense for the Edinburgh outbreak. For five or six weeks, he said, before the dysentery appeared there in the end of July, 1828, the tendency to bowel affections during the epidemic fever (which was chiefly of the relapsing type) was increased in a very marked degree. The same tendency continued throughout the whole progress of the dysentery; “nay in some instances true acute dysentery was formed during the height or towards the termination of continued fever; and now that the dysentery has in great measure disappeared, or assumed a mild form, the tendency of low gastro-enteric inflammation to accompany continued fever is very strongly marked, perhaps is more frequent than ever.” This may relate to a remarkable outbreak of fever among the richer classes in the New Town of Edinburgh, more talked about than written on, which seems to have been enteric or typhoid, according to the clinical history of a case of it that came from Edinburgh to Hamilton and was recorded by a physician of the latter place[1463]. It was more especially that strange epidemic in Edinburgh that Dr Andrew Buchanan had in mind when he wrote that the dysentery of 1827-28 was not the only disease due to exhalations from the soil with which Scotland had of late been visited[1464]. This is an instructive line to take in seeking an explanation of the dysentery of 1827-28, even if we keep something of the old doctrine of heats and chills as affecting those who labour in a damp atmosphere. The ground-water theory of miasmatic infective diseases was not then formulated; but there has rarely been in our latitudes so signal an instance of extreme drought and heat followed by excessive dampness as in the two years 1825 and 1826, and the year 1827. The second dry year, 1826, was certainly the season when enteric fever was described and figured for the first time in London. It was said, also, that enteric cases occurred among the relapsing fever and dysentery of Dublin in the same year; and enteric cases are known to have occurred in Edinburgh towards the end of the epidemic of relapsing fever and dysentery, which was one or two years later in that city than in Dublin. In Glasgow, where the dysentery was probably a more extensive outbreak than elsewhere, there appears to have been at that time no enteric fever; in London, on the other hand, where there was a good deal of the latter, there does not appear to have been any notable prevalence of dysentery.

Along with the cholera nostras which was unusually common in the autumn of 1831, just before the outbreak of Asiatic cholera, there was some dysentery, notably an epidemic at Bolton[1465]. At the end of the Asiatic cholera of 1832 a succession of cases of dysentery occurred in the Edinburgh Charity Workhouse[1466].

The next occasion of dysentery was the autumn of 1836, which was, like that of 1827, a wet season. The outbreak at Glasgow on this occasion is recorded only in a few figures (the medical journal of the city having ceased to appear for a time), according to which there were 144 cases throughout the year treated by the surgeons to the poor, of which 8 were fatal, and 15 cases sent to the Infirmary, of which 4 were fatal[1467]. At Dundee also, from October to December, 1836, bowel-complaints were not unusual among the cases of typhus, which occurred in hundreds. “Many of the cases of diarrhoea and dysentery,” said Arrott, “occurred in December, and were accompanied by catarrhal and rheumatic symptoms, implying an origin distinct from the bilious diarrhoea and bilious vomiting of summer.” Of 22 cases of dysentery at the Infirmary, 2 were fatal[1468].

Next year, 1837, there occurred in Somersetshire a remarkable epidemic which was for the most part dysenteric. It was seen first at Bridgewater, and in July it caused two deaths at Taunton, where it afterwards prevailed with high malignancy. Of 223 deaths, 206 were set down to dysentery, 16 to diarrhoea and 1 to cholera; the high ratio of children’s deaths in the following table of ages is in accordance with other recent experiences to be given in the sequel:

Over Ages 0-5 -10 -15 -20 -30 -40 -50 -60 -70 -80 -90 90

Deaths 93 17 11 7 6 3 7 16 26 24 11 2

The monthly mortalities were, 75 in August, 105 in September, 29 in October, 10 in November, 2 in December. The epidemic spread partially amongst the unions around Taunton[1469].

In London from the beginning of registration (1837) until 1846, the deaths set down to dysentery averaged fully a hundred in the year--a statistical fact to which there is nothing corresponding in contemporary writings: Watson said it was hardly ever seen in practice except in the chronic form among sailors and soldiers who had contracted it abroad. During the prevalence of the “Irish fever” of 1846-48, the disease was truly epidemic and a cause of many deaths along with typhus itself, especially in Liverpool and mostly among destitute Irish. In 1846 it was in Milbank Penitentiary[1470]. A most instructive instance of its connexion with the Irish emigration occurred at Penzance in the summer and autumn of 1848.

The brig ‘Sandwich’ sailed from Cork for Boston, U. S., in the end of May, carrying a number of Irish farmers and their families. Having met with rough weather and head winds she put in leaky to Penzance on 7 June, sixteen days out from Cork. The provisions had been bad and there was sickness in the ship, with a very filthy state of things. Three of the women passengers died on shore of dysentery. The ship sailed again on 10 July, two more of the emigrants dying of dysentery before she reached Boston, while two of the crew survived the attack. On 16 July, two cases of the same disease occurred among the lower class in Penzance, and thereafter the epidemic spread widely through most parts of the town and the three adjoining parishes of Madron, Galval and Paul, causing a great mortality, as in the following table:

_Deaths from Dysentery in Penzance and three adjoining parishes._

1848

Deaths from all Deaths from Deaths from Total causes in Dysentery in Dysentery in deaths from Penzance and 3 Penzance town 3 other parishes Dysentery other parishes

July 5 0 5 31 August 37 1 38 71 Sept. 26 12 38 67 Oct. 13 9 22 48 Nov. 1 1 2 31 -- -- --- --- 82 23 105 248

As many as five hundred cases were under medical treatment in the town. No death occurred there or in the three parishes within the registration district after 10 November, “but very many in the country beyond its limits.” Of the 105 deaths in the table, 46 were of young children, 35 of aged persons, and 24 between the ages of five and sixty years[1471]. There was no resisting the evidence that an infection had been introduced by the weather-bound Irish emigrants; instances were also known of new foci in the country districts having been created by domestics or others suffering from dysentery who had been sent from Penzance to their homes. At the same time the summer had been exceptionally wet, the rainfall having been as follows:

Inches of rain

May 0·777 June 3·287 July 3·277 Aug. 4·972 Sept. 3·042 Oct. 4·425 Nov. 3·981

A singular epidemic of dysentery occurred between the 14th and 26th September, 1853, among the thirty-six inmates of a row of nine cottages near the village of Hermiston, five miles west of Edinburgh. Seven children were attacked, of whom six died, and six adults, who all recovered. Besides these there were three cases among the four inmates of a cottage about a hundred yards away, and one case in each of two houses in the adjacent village of Hermiston. Christison found that a drain which received the sewage or slops of the hamlet was in a most offensive state, having been choked probably for years, and that the water of a well near it was foetid. These are the conditions that have often caused village epidemics of enteric fever in recent times; but there was no doubt that the disease in this case was dysentery[1472]. Another asylum outbreak of dysentery occurred in 1865 in the Cumberland and Westmoreland Asylum[1473].

Perhaps the last general prevalence of dysentery was during the Asiatic cholera of 1849, when the house-to-house visitations in Leeds and some other towns brought to light a somewhat surprising number of cases mixed with the more ordinary bowel-complaints of the season.

It is impossible to trace the subsequent history of dysentery in England by the usual statistical means of the Registrar-General’s tables of the causes of death, for the reason that dysentery, a rare and curious disease of all ages in this country, is merged with diarrhoea, one of the commonest causes of infantile mortality. However, it is not likely that any such epidemic outbursts, local or general, as those described for certain years of the 18th and 19th centuries could have occurred without their being otherwise known. It may be safely said that there has been little of it in this country for the last thirty or forty years, except among a few soldiers, sailors or others returned from abroad; in Ireland itself, the immemorial “country disease” has now only a small annual total of deaths.

One of the last experiences of dysentery in an English port was instructive for the relation of the disease to typhus fever.

On 16 February, 1861, an Egyptian frigate, the ‘Scheah Gehaed,’ sent from Alexandria to be fitted with new engines, arrived in the Mersey. The only European on the ship was her commander, an Austrian. She carried 476 men, mostly Arabs, with a small proportion of Nubians and Abyssinians. Some two hundred were convicts, who had been brought on board in chained gangs. The passage had been long and stormy, and attended with much sickness, dysenteric and diarrhoeal; one man died and was thrown overboard two or three days before the ship reached Liverpool. The pilot who boarded her was at once struck by the horrible state of filth of the ’tween decks; he remained two days on board, and on returning home said to his wife, “This frigate will be heard of yet.” He sickened in about a week of malignant typhus and died. Two others who boarded the ship took typhus, of whom one recovered. There had been no fever on board during the voyage. Thirty-two of the Arabs or Nubians were admitted to the Southern Hospital suffering, most of them, from dysentery or diarrhoea. Typhus fever attacked 17 of the ordinary patients, 2 nurses, 2 porters, 2 house-surgeons and 2 others in the hospital, of whom several died. The Arabs &c. to the number of 340 were taken in batches of 80 a day to a public bath, in which they remained three hours. Typhus broke out among the bath attendants. The whole number of cases of typhus traced to the ship was 31, of which 8 were fatal. The ship was sunk in the graving dock in order to clean her[1474].

This is a classical instance of the breeding of typhus from the effluvia of dysentery, of which other instances, on a greater scale, have been given in connexion with the Jamaica expedition of 1655 (in the former volume), the siege of Londonderry and the camp of Dundalk in 1689, the hospitals after the battle of Dettingen in 1743, and the Irish famine of 1846-48.

## CHAPTER IX.

ASIATIC CHOLERA.

The Indian or Asiatic cholera, which first showed itself on British soil in one or more houses on the Quay of Sunderland in the month of October, 1831, was a “new disease” in a more real sense than anything in this country since the sweating sickness of 1485. The English profession had been hearing a good deal about it for some years before it reached our shores. The outbreak in Lower Bengal in 1817, from which the modern history of cholera dates, had been the subject of reports and essays by Anglo-Indian physicians and surgeons; an extensive prevalence of it in the Madras Presidency shortly after, as well as in Mauritius in 1819 and 1829, had been observed by other medical men in the service of the East India Company or of the British army or navy. Many who had seen cholera in India, and some who had written upon it, returned to England in due course, so that the formidable new pestilence of the East began to be heard of in medical circles at home. Various essays upon it issued from the English press between 1821 and 1830[1475]; and in 1825 it appeared for the first time, and at considerable length, in the pages of an English systematic treatise, the new edition of Dr Mason Good’s ‘Study of Medicine.’

Previous to 1829, Asiatic cholera had obtained no footing in Europe. The first great movement westwards from India through Central Asia, which was continuous with the memorable eruption in Bengal after the rains of 1817, had reached to Astrakhan, at the mouths of the Volga, and had there caused the deaths of some 144 persons in September, 1823. Another progress westwards from India, after an interval of six years, reached the soil of European Russia in the Government of Orenburg in August 1829, the mortality in the whole province during the autumn and winter (to February, 1830) amounting to about one thousand. A much more severe epidemic of it arose in the summer of 1830 in the town and province of Astrakhan (supposed to have been introduced by an infected brig from Baku), which spread with enormous rapidity, destroying in the course of a month some four thousand in Astrakhan itself and upwards of twenty thousand in other parts of the province[1476]. Thus established in the basin of the Volga, Asiatic cholera overran the whole of Russia. Before the spring of 1831 it had entered Hungary and Poland, and in the end of May had reached Danzig and other German ports on the Baltic and North Seas. Lord Heytesbury, the British Ambassador at St Petersburg, had sent home a despatch upon it early in 1831; in April, the Admiralty issued orders for a strict quarantine of all arrivals from Russia at British ports, which were afterwards extended to arrivals from all ports abroad invaded or threatened by cholera. On 20 June a royal proclamation ordering various precautions was issued, and next day a Board of Health was gazetted, composed of leading physicians in London and of the medical heads of departments, with Sir Henry Halford as president. Local Boards of Health were formed voluntarily in many parts of the country during the summer of 1831. Two medical men were at the same time commissioned by the Government to proceed to Russia to study the disease there, their letters to the Board of Health commencing from the 1st of July. The growing interest in the disease as it came nearer called forth another crop of writings, some of them based on old Indian experience, others speculative[1477]. The most important of these was the treatise by Orton, which had been published in its original form at Madras in 1820. Writing from Yorkshire in August, 1831, he surmised (with a proviso that no one could say confidently what might happen) that Asiatic cholera might be expected to be a mild visitation upon Britain at large, falling most upon the large manufacturing towns in which typhus was common, but that it would be “far otherwise” with Ireland owing to its chronic poverty, distress and over-population. By a singular chance the only town which he specially mentioned in England was Sunderland, where, he had been told by Dr Clanny, there had been an unusual number of cases of malignant cholera nostras in the early part of the autumn: “it is greatly to be feared,” he said, “that those are but the skirts of the approaching shower[1478].”

In other places besides Sunderland there had been perhaps more than the usual amount of summer diarrhoea in 1831. Dr Burne, in his London dispensary reports, entered on the 2nd and 16th July an unusual prevalence of “dysenteric diarrhoea and cholera,” and cases of scarlet fever of an “adynamic” type or with a tendency to fatal collapse[1479]. (Clanny observed the same type of scarlatina at Sunderland along with some typhus.) Choleraic disorders were uncommonly rife on board the ships of war in the Medway[1480]. A succession of twenty-four cases at Port Glasgow, from 2 July to 2 August, chiefly among workers in Riga flax, gave rise to an alarm of the real Asiatic cholera, the more readily that the first case was fatal (the only death)[1481]. Similar alarms arose at Leith and Hull.

Asiatic Cholera at Sunderland in October, 1831.

In the end of July and in August, Sunderland and the adjoining villages and farms in the valley of the Wear were visited with “a very general prevalence of the indigenous cholera of the country, bearing in most instances its usual leading feature--that of excessive bilious discharges[1482].” Few, who were not attacked with actual cholera nostras, were altogether free, it was said, from diarrhoea or disordered digestion. Many of the choleraic cases were unusually malignant, of which the following are instances:

Allison, aged fifty, a painter of earthenware residing in a low situation on the bank of the Wear two miles above the town, was attacked at 4 a.m. on the 5th of August with vomiting and purging of a watery whitish fluid, like oatmeal and water. His hands and feet were cold, his skin covered with clammy sweat, his face livid and the expression anxious, his eyes sunken, his lips blue, thirst excessive, his breath cold, his voice weak and husky, and his pulse almost imperceptible. He passed into a stage of reactive fever and got well. Arnott, a farm-labourer on the opposite bank of the Wear from the man Allison, was seized at 2 a.m. on the 8th August with precisely the same symptoms, and died in twelve hours. Neither he nor Allison had any intercourse or relation with seamen or the shipping of Sunderland[1483]. Another case on the 8th of August came to light afterwards. A woman in the village of West Bolden, four miles from Sunderland, on the Newcastle road, was found by a surgeon from the town to be suffering from choleraic sickness, of which she died twelve hours from its onset[1484].

A week after these cases in the country not far from Sunderland, there occurred the death, on 14 August, of one of the Wear pilots named Henry. He had been troubled with diarrhoea for some time before, but not so as to keep him from his occupation. Having gone down in the direction of Flamborough Head to look for ships, he picked up a vessel between that and the Wear, piloted her in, and, a few days after, piloted her out again. The identity of the vessel was never traced, but it was alleged that she had come from an infected port abroad. The last time Henry was in his boat he was seized with violent vomiting and purging, and died at his house after an illness of twenty hours. A brother pilot, who looked in at the house on the day of his death, fell into a similar choleraic disorder, but recovered[1485]. On the 28th of August a shipwright died of the same; also about the end of August two persons at a distance of four or five miles from Sunderland. In September, it is said, there were other cases and fatalities. Early in October the authentic particulars of cholera in Sunderland begin. Dixon attended one case, which was fatal on the 9th October. Another case, which came to light three months after, was that of a girl of twelve, named Hazard, residing on the Fish Quay, who was well enough on Sunday the 16th October to have been twice at church. She was seized in the middle of the night following with the sudden and appalling symptoms of choleraic disease and died on the Monday afternoon[1486]. A few doors off on the same quay lived a keelman named Sproat, aged sixty; he occupied a large, clean, well-ventilated room on the first-floor of a house in the most open part of the quay, opposite to a crowded part of the anchorage. He was in failing health, and had been troubled with diarrhoea for a week or ten days previous to the 19th October, on which day he had to give up work. Next day, Thursday, the 20th, a surgeon who had been sent for found him vomiting and purging, but not at all collapsed, with no thirst, and in good spirits. He improved so much that on Friday he had toasted cheese for supper and on Saturday a mutton chop for dinner, after which he went out to his keel on the river for a few minutes. On his return he was seized with rigor, cramps, vomiting and purging. Medical aid was not sent for until seven on Sunday morning, when he was found in a sinking state, pulseless, speaking in a husky whisper, his face livid and pinched, his limbs cramped, the purgings like “meal washings.” He continued like that for three days, and died on Wednesday, the 26th October, at noon.

This came to be reckoned the first death from Asiatic cholera in England.

His grandchild, a girl of eleven, while moving about the room an hour after the death, was suddenly seized with faintness, pains in the stomach-region, vomiting and purging of watery matters; she was taken to the Infirmary and soon got well. The day after his father’s death, Thursday, the 27th October, William Sproat, junior, a fine athletic young keelman, who had attended on his parent during his illness, was found lying in a low damp cellar near to the Fish Quay, suffering from choleraic symptoms; he had been ill only a few hours, and was removed (with his daughter as above) to the Infirmary the same evening. He became gradually worse: on the 30th he was continually throwing himself about, moaning and biting the bedclothes; on the 31st he was lying on his back comatose, his eyes open, the pupils wide and insensible, and the breathing stertorous, in which state he died the same day. An old nurse at the Infirmary (Turnbull) helped to place the body in the coffin, went to bed in a state of considerable fear, and was seized at one in the morning with symptoms of cholera, of which she died after a few hours.

Meanwhile there had been two other fatal cases unconnected with the Sproats or the Fish Quay. On the quay of Monk Wearmouth, across the river, lived a shoemaker named Rodenburg, aged thirty-five. He occupied a poor hovel and had a large family, but he was in good work and wages. On Sunday, the 30th October, he had pork for dinner, and what was left of it for supper. In the middle of the night he was seized with vomiting, and with purging of a fluid like water-gruel in vast quantities; when visited by the medical men, he spoke in a husky whisper, his nails were blue, his skin livid, covered by cold sweat, his limbs cramped. The spasms ceased about nine o’clock on Monday morning; about noon he asked to be raised in bed, and died as they were raising him. On the very same night, between Sunday and Monday, a keelman named Wilson, who lived with his wife in a decent room in the High Street, and had attended the Methodist chapel on Sunday, was seized with cholera at 4 a.m. on Monday, and died the same afternoon at three.

These six cases within a few days, all fatal but that of the girl of eleven, looked like the real Asiatic disease. Kell, an army assistant-surgeon stationed at Sunderland with the reserve companies of the 82nd Regiment, had suspected that the earlier case of the pilot Henry was true Asiatic cholera (which he had seen in Mauritius in 1829), and had written to the Board of Health. At a meeting of the faculty at the Infirmary on the morning after the admission of Sproat junior and his child (28th October), Kell urged upon them that the disease was Asiatic cholera, but all the twelve present, save Dr Clanny, who was in the chair, maintained that it was common indigenous cholera. However, when the younger Sproat died, and the nurse after him, and two others in different parts of the town, a full meeting of medical men at the Exchange came unanimously to the opinion that these were cases of “spasmodic cholera.” A meeting of the Board of Health and leading citizens was at once held, who were informed that, in the unanimous opinion of the medical gentlemen of the town, “spasmodic cholera prevailed in Sunderland.” The authorities in London having been kept informed (principally by Kell), a surgeon of Indian experience was sent down by the Board of Health on the 5th November, and a colonel by the lords of the Council on the 6th, to act as commissioners.

It happened that no more cases occurred for three days after the death of the nurse at the Infirmary; so that the doctors, like Pharaoh in the intervals between the plagues of Egypt, were beginning to repent of their diagnosis. The shipping trade of Sunderland was threatened by these newspaper alarms, and by the presence of two Government commissioners in the town; while Kell was demanding a ship of war off the mouth of the Wear, and a battery on shore, to make the quarantine respected. The Marquis of Londonderry, interested in the coal-trade, wrote to the _Standard_ that the alarm was false. The magistrates, shipowners and leading residents, who had met on the 9th November to raise money for a cholera hospital, assembled again in various public meetings or caucuses on the 10th and 11th, and passed resolutions that there was no Indian or other foreign imported cholera in Sunderland, that it was a wicked and malicious falsehood to say there was, and that there was no need of quarantine on the Wear. One of these meetings was attended by fifteen medical men (most of them from the residential suburb of Bishop Wearmouth), who severally expressed the opinion in various terms, that the recent fatal cases were aggravated cases of English cholera, not contagious or infectious, while three more sent letters backing up Lord Londonderry and the shipowners. On the 12th of November, twenty-seven medical men signed a declaration to the same effect. Some of these remained unconvinced by the progress of events, Dixon arguing as late as 23 January, 1832, that the epidemic in Sunderland, which was by that time over, had been one of “spontaneous malignant cholera.”

Two new seizures occurred on the 7th November, none on the 8th, seven on the 9th, one on the 10th, and so on for fully six weeks longer until Christmas, when the cases became very occasional, so that on the 9th of January, 1832, Sunderland was declared by the Board of Health to be free of cholera. The largest number of seizures reported on one day was nineteen on the 8th of December; on the 10th of that month there were sixty-three cases under treatment at once; the whole number of cases from 23rd October to 31st December was 418, of which 202 were fatal; the whole deaths at Sunderland by the cholera of 1831-32 are given at 215, so that the epidemic exhausted itself there before it had well begun elsewhere in the country. The effect of it upon the death-rate is shown in a comparison of the burials for November and December in three successive years[1487]:

_Burials in the parish of Sunderland._

November December

1829 29 44 1830 39 76 1831 122 127

The way by which the virus entered Sunderland was never traced. It was known, however, that deaths from cholera had occurred among the crews of Sunderland ships lying at Cronstadt and Riga; and as it was the practice for vessels owned in Sunderland to come home from their summer trading towards the end of the season, so as to lay up during the winter, it was suspected that the clothes of some of the dead men had been brought over and sent ashore. The quarantine in the Wear was far from effective: the station was higher up the river than the loading moorings, so that suspected ships had to pass through a crowd of ordinary shipping to get to it. It appears that hardly any ships were quarantined, except some from Dutch ports where no cholera then existed.

This first experience of Asiatic cholera on British soil brought out very clearly one character of the infection which was seen to attend it everywhere during the following year, and has always attended it in every subsequent invasion of the disease. The virus, for all its opportunities, showed a marked preference for, an almost exclusive selection of the lowest and least cleanly localities, and a considerable preference for persons of drunken or negligent habits. Sunderland consisted of three parts--the parish so named, the parish of Bishop Wearmouth, which was the west end of Sunderland or the residential quarter of the wealthier class, and across the river the parish of Monk Wearmouth, with the adjoining Shore. The cholera was almost wholly confined to Sunderland proper; Ainsworth says that no cases occurred, to his knowledge, in the parish of Bishop Wearmouth, and not above six in Monk Wearmouth; another gave six or eight cases in each of these parishes, but increased the estimate to eighteen or twenty in each according to later information. Bishop Wearmouth stood about seventy feet higher than the highest part of Sunderland; it was well built, and its population of 14,462 (with 363 more in the Pans), included the whole of the wealthier class with the trades dependent on them. Monk Wearmouth, with a population of 1498, and the adjoining Shore with a population of 6051, were irregularly built on the north bank, and occupied by the same class (keelmen, sailors, labourers and workmen in the coal, iron and shipping trades) as Sunderland itself; but for some reason, connected perhaps with its soil and elevation, it escaped with a very few cases of cholera[1488]. The parish of Sunderland, with a population of 18,916, was not all visited equally. The focus of the cholera, says Ainsworth, was the town moor, a large piece of pasture-land stretching to the sea-shore at the south-east end of the town, having a subsoil tenacious of water, marshy in the winter months, and its roads almost impassable. Upon this open space was deposited, and left to accumulate for weeks together, the filth from the narrow lanes and passages of the low-lying and crowded quarter at the seaward end of the parish, to the south of the High Street. Some of the streets occupied by the poorer class consisted of old residences of the well-to-do, now divided into tenements. Certain streets had as many as a dozen or twenty common middens, “let in” to the street fronts of houses and covered by trap-doors, in which the domestic refuse and sweepings of the street were collected as a source of profit, and sold at stated times to farmers for manure. Most of the attacks happened in this low-lying part of Sunderland, with a soil and foundations sodden with filth, houses overcrowded and badly ventilated, and its residents subject to the alternations of excess and want (with much pawning of clothes, &c.) peculiar to a port from which one or two hundred sail would leave with a fair wind or arrive in the river together[1489]. About four hundred were attacked in a population of eighteen thousand during a space of two months. The cases among the wealthier classes were nearly all in the households of medical men:--the mother of one doctor, living with him, died of Asiatic cholera, the wife of another came safely through an attack, one or more medical men had the symptoms in one degree or another. In the end of November, five old people in the poor’s house were fatally attacked all at once, in different parts of the building. A cholera hospital had been provided at an early stage of the outbreak, but the relatives of those attacked seldom permitted their removal to it, a prejudice against it having been aroused by the post-mortem examination of the first victims. Most of the cases were accordingly treated at their homes, which were “always crowded to excess by the immediate attendants or relatives, and by others from mere curiosity.” A fund of two thousand pounds was raised for the distressed families, to which the Government gave one hundred. Sunderland became for two or three weeks a centre of interest to medical men, who came to see the cholera from various parts of England, Ireland and Scotland, while MM. Magendie and Guillot came from Paris, and M. Dubuc from Rouen.

The symptoms and morbid anatomy of cholera as it was known in India were seen without ambiguity in the Sunderland epidemic. In a few cases death followed very quickly without the distinctive intestinal symptoms; but usually the unmistakeable thing was a sudden seizure, often in the night after a hearty supper, marked by profuse “meal-and-water” or “rice-and-water” purging, by vomiting, faintness or sinking at the pit of the stomach, thirst, pulselessness, cramps of the limbs, restless tossing, coldness, blueness and clamminess of the surface, and shrunken features. The _facies Hippocratica_ had not been seen on so extensive a scale in England since the sweating sickness of three hundred years before. The end was sometimes in deep coma, at other times in delirium with convulsive or spasmodic movements. The chief point in the morbid anatomy was the engorgement of the lungs, great veins, and right side of the heart, from which the disease was named “cholera asphyxia.” The blood was thick and tarry[1490].

Extension of Cholera to the Tyne, December, 1831.

Before Sunderland had been declared by the Board of Health to be free of cholera, on the 7th of January, 1832, the infection had gained a footing in Newcastle, Gateshead, North Shields, Houghton-le-Spring, and some places on the road to Edinburgh. The mildness of that winter was somewhat favourable to its diffusion; in November there had been some days of severe frost in the midst of generally mild weather, December was warmer than usual, the pastures being green and spring-like, while January was warm and dry almost beyond precedent. The first cases in new centres were usually tramps or others who had come from Sunderland[1491]; but there were some puzzling attacks. Thus Dixon says that on 12th December, 1831, he visited a woman of fifty who died of cholera after twelve hours, “in a lonely district unconnected in situation with any previously infected place,” and where there had been no personal liability to contagion; a young man lodging in the house died three days after with the same symptoms.

At Newcastle, as at Sunderland, fatal cases of choleraic disease were discovered from the beginning of autumn; one such, on 4 August, at the village of Team, two miles to the south-west of Newcastle, was said to have been as little of the nature of bilious cholera, and as truly spasmodic cholera, as those in the subsequent great epidemic. Another suspicious death occurred a little below Newcastle on the 26th October, the same day as the first acknowledged death from the Asiatic disease in Sunderland. A month passed before the next death, marked by spasmodic and non-bilious symptoms, occurred at Newcastle--on the 26th November.

At length, on the 7th of December, 1831, the Asiatic cholera was declared to be in the town. The earliest cases of it were found in low-lying poor houses along the river[1492]. Gateshead, on the south bank of the Tyne, had only two cases until a day or two before Christmas; at length, on Christmas-day, there was a sudden explosion of the infection simultaneously at many points.

“On the 25th [December, 1831] about one o’clock,” wrote Brady[1493], “we were assailed by a third and fourth example of the disease, and before the next morning at ten o’clock, very considerable numbers had fallen sacrifices to its pestilential ravages. Within a space of twelve hours it spread itself over a diameter of two miles, and appeared to pay but very little distinction to altitude of situation, for the higher parts of the town were laid under its stroke in an equal degree, or nearly so, with the lower. Pipewellgate, Hillgate, the banks above Pipewellgate, Oakwellgate, the lanes leading from it, Jackson’s chare, Nun’s Lane, Wreckington, Gateshead Low Fell, Low Team--situations as different in their external character as can well be conceived--were all indiscriminately exposed to its fury.”

Greenhow’s summary of this remarkable explosion on the afternoon and night of Christmas-day is that “at nearly fifty different points cases occurred almost at the same instant.” The attack at Gateshead was short and severe; at Newcastle it was less concentrated and of longer duration, affecting the population in the low and dissolute localities along the river, such as Sandgate and the Close, while there were two or three fatalities about the 6th January among the wealthier residents. The hospital cases in Newcastle and Gateshead to the 9th of February were:

Cases Deaths

Sandgate Hospital 55 23 Castle Hospital 12 8 St John’s and St Andrew’s 15 8 Gateshead Hospital 36 21 --- -- 118 60

As at Sunderland, the bulk of the cases were treated at their homes--1330 cases, with 437 deaths, to the 9th of February. As the whole number of deaths at Newcastle and Gateshead, while the cholera of 1832 lasted, was 801 in the returns to the Board of Health, it would appear that the epidemic had dragged on through the spring and perhaps the summer, which were its seasons elsewhere.

The colliers’ villages on both sides of the Tyne for two or three miles above and below Newcastle and Gateshead were sharply visited at the same time. Below Newcastle, on the north bank, it invaded Dent’s Hole, a dirty narrow lane along the margin of the river, overhung by its banks, filled with mud and filth rising in heaps above the thresholds of the houses; also on the same side, Walker, Howden-Pans, and so on to North Shields; on the south side below Gateshead it visited Felling and other villages. South Shields and Westoe escaped for several weeks, but at length about the 20th of February the epidemic began there and caused 147 deaths before it ceased.

Some of the worst village outbreaks occurred above Newcastle on both sides of the river. Swalwel, a low dirty village of iron-workers, near the confluence of the Derwent with the Tyne had a very virulent attack. Dunston, another low-lying village on the south bank, two miles above Gateshead, subject to inundation from the small tributary stream running through it, had twenty-three deaths among the 400 inhabitants in about a fortnight, most of the victims being old, dissipated and debilitated. On the other hand, Whickam Fell, standing on the hill between Dunston and Swalwel, escaped with only one case, while Bensham, another elevated village between Gateshead and Dunston, escaped altogether; just as Byker, a high-lying village on the north bank, only half a mile from Dent’s Hole, had but a single mild case.

On the north bank above Newcastle the disease was most severe in the villages of Bell’s Close, Lemington and Newburn. The epidemic in the last of these was indeed unparalleled. As in all the other villages attacked, the epidemic was soon over, but not before two-thirds of the inhabitants had suffered either from choleraic diarrhoea or cholera proper. Newburn was a village of some 131 houses, built in the face of the high north bank of the river five miles above Newcastle, its population being 550. The houses stood in two rows, one above the other, the church and churchyard standing in open ground midway between the lower and upper streets of the village; a small stream ran through it to the Tyne. The inhabitants were mostly wherrymen, coal labourers, or glassworkers; they were a healthy community, above indigence, housed in clean, neat, comfortably furnished clay-floored cottages. The first case of cholera, in a man who lived close to the brook, proved fatal on the 4th of January, 1832. There was no new case until the 10th, after which there were several deaths every day. From the night of the 15th until noon of the 16th fifty were attacked, twelve or thirteen of them with the worst kind of spasmodic cholera, the rest with diarrhoea. By the 2nd of February the epidemic was over. Three hundred and twenty had either cholera or cholerine, of whom fifty-seven died (the Board of Health return gives 274 cases and 65 deaths to 25 January), the daily deaths having been as follows[1494]:

_Cholera in Newburn, near Newcastle, 1832._

Deaths

Jan. 4 1 11 4 12 3 13 4 14 6 15 5 16 6 17 3 18 5 19 3 20 3 21 2 22 3 23 2 24 2 25 1 26 2 27 1 28} 29} 1

The other chief centres of cholera in the northern coal district, besides those mentioned, were Houghton-le-Spring and Hetton (which had together 311 cases and 66 deaths to the 28 of January), the colliery village of Earsden, and the port of Tynemouth.

The Cholera of 1832 in Scotland.

It was not until April that the infection began to show itself on the same scale in other parts of England. The next parts of the kingdom to be invaded after the Wear and the Tyne were the coal and iron districts of East Lothian and Lanarkshire, the cities of Edinburgh and Glasgow becoming infected soon after. A fatal case, in a destitute tramping sailor occurred at Doncaster, in the beginning of January, but led to no outbreak; two fatal cases occurred at Morpeth about the same time, the second of the two in a bagman who had just spent three days making his rounds in Newcastle and the infected villages near it. It was on the high road to Edinburgh, at Haddington, Tranent and Musselburgh, that the next focus of cholera was established. Previous to the 14th of January there had been 47 cases, with 18 deaths, in and near Haddington, among the miners and others of the labouring class. At Tranent, seven miles nearer Edinburgh on the main road, with a population of 1700 miners and labourers, a boy died of cholera on the 18th January, the infection spreading so rapidly that before the 25th there had been 61 attacks with 26 deaths, which rose to 205 attacks and 60 deaths by the 8th of February. A few cases occurred also at North Berwick and a good many at Preston Pans; while Musselburgh became the scene of one of the most deadly outbreaks in the whole history.

Musselburgh, with Fisherrow, was not then the place of villas which it afterwards became, but was occupied by a working class, who combined the three industries of coal-mining, weaving or other factory work, and fishing. To add to the ordinary insanitary risks of such a combination, some fifteen hundred hands had been out of work for two months, and were in “a state of great misery.” The first case of cholera appeared there on Wednesday, the 18th January, three days after the first death at Tranent. The virulence and certainty of the infection will appear from the following by D. M. Moir, the distinguished author of _Mansie Waugh_ and other writings in prose or verse, who practised his profession at Musselburgh:

“A girl at Musselburgh, whose mother kept a lodging-house, was found in a state of complete collapse on the morning of Thursday, the 19th January--the day after the first appearance of the pestilence. She died on that afternoon, between five and six, and was buried by moonlight the same evening.... The mother during the night of Saturday was also similarly seized, and fell a victim on the following noon. Her sister, who had walked from Leith on the same morning to condole with her in her family distress, was immediately affected on entering the house; but her symptoms being overlooked in the misery around her, medical assistance was not called in, until, on the return of the nieces from the interment, their aunt was discovered dead on the floor of the dwelling. Her husband, Baxter, a man of intemperate habits, came out to enquire into her fate; and immediately on his return home to Leith was seized with the distemper and died.”

In three weeks there were more deaths from cholera than from all causes in the whole of an ordinary year. To the 22nd of February, just over a month from its outbreak, the disease had attacked 435, of whom 193 died. The medical profession (the senior of whom was a man of original talent, Thomas Brown, author of an essay on smallpox, in 1808, and one on the Indian cholera in 1824), were greatly taxed by the numerous calls upon them: Moir met one night a young colleague who complained of feeling ill, and was advised by the former to go home at once; he continued his rounds for an hour longer, and died of cholera next morning. Edinburgh, only five miles distant, was in constant communication with Musselburgh; and at length three or four cases appeared in the city in persons who had been at the infected place. The Edinburgh cases, however, did not multiply rapidly; to the 8th of February, there had been 8 cases with four deaths; to the 28th of February, 35 cases, with 18 deaths; to the 20th of March, 39 cases, with 20 deaths. On the other hand, the suburb of Water of Leith, had 48 cases, with 23 deaths at the same date. On the 6th April, 1832, the figures for Edinburgh and certain of its suburbs respectively were:

Cases Deaths

Portobello 44 24 Water of Leith 58 30 Canonmills 18 12 Duddingston 10 3 Edinburgh 62 38

Of the border towns, Hawick was infected on the 14th January, probably from Morpeth, and had a not very extensive epidemic, of somewhat mild type[1495]. Coldstream, on the Tweed, a few miles above Berwick, had 109 cases and 37 deaths to the 20th of March.

Meanwhile the infection had sought out the weak spots in the west of Scotland--the mining and weaving villages in Lanarkshire, the city of Glasgow and the manufacturing town of Paisley. On Sunday, the 22nd January, a boy was taken ill in church at Kirkintilloch (a village on the Forth and Clyde canal, seven miles north-east of Glasgow), and died next morning: that was the first case in the west of Scotland. Cases multiplied in Kirkintilloch, so that by the 6th of March there had been thirty-two deaths, but no more for the rest of the season. A few days after the boy was seized in church there, a first case occurred in the mining village of Coatbridge, six or seven miles to the south-east, in an old man living in a “back land” in very poor circumstances, who had not been in Kirkintilloch nor had communication with such as had been there; other cases followed slowly, and at length there was a more severe outbreak.

Glasgow at once took precautions. A Board of Health had been formed there early in the summer of 1831. In February, it had command of £8000 raised by voluntary subscriptions, and it made provision of 236 cholera beds in five hospitals. The theatres were closed, and “evening sermons” discouraged; while all the passenger boats (for a time also the goods barges) on the Forth and Clyde canal, and on the Monkland canal (near to which was Coatbridge) were stopped. District committees were formed in all parts of the city.

The first victim was Janet Lindsay, a drunken old woman who lodged with widow Proudfoot and her daughter in Todd’s Close, Goosedubs; she was asthmatic, and had not been beyond the Goosedubs for weeks. Her seizure, with vomiting and purging, was on the afternoon of Thursday, 9th February, and her death on Saturday morning. Also on the 9th February, in the suburb of Woodside, remote from Goosedubs, the infant of one McGie was attacked with cholera, suffered much from cramps on the 10th and died on the 11th, the father, mother and others of the family afterwards suffering from cholera. The third case, fatal in a few hours, appeared early in the morning of Friday the 10th in a boy living in Millroad Street, a mile east of the Goosedubs, who had been subject to diarrhoea for some weeks. The fourth victim was a gardener in Macalpine Street, a locality also remote from the Goosedubs and in the opposite direction from Millroad Street, who had walked three miles to Pollokshaws on the 9th, and had partaken of tea with friends at Crossmyloof on his way back, in excellent health: he was seized at midnight with purging, and died on the afternoon of the second day. The fifth case was in Partick on the 11th, the sixth in Bridgegate on the 12th, not far from the close in the Goosedubs where the first case had occurred. On the 17th the first of many cases occurred in Paisley, and on the same day there was a case at Maryhill (population of some 500), followed by six more before the next afternoon. Thus there were, besides the case of cholera in the very heart of old Glasgow, half-a-dozen other cases the same day or in the next day or two, at scattered points all round the city. About fifty of the neighbours had visited Janet Lindsay in Todd’s Close, and some had helped to lay her out. The next case in the close was of a woman who had stopped in the street to talk with the widow Proudfoot shortly after the body had been removed; this woman was seized at seven next morning (Sunday, the 12th Feb.), and died in the hospital after twenty-four hours. Three days passed, and then there occurred two other cases, both fatal, in Todd’s Close, one of them being the widow Proudfoot herself, who refused to be taken to the hospital, and would receive no other medicine or cordial but whisky. No other cases occurred in the close for several weeks; but within a range of two hundred yards of it there were 46 cases from the 13th to the 29th of February. It was, indeed to this region of Glasgow, the Goosedubs and the Wynds, that the infection was chiefly confined for the first few weeks; it was especially severe in Francis’s Close, Broomielaw, a collection of small wretched hovels, in which some twenty died of cholera[1496]. The state of the three old Wynds of Glasgow and of other the like localities has been already referred to under a date a year or two before the outbreak of cholera (supra p. 598).

No better instance could be given of the inscrutable ways in which the infection of cholera found out the weak places and the likely subjects than the explosion in the Glasgow Town’s Hospital or pauper infirmary on the 22nd of February, some twelve days after the first cases in various parts of the city and suburbs.

The infirmary, built in two blocks on the north bank of the Clyde, contained 395 inmates occupying 296 beds, some 60 or 70 of whom were insane or fatuous. The fatuous lived in ground-floor cells of the north block, from seven to eleven feet square, with a stone vaulted roof, a stone floor, no fireplace, damp from situation and want of sun, but all the more damp from being often washed owing to the uncleanly habits of the inmates. At eight on the morning of the 22nd February two fatuous paupers in adjoining cells were found cold and pulseless; they had vomited and purged during the night, although they had been well the evening before; each of the two cells had three beds with five occupants. One of the two seized died next day, the other recovered in a week, having had severe spasms and a degree of collapse. Cases appeared almost at the same time in various parts of the building, most of them in scattered individuals, but in one instance in as many as five together in a garret holding twenty-two. From the 22nd February to the 9th of March there were 64 attacks of cholera in this pauper institution[1497]. Besides the five deaths in the Sunderland Workhouse, this was the first of many instances of the remarkable invasion of such institutions.

Until July the infection had been limited in Glasgow to certain of the lowest localities, and even in these it had declined almost to extinction in the last week of May. As the summer advanced it increased somewhat again, and in the first days of August it took a sudden start, reaching a maximum of 181 attacks in one day, and 817 in a week. It was no longer confined to the poorest districts, but became diffused all over Glasgow, so that “there was scarcely a street where one or more cases did not occur.” From this enormous prevalence in August, it declined again in September, but once more took a start in the last few days of that month and in the first week or two of October. The last outburst was ascribed to the effects of the Glasgow public holiday on 28 September, to celebrate the passing of the Reform Bill for Scotland, but the course of the epidemic clearly followed the season, being precisely parallel in Edinburgh, in Dumfries and in the coast towns of Fife. From the middle of October, the disease declined rapidly and was extinct before the middle of November. The following table shows week by week the number of new cases reported daily to the Board of Health, and the deaths in each week[1498].

_Cholera in Glasgow, 1832 (population 202,426)._

Week New ending cases Deaths

Feb. 19 62 21 26 113 46 Mar. 4 68 39 11 85 60 18 94 50 25 150 61 April 1 138 74 8 112 57 15 99 50 22 120 60 29 71 40 May 6 71 39 13 73 39 20 41 31 27 21 11 June 3 6 7 10 45 17 17 72 39 24 168 70 July 1 127 72 8 131 62 15 143 68 22 229 101 29 218 113 Aug. 5 817 356 12 699 339 Aug. 19 483 228 26 419 178 Sept. 2 231 122 9 117 50 16 60 31 23 84 33 30 165 90 Oct. 7 310 140 14 173 95 21 95 58 28 47 29 Nov. 4 41 18 11 10 11 ---- ---- Total 6208 3005

The effect of the epidemic upon the general mortality of Glasgow is shown in the table of deaths from all causes and from cholera month by month, compiled from the burial registers, which make the cholera deaths 161 more than the returns to the Board of Health.

_Glasgow Mortality in 1832._

All Cholera deaths deaths

Jan. 824 -- Feb. 874 87 March 955 264 April 816 229 May 677 125 June 783 196 July 990 441 Aug. 1755 1222 Sept. 749 243 Oct. 755 334 Nov. 529 25 Dec. 571 -- ------ ---- 10,278 3166

While the cholera lasted (12 Feb.-11 Nov.) the burials from all other or ordinary causes were 4958; in the corresponding nine months of 1831 they were 4862, having been excessive in that year owing to fever. The baptisms from 15 December, 1831, to 14 December, 1832, were 3388; so that the cholera alone destroyed nearly as many lives, chiefly adult, as there were children born in the year.

Upwards of a thousand of the cases were treated at the Albion Street Hospital, under the direction of Dr Lawrie, who had had a large experience of cholera in India. His statistics are as follows[1499]:

_Albion Street Cholera Hospital, Glasgow, Feb.-Sept. 1832._

Males Females Both sexes Percentages Cases Deaths Cases Deaths Cases Deaths of deaths

370 251 662 419 1032 670 64·9

Percentages Ages Cases Deaths of deaths

0-7 43 25 58·1 7-20 93 47 50·5 20-30 231 112 48·8 30-40 211 137 64·9 40-50 204 136 66·1 50-60 116 95 81·0 Over 60 134 120 89·5

_Monthly Cases and Deaths._

Percentages Cases Deaths of deaths

Feb. 40 33 82·5 March 97 69 71·1 April 122 81 66·3 May 56 40 71·4 June 126 94 74·5 July 240 143 59·5 Aug. 273 176 64·4 Sept. 64 33 51·5

The noteworthy points are: first, the great excess of women admitted, which was observed also at Edinburgh; secondly, the higher rate of fatality at the two extremes of life, which is the rule in some other infections; and thirdly, the lower ratio of deaths to cases during the height of the epidemic in the end of summer, which is explained, as Craigie remarked for Edinburgh, simply by the fact that the infection was no longer in the worst localities, but was attacking “a greater number of persons, and consequently much better constitutions.”

The Glasgow cholera of 1832 was far more destructive than that of Edinburgh per head of the population, according to the following:

Glasgow Edinburgh

Population 202,426 136,301 Attacks of Cholera 6208 1886 Deaths by Cholera 3005 1065

The fluctuations of the epidemic in the two cities were closely parallel. In Edinburgh from the middle of February to the middle of June the new cases usually ranged from five to ten or fifteen a day, with an occasional excess, as on the 29th of April when there were twenty-six persons seized. As in Glasgow, there was a marked lull in the end of May and beginning of June, after which the seizures became more common and remained somewhat steady to the end of July, some days having as many as twenty attacks. The largest number in one day in August was nineteen, the September maximum sixteen (on the 28th). Edinburgh thus missed the enormous outburst that Glasgow had in August, while the September experiences were much the same in the two cities. The first week of October, which was the time of a second maximum in Glasgow (far below that of August), was the worst time of the whole epidemic in Edinburgh, the cases coming from all parts of the city, as in Glasgow they had done in August.

_Successive days of most extensive Cholera in Edinburgh, 1832._

New cases

Oct. 1 22 2 23 3 44 4 45 5 23 6 30 7 27 8 18 9 13 10 26

This gives 214 cases in the week ending 7th October, as compared with Glasgow’s 310 in the same week.

At the Castle Hill Cholera Hospital, 318 were admitted and 187 died. The ages, with the rates of fatality at each age-period, agree closely with those already given for the chief hospital in Glasgow. The smaller ratio of hospital fatality in the second half of the epidemic was perhaps more marked in Edinburgh: 119 cases, with 85 deaths, from the opening of the hospital to 5 July; 199 cases, with 97 deaths, from 5 July to the closing of the hospital. That larger proportion of recoveries may have been due in part, Craigie thinks, to better methods of treatment; but, in his opinion, it was mainly owing to the greater number of strong constitutions among those attacked over a wider area of the city.

Beyond the statistics and other particulars for Glasgow and Edinburgh, and the minute accounts of the first outbreaks in the beginning of the year, there is little exactly recorded of the cholera of 1832 in the rest of Scotland; but the following table, compiled according to counties from the alphabetical list of the London Board of Health, will serve to show the epidemic in outline.

_Deaths by Asiatic Cholera in Scotland, 1832._

No. of places Places with highest mortalities Counties Deaths attacked in each county

Caithness 96 iii Wick 69, Thurso 26, Latheron 1 Sutherland -- -- Ross and Cromarty 102 vii Tain 55, Dingwall 17, Avoch 12, Cromarty 11, Several villages no return Inverness-shire 191 iii Inverness 177 Nairnshire 5 i Nairn 5 Moray -- -- Banffshire 15 i Rathven (Buckie) 15 Aberdeenshire 108 ii Aberdeen and Footdee 99, Collieston 9 Kincardine -- -- Forfarshire 552 iv Dundee 512, Cupar Angus 17, Arbroath 13, Liff and Benvie 10 Perthshire 81 v Perth 66, Auchterarder 7, Kenmore 4, Tulliallan 3 Fife and Kinross 301 xii Cupar and district 108, Kirkaldy and Dunnikier 104, Dysart 39, Wester Wemyss 17, Kinghorn 15, Burntisland 13, Anstruther 10, Leven 14, St Andrews 5 East Lothian 213 vii Tranent 78, Haddington 65, Dunbar etc. 38, Prestonpans 28 Berwickshire 41 Coldstream 41 Midlothian 1780 xiii Edinburgh 1065, Suburbs of, 146, Leith 267, Musselburgh and Fisherrow 202, Newhaven 52, Portobello 33 Linlithgowshire -- -- Clackmannanshire 75 i Clackmannan 75 Stirlingshire 247 x Alloa 72, Stirling 35, Falkirk 36, Larbert 31, Balfron 28, St Ninian’s 15, Bothkenner 10, Carriden 13, Grangemouth 8 Lanarkshire 3575 xii Glasgow 3005, Pollokshaws 143, Govan 77, Old Monkland 125, Rutherglen 65 Renfrewshire 1001 xi Paisley 444, Greenock 436, Port Glasgow 69 Dumbartonshire 86 iii Dumbarton 67, Bonhill 13, Helensburgh 6 Bute 14 i Rothesay 14 Argyle 35 ii Inverary 25, Campbelltown 10 Ayrshire 466 x Kilmarnock 205, Ayr 190, Dairy 22, Irvine 19 Kirkcudbrightshire 133 iv Troqueer (Maxwelltown) 125, Kirkcudbright 3 Dumfriesshire 441 v Dumfries 418, Caerlaverock 15 Roxburghshire 34 i Hawick 34 (second outbreak only).

Near Glasgow numerous centres of cholera were established, among which Paisley, Greenock and Dumbarton suffered heavily during the same space as Glasgow, from February to November. Rothesay, Campbelltown and Inverary had epidemics in spring or early summer. In June and July the infection was carried effectually into Ayrshire (an earlier importation to Doura, near Kilwinning, in March, having proved abortive) and caused great mortalities at Kilmarnock[1500] and Ayr[1501], as well as much alarm and a good many deaths at Dalry, Irvine and Loudoun. In the latter half of September a most disastrous outbreak began in Dumfries and in the neighbouring Maxwelltown[1502].

The epidemic in Leith and Newhaven proceeded at the same time as in Edinburgh. Another important centre was the midland coal-field of Stirlingshire and Lanarkshire, where the mortality was mostly autumnal. Perth had been reached early in March, Dundee at the end of April, the latter having a visitation on the same scale as Glasgow, Edinburgh, Paisley and Greenock. From Dundee, Cupar Fife was infected about the middle of August, and had a severe epidemic almost confined to paupers[1503]. In the autumn there was much cholera among the fishing population from Thurso to Dunbar and Berwick. Inverness had been infected early in May, and was probably the centre from which the disease spread in the end of summer, during the herring fishery, to the coast towns and fishing villages, as well as to Tain and Dingwall. Only a few of these places made returns to the Board of Health; but it is probable from what Hugh Miller relates of the villages near Cromarty that the disease had been more widely spread. That author has described the condition of things in his native town. Its landlocked bay had been made a quarantine station, and was full of shipping flying the yellow flag. Cholera had “more than decimated” the villages of Portmahomak and Inver, and was prevalent in the parishes of Nigg and Urquhart, with the towns of Inverness, Nairn, Avoch, Dingwall and Rosemarkie. The numerous dead at Inver were buried in the sand, infected cottages had been burned down, the infected hamlets of Hilton and Balintore had been shut off from the neighbouring country by a cordon[1504]. The citizens of Cromarty, hitherto untouched, followed the advice of Miller at a public meeting and took the law into their own hands, guarding all the approaches to their peninsula and subjecting all arrivals to fumigation with sulphur and to some undescribed application of chloride of lime. The infection, however, got in by an unguarded channel. A Cromarty fisherman had died of cholera at Wick; his clothes had been ordered to be burned, but a brother of the dead man, who was in Wick at the time, secured some of them and brought them home. He kept them in his chest for a month before he ventured to open it. Next day he was seized with cholera and died in two days. Thereafter the disease crept about the streets and lanes for weeks, striking down both the hale and the worn-out. Pitch and tar were kept burning during the night at the openings of the infected lanes; the clothes of the dead were burned; many of the fishers left their cottages and lived in the caves on the hill until the danger was past[1505].

Among the numerous fishing villages of the Moray Firth, Buckie is the only one given as severely touched by the infection (fifteen deaths). Only one small village of the Aberdeenshire coast, Collieston, is known to have had cholera (nine deaths)[1506]. The Aberdeen epidemic was not severe, and appears to have been mostly in the fishers’ quarter. The Montrose district escaped altogether in 1832; but in June, 1833, the true Asiatic cholera broke out in the fishing villages of Ferryden and Boddin, on the opposite shore of the South Esk from Montrose. Arbroath had a few deaths in August, 1832, while several of the small towns on the coast of Fife had from that time to the end of the year visitations which were only less alarming than those on the south side of the Firth of Forth at the beginning of the year. To sum up the epidemic in Scotland, it caused nearly ten thousand deaths, of which Glasgow and its suburbs had about one-third, Edinburgh, Leith, Dundee, Greenock, Paisley and Dumfries, another third, while a large part of the remainder occurred among the mining and fishing populations[1507].

The Cholera of 1832 in Ireland.

The forecast of Orton in the summer of 1831, that Ireland would be the chosen soil of the Asiatic pestilence owing to the state of misery, at that time, of the mass of its people, was realized in a measure. But the cholera in Ireland, as elsewhere in Europe, showed itself chiefly as an urban disease, falling disastrously upon the poorest quarters of Dublin, Limerick, Cork, Galway, Sligo, Drogheda and other towns, but by no means seriously upon the immense population who occupied the country cabins. Scotland, indeed, had a higher ratio of cholera deaths than Ireland per head of the population; whereas Dublin had nearly twice as many deaths as Glasgow, their populations being almost exactly equal (about 200,000), and Cork had nearly the same number as Liverpool. The following table gives the comparison of the three divisions of the United Kingdom, including the cholera deaths of 1831 in England, but not those of 1833, which were more numerous in Ireland than elsewhere.

Population in 1831 Cholera deaths

England and Wales 13,897,187 21,882 Ireland 7,784,539 20,070 Scotland 2,365,114 9592

The first undoubted case of Asiatic cholera was found in Dublin on 22 March, 1832. On the 25th of that month, Harty, who was physician to all the Dublin prisons, notified to the Board of Health cases in the Richmond Bridewell which he believed to be true spasmodic or malignant cholera[1508]. It was reported from Cork on the 12th of April, from Belfast on the 14th, Tralee on the 28th, Galway on the 12th of May, Limerick on the 14th, Tuam the 4th of June, Waterford the 1st of July, but not until 21 August from Wexford and about the same time from Londonderry. Doubtless remoteness from the ordinary routes of vagrants was the reason why the infection was later in some places, such as Wexford. The old Liberties of Dublin, which harboured crowds of beggars in dilapidated tenement-houses, became a focus of virulent infection. As the summer advanced whole families in some of the most wretched lanes were cut off; news from Dublin on 29 June says that the pestilence was worst in Sycamore Alley, in a single house of which twenty persons had died in the course of four or five days[1509]. Certain streets sent fifty patients to the Cholera Hospital for one sent by other streets that were seemingly no better off[1510]. The great hospital in Grange Gorman Lane, capable of holding 700 and sometimes occupied by 500, would on some nights or early mornings (from midnight to 7 a.m.) receive forty or fifty new cases, and within a week would be having at the same hours only two applications. During four successive days it admitted a total of 285 cases, during the next four days 497 cases, and during four days a fortnight later only 134 cases. The worst time was from the 10th to the 14th of July, when 615 were admitted. A day or two of rain seemed always to send up the number of cases carried to the hospital[1511]. Until the beginning of June hardly anyone under fifteen was attacked; but in July the attacks of children were about one in thirteen or fourteen of adults, a case of pure cholera having been observed in an infant three weeks old. As at Glasgow and Edinburgh, more women than men were taken to the hospital (138·17 females to 100 males)[1512].

As the infection spread in Dublin during the early summer a panic arose in the city, and alarm over the whole province of Leinster. Runners, as in the old times of the torch of war, were to be seen hurrying everywhere through the neighbouring counties carrying a smouldering peat, of which they left a small portion at every cabin in their direct line, with a sacred obligation upon the inmates to carry the charm to seven other houses, and the following exhortation: “The plague has broken out; take this, and while it burns offer up seven paters, three aves, and a credo in the name of God and the holy St John that the plague may be stopped”! Men, women and children scoured the country with the charmed turf in every direction, “each endeavouring to be foremost in finding unserved houses.” One man in the Bog of Allen had to run thirty miles before he had discharged the obligation laid upon him[1513]. It does not appear, however, that the infection was at all general among the scattered cabins, hamlets or even considerable villages. In the rural parts of Wicklow there were only eight deaths from it, in Fermanagh four, in county Derry three, in Armagh thirteen, in Carlow none until the next year. In Clare the deaths in country districts were more than twice as many as in Ennis and other towns of the county. In Sligo county, again, there were only 62 deaths among the peasantry to 698 in the towns, nearly the whole of the latter total belonging to the county town and seaport. The epidemic in Sligo town was one of the worst in Ireland. It was reported that forty or fifty were buried in one day in a trench, one-half of them without coffins but wrapped in tarred sailcloth. It is said, also, that seven of the medical men died of cholera in the course of three months[1514]. Thousands of the population, which numbered about 14,000, fled from the town, the wealthier paying large sums for a room or two in a country cottage, the poorer living in tents or sleeping under the hedges. In August the guard of the mail coach which ran from Sligo by way of Strabane to Londonderry was taken with cholera on the road and died at the latter town, no case having occurred in Londonderry up to that time[1515].

The outbreak at Drogheda was as sudden and disastrous as at Sligo. At Belfast also the disease began with enormous fatality, but, according to the table, the deaths eventually were few in proportion to the attacks. The other towns which had highest mortalities were Cork, Limerick, Galway and Kilkenny--all seaports except the last. In Waterford the great outbreak was delayed until 1833.

Many of the counties had more deaths among the peasantry in 1833 than in 1832, Limerick county in particular. The following instance is related of a small hamlet about a mile to the south-east of Armagh:

The hamlet consisted of five or six dwellings on both sides of the road. On the 19th July, 1833, a man in delicate health, who had received a jar of sea-water two days before, and had drunk three or four pints of it, was seized with cramps, and blueness and collapse, after the purging induced by the sea-water; he died on the 20th and was buried on the 21st. His brother, who lived next door under the same roof, was seized with cholera on the evening of the 21st, having attended the funeral, and died comatose after five or six days’ illness. A man who lived across the road, and had also been at the funeral of No. 1, was seized with cholera the same evening (21st), and died in forty-eight hours. On the night of his burial his son aged thirteen and a married daughter who lived in the house were seized, the boy dying the same night “very black,” and the daughter after a lingering illness of five or six days. The only other attacked was a girl, who recovered under treatment by bleeding &c.[1516]

In 1833 the whole number of deaths assigned to cholera in country places was 2,756, while 2,552 deaths were reported from the towns. It appears to be accepted (by Wilde) that true Asiatic cholera lingered in Ireland until 1834, and that it had caused a considerable part of the 4,419 deaths assigned to “cholera” under that year in the Census of 1841. There is one reference to undoubted cases of the Asiatic type in 1834 in Ross, Nenagh and other places in the same district[1517].

Assuming that all the deaths so called in the three years 1832, 1833 and 1834 were true Asiatic cholera, that imported infection accounted for 1 in 5·68 deaths from all causes in Munster, 1 in 5·98 in Leinster, 1 in 9·86 in Connaught and 1 in 15·15 in Ulster. The proportion of attacks to fatalities in eight of the principal towns in the following table varies much, Belfast having comparatively few deaths for all its many cases, and Kilkenny three deaths to about five cases: these differences must have depended upon the number of cases of “cholerine” or diarrhoea which attended the true “spasmodic” or collapse-cholera, and may or may not have been counted in the returns.

_Deaths from Asiatic Cholera in Ireland, 1832-33._

1832 1833 No. of Country Town Country Town places with deaths deaths deaths deaths Cholera LEINSTER Carlow -- -- 64 116 vi Dublin 460 187 32 17 xxiv _Dublin City_ -- 5632 -- 166 Kildare 108 72 55 104 xi Kilkenny 91 14 130 29 ix _Kilkenny City_ -- 296 -- 144 King’s 40 288 10 -- v Longford 22 63 -- -- iii Louth 115 189 -- -- viii Meath 61 105 81 113 vii _Drogheda Town_ -- 491 -- -- Queen’s 17 111 16 -- iv Westmeath 18 121 84 5 iv Wexford 126 362 24 150 v Wicklow 8 40 -- 23 iv

MUNSTER Clare 453 281 166 8 xiii Cork 325 1028 466 240 xxxv _Cork City_ -- 1385 -- 234 Kerry 87 440 109 181 viii Limerick 82 4 668 173 xvi _Limerick City_ -- 1105 -- -- Tipperary 198 910 224 208 xii Waterford 52 52 48 79 ix _Waterford City_ -- 24 -- 245

ULSTER Antrim 70 66 -- 75 v _Belfast Town_ -- 418 -- -- Armagh 13 57 2 -- vi Cavan 21 11 70 51 vi Donegal 37 139 141 -- vii Down 110 423 65 37 xiv Fermanagh 4 50 -- 9 iv Londonderry 3 222 -- -- iv Monaghan 64 50 13 43 iv Tyrone 100 193 17 9 ix

CONNAUGHT Galway 141 430 82 -- xii _Galway Town_ -- 596 -- -- Leitrim 1 -- 101 -- vi Mayo 151 325 12 68 xi Roscommon 47 105 38 25 vii Sligo 62 698 25 -- iv

The Cholera of 1832 in England.

The certainty that Asiatic cholera was at Sunderland in November and at Newcastle in December, 1831, led to quarantine of ships arriving in the Thames from the Wear and the Tyne. The early numbers of the ‘Cholera Gazette’ published lists of vessels from these northern coal ports detained at Stangate Creek on the Medway[1518]. At length about the middle of February, 1832, three suspicious cases occurred together in Rotherhithe, one of them being of a man who had been scraping the bottom of a Sunderland vessel. Other cases came close upon these in the parishes on both sides of the Thames from Rotherhithe and Limehouse to Lambeth and Chelsea, especially in the Southwark parishes.

The diagnosis of Asiatic cholera was vehemently contested for several weeks by a section of the profession, who frequented the Westminster Medical Society and had for their organ the ‘London Medical and Surgical Journal.’ The slow progress of the disease at first, and the apparent extinction of it for a week or two at the end of May (as at Glasgow and elsewhere in Scotland in the same weeks) encouraged these doubts, although the 994 fatalities in 1848 cases from 14 February to 15 May were quite unlike any experience of cholera nostras. After the river-side parishes, cases were reported most from other crowded parts, such as St Giles’s in the Fields. From the middle of June the infection became more severe and widely spread, still making the river-side parishes its chief seat, but extending beyond Southwark on one side, and on the north side to such localities as Fetter Lane, Field Lane and parts of the City. From the 15th of June to the 31st October the cases in London were 9142 and the deaths 4266; in November and December only thirty more cases were known, of which one half were fatal. The total for the year in London came to 11,020 cases with 5275 deaths. This was admitted to have been for Asiatic cholera a slight and partial visitation of the metropolis. London with a population of a million and a half had actually fewer deaths than Dublin with its two hundred thousand inhabitants. Paris had more cholera deaths in one week of April (5523 deaths, April 8-14) than London had in all the year.

_The Asiatic Cholera of 1831-32 in England._

No. of places Places with highest Deaths attacked mortalities in each county

London 5275 Surrey, part of -- -- Kent 135 xi Minster (Sheerness) 38 Sussex -- -- Hampshire 91 ii Portsmouth 86, _Southampton no return_ Berkshire 52 iv Wantage 27 Middlesex, part of 62 iv Uxbridge 34, Edmonton 11 Buckinghamshire 105 iv Aylesbury 60, Olney 22 Oxfordshire 219 xii Oxford 86, Bicester 64 Northamptonshire -- -- Huntingdonshire 45 iii Fenstanton 21, Ramsey 20, St Ives 4 Bedfordshire 40 ii Bedford 36 Cambridgeshire 208 iv Whittlesea 97, Ely 61, Wisbech 41 Essex 38 iv Barking 18, Chelmsford 10 Suffolk 1 i Woodbridge 1 Norfolk 232 vi Norwich 129, Lynn 49, Denver 27, _Yarmouth no return_ Wiltshire 14 ii Chippenham 9, Farley 5, _Salisbury no return_ Dorset 19 ii Bridport 16, Charmouth 3 Devon 1901 xxvii Plymouth 702, Devonport 228, East Stonehouse 133, Exeter 386 Cornwall 308 xi St Paul 81, Penzance 64 Somerset 142 v Paulton 66, Bath 49, Tiverton 23 Gloucestershire 932 viii Bristol 630, Clifton 64, Gloucester 123, Tewkesbury 76, Upton 34 Herefordshire -- -- Shropshire 158 vii Shrewsbury 75, Oldbury 37, Madeley 27 Staffordshire 1870 xiv Bilston 693, Tipton 281, Sedgley 231, Wolverhampton 193, King’s Winsford 83, Wednesbury 78, Walsall 77, Newcastle-u.-Lyme 60, W. Bromwich 59, Darlaston 57, Stoke 46 Worcestershire 579 xi Dudley 77, Worcester 79, Kidderminster 67, Droitwich 63, Redditch 38 Warwickshire 188 xii Nuneaton 56, Coleshill 32, Birmingham 21 Leicestershire 5 i Castle Donington 5 Rutland -- -- Lincolnshire 80 viii Gainsborough 41, Owston 17 Nottinghamshire 352 vii Nottingham and suburbs 322, Newark 25 Derbyshire 16 i Derby 16 Cheshire 111 vi Northwich 30, Stockport 29, Runcorn 18, Nantwich 14, Chester 14, Brimmington 6 Lancashire 2835 xiv Liverpool 1523, Manchester 706, Salford 216, Warrington 168, Lancaster 114, Wigan 30 West Riding, York 1416 xxvii {Leeds 702, Sheffield 402, Hull 300, East Riding, York 507 iiii { York 185, Wakefield 62, Rotherham North Riding, York 47 ii { 34, Selby 32, Goole 36, Bradford { 30, Whitby 27, Doncaster 26 Durham 850 viii Sunderland 215, Gateshead 148, S. Shields 147, Stockton 126, Jarrow and Hebburn 70, Hetton &c. 97 Northumberland 1394 xiv Newcastle 801, Villages near 259, N. Shields &c. 98, Berwick 84, Tweedmouth 72, Blyth 42 Cumberland 702 vii Carlisle 265, Whitehaven 244, Workington 119, Maryport 42, Cockermouth 25, Allonby 4 Westmoreland 68 i Kendal 68 Monmouth 15 ii Newport 13, Abergavenny 2 South Wales 343 vii Merthyr Tydvil 160, Swansea 152, Haverfordwest 16 North Wales 140 viii Denbigh 47, Carnarvon 30, Flint 18, Newtown 17 Isle of Man 146 i Douglas 146

It will appear from the annexed table (here compiled according to counties for the first time) that the cholera of 1832 visited most parts of England. The dates of outbreak at each place (omitted in the table) show that its great seasons everywhere, except at Sunderland, Newcastle and Musselburgh, were the summer and autumn. New centres or foci of infection were made in all directions, and in a good many small places there were epidemics which produced much alarm although the figures look insignificant in the statistical table. Some counties, such as Leicestershire, Herefordshire, Derbyshire, Northamptonshire, Lincolnshire, Suffolk, Sussex, Dorset, Wiltshire, and several of the Welsh counties, escaped with a few cases at perhaps one village or town. Some towns, such as Birmingham, Cheltenham, Cambridge and Hereford, had only a few cases (or none) in 1832 as in the later epidemics in England. Most of the towns which now head the list of high death-rates by common summer diarrhoea, chiefly infantile (as in the preceding chapter), had only a few imported cases but no real epidemic extension; these were Preston, Blackburn, Bury, Rochdale, Oldham, Bolton, Halifax, Leicester and Coventry; while Bradford, Stockport and Wigan had comparatively few. The greater epidemics, besides those which started the disease at Sunderland and Newcastle, were, in order of time, at Hull and Goole, Liverpool, Manchester, Warrington, Leeds, Sheffield, Nottingham, Bristol, Plymouth, with Devonport and Stonehouse, Southampton, Portsmouth, Exeter, Salisbury, various towns of the Black Country in South Staffordshire, Dudley, Merthyr Tydvil, Carlisle, Whitehaven, with other ports of the Cumberland coal-fields, and Douglas in the Isle of Man. Devonshire, Cornwall, the West Riding of Yorkshire, Worcestershire and Warwickshire had each a large number of minor centres, besides the greater foci at Plymouth and Exeter, and at Leeds and Sheffield. The severity of the disease in some parts of England called forth a few special accounts, from which certain representative details may be taken.

The most disastrous outbreak in all England was at Bilston, in the centre of the Black Country, near Wolverhampton[1519]. The first cases in that part of England were at Dudley early in June, in some travelling German broom-sellers. In the end of June a canal boatman from Manchester died of cholera in his boat four miles from Wolverhampton; the boat was sunk. In the first week of July another canal boatman died of cholera at Tipton, after returning from Liverpool. The infection became established during July in the parish of Tipton, thickly peopled with miners and iron-workers[1520]. At length on the 4th of August a case occurred in the adjoining town of Bilston, about two and a half miles to the south-east of Wolverhampton.

Bilston was a town of 14,492 inhabitants, nearly all of the working class. It was irregularly built on high ground, full of forges and surrounded by mines. Its soil was perfectly dry “from the water having been drawn off for the purpose of getting the mines[1521].” The streets were for the most part wide and open; many houses stood in courts and back yards, but the town was so irregularly built as not to be densely crowded. The Birmingham and Staffordshire Canal passed through the whole length of the township, and there was one small brook traversing the town. The people usually earned good wages, but trade had been depressed since March, 1832. There was a good deal of drunkenness among them, and a peculiar addiction to the sports for which the Black Country is still celebrated, including at that time bull-baiting. The public health was in general good, the deaths having been 23 in May, 31 in June, and 25 in July. The churchyard of the original chapel was full; a new chapel had been built, and a burial-ground consecrated, in 1831. Bilston wake had been held on 29th July, 1832, with the usual orgies notwithstanding the depression of trade. On the night of Friday the 3rd of August a married woman in Temple Street, occupying a poor and filthy house, who had supped heartily on pig’s fry and had drunk freely of small beer, was seized with purging, which turned to fatal spasmodic cholera. Within an hour medical aid was sought for two more cases of the same in poor and filthy houses in Bridge Street and Hall Street, about four hundred yards from each other and from the house in Temple Street. At the back of the latter was a most offensive pigsty, and beyond the pigsty a poor cottage in which lived a widow and four children; cholera attacked them, two of the children dying on the 6th August and another on the 7th. The night of the 9th of August was most oppressively hot. In the week ending the 10th August there had been 150 cases and 36 deaths from cholera. On the 10th the disease appeared in a new quarter to the west, called Wynn’s Fold; the 12th was again an oppressively hot day, followed by rain over-night. On the 14th the disease began its ravages in Etlingshall Lane, at the western end of the township, a mile from the scene of the first outbreak. The attacks in the week ending 17 August had risen to 616 and the deaths to 133. On the 16th it was remarked that the flies had disappeared and the swallows with them; both came back together when the epidemic was declining. Whole families were now being cut off, father, mother and perhaps three children. Mr Leigh, the curate of the parish, went on the 18th to Birmingham to secure a supply of coffins and medical aid, the medical men of the town being worn out (two of them died a few days after). The deaths between the 19th and 26th of August numbered 309. On the latter date a dispensary was opened, after which the proportion of fatalities to attacks became less. On the 18th of September, the last death occurred, and the epidemic was over, having attacked 3568 in a population of 14,492, and destroyed 742, of whom 594 were over ten years of age. The following is the complete bill:

_Cholera at Bilston, 1832._

Week Deaths under ending Attacks Death ten years

Aug. 10 150 36 5 17 616 133 23 24 924 298 58 31 832 184 34 Sept. 7 694 62 18 14 250 23 6 21 102 6 4 ---- --- --- 3568 742 148

No fewer than 450 Bilston children under the age of twelve were left orphans by the cholera; for them a national subscription was made to the amount of £8536. 8_s._ 7_d._, and applied to the building and support of a Cholera Orphan School, which was opened on the 3rd of August, 1833, the first anniversary of the outbreak of cholera in the town.

In the adjoining parish of Sedgley, although the deaths were only 290 in a larger population (20,577), the infection was as severe in certain places. “Sometimes a whole hamlet seemed to be smitten all at once, so that, in some of the streets, or rather rows of tenements, there was scarcely a house without one sick, or dying, or dead.” At Tipton, in one family of 14 no fewer than 12 died; and in eight different tenements every inhabitant was swept off. At Dudley one had a narrow escape of being buried alive. In twelve parishes or townships, with a population of 160,000, cholera attacked about 10,000 and cut off about 2000. The effects of the pestilence were all the more terrible from its swiftness, for in each parish it was in full vigour not above a month. The population of miners and iron-workers, a rough set addicted to brutal sports and to drunkenness, could not believe that brandy was not a specific, and made it circulate at funerals to fortify against infection. A reformation of morals and revival of religion is said to have followed the scourge[1522]. The following is the list of chief centres in the Black Country:

Cholera deaths

Bilston 693 Tipton 281 Sedgley 231 Dudley 277 Wolverhampton 193 King’s Winford 83 Wednesbury 78 Walsall 77 Newcastle-under-Lyme 60 West Bromwich 59 Darlaston 57 Stoke-on-Trent 46

Wolverhampton, which was one of the chief Staffordshire centres of the next cholera in 1849, got off somewhat easily in 1832 with 576 attacks (193 deaths), or one in forty of the population.

It was most common and fatal in a lane called Caribee Island, a narrow filthy cul-de-sac with an open stagnant ditch down the middle, inhabited chiefly by poor Irish. The influence of ground soaked with sewage was shown also in the frequency of cases of cholera among persons in easy circumstances in the residential locality of Darlington Street--“a wide airy street consisting of two rows of houses at its upper end, nearest the centre of the town, but of only one at the lower part, where it is a raised causeway, open on one side to the gardens and meadows beyond. The lower rooms of the houses, being below the level of the street, are consequently very damp; and within a few yards of the backs of these houses runs a wide ditch, the main sewer of that side of the town, which is dammed up and diverted into several large cesspools, or receptacles for the mud and filth which it deposits. These, in warm weather, emit such offensive exhalations as to be almost intolerable to the persons who live near them.... It is singular that this was the only part of the town in which persons in easy circumstances took the disease[1523].”

The cholera had reached Liverpool in the end of April (perhaps from Hull and York), and attacked 4912 in a population of 230,000, causing 1523 deaths before the end of autumn. The very large number of cellar-dwellings and back-to-back houses in the town at that time favoured the infection; but Liverpool was on all subsequent occasions one of the worst centres. Two incidents in 1832 are connected with ships.

On 18 May, 1832, the ‘Brutus,’ of 384 tons, sailed from Liverpool for Quebec, with a crew of 19, and 330 emigrants who were pauper families from agricultural districts sent to Canada at the cost of their respective poor-law Unions. The emigrants were ill-provided with bedding and clothes, and the ship was under-provisioned. Two days after sailing, or seven days, or nine days (accounts differing), a case of cholera occurred in an adult, who recovered. Other cases quickly followed, with enormous fatality, until the deaths reached 24 in a day. On the 3rd of June the captain put back for Liverpool, his provisions having run short, and his drugs (laudanum) being exhausted. By the time the ship reached Liverpool there had been 117 cases of cholera (of which four were among the crew) and 81 deaths, seven cases remaining at her arrival, of which two ended fatally, making the deaths 83[1524].

Another Liverpool incident is noteworthy:

“One morning a mate and one or two men, who had gone to bed the preceding evening in good health on a vessel lying in one of the Liverpool docks, were found suffering from cholera. The men were immediately removed to a hospital and the vessel ordered into the river; when another vessel, with a healthy crew took its situation in the dock: the next morning all the hands on board the second vessel fell sick of the cholera. Upon examining the dock in this part, a large sewer was found to empty itself immediately under the spot where these vessels had been placed[1525].”

One of the ablest accounts of the cholera of 1832 was that by Dr Gaulter, of Manchester. The deaths there were 706, and 216 in Salford; but it appeared surprising that, being so many and widely spread, they should not have been many more.

An inspection by the local Board of Health two months before the first case appeared “disclosed in the quarters of the poor--a name that might be almost taken [at that time] as a synonym with that of the working classes--such scenes of filth and crowding and dilapidation, such habits of intemperance and low sensuality, and in some districts such unmitigated want and wretchedness,” that the picture correctly drawn seemed to many a malicious libel. From that picture, “it was certainly to have been expected that nearly the whole mass of the working population would have been swept away by the disease.” There were few good sewers, and it would have required £300,000 to sewer Manchester thoroughly. As it was, the infection progressed slowly from the first case on 17th May until the end of July[1526]. It was the same in Salford, where it “crept about slowly for three or four weeks attacking solitary individuals or single families in streets and situations the most distant and unconnected, and then suddenly fixing itself in the lower and most populous part of the town.” It was in the end of July and beginning of August that the sharp outburst took place in Manchester also. An old soldier well known in the streets as a seller of matches, who “could take a pint of rum without winking,” died of cholera in Allen’s Court. His body was allowed to lie in the house two days and a half. In four houses of Allen’s Court, 17 cases occurred within forty-eight hours, of which 14 were fatal; this court was afterwards known as Cholera Court. In the same few days the infection was most deadly in Back Hart Street, “infamous as a nest of vagabonds and harlots,” and in a street behind it, in which nearly the whole of fourteen attacks ended fatally. Blakely Street, a bad fever locality in the time of Ferriar (_supra_, p. 150), had the most malignant kind of cholera in its lodging-houses. It was remarked that few of the factory hands took it: of 1520 employed in Birley and Kirk’s mill, only 4 were attacked during the epidemic; more women than men took cholera, and generally those that were employed about dwelling-houses were the victims[1527].

The whole cholera bill at Manchester was as follows:

_Progress of the Epidemic._

Attacks

May 4 June 37 July 108 August 650 Sept. 261 Oct. 172 Nov. 33 Dec. 2 Jan. 2

_Ages of the patients._

Attacks Deaths

1-15 199 101 15-25 153 53 25-35 264 98 35-45 192 93 45-55 197 116 55-65 120 85 65-80 85 68

Three cholera hospitals were provided in Manchester, at which about one-half of all the cases were received:

Cases Deaths

Swan Street Hospital 443 234 Knott Mill Hospital 242 122 Chorlton on Medlock Hospital 29 17 At their homes 697 335

In Salford all the patients were treated at their homes--644 with 197 deaths; there were also 60 cases among the prisoners in the New Bailey, with 19 deaths.

The Swan Street Hospital was the occasion of a remarkable cholera riot on the 2nd of September. A mob numbering several thousand persons filled the streets near the hospital; in the thick of it was carried a small coffin, from which the headless trunk of a child was taken at intervals and shown to the crowd. The child had died of cholera in the hospital and the body had been examined _post mortem_. Some rumours of this had gone abroad, the body was exhumed, and was found unaccountably mangled. This was the time when intense feeling had been roused all over the country by the procuring of bodies for anatomical dissection, the prejudice extending to the ordinary pathological inspection also. At Sunderland the holding of two or three necropsies had turned the people against the Cholera Hospital. At Dublin there was a rigid rule that no body was to be examined after death in the great cholera hospital of some 700 beds. The body of the child exhumed at Manchester had been found with the head severed, and the rioters declared that it had been murdered. They broke into the hospital, carried off the patients to their homes, and wrecked the furniture and fittings of the wards. The military was at length called out to clear the streets[1528].

The epidemic of cholera at Bristol reproduced most of the incidents at other places. There had been numerous suspicious cases of choleraic disease in the early summer, including an outbreak in the gaol in the first week of July.

The first unequivocal cases occurred on the 11th July in a filthy court, in strangers from Bath where there was then no cholera. About the same time the infection showed itself at several places apart, especially in the destitute suburb of St Philip, in the south-east of the city. One of the worst centres was the city Poorhouse, in which 268 cases with 94 deaths occurred from the 24th July to the 20th August. The largest number of seizures on one day was 79 on the 17th August, the largest number of deaths 33 on the 15th. After that it gradually declined, and was over by the middle of November. The attacks reported were 1612, the deaths 626; but these figures came short of the truth, as many cases were not reported, and the burials from all causes were in excess of the average for the season after deducting the reported cholera deaths. Although it fell at Bristol, as elsewhere, upon the poorest quarters and the most abandoned or destitute class, yet it showed caprices among these. Marsh Street, the abode of the lower Irish, and one of the most thickly peopled parts of the city, was the last place visited. Lewin’s Mead, a low and crowded quarter, had only a few scattered cases[1529].

Little is known of the great epidemic in Plymouth, Devonport, and East Stonehouse, beyond the gross result that it caused 1063 deaths in the town and the two dockyards[1530]. Of the outbreak at Southampton not even the figures are known, the only important omission, besides the epidemic at Salisbury, in the whole of the cholera of 1832. On the other hand the Exeter cholera has been related at greater length than any[1531].

It was mainly an autumnal outbreak, the largest number of attacks on one day being 89 on the 13th August, and the maximum daily burials 30 a few days before. The total attacks were 1135, the deaths 345; they were chiefly in the south-western suburb of the city, among the poorer class, the two St Mary parishes having 3·65 and 3·26 per cent. of their population attacked, the parish of St George 3·41, St John 2·73, and Trinity 1·54, while two whole parishes had no cases.

Somewhat late in the autumn the infection spread through Cornwall. Its general prevalence was also late in the South Wales mining district (insignificant compared with its enormous ravages there in the next cholera of 1849) and in Carlisle, in Whitehaven and the other seaports of Cumberland. Hartlepool, for all its nearness to the original centre of cholera infection in Sunderland, was one of the last places to be infected, in the autumn of 1832[1532].

The Central Board of Health made no report upon the cholera of 1832, unless a document sent to the king (William IV.) may have consisted of something more than the alphabetical list of infected places, with dates and numbers, which Sir James Clark found some years after in a drawer of the royal library. But some lessons of the epidemic were obvious without the aid of an official report. The late summer and autumn was undoubtedly its chief season--except in places where the poison had, as it were, spent itself in the winter or early spring, such as Sunderland and Musselburgh. A subsidence and seeming extinction of the epidemic in spring and early summer was observed at Glasgow and Edinburgh as well as in London; but it was far otherwise in Paris, where sixteen thousand deaths occurred in the single month of April[1533]. As to locality, the infection seemed to prefer low grounds, such as the shore quarters of seaports and the banks of rivers. The town moor of Sunderland, around which the infection found its first habitat in Britain, appeared to be a typical cholera soil--a wet bottom of tenacious clay, almost impassable in winter from the water standing in it, the surface covered with heaps of excremental and other refuse from the crowded lanes near it. But the greatest centre of cholera in England in 1832, the town of Bilston, seemed to be the reverse of this--a rising ground from which the water had been drained away by the numerous mines of coal, iron and limestone all round it. Again, in towns or villages built upon a slope or on heights and hollows, such as Gateshead, Newburn and Collieston (most of all in Quebec on the steep bank of the St Lawrence), the infection did not confine itself to the lower part only. But it was remarked that among the Tyneside villages several on high ground escaped altogether, although within a mile or two of others severely visited. This question of elevation comes up more definitely in the cholera of 1849.

Another obvious thing in the epidemic of 1832 was that many of the first victims were among the destitute, drunken or reckless class. But there were innumerable exceptions, notably in Paris, where the multitude of victims included several peers, deputies, diplomatic personages and the prime minister.

One of the most striking things in the habits or preferences of cholera in 1832 was the early and unaccountable selection of the inmates of lunatic asylums, the fatuous paupers of workhouses, prisoners, or other immured persons badly housed and ill-fed. In most of these cases it was a mystery how the poison of cholera had got inside the walls. The earliest important instance was that of the Town Hospital or pauper infirmary of Glasgow. Other instances were the lunatic wards of Haslar Hospital, Hanwell asylum, Bethnal Green lunatic asylum, Lancaster county asylum, the Manchester New Bailey, situated in Salford, Coldbath Fields Prison, London, Clerkenwell workhouse (65 deaths), Bristol poorhouse (94 deaths). In the remote Westmoreland village of Hawkshead, thirteen miles from Kendal, cholera appeared unaccountably among the sixteen inmates of the poorhouse, attacking eight of them with sudden and severe symptoms so that four died; it was impossible to trace the introduction of the virus, but the poorhouse was nearly surrounded with stagnant water[1534].

Hardly anything was more keenly debated than the question as to how cholera spread. It was not difficult to find some instances of infection seemingly got from contact with living or dead cholera bodies: cases suggestive of that occurred at Sunderland at the outset, and later in Ireland more especially[1535]. In the Swan Street cholera hospital at Manchester, eight nurses took the infection, of whom four died. But on the whole the immunity of nurses (as in the Great Gorman Lane hospital of Dublin) and of medical men was remarkable. Although constantly in the presence of cholera patients, sometimes lingering over them, as in the operation of blood-letting, very few took the disease. In Manchester only one medical practitioner was known to have had an attack, a mild one. Gaulter says that Dr Alsop, of Birmingham, and Mr Keane, of Warrington, were the only two medical men known to him to have died of cholera in England; but two of the Bilston doctors died in the height of the epidemic there, one died at Musselburgh, seven at Sligo, and two at Enniskillen. The truth of the matter in cholera appeared to be the same as in plague and yellow fever, the two great infections that resembled cholera most closely as soil-poisons: namely, that contagion from the persons of the sick was a contingency, as Rush, of Philadelphia, had taught for yellow fever in the end of last century, and Blane had taught after him. A London writer stated this very fairly in 1832[1536]:

“I believe that this disease, like many other epidemic diseases, although communicable by miasma in the atmosphere, and originating or being producible from a peculiar state of that acting upon the earth, is sometimes contagious (or communicable from person to person) and sometimes not contagious. I believe the contagious nature of the disease depends: first, upon the number accumulated in one place, and the unhealthiness or ill-ventilated state of that place; or, in other words, upon the degree in which the miasma is condensed; secondly, upon the length of time a person remains exposed to the poison; third, upon the debility, or morbid irritability, and consequent susceptibility of the person’s frame, especially of the abdominal viscera.” The miasmata of an apartment, to be strong enough to become contagious, must arrive at a certain degree of concentration.

Cholera was, at all events, very different from typhus fever in the point of contagiousness: for in the epidemics of the latter many medical men fell victims, and the susceptibility to contagion was greater in proportion to the health and vigour of those who mixed with the sick.

It was well understood in 1832 that foul linen, bedding and clothes were a most certain means of carrying the poison, especially if they had been kept concealed for a time, or packed away in a chest or bundle. This was precisely the old experience of plague. The theory that the poison of cholera was conveyed in the drinking-water, of which illustrations were collected in 1849 and 1854, was not applied to any of the particular outbreaks in 1832. But one writer made a guess at it, assuming, as Snow did in 1849 and 1854, that the stomach and bowels were the organs by which the virus entered the system:

“From an attentive observation of the course this epidemic has taken in those places and countries which it has hitherto visited, I have been induced to draw the conclusion that a noxious matter or poison, being generated in the earth, has been diffused in the different springs in such situations [therefore he suggests the filtering of water through charcoal], and that this matter, being conveyed into the stomach with the fluid in question, produces that train of symptoms which, commencing in this organ, afterwards extends with more or less rapidity to the rest of the body[1537].”

In the treatment of cholera in 1832 many things were tried. The view taken of the pathology naturally determined the means of cure. To check the premonitory diarrhoea was seen to be of the first importance, and to that end laudanum or other form of opium was the familiar means. Lawrie, at Glasgow, found it most satisfactory, at a time when the profession in London were, as he says, denouncing it as a pernicious error. Towards the end of the epidemic in Dublin, Graves combined with the opium acetate of lead in large doses (a scruple of acetate of lead with a grain of opium, divided into twelve pills, one to be given every half-hour until the rice-water evacuations from the stomach and bowels began to diminish)[1538]. Some professed to find great benefit from blood-letting at a sufficiently early stage in the attack[1539]. The enormous drain of the fluids, leaving the blood thick or tarry, suggested to some that saline substances would be beneficial. The saline treatment was indeed the principal subject of writing during the year 1832. One way was to give saline drugs by the mouth; another way was to inject into a vein a large quantity of distilled water with some common salt and bicarbonate of soda dissolved in it, the vein at the bend of the elbow being usually chosen to operate on. Some were confident that they had saved lives in this manner, others were equally clear that salines were useless. One writer had abandoned salines by the mouth as a “most useless remedy,” while he had not lost faith in their intravenous injection, four having recovered out of twenty-three in which he had tried it. At length, however, the intravenous use of salines was abandoned also[1540].

It is well known that the greatest of all the lessons taught by cholera was the need of sanitary reform. The disease in its successive visitations so obviously sought out the spots of ground most befouled with excremental and other filth as to bring home to everyone the dangers of the casual disposal of town refuse. It was not until some years after the first visit of cholera that much was done in the way of extending the main drainage of towns, connecting the house-drainage systematically therewith, getting rid of open nuisances in back yards, and protecting the water-supplies from contamination. The Report of the Health of Towns Commission, 1844, was “the great magazine from which sanitary reformers drew their weapons[1541].” In the next few years an active school of sanitarians arose, including Sutherland of Liverpool, Grainger of London, and others. In 1848 was passed the first Public Health Act, administered by a Board of Health, of which Lord Shaftesbury was chairman, Chadwick and Southwood Smith members. London was excepted from the scope of the Act; but the City had a most vigorous medical officer in the person of John Simon, whose reports dealt with public sanitation on broad principles applicable to the capital and the whole kingdom. The movement in favour of sanitation, thus begun, received an irresistible impulse from the cholera of 1849, the lessons of which were as obvious as those of 1832.

The cholera which reached Orenburg in 1829 and Astrakhan in 1830 lingered in one part of Europe or another until 1837, Portugal and Spain having been its chief theatre in 1833, the south of France in 1834, Italy in 1835 and 1836, Austria, the Tyrol, Bavaria and (for the second time) Poland and the Baltic ports in 1837. In England, there was some revival of the seeds of it in 1833, as many as 1454 deaths being put down to Asiatic cholera in London from the 1st of August to the 7th of September. There was an undoubted epidemic of it at the fishing village of Ferryden, near Montrose, in June, 1833 (27 deaths during four weeks in a population of 700), the infection having been brought by one or more of the crew of the smack ‘Eagle’ from the Thames[1542]. In Glasgow a case occurred in Boar Head Close, High Street, on 30 May, 1833, which had the blueness, pinched face, whispering voice and cold clammy skin of Asiatic cholera[1543]. In Ireland there were a good many outbreaks in 1833, especially in villages or hamlets, and it is believed that these were renewed in 1834. But the most singular reappearance of cholera in the British Isles was in the month of December, 1837, some two months after it is believed to have ceased elsewhere in Europe. Outbreaks of true cholera in that month were observed at several places in the south of Ireland-around Bere Haven[1544], at Youghal, at Waterford, and at Dungarvan, where they went so far as to form a board of health[1545]. It was suspected to have been in Limehouse, on the Thames, in November. The most remarkable explosion of it was in the month of January following (1838) among the inmates of the Coventry House of Industry, of whom no fewer than 55 died in the course of four weeks--a mortality from choleraic disease that could hardly be explained on the hypothesis of cholera nostras even if the season had been the proper one[1546].

The Cholera of 1848-49 in Scotland.

The invasion of cholera from India, which reached Britain in the autumn of 1848, had progressed as far as Peshawur and Cabul from 1842 to 1844, and thereafter step by step continuously through Herat, Samarkand, Bokhara, Astrabad and Teheran by the caravan routes. In the beginning of 1847 it entered Russia by the two great interior waterways of the Volga and the Don. Next year, 1848, it reached the German shores of the Baltic and North Seas, and within a few weeks of its appearance at Hamburg, it was found established on British soil at Edinburgh and Leith in the beginning of October. The severe outburst which followed in the south of Scotland was purely a winter epidemic, like that of Durham, Northumberland and East Lothian on the last occasion in the winter of 1831-32. It will not be necessary to give the details of the cholera of 1848-49 so fully as has been done for 1831-32, but merely to notice special points.

The cholera of 1848 broke out almost simultaneously at Newhaven and Edinburgh, on the 1st and 2nd of October, and at Leith on the 9th. At Newhaven nearly the whole population was suffering from diarrhoea, in the midst of which epidemic the true cholera raged for four weeks only, to the 28th October, attacking 30, of whom 20 died. In Leith the deaths were 185 (males 75, females 110). The Edinburgh outbreak lasted until the 18th of January, 1849, causing 801 attacks, with 448 deaths (or 478 deaths, of which 196 were males and 282 females). A cholera hospital was opened in Surgeons’ Square on the 28th of October, the admissions and fatalities to 14th December being as follows:

Females Males Total

Admitted 152 96 248 Died 90 64 154

Of the whole 248 cases, the Grassmarket sent 42, the Cowgate 37, the Canongate 33, College Wynd 16, High Street 14, and numerous scattered localities of the New and Old towns one or more cases each. Severe outbreaks took place also at Niddry, Restalrig and Loanhead, villages close to Edinburgh[1547]. While this limited epidemic was proceeding in and around the capital, the infection appeared in the mining region of Carron at the head of the Firth of Forth, where there were some 400 cases after the 6th of December, and in some other mining villages of the Scotch midlands.

Glasgow was infected on the night of the 11th November, in the suburban district of Springburn, on the north-west of the city close to the Forth and Clyde Canal. The choice of this spot to begin upon was intelligible enough in one way, but singular in another. Springburn had come into existence as a poor village of weavers about the year 1820; before the cholera year of 1832 it had grown to a population of 600, and was thought a likely spot for cholera inasmuch as it was one of the most wretched communities in Scotland. It occupied the site of a half-drained bog below the level of the canal, from which the water percolated into its subsoil; its houses were low, always damp, and full of filth. During all the cholera in Glasgow in 1832 there had not been a case in Springburn until the 6th of September, when a girl of the village came home with it and died; during her brief illness she was visited by the greater part of the villagers, but no other case occurred until six weeks after, on the 15th of October[1548]. At this spot, where the cholera of 1832 may be said to have left off, it began in 1848 with a sudden explosion of numerous attacks scattered all over the locality; a doctor attended twenty-one cases before he found two together in the same house or even in the same lane. There had been forty cases there in November, before any case was discovered in Glasgow; at length it seemed to spread from Springburn all round as if from a centre, while it also lingered there longer than anywhere else in the city and suburbs[1549]. On the 5th of December a case was reported on the south bank of the Clyde, and another on the 9th in the west end. Within a few days the disease fell upon all parts of the city with the suddenness of a thunder shower; it reached a height in the Christmas week, one day, the 30th December, having 158 burials from cholera. After the orgies of the New Year there was a fresh outburst, 235 cases having been reported on the 5th of January. The proportion of fatalities was as high as 60 per cent. at the beginning of the epidemic, 50 per cent. about Christmas and the New Year, and thereafter from 30 to 40 per cent. The epidemic was short and sharp, declining irregularly after the first or second week of January, and ceasing, but for a few dropping cases, about the 8th of March.

The deaths in Glasgow, which included many among the wealthier class and made the festival season of 1848-49 to be long remembered, were about 3800, or 1·06 per cent. of the population (355,800), a higher total but a lower ratio than in 1832, when the deaths, distributed over many more weeks of the year and largely due to two revivals in August and October, were 1·4 per cent. of the population. At Paisley there were 68 deaths from 26 December to 24 February, and at Charlestown 115 deaths all in some five weeks from 15 January to 19 February.

It was in the same season of midwinter that the cholera burst suddenly upon many mining villages of Lanarkshire and Ayrshire.

In that unlikely season there was an almost universal prevalence of diarrhoea. At the mining village of Carnbroe, near Coatbridge, there were five sudden attacks on the last night of the old year, one of them fatal. On New Year’s day there were forty attacks, thirteen of them fatal in a few hours. Terror seized the whole place: one man cut his throat in sheer fright. Diarrhoea attacked 1100 of the 1200 inhabitants, and turned to spasmodic or rice-water cholera in 240 of them, of whom 94 died, the rate of fatality being excessive only in the first few days. By the end of February the epidemic was over.

In the town of Coatbridge, with a population of 4000, the various grades of sickness were classified as follows:

Vomiting, purging and Rice-water Deaths by Diarrhoea cramp purging Cholera Cholera

2659 480 175 107 61

In the town of Hamilton, population 9000, the infection was most malignant, 440 cases yielding 251 deaths from the 24th of December to the 7th of March. The same ravages of winter cholera occurred at some of the Ayrshire ironworks, such as Glengarnock, among a very rough and drunken class, who were made more than ordinarily reckless and drunken by this unaccountable visitation. It was also severe in Riccarton and other mining villages round Kilmarnock, but less prevalent in that town itself. Dumfries and Maxwelltown, which had been among the last places visited by the cholera of 1832, were infected in the middle of November, 1848, about the same time as Springburn near Glasgow. One of the Dumfries doctors died of rapid cholera on the 10th December, the parochial board fell into disputes with the faculty, and the infection proceeded amidst great confusion in the poorest parts of the town, causing about 250 deaths before Christmas. After that it subsided quickly[1550].

The other centres in the south of Scotland were Selkirk (13 deaths), Kelso (Dec. to end of Jan., maximum of 12 attacks in a day) and Jedburgh, which last had escaped in 1832 but had now a very rapid and extensive epidemic in its lower parts among drunken people especially. A few cases occurred at Moffat, in December; a man who was seized in crossing the hills died in a shepherd’s hut eight miles from Moffat after twenty-one hours illness[1551].

The only recorded epidemic in the north of Scotland in the proper cholera season, the summer of 1849, was at Dundee. But there was a small outbreak in March and April at Campbelton (41 cases, 14 deaths) and Inverness (23 cases, 12 deaths)[1552].

The infection began in Dundee on the 29th of May, 1849, in Fish Street, the filthiest part of the town. It prevailed in high and low situations, but usually in the old localities of typhus fever. One group of houses, said to have had a population of 100, had 40 deaths. Dudhope Crescent, consisting of seventeen large five-storied tenement houses occupied by clean and respectable people, had 57 deaths. In about a fourth part of all the fatalities, death was from sudden collapse; this was a feature of the 1849 cholera also in Ireland; but in Dundee, as elsewhere, there was usually premonitory diarrhoea, and a very general prevalence of diarrhoea which never came to true cholera[1553].

The Cholera of 1849 in Ireland.

The cholera of 1849 found Ireland in a state of exhaustion and confusion. The fever and dysentery that followed the great potato famines of 1845 and 1846 were still far from extinct; the workhouses, which had not existed in 1832, were full of paupers. The mortality of nearly half a million in the famine years, and the emigration of perhaps three times as many, had reduced greatly the population of the scattered cabins, hamlets and villages; but the towns were more populous than ever from the immense number of destitute persons that had gravitated to them. In these circumstances it was not surprising that the cholera of 1849 should have been more disastrous than that of 1832. The infection appeared first in Belfast in November, 1848, in a man who had come with his family from Edinburgh and had been admitted into the workhouse. Some thirty cases of cholera among the inmates followed his death, and at length the infection was started at large in the town, probably by a man who had been discharged from the workhouse[1554]. The cholera of 1849 in the capital of Ulster was more fatal than that of 1832, causing 969 deaths in 2705 attacks. Over Ireland generally its great season appears to have been, as in England, the summer, and in part also the spring. Excepting Belfast, the principal cities and towns had fewer deaths than in 1832; Dublin having only 1664 as compared with 5632, Cork 1329, or nearly the same number as in 1832, Limerick 746, which was about a fourth less, Galway less, Waterford about the same as in 1832 and 1833 together, and Drogheda as severe an epidemic as last time. But the smaller towns and the rural districts generally suffered more. The deaths for all Ireland returned to the Board of Health were 19,325, nearly the same total as in 1832; but there were no returns included from Wicklow, Cavan, Fermanagh and Donegal, and it is probable that the returns were otherwise incomplete, the census taken in 1851 giving 30,156 cholera deaths under the year 1849, and 35,989 in the whole decennial period from 1841. The larger total was distributed as follows:

Urban Rural In hospitals In workhouses

10,653 10,656 7964 6716

The number of rural deaths is much larger than in 1832. There were only a few towns with over 2000 inhabitants that escaped--one in Connaught, six in Munster, one out of forty-one in Leinster, while seventeen towns were visited in Ulster. The counties of Dublin, Carlow, Clare and Galway suffered most; of the smaller towns, Tralee and Dingle lost heavily, both among the poor and the rich. The town of Ballinasloe, near the confluence of the Suck with the Shannon, had 756 deaths from 23 April to 19 August, a great part of them in the workhouse. In clinical characters, the cholera of 1849 was noted in Ireland, as in Scotland and England, for the high proportion of sudden fatalities, about one-third, without the warnings of diarrhoea or the usual choleraic symptoms. It was remarked also that many children under the age of seven died of cholera, about one in ten of all ages. There was a second season in 1850, with 1768 deaths (according to the census), but hardly comparable to the return of cholera in 1833 in the country districts more particularly.

The Cholera of 1849 in England.

The brief but very severe epidemic of cholera in the south of Scotland in midwinter was all over and done with for good before the disease really began in England. Hull, which had a few cases on board ship in the end of 1848, about the same time as the infection began to rage in Edinburgh and Leith, was spared its great visitation, the greatest in all England, until the late summer and autumn[1555]. The progress of the infection in London also was strangely different from that in Scotland. There were undoubted cases in Bethnal Green and other out-parishes in the autumn of 1848, and there seemed no reason why the infection should not run through the population and exhaust itself at once, as in Glasgow. But it will appear from the following table of the deaths in London that the real outburst was delayed until the summer and autumn of 1849:

Cholera deaths

1848 Sept. 11 Oct. 122 Nov. 215 Dec. 131

1849 Jan. 262 Feb. 181 March 73 April 9 May 13 June 246 July 1952 Aug. 4251 Sept. 6644 Oct. 464 Nov. 27

Although a certain number of deaths were returned in October and November, 1848, they came in twos or threes from many parishes of the metropolis and made no great impression upon any one locality. It was not until the beginning of December that the presence of cholera was fully realized, owing to an extraordinary explosion of the disease in a huge pauper institution at Tooting. The school contained about a thousand children, of whom some three hundred took Asiatic cholera, with one hundred and eighty deaths, in the course of three or four weeks: this was the whole cholera mortality that the parish of Streatham had from first to last. In the spring months the cases declined all over London in a very remarkable way, so that it looked for a time as if the infection were extinct, just as in 1832. But in June there was a revival, and thereafter a steady increase to the maximum of 6644 deaths in September. The table given under the year 1866 shows upon what parishes the mortality fell most--those of Southwark, Bermondsey, Rotherhithe, Greenwich, Newington, Lambeth and Battersea on the south side, of Westminster, the City and Liberties, Shoreditch, Bethnal Green and Whitechapel on the north side of the Thames. It was a more severe visitation per head of the inhabitants than that of 1832, cutting off many beyond the limits of the destitute and reckless class who were its most usual victims on the first occasion. Many of the respectable class of workmen and small shopkeepers were among the victims. Several medical men died of it, including one well-known surgeon, Mr Aston Key, at his house in St Helen’s Place, Bishopsgate, on 23 August, after a few hours’ illness. As in Ireland, and at Dundee, an unusually large proportion of the London deaths, perhaps a fourth part, were from sudden collapse and blueness, without premonitory diarrhoea or predominant intestinal symptoms. Opinion was strongly against contagiousness in this epidemic. There were 478 cases treated in St Bartholomew’s Hospital, but not one of the nurses took cholera.

The infection seemed to find out the insanitary spots and to act miasmatically upon the residents. The common remark in all parts of England, Scotland and Ireland was that the localities that suffered most from the typhus fever of 1847-48 suffered most also from cholera. The one black spot in Kensington was a poor district on the north side of the parish known as the Potteries, where an immense number of pigs were kept.

One of the most remarkable features of the cholera-seasons of 1848-49 was the extensive prevalence of common bowel-complaints. Evidence of this has been given for the south of Scotland just before or during the cholera of midwinter, a season when diarrhoea is not usual. It was equally remarked in England in the course of 1849. In the Taunton workhouse, where true Asiatic cholera broke out in November, there had been many cases of bowel-complaint, as well as of fever, in the spring (7 deaths from dysentery and diarrhoea, 5 from fever). In the Exeter workhouse there were eighteen deaths from dysentery in the end of the year, although there is nothing said of cholera, which caused only 44 deaths in the whole city. The efforts of the inspectors sent by the Board of Health were in great

## part directed to finding out the cases of “premonitory” diarrhoea, by

house-to-house visitation, and insisting upon the importance of checking it before it could turn to true cholera. Leeds will serve as an example of English towns. In an incomplete survey after the month of July there were found 5129 cases of simple diarrhoea, 1484 cases of dysentery, 1273 cases of choleraic diarrhoea, and 1090 cases of true cholera[1556]. It was something of a paradox that, with such excessive prevalence of ordinary bowel-complaints, an unusual proportion of the cases of true cholera proved quickly fatal with symptoms of collapse and asphyxia only.

Just as the first startling indication of the presence of Asiatic cholera in London was the enormous fatality in the pauper school at Tooting in the winter, so in some other towns the infection seemed to pick out workhouses or prisons to begin upon. At Belfast there were forty cases in the workhouse before there was one in the town. At Liverpool there were 28 cholera deaths in the first quarter of 1849, of which 8 were in the workhouse. At Wakefield, 19 died of cholera in January, 16 of these in the House of Correction. Among the people at large the infection made little progress until the summer. In the first and second quarters of the year it is heard of, but to a moderate extent, in the towns and colliery districts of Durham and Northumberland, which were the scene of its earliest outbreak in the winter of 1831-32. It was also beginning in the poorest and filthiest parts of Liverpool, Bristol and Plymouth. Its great season all over England was July, August and September, the incidence of the disease according to counties being shown in the table. The right-hand column, showing the number of deaths at the principal centres in each county, must serve for a conspectus of the epidemic.

_Cholera Mortality in England and Wales in 1849._

Death-rate per 1000 Deaths inhab. Principal centres in each county

England and Wales 53293 3·0 London 14137 6·2 Lambeth 1618, Newington 907, Bermondsey 734, Southwark 1704 Surrey, part of 255 1·3 Kent, part of 1208 2·5 Gravesend, Milton, Rochester, Chatham, Margate, Ramsgate, Maidstone Sussex 346 1·1 Hastings Hampshire 1245 3·2 Portsmouth 568, Southampton 240 Berkshire 148 ·8 Middlesex 406 2·7 Edmonton, Barnet Hertfordshire 323 1·9 Hitchin 127, Hertford 81, Watford 45 Buckinghamshire 175 1·2 Marlow, Wycombe 100 Oxfordshire 117 ·7 Oxford 44, Witney 33 Northamptonshire 141 ·7 Northampton 49, Peterborough 49 Huntingdonshire 14 ·2 Bedfordshire 72 ·6 Bedford 37, Biggleswade 28 Cambridgeshire 269 1·4 Wisbech 138, North Witchford 85 Essex 580 1·7 West Ham 134, Romford 163, Rochford 105, Harwich Suffolk 79 ·2 Ipswich 18, Mutford 27 Norfolk 223 ·5 Yarmouth 87, Norwich 38 Wiltshire 320 1·3 Salisbury 165, Devizes 67 Dorset 122 ·7 Weymouth 59, Poole 31 Devon 2366 4·2 Plymouth 830, Stonehouse 171, Stoke Damerel 721, Plympton St Mary 151, Tavistock 140, Totnes 107 Cornwall 835 2·4 St Germans 236, Liskeard 132, St Austell 135, Redruth 133 Somerset 923 2 Bridgewater 235, Keynsham 77, Bath 90, Bedminster 281 Gloucestershire 1465 3·5 Bristol 591, Tewkesbury 59, Gloucester 119, Clifton 563, Dursley 58 Herefordshire 1 ·01 Shropshire 316 1·3 Bridgnorth 75, Shrewsbury 116 Staffordshire 2672 4·4 Newcastle-under-Lyme 241, Wolverhampton (incl. Bilston, Tipton, Sedgley) 1365, Stoke 103, W. Bromwich 250, Dudley 412, Walsall 186 Worcestershire 432 1·7 Stourbridge 314 Warwickshire 293 ·6 Coventry 202, Birmingham 29, Warwick 20 Leicestershire 8 ·08 Loughborough 7, Leicester 2 Rutlandshire 7 ·4 Lincolnshire 372 ·9 Gainsborough 246, Boston 35, Grimsby 29 Nottinghamshire 137 ·5 East Retford 21, Basford 42, Nottingham 18 Derbyshire 50 ·06 Derby 18 Cheshire 653 1·6 Nantwich 181, Runcorn 82, Stockport 72, Birkenhead 139 Lancashire 8184 4·1 Liverpool and W. Derby 5308, Wigan 503, Manchester 878, Chorlton 280, Salford 237 West Riding 4151 3·2 Huddersfield 52, Bradford 426, Hunslet 884, Dewsbury 224, Wakefield 241, Pontefract &c. 238, Leeds 1439 East Riding 2140 8·7 Hull and Sculcoates 1834, York 174, Pocklington 37, Howden 58 North Riding 47 ·2 Whitby 10 Durham 1642 4·2 Darlington 4, Stockton 248, Durham 192, Hartlepool, Chester-le-Street 134, Sunderland 363, Gateshead 257, S. Shields 201 Northumberland 1417 4·8 Newcastle 295, Tynemouth 815, Alnwick 142 Cumberland 419 2·2 Carlisle 51, Cockermouth 282, Whitehaven 79 Westmoreland 1 ·02 Monmouth 775 4·1 Newport 246, Pontypool 69, Abergavenny 438 S. Wales 3544 6·1 Merthyr Tydvil 1682, Cardiff 396, Neath 738, Llanelly 45, Swansea 262, Carmarthen 142, Crickhowell 95 N. Wales 245 ·6 Holywell 86, Montgomery 37, Carnarvon 21

The highest rates in the table are for the East Riding, owing to Hull (24·1), for South Wales, owing to Merthyr Tydvil (23·4), for Northumberland and Durham, for Staffordshire, owing to the iron district round Wolverhampton, for Devonshire, owing to Plymouth, for Lancashire, owing to Liverpool, and for Monmouth, owing to a few mining places. The miners suffered most, the lower class in the seaports next most severely. The Black Country in the south of Staffordshire, which had been the worst centre of the 1832 cholera, was again one of its chief centres in 1849, the mortality falling most, as before, upon the town of Bilston, and next to it upon Willenhall and Wolverhampton. But a great rival to the Staffordshire coal and iron mining had sprung up since 1832 in Glamorgan; and it was in this comparatively new region of miners that cholera in 1849 reproduced the Black Country horrors of 1832 and, indeed, surpassed them.

Merthyr Tydvil had sprung up more like a vast miners’ camp than like a well-ordered municipality. Along the eastern side of the Taff valley, on the slopes and in bottoms of the hills, but everywhere at an elevation of some four or five hundred feet above the level of Cardiff docks, were numerous groups of mean-looking miners’ cottages, with their attendant ale-houses, small retail shops, schools and meeting-houses. This peculiar township had drawn to itself the special notice of the Health of Towns Commission in 1844: “From the poorer inhabitants (who constitute the mass of the population) throwing all slops and refuse into the nearest open gutter before their houses, from the impeded course of such channels, and the scarcity of privies, some parts of the town are complete networks of filth emitting noxious exhalations.... During the rapid increase of the town no attention seems to have been paid to its drainage.”

In this district the registrar had returned 162 deaths from “cholera” in the year 1841, which must have been from an unusually severe type of cholera nostras or British cholera. A first case of Asiatic cholera occurred at Cardiff in a sailor on the 13th of May, 1849, a week after there was a case at Lower Merthyr, and a week after that another at Upper Merthyr. In the course of the summer the ravages of the disease were enormous in the hilly mining regions of the interior of Glamorgan and Monmouth, as well as severe in the seaports:

Merthyr Tydvil 1682 Cardiff 396 Neath 738 Swansea 262 Abergavenny district 438 Pontypool 69 Newport 246

The peculiar selection of the mining townships was well shown in the district of Abergavenny: of 378 deaths from cholera in the third quarter of 1849, only 9 occurred in Abergavenny town, while 157 were at the iron-works of Tredegar and 210 at those of Aberystruth, just as, in the winter preceding, the villages of the iron-works all round Kilmarnock had been ravaged by cholera while there was little of it in that town itself.

Another chief centre of cholera in 1849 was the port of Hull. Including the district of Sculcoates, it had the following enormous mortalities from cholera in four weeks of September: 398, 507, 524 and 171, the whole epidemic from July to the 18th of October producing 2534 deaths[1557]. Its neglect of scavenging became a classical instance of the favouring conditions of cholera. An open space at Witham called the “muckgarths,” from the refuse deposited upon it, was one of the worst centres, just as the town moor of Sunderland, used for the same purpose, had been in 1831[1558]. In the other ports, Liverpool, with West Derby, Bristol with Clifton, and Plymouth with East Stonehouse and Devonport, the infection was most severe (see Table), and was observed to choose the poorest streets, lanes and houses, where there had been most typhus for a year or two before[1559]. On the Tyne, the greatest centre on this occasion was not Newcastle, but Tynemouth. The city of Durham, which escaped the cholera of 1832, had a severe visitation. The chief inland centres, besides the mining districts of Staffordshire and Glamorgan, were Manchester and the cloth-making towns of Airedale,--Leeds, Hunslet, Bradford, Dewsbury, and some others in the West Riding. Most of the Lancashire towns occupied with the cotton industry again escaped with little cholera--Preston, Clitheroe, Oldham, Bury, Rochdale, Bolton, Blackburn, Ashton and Chorley. Wigan had nearly twenty times as many deaths as in 1832; on the other hand Sheffield had only a quarter of its former cholera mortality, while Nottingham and Norwich had this time very little. Birmingham, Leicester, Cheltenham, Hereford, Stafford, Ipswich, Cambridge and Colchester were again almost or altogether free from infection. The agricultural counties, notably the Eastern counties, escaped once more with few centres of infection, and these unimportant. Cumberland as a whole had fewer deaths than in 1832, while Cockermouth had more. Exeter, which was severely visited on the former occasion, escaped almost wholly, while Totnes and Tavistock, with the surrounding Dartmoor country and other towns in Devon, had epidemics of the first degree for their size. In England as a whole the cholera of 1849 was more severe relatively to the numbers living than that of 1832, its great centres having been the same, or of the same kind, on both occasions[1560].

The cholera of 1849 reproduced very closely the former characteristics. The attacks were often in the night, especially in persons who had supped heartily on the coarser kinds of savoury meat. With the same undoubted preference for the poorer and more filthy quarters of towns, the infection showed also a certain apparent caprice in fixing on some places and avoiding others.

Thus at Leeds it was most malignant in the locality of York Street and Marsh Lane (an old centre of plague and typhus), which had lately been drained at a cost of some thousands of pounds, “whilst in the adjoining district, which lies nearly level with the river, and will scarcely admit of any sewerage, I have not heard,” writes the registrar, “of a single case of cholera”--an experience similar to that of a low-lying district of Bristol in 1832. At Liverpool, where much had been undertaken for sanitation since the disastrous Irish fever of 1847-48, the cholera appeared to Dr Duncan, the medical officer of health, to attack sewered and unsewered streets impartially. Another singular thing, which used to be noticed in the plague and is observed in the malarial fevers of towns abroad, was the choice of one side of a street only: thus, at Rotherhithe, in a street where numerous deaths occurred, they were nearly all one side of the street, in houses occupied by respectable private families, only one house having been infected on the other side; at Bedford, two streets showed the same thing.

In London, the least elevated parishes on both sides of the Thames were again its chief seats. Dr Farr, the superintendent of statistics, deduced the law that the death-rate from cholera in London was inversely as the altitude of the parish, and he showed, by a somewhat rough grouping of the cholera deaths, that the law applied to all England[1561]. An empirical generality such as that may have some value; but it is the exceptions to it that show the inward meaning of the fact.

Merthyr Tydvil, which was the worst cholera-spot in England with the possible exception of Hull, was five hundred feet above the level of Cardiff, its seaport, where the death-rate was much lower. Neath, also, had much more cholera than Swansea. Newcastle-under-Lyme, situated near the source of the Trent, and the highest town in the course of that river, had a far more severe visitation of cholera than any other town upon it all the way to its mouth. At Tavistock among the Dartmoor hills, cholera “sat for many a week,” as Kingsley says, “amid the dull brown haze, and sunburnt bents and dried-up watercourses, of white dusty granite.” But the poorer and more populous part of Tavistock was a somewhat peculiarly shut-in basin, which was “very often involved in fog during the night.” The town had escaped cholera in 1832, but one of its physicians, writing in 1841, and recalling its dreadful plague of 1626, did not feel sure that it would escape if cholera came back[1562]. Again, one thinks of Salisbury as standing among high downs; but it had a wet subsoil, bad sewerage, and bad water supply, and in 1849 it had 200 deaths from cholera among all classes in two months[1563].

In the not very extensive outbreak at Sheffield, one of its chosen seats was an elevated district called the Park, inhabited by colliers. At Bedlington colliery, near Morpeth, the cholera deaths in November were in the miners’ houses on the hill side. The elevated, airy and clean village of Loanhead, near Edinburgh, had 46 deaths in its population of 1200, during a few weeks of midwinter. In Dundee, built upon a steep slope at the waterside, there were bad centres of cholera in the higher parts as well as in the lower.

The determining thing appears to have been not so much the elevation as the configuration of the ground; any basin, or cup, or shelving terrace, any natural collecting-ground of moisture and organic refuse in the soil, may become a seat of cholera, whether it be at the sea-level or several hundred feet above it, provided it have a sufficient number of human occupants and a mode of drainage inadequate to its peculiar needs. Such was the situation of Merthyr Tydvil, of Neath, of Newcastle-under-Lyme, of Tavistock, of some colliery villages, and of certain localities in towns such as Dundee. Such, of course, was also the situation of the London parishes next the river on the south and east, of Hull, of Plymouth, of Liverpool, and of other seaports on estuaries. Neither altitude nor configuration means anything for cholera unless the ground itself be full of rotting filth. In all England and Scotland the cholera chose, as if by an unerring instinct, those not very extensive mining parts of the counties of Stafford, Glamorgan, Durham, Lanark and Ayr, which had as many hundreds of inhabitants to the square mile, and as little provision for the safe disposal of their excrements, as those village communities of Lower Bengal in which the infection had become established since 1817 as if it were an annual product of the soil.

The Report of the Board of Health brought to light many instances in which it seemed probable that cholera had been favoured, if not induced, by the water of wells contaminated with organic filth soaking through the ground or entering with the surface water. This was especially the case at Merthyr Tydvil. It was during the next cholera, that of 1854, that the question of contaminated water came into great prominence, in connexion both with wells and with the vast volumes of water supplied through the mains of water companies.

The Cholera of 1853 at Newcastle and Gateshead.

The third visitation of Great Britain and Ireland by Asiatic Cholera was in 1853-54. There had been none of it in any part of the kingdom since 1850; but it is not so clear that all other European countries, especially Poland, were equally free from it. Whether due to a new approach from Asia, or to a rekindling of smouldering fires, cholera appeared in the Baltic ports in the summer of 1853, and soon after reached the Tyne. For the third time a severe but localized epidemic was the prelude--this time at Newcastle and Gateshead, just as in 1848 at Edinburgh, Glasgow and the south of Scotland, and in 1831 at Sunderland and Newcastle.

In the cholera of 1849, which was the most general and the most severe visitation that England has had, Newcastle escaped with a light visitation and Gateshead with a moderate or average one, while Tynemouth (with North Shields) had about twice as many deaths as Newcastle and Gateshead together (12·9 deaths per 1000 inhabitants). In 1853 it was the turn of Newcastle--for no better reason, perhaps, than its escape last time. The very thorough and masterly inquiry by Messrs Simon, Bateman and Hume did, indeed, reveal a most unwholesome state of things; but the town was no worse or only a little worse than in 1849, when the cholera had dealt lightly with it, and it was probably an average sample of the insanitary condition of the greater English industrial towns in the time of their rapid growth and before the period of well-ordered local government had arrived. In some parts, such as Sandgate, the dwellings of the labouring class were “not fit to live in”; in the newer mean suburbs, it was found, as in Glasgow twenty years before, that cellars had become the dwelling-places of a class who in former times lived above ground. Those who had been dispossessed by the railways and other public structures had not been provided for elsewhere; so that, with more trade and better wages, the working class were worse housed than before. Overcrowding, for which the ports on the Tyne and Wear are still pre-eminent, was then most excessive. Only the better-class houses had the water laid on. Excremental offences to sight and smell were everywhere. There was a system of main sewers, passably good; but house-drainage or connexions with the main drains were quite casual. The scavenging of the town was greatly neglected. Piggeries, slaughter-houses and other such nuisances, were uncontrolled. The burial-grounds were over-full. With all this the death-rate of Newcastle could be low enough in a good year, such as 1844, when it was 20·9 per 1000; in the year of the Irish fever, 1847, it rose to 32·8; and in other years it fluctuated between those extremes, according to the nature of the seasons[1564].

The cholera of 1853 was a sudden explosion in the heavy stagnant atmosphere of the month of September. No one knew where the infection came from; there were, of course, ships arriving from the Baltic, but no

## particular source was ever traced. On the 30th or 31st of August, a case

occurred of the rapidly fatal kind; before a week there were about a hundred attacks daily all over the town. From the 13th of September the deaths in Newcastle mounted up rapidly as follows:

Cholera deaths

Sept. 13 59 14 90 15 106 16 114 17 103 18 103 19 111 20 85 21 68 22 82 23 60 24 56

In the thirty days of September there were 1371 deaths, and some one or two hundreds more in the first part of October, when the infection ceased almost abruptly, the total of deaths to the 4th of November having been 1533. During the same time Gateshead with a population of 26,000, had 433 deaths, or in a ratio nearly equal to that of Newcastle. On the other hand Tynemouth, with a population of 30,000, had only twelve deaths, several of them in vagrants or other arrivals from Newcastle, the rest in a cluster of pitmen’s cottages on the outskirts of North Shields.

It was freely rumoured at the time, and was even repeated with much unction in so dry and deliberate a work as the report of the Registrar-General, that the cholera at Newcastle and Gateshead in September, 1853, was owing to the sudden contamination of the town’s water with sewage. The facts about the water-supply are as follows: Previous to 1848, Newcastle was supplied with Tyne water pumped up at Elswick, and passed through the settling tanks and filtering beds. In 1848 the Whittle Dean Water Company, incorporated in 1845, had their new supply ready, and the old company, with its pumping station at Elswick, was superseded. The new supply was collected from landward sources, and was apt to be peaty. There was a great demand upon it, especially for public works (it was supplied to comparatively few houses), so that the distribution in 1853 had increased 2½ times since the company began in 1848. They had extended their collecting area to meet this demand; but, owing probably to the drought, they found it necessary on the 6th of July, 1853, to resort to the old pumping-station at Elswick for about a third part of all the water that flowed daily through the mains. This had gone on for eight weeks before the epidemic began, and was promptly discontinued on 15 September, as soon as the possible danger from Tyne water was realized. The pumping-station was higher up the river than the only one of the Newcastle sewers that discharged in its vicinity. There were complaints about the water, but these appear to have been chiefly of the peaty colour or flavour, which came from the Whittle Dean part of the mixture. The water from the mains was not equally bad at all points, as if the suspected contamination might have occurred in its transit through the town. Also the water of some wells was complained of as offensive at the same time, which was the season of the year when the springs are lowest. Gateshead was also supplied by the mains of the Whittle Dean Company. It is clear from the report of the Commissioners that they considered the water of Newcastle and Gateshead to have been a very subordinate factor, if a factor at all, in the epidemic of cholera.

The Cholera of 1854 in England.

The great epidemic at Newcastle and Gateshead was over by November, 1853, those towns having no share in the general epidemic in England in 1854, although it visited their near neighbour Tynemouth. The interest of the cholera of 1854 centres chiefly in London[1565]. Few of the great foci of infection in 1849 were visited severely. Liverpool, which never escaped, had a moderate epidemic, Merthyr Tydvil also had about a fourth part of its 1849 mortality, Dudley had the disease somewhat severely, while some towns, such as Norwich, Wisbech and Sheffield, had more than usual. But Plymouth, Hull, Bristol, Manchester, Leeds, the towns of the Black Country and nearly all the populous places that had suffered heavily either in 1832 or in 1849, or on both occasions, escaped in 1854 with little cholera or none[1566]. The table shows the incidence of the epidemic (as well as that of 1866) according to counties.

_Cholera Mortality in England and Wales in 1854 and 1866._

1854 1866 Rate Rate per per Deaths 1000 Deaths 1000

England and Wales 20097 14378 ----------------------------------------------- London 10738 4·3 5596 1·9 Surrey, part of 252 1·2 82 Kent, part of 1056 2·1 284 Sussex 94 ·3 79 Hampshire 130 ·3 417 ·9 Berkshire 49 ·2 3 Middlesex, part of 380 2·4 51 Hertfordshire 97 ·5 9 Buckinghamshire 68 ·5 10 Oxfordshire 183 1·0 4 Northamptonshire 152 ·7 7 Huntingdonshire 18 ·3 1 Bedfordshire 61 ·4 22 Cambridgeshire 270 1·3 7 Essex 513 1·4 471 1·0 Suffolk 67 ·2 15 Norfolk 381 ·8 15 Wiltshire 60 ·2 11 Dorset 45 ·2 6 Devon 188 ·3 525 ·9 Cornwall 24 ·06 21 Somerset 21 ·04 68 Gloucestershire 260 ·6 39 Herefordshire 1 ·01 2 Shropshire 13 ·05 17 Staffordshire 426 ·6 30 Worcestershire 103 ·4 36 Warwickshire 89 ·2 15 Leicestershire 14 ·06 3 Rutlandshire 9 ·08 -- Lincolnshire 134 ·3 48 Nottinghamshire 80 ·3 1 Derbyshire 17 ·06 20 Cheshire 141 ·3 391 Lancashire 1775 ·8 2600 1·0 West Riding 470 ·3 283 East Riding 70 ·3 54 North Riding 84 ·4 21 Durham[1567] 2·9 352 ·6 Northumberland[1568] 5·7 224 Cumberland 35 ·2 32 Westmoreland 1 ·02 1 Monmouth 18 ·1 204 South Wales 887 1·4 2033 2·9 North Wales 34 ·08 256

Principal centres in each county 1854 1866

England and Wales

London South of Thames, Eastern Eastern parishes 3691 parishes Surrey, part of Kent, part of Sussex Hampshire Portsea Island 20, Portsea Island 129, Southampton 48 Southampton 41 Berkshire Middlesex, part of Brentford 196 Hertfordshire Buckinghamshire Oxfordshire Northamptonshire Towcester 86 Huntingdonshire Bedfordshire Cambridgeshire Wisbech 176, Ely 46 Essex West Ham 124, Romford West Ham 389 113, Maldon 102 Suffolk Norfolk Norwich 193, Yarmouth 41 Wiltshire Dorset Devon Plymouth 59, Stonehouse Exeter and St Thomas 247, 15, Devonport 2, Newton Abbot 57, Bideford 46 Totnes 146 Cornwall Somerset Gloucestershire Bristol 76, Clifton 92, Gloucester 48 Herefordshire Shropshire Staffordshire Dudley 256, Wolverhampton 80

Worcestershire Worcester 45 Warwickshire Leicestershire Rutlandshire Lincolnshire Great Grimsby 68 Nottinghamshire Worksop 27, Nottingham 16 Derbyshire Cheshire Chester Lancashire Liverpool 1084, W. Derby Liverpool and W. Derby 206, Wigan 158 2122, Wigan 137

West Riding Sheffield 126, Dewsbury 66, Leeds 48 East Riding Hull 27 North Riding Whitby 33, Guisboro’ 30 Durham Stockton, Auckland, Durham Northumberland Newcastle 1431, Gateshead 525, Tynemouth 203 Cumberland Westmoreland Monmouth South Wales Merthyr Tydvil 455, Swansea 521, Neath 520, Cardiff 255, Neath 54, Llanelly 232, Merthyr Brecon 54 Tydvil 229 North Wales

The London cholera of 1854, like that of 1832 and of 1849, fell most upon the southern (Southwark etc.), eastern and southeastern parishes (Table, p. 858). But it fell somewhat unequally upon these; and for Southwark and Lambeth the water supply was seized upon as the thing that made the difference. There were two water companies in South London, the Lambeth company and the Southwark and Vauxhall company. The parish of Christ Church, Lambeth, chiefly supplied by the Lambeth company, had a death-rate from cholera in 1854 of only 0·43 per 1000 inhabitants; whereas the parish of St Saviour, supplied by the Southwark and Vauxhall company, had a death-rate of 2·27 per 1000. In 1849 there had been no such disparity between them, the death-rate of Christ Church being if anything the higher of the two. Now it happened that in the interval of the two epidemics of cholera the Lambeth company had removed their intake works from opposite Hungerford Market to Thames Ditton, whilst the Southwark and Vauxhall company still continued to draw their supply from the Thames near Vauxhall. Here was a fine instance of the logical method of difference. Farther, within the parish of Christ Church itself, it was sought to show that the cholera followed the lines of old water supplies, and did not follow the mains from Thames Ditton. After 1854 the Southwark and Vauxhall company also made their intake at Thames Ditton. According to the water-hypothesis of cholera, it is not surprising, as we shall duly find, that the whole of the South London parishes, which had been the chief seats of the cholera in 1832, 1849, and 1854, escaped in 1866 with a very slight visitation. Newcastle was another chosen instance of cholera distributed by the water mains; but, as we have seen, that was improbable. Another instance was Exeter: its water supply in 1832, when part of it had a disastrous epidemic of cholera, was taken from the Exe, and was impure; in 1849, when it had only a tenth part of its last cholera mortality, its water supply had been greatly improved; in 1854 it had 10 deaths; but in 1866, Exeter with the registration district of St Thomas had 247 deaths, and Totnes had 146,--for their size about the most severely visited towns in England.

In the London cholera of 1854 a very sudden and simultaneous explosion in the district of Soho attracted much notice[1569]. The district stands high, which did not save it from being the scene of the first outbreak in the great plague of 1665. In the subdistricts of St Anne, Golden Square and Berwick Street, with a population of 42,000, many of them well-to-do families, there were 537 deaths from cholera, a rate of 12·8 per 1000, contrasting with the rate of 6 per 1000 for all London. The attacks and fatalities were remarkably numerous for one or two days, falling at once thereafter to about a half. There was a pump in Broad Street, in the centre of this district, which was supposed to have dispersed cholera broadcast in its contaminated water; a death had occurred in Swain’s Lane, at the foot of Highgate Hill, of a person who had drank the water of the Broad Street pump. The whole incident was seized upon and worked up by Dr Snow, who had written a speculative essay in 1849 upon the probability of cholera being conveyed by water, according to the similar theory of Parkin in 1832[1570]. The Board of Health, having very full data before them of the Soho outbreak in all its aspects (including a whole biological treatise upon the organisms found in water), did not adopt Snow’s conclusion, although he had enthusiastic followers at the time, and has probably more now[1571]:

“In explanation of the remarkable intensity of this outbreak within very definite limits, it has been suggested by Dr Snow that the real cause of whatever was peculiar in the case lay in the general use of one particular well, situate at Broad Street in the middle of the district, and having (it was imagined) its waters contaminated by the rice-water evacuations of cholera patients. After careful inquiry we see no reason to adopt this belief. We do not find it established that the water was contaminated in the manner alleged; nor is there before us any sufficient evidence to show whether inhabitants of the district, drinking from that well, suffered in proportion more than other inhabitants of the district who drank from other sources.”

The Cholera of 1853-54 in Scotland and Ireland.

The cholera of 1853-54 in Scotland has not been so fully recorded as either of the two preceding epidemics. It is said to have caused about six thousand deaths, of which 3892 were in Glasgow alone, and a considerable part of the remainder in Edinburgh and Dundee. The infection began to appear in the end of September, having been derived probably from the dreadful explosion at Newcastle. A few early cases occurred at Dunse, in Berwickshire. On the 16th September, 1853, the old Cholera Hospital at Edinburgh, in Surgeons’ Square, was opened, but received only 45 cases until the beginning of June, 1854, when it was closed. In the autumn of 1854 the real epidemic began, the hospital being re-opened on 24th August, from which date until the 30th November the admissions were 198. These hospital figures indicate for Edinburgh a milder epidemic than that of the winter of 1848, which was itself milder than that of 1832. The cases came mostly from the very same localities of the old town as in 1848. There were 145 females to 97 males; the deaths were 117 in 243 cases admitted[1572].

The epidemic at Dundee was a late autumnal or winter one, in the end of 1853, and of great severity, the mortality having probably exceeded 500. The Glasgow epidemic had a course very nearly parallel to that of 1832, and quite unlike the extraordinary winter explosion of 1848-9. It began, indeed, in winter--about the 15th of December, 1853, and had caused 849 deaths to the 27th of February; there was a sharp rise of the mortality from the 13th to the 24th of March, the total deaths to that date being 1306. As in 1832, the infection appeared to die out in the late spring and early summer; but in June it revived and increased in virulence until August, after which it subsided gradually until November, the whole mortality having been 3892, or ·98 per cent. of the population, nearly the same ratio as in 1848-9, (1·06) and a lower ratio than in 1832 (1·4). The first part of the epidemic fell chiefly on the north and east of the city, the second part, in summer and autumn, was all over the city, as in 1832, and among all classes, as in the winter of 1848-49, but perhaps less disastrously in the best quarters of the city than the last had been. The cholera hospital received a comparatively small part of all the cases--600 of cholera, 253 of diarrhoea, the deaths being 306, or less than a tenth part of the whole mortality[1573].

It is probable that the mortalities in Scotland on this occasion, besides those in Glasgow, Edinburgh and Dundee, were neither so general nor so great as in 1832. One remarkable outbreak happened at the village of Symington, in Ayrshire: in a population of 240 there were 110 attacks and 30 deaths; nearly all the cases were in houses on one side of the village street, which got their water from a public well; the houses on the other side, having private wells (and differing, doubtless, in other respects), were notably free from the infection[1574].

The cholera of 1854 was unimportant in Ireland. Cases appeared among emigrants on board ships in Belfast Lough and at Queenstown in the end of 1853, but no diffusion took place until 1854, and then only to a moderate extent. It is supposed that some 1706 persons died of it in Ireland in that year, according to the retrospective figures of the census of 1861; but a good many deaths from “cholera” were returned for every year of the decennium, so that it is improbable that the whole 1706 in 1854 were of the true Asiatic type. Ulster had 895 of these, Leinster 453, Munster 324, and the whole of Connaught only 34[1575].

The Cholera of 1865-66.

Asiatic cholera reached Europe by a new route in 1865--by the way of Egypt with the pilgrims returning from the Hâj at Mecca. In the course of the autumn it appeared at Southampton and caused 35 deaths from 24 September to 4 November. A strange extension from Southampton (or from Weymouth) took place to the village of Theydon Bois in Epping Forest, where nine deaths were traced to one house from 28 September to 31 October, unhappily including the death of a most estimable medical gentleman who tasted the water of a well into which the evacuations of the sick had probably percolated.

The cholera having become established on the continent of Europe in the end of 1865, was brought into England by emigrants passing from Hull and Grimsby to Liverpool on their way to America. On board one of the emigrant steamships, the ‘England,’ a very severe epidemic arose in mid-Atlantic in April. Liverpool had once more a severe epidemic (2122 deaths); but the only other important centres in England, besides London, were Swansea, Neath, Llanelly and Merthyr Tydvil, Chester and Northwich, a group of towns on the Exe in Devonshire, and Portsmouth with other places in Hampshire. Still, the deaths in all England made the large total of 14,378, no county excepting Rutland being absolutely free. That means that the infection, although widely diffused, now wanted the conditions favourable to its development and effectiveness; and that, again, seems to mean that a vast improvement had been made in the sewering of towns, in scavenging, and in all other matters of municipal police by which the soil of inhabited spots is preserved from saturation with excremental and other filth.

The interest of the cholera of 1866 centres in London, and chiefly in the fact that three-fourths of the deaths, to the number of 3696, took place in the eastern parishes, Whitechapel, Bethnal Green, Poplar, Stepney, Mile End, St George’s in the East, and Greenwich. These had in former epidemics a fair share; but hitherto they had been surpassed by the Southwark parishes and others on the south of the Thames from Battersea to Rotherhithe, and nearly equalled by Shoreditch and the Liberties of the City. The comparative table of the four great choleras of London shows how remarkably the infection in 1866 had left its old principal seats, remaining, as if a residue, only in the East End, with death-rates comparable to those of 1849.

_Comparative view of the Four Epidemics of Cholera in the several parishes of London_[1576].

1832 1849 1854 1866 (17 wks. end. 4 Nov.)

Rate Rate Rate Rate per Deaths per Deaths per Deaths per Deaths 10,000 10,000 10,000 10,000

Kensington 10 52 24 260 35 490 3·7 85 Chelsea 80 272 46 247 47 300 3·3 22 St George, Hanover Sq. 10 74 18 131 38 295 1·7 18 Westminster 50 450 68 437 60 423 6·2 43 St Martin in the Fields -- -- 37 91 24 58 4·2 10 St James, Westminster -- -- 16 57 152 485 3·5 13 Marylebone 30 355 17 261 16 347 3·0 54 Hampstead -- -- 8 9 11 14 ·8 2 Pancras 20 230 22 360 13 248 6·0 138 Islington 10 39 22 187 8 97 4·3 120 Hackney 2 8 25 139 11 73 10·6 103 St Giles 50 280 53 285 21 115 9·2 49 Strand 1 26 35 156 24 111 6·6 29 Holborn 10 46 35 161 5 25 5·2 22 Clerkenwell 10 65 19 121 9 59 7·0 45 St Luke 30 118 34 183 9 52 8·1 46 East City } 45 182 23 85 15·7 59 West City } 50 605 96 429 10 126 18·8 60 City } 38 207 14 71 5·0 20 Shoreditch 10 57 76 789 20 237 10·7 139 Bethnal Green 50 345 90 789 20 192 60·4 611 Whitechapel 110 736 64 506 40 330 84·2 909 St George in the East 30 123 42 199 30 154 87·9 385 Stepney 50 358 47 501 32 388 107·6 559 Mile End Old Town -- -- -- -- -- -- 67·7 501 Poplar 40 101 71 313 38 208 90·8 837 St Saviour } 120 1128 153 539 134 495 7·4 32 St Olave } 181 349 162 315 8·5 21 Bermondsey 70 210 161 734 158 845 5·3 35 St George, Southwark -- -- 164 836 101 546 6·6 38 Newington 40 200 144 907 101 696 2·8 26 Lambeth 40 337 120 1618 63 941 6·5 114 Wandsworth 10 46 100 484 77 422 4·8 40 Camberwell 30 107 97 504 91 553 5·6 46 Rotherhithe 10 19 205 352 147 285 8·7 25 Greenwich 20 149 75 718 53 576 19·5 284 Lewisham -- -- 30 96 20 81 6·1 56 Stratford -- -- -- -- -- -- 77·6 -- West Ham -- -- -- -- -- -- 49·3 -- Leyton -- -- -- -- -- -- 13·1 --

There was one significant thing associated with the peculiar incidence of the cholera of 1866 upon the East End. The main drainage of London, consisting of a high level and a low level sewer on each side of the Thames, was commenced in 1859, and was formally opened on 4 April, 1865. The two levels on each side of the river made together a length of eighty-two miles; the cost, with pumping station, was £4,200,000. When the cholera of 1866 broke out, only one part of the system was incomplete and not yet in working, namely, the low level main drainage on the northern side, which served the whole of the cholera-stricken parishes from Aldgate to Bow. However, the official mind in this country has somehow become prejudiced against the well-known and usually accepted generalities of von Pettenkofer, which make more of a foul soil in the causation of miasmatic infections, than of contaminated surface water or contaminated water from reservoirs. Accordingly, the somewhat remarkable fact that the East End of London alone retained its old proclivity for choleraic infection was not joined to the fact of its being the only great division of the capital still unsewered, but to the fact that it was supplied by water taken in from the river Lea in Hertfordshire and (it was alleged) insufficiently filtered or otherwise purified at the Old Ford waterworks[1577].

The extension to Scotland in 1866 was late in the season and insignificant compared with former epidemics. It was heard of about the end of summer in Fraserburgh and one or two other ports or fishing places on the East Coast, but it was not until October and November that it attracted notice in the eight principal towns, the whole mortality from it in Glasgow being 53, in Edinburgh 154, in Dundee 105, in Aberdeen 62, in Paisley 2, in Greenock 14, in Leith 95, and in Perth 15. Besides these deaths there were 435 more in smaller towns or villages. The year was a very healthy one, the death-rates of Glasgow, Greenock and Perth having been below the mean of the previous ten years.

In Ireland the cholera of 1866 was even slighter than in Scotland, the only considerable epidemic having been at Belfast.

Cholera has never obtained a footing in London since the epidemic of 1866. In 1873, while the disease was unusually active in some parts of Europe, a few cases occurred in Wapping among Scandinavian emigrants on their way to America, who had been landed for a few days. But the infection did not spread. In 1884, when cholera came from Cochin China to Toulon and Marseilles, two or three cases occurred on board steamships arriving at Cardiff and Liverpool. In 1893, when the disease raged in Hamburg, a number of choleraic cases occurred at Grimsby in August, which were considered certainly Asiatic owing to their high degree of fatality. In August-October, the deaths from cholera, whether cholera nostras or the Asiatic type, or both together, were about thirty in Grimsby, eighteen in Hull, and about fifty more in various other places, chiefly in the south of Yorkshire. The autumn of that year was favourable to bowel-complaints and to enteric fever.

The Antecedents of Epidemic Cholera in India.

The antecedents and circumstances that made the year 1817 so critical for cholera in India, and for its diffusiveness far beyond India, constitute one of the greatest problems in epidemiology. A full and minute examination of them cannot be attempted here; but the chapter would be incomplete without some statement on the subject, which, if summary, need not be dogmatic. Cholera with the same symptoms and a similar degree of fatality was certainly not new to India about the year 1817; it can be traced from the earliest records of the Portuguese and other Europeans in India, if not also in other countries in ancient times[1578]. The mortalities among troops during the military operations in the Northern Circars in 1781 and 1790, and the deaths of some 20,000 pilgrims in eight days during the Hurdwar festival of 1783, were undoubtedly from the same epidemic infective cholera that was seen fifty years after in Europe. But these were occasional great explosions, which arose suddenly and ceased abruptly; whereas from about 1817 onwards the infection became, as it were, a seasonal product of the soil of Lower Bengal year after year, and at the same time began to range widely beyond its “endemic area” to other provinces of India, beyond the North-Western frontier to Central Asia and to Europe, and across the ocean to America. It was not by any sudden change in the year 1817, we may be sure, that cholera began to be endemic at various places far apart in the valley of the Ganges. Things must have been tending towards that manifestation for some time before, and those things must have been of the same kind that made the great explosion at Hurdwar in 1783 and have made many other great explosions at the Indian religious festivals in later times. Briefly the opinion may be hazarded, that it was the permeation with excremental matters of the soil at large in and around Bengali villages that gave rise to the endemic miasmatic infection of cholera. The _odor stercoreus_ of those innumerable village communities is, or used to be, a familiar fact, just as it is well known to be the custom there to dispense with latrines or other systematic provision for the disposal of faecal matters. But it may seem improbable that personal habits of the peasantry, not unknown in other countries, and immemorial in Lower Bengal itself, should have led to a definite disease-effect in a certain year of the 19th century and perennially thereafter. As to the special risk of engendering such a soil-poison in the valley of the Ganges, it has to be said that the region is peculiar in its alternations from extreme saturation to extreme dryness, within a stratum of alluvial or other porous soil which has a bed of impervious blue clay beneath it at a depth seldom more than 10 feet. It is just where such extreme fluctuations of the ground-water within a limited range occur from season to season, that organic matters in the soil are most apt to develop a miasmatic infective property. But why should the year 1817 have been, by the general consent of Anglo-Indian observers, the beginning of a new era in the history of cholera? The guiding principle in all such cases is, that things must have been moving that way before, and that in the

## particular season there had been reached at length such a degree of

aggravation as to make a specific result manifest or the cumulative causes effective. Two things may be indicated as relevant to this assumed aggravation, or integration of accumulating causes. One was a certain gradual change in the beds of rivers, especially in the province of Behar, which entirely altered the relative amount of water flowing above ground and under ground, and must have made a difference in kind and in degree to the decomposition-processes in the soil. (In Burdwan these changes in the ground-water have caused much miasmatic fever since about thirty years ago.) The other thing was the increase of the number of cultivators per square mile under British rule. The latter cannot be stated with even approximate exactness for periods before the census of 1872; but there can be no reasonable doubt that the increase was great and progressive from the end of last century, owing to the cessation of intertribal wars, and of famines which were chiefly caused by the overflow of rivers now no longer subject to floods, and of wilful and barbarous checks to population. Among the cholera localities of 1817 were some that have now the greatest pressure of inhabitants on the soil, not in cities, but in uniformly dispersed rural communities--such as the division of Patna with 637 inhabitants per square mile, the district of Jessore with 693, and of Dacca with 756. This is of course a very general account of the matter, which a minute study of localities and seasons might show to be highly inadequate; but in seeking for some circumstances of aggravation at the

## particular juncture, the two things that have been mentioned, both of them

coincident historical matters of fact, will appear to be not irrelevant according to the received teaching on the favouring conditions of cholera.

NOTE ON CEREBRO-SPINAL FEVER.

British experience, or the records of it, afford so little material for the history of epidemic cerebro-spinal fever (very abundant for France, Germany and the United States of America, see Hirsch, III. 547) that it has not seemed desirable to interpolate the subject in the chapter on Typhus and other Continued Fevers. Although our experience of it has fallen perhaps wholly within the period of exact statistics of the causes of death (saving some doubtful identifications in the 18th century), yet the registration tables contain so few deaths from it that it hardly seems as if a new and remarkable type of fever of the typhus kind had really been in our midst. There are, however, two periods when a good many papers were written upon it in Ireland and England, the years 1865-67 and the year 1876. When the first cases were seen in London in 1865 Murchison pronounced the new fever to be closely allied to typhus (_Lancet_, 1865, p. 1417). At the same time in Ireland it was sometimes called “the black death,” from the dark or livid vibices of the skin, or purpura maligna, or purpuric fever (J. T. Banks, _Dubl. Quart. Journ. Med. Sc._ XLIII. 98; E. W. Collins, _ibid._ XLVI. 170; Cogan, _ibid._ XLIV. 172; Gordon, _ibid._ XLIV. 408; H. Wilson, _ibid._ XLIII.; Haverty, _ibid._; T. W. Belcher, _Med. Press_, N. S. III. 167; J. H. Benson, _ibid._ III. 387; editor, _ibid._ 506. For England, S. Wilks, _Lancet_, 1865, I. 388, _Brit. Med. Journ._ 1868, I. 427; F. J. Brown, _Trans. Epid. Soc._ II. (1865), 391; J. N. Radcliffe in Reynolds’ _System of Medicine_, 1st ed. II. 676; H. Day, _Lancet_, 1867, I. 731). In the second period, 1876, there were many cases in England, especially in the Midlands, but it is said that they were usually diagnosed as typhoid fever (Sir Walter Foster, _Brit. Med. Journ._ 1892, II. 278, and _Lancet_, 1876, I. 849; Neville Hart (for Birmingham), _St Barth. Hosp. Rep._ XII. (1876), 105; H. Thompson, _Lancet_, 1876, I. 849. The Irish papers in the second period are by T. W. Grimshaw, _Dub. Journ. Med. Sc._ LXI. 520, and LVII. 375; E. H. Bennett, _ibid._ LIX.; Brabazon, _Brit. Med. Journ._ 1876, I. 509). An epidemic of cerebro-spinal fever, resembling typhoid, was described for a Shropshire village in May, 1891 (Monk, _Brit. Med. Journ._ 1892, II. 278). A case which came under my notice on 19 March, 1894, in an eastern parish of London, has led me to doubt whether the half-dozen or so of deaths annually certified in London as from cerebro-spinal fever (contrasting with as many hundreds in New York), are of the slightest statistical value.

A young woman, aged 16, an artificial flower maker, became ill with pains in the limbs and was taken as an out-patient to a hospital. Thereafter she became light-headed. A private practitioner (M.R.C.S.) was called in, who found her with a temperature of 103°, excited, and inclined to clutch spasmodically at his arms; her coarse black hair was full of pediculi and nits. She died next day, having had sent her by the practitioner a draught of chlorodyne on account of her extreme restlessness. An inquest was appointed, and the practitioner ordered to make a post-mortem examination. He attended the inquest and gave evidence that death was due to “congestion of the brain.” The jury were dissatisfied, and the coroner adjourned the inquest for a second examination by a skilled pathologist. After spending two hours looking for the cause of death (there was no congestion of the brain), I discovered that the base of the brain had been left in the skull intact, the hemispheres having been sliced off by a horizontal section in the plane of the saw-draught round the cranium. On raising the frontal lobes I saw green flaky lymph lying on the orbital plates and on the corresponding surfaces of the arachnoid; the same was found on the optic commissure, the surface of the pons, the medulla and over a small area of the under convexities of the lateral lobes of the cerebellum, where it amounted to little more than whitish opacity. The lymph was purely basal, solely on the arachnoid, not in the fissures or sulci. The examination having already lasted over two hours, it was found impracticable to expose the spinal cord. The facts previously found were: an extensive blood-shot state of the left conjunctiva with oedema of the upper lid (there was no obvious intra-orbital disease); round dusky-red spots on the outer sides of the thighs and on the shoulders; both lungs in a state of solid purple congestion at the bases, crepitant at the apices, the costal pleura dark red or livid; the tongue large and flabby, congested around the broad papillae; the stomach at the cardiac end, exactly corresponding to the pressure of a mass of hard undigested food, dotted with numerous small round ecchymoses under the serosa; six inches of the lower end of the jejunum, corresponding to a mass of hard impacted faeces, dotted with the same subserous ecchymoses; a narrow belt of deep congestion round the broad ends of the kidney pyramids; the mucosa of the fundus uteri haemorrhagic. There was no herpetic eruption. At the adjourned inquest the cause of death was found to be cerebro-spinal fever, and was so certified by the coroner to the Registrar-General. The practitioner who attended the deceased was unable to say whether the most distinctive of all the symptoms, the violent retraction of the occiput upon the shoulders, was present or absent. It is improbable that this was a solitary case of epidemic cerebro-spinal meningitis in the East End of London in the spring of 1894, (the early spring being the distinctive season of the infection). Even if it were the only case, it narrowly missed being returned as a death from “congestion of the brain,” and that, too, after post-mortem inquisition. The practitioner’s statutory fees were three guineas. There has lately been collected much evidence upon certificates of death, and upon diagnosis under the Notification Act, which makes it doubtful whether our mortality statistics are as correct in substance as they are methodical and exhaustive in form.

INDEX.

Aberdeen, famine of 1622, 30, relapsing fever of 1818, 175, typhus of 1838-40, 189, 192, relapsing of 1843, 204, ratio of enteric in 1864, 210, influenza of 1831, 379 _note_, smallpox in 1610, 434, measles of 1808, 651-2, putrid sore-throat in 1790, 718, dysentery near, 784, cholera in 1832, 815

Aberystruth, cholera in 1849, 845

Ackworth bill of mortality, 528 _note_

Acland, Sir H. W., cholera at Oxford in 1854, 851 _note_

Adams, Joseph, cowpox, 559, liberty for inoculators, 609

=Adynamic= fever, 182

=Ague=, etymology of, 225, 301, name of typhus in Ireland, 301

=Agues=, epidemic, joined with influenzas, 300, summary of in 16th and 17th cent., 306-14, of 1678-80, 329, in Scotland after the union, 341, of 1727-29, 341, of 1780-85, 366, table of, at Kelso Dispensary, 370, of 1826-28, 378, of 1827 in Ireland, 273, in 1846-47, 391, in a Somerset village, 393, no record of, during the influenzas of 1890-94, 397

Aikin, John, Warrington smallpox, 553

Akenside, Mark, dysentery in London 1762, 778, theory of dysentery and rheumatic fever, 782

Alderson, John, contagion of typhus, 153

Alison, William P., no enteric cases in 1827, 187

Althaus, Julius, nervous sequelae of influenza, 397 _note_

Amyand, sergeant-surgeon, inoculations by, 469-70

Andrew, John, formal inoculation, 497

Anstruther, enteric fever 1835-39, 199

Arbuthnot, John, malignant fever in London, 67, pestilent air of cities, 84, influenza of 1733, 347, theory of influenza, 402-5

Armagh, smallpox burials at in 1818, 572, cholera in a hamlet near, 818

Arnot, Hugh, inoculation a complete remedy, 516

Arrott, James, fever at Dundee, 192-3

Astruc, Jean, history of whooping-cough, 666

=Asylums=, cholera in, 809, 831, dysentery in, 787, 791

Aubrey, T., miasmata of Guinea Coast the cause of dengue, 424

Aylesbury, gaol typhus, 153

Aynho, statistics of smallpox in 1723, 520

Ayr, dysentery, 787, cholera of 1832, 814

Ayrshire, cholera at iron-works, 837

Baillou, G. de, first to mention whooping-cough, 666

Baker, Sir George, history of cinchona bark, 320 _note_, merits of Talbor, 322, epidemic agues of 1780-85, 366-7, failure of bark in ditto, 368, merits of Jurin, 479, Sutton’s inoculation, 498, cowpox, 558, dysentery of 1762, 778

Ballard, Edward, occupation of mothers as a cause of infantile diarrhoea, 766 _note_, “healthy” infants have due share of same, 768, slight fatality of diarrhoea in adults, 769

Banff, inoculation not general, 510

Bangor, enteric fever in 1882, 220

Barbone, Nicholas, builder in London after the Fire, 86

Barcelona, sickness at among the troops in 1705, 106

Bard, Samuel, throat-disease in New York, 690

=Bark, cinchona=, use and abuse of in fevers, 318-25, failure of in epidemic agues, 368

Barker, John, of Sarum, epidemic typhus of 1741, 79, 80, 83; Sydenham as phlebotomist, 450

Barker, John, of Coleshill, type of fever in 1794, 157, agues in 1781, 367, influenzas of 1788 and fol. years, 370, smallpox a bugbear, 517

Bartholin, Thomas, transplantation of disease, 474

Bateman, Thomas, decline of fever 1804-16, 163, epidemic fever of 1816-19, 168, cause of differences of type, 169, ratio of relapsing cases, 172, fatal smallpox in Shoe Lane, 547, 568, measles of 1807, 650, dysentery rare, 785

Bath, rumour of plague &c. in 1675, 34, 458, influenza of 1782, 364 _note_, of 1788, 372, of 1803, 375, smallpox of 1837, 604, age-incidence of same, 624

Beddoes, Thomas, influenza of 1803, 375

Belfast, mortality in military hospital 1689-90, 234, fatality of fever and dysentery 1846, 294, recent enteric fever, 299, cholera in 1832, 818, in 1849, 839, in 1853-4, 856

Bent, Thomas, crystalline smallpox at Derby in 1818, 577

Berkeley, Bishop, queries on Irish economics, 239, dysentery and fever at Cloyne, &c. 1740-41, 241-2, tar water in smallpox, 546

Berkeley, relapsing fever in 1794-5, 156

Berkhamstead, general inoculation at, 509

Bernoulli, saving of life by inoculation, 629

=Bilge-water= a cause of ship-fever, 105, 106 _note_

Bideford, incidence of influenza in 1803, 376, cholera in 1854, 851 _note_

Bilston, cholera in 1832, 824, in 1849, 845

Birmingham, scarlatina in 1778, 710

Black, William, safety of inoculation, 608

=Black Assizes= at Taunton in 1730, 92, alleged at Launceston in 1742, 93, at the Old Bailey in 1750, 93, at Dublin in 1776, 98

“=Black Death=,” Irish name of cerebro-spinal fever, 863

=Black Fever=, Irish name of relapsing fever, 289

Blackmore, Sir Richard, hysteric or little fever, 68, against inoculation, 479

Blagden, Charles, materies of influenza, 406

Blakiston, Peyton, influenza of 1837, 387

Blandford, effects of inoculation on smallpox at, 513

=Bloodletting= in fevers, Sydenham’s practice in, 3, attack on in 1741, 83, in ship-fevers, 104, from the jugular by Freind, 107, of doubtful use in low fever, 122, revival of in 1817, 170, 172, in relapsing fever, 174, 175 _note_, 176, unsuitable in the fevers of 1830-40, 189, unsuitable in the relapsing fever of 1842, 203, in case of Charles II., 325, in influenza of 1743, 350, failure of in influenza of 1833, 381, Whitmore opposed to in influenza of 1658, 381 _note_, history of in smallpox, 445-50, in whooping-cough, 667, 668, injurious in epidemic angina, 701, in the cholera of 1832, 833

Boate, Gerard, fluxes and fevers of Ireland, 226

Boerhaave, Hermann, antidotes to smallpox, 494

Bolton, dysentery in 1832, 789

Boringdon, Lord, Vaccination Bills in 1813 and 1814, 609

Borlase, Edmund, dysentery of Ireland, 228

Boston, U. S., inoculation, 483, 485, smallpox epidemic of 1721, 485, tar-water in smallpox, 546, adult cases in the smallpox of 1721 and 1752, 626, throat-distemper of 1735-6, 688

Boston, Eng., agues in 1780, 367, 368, statistics of smallpox 18th cent., 525, 540, 557

Boufflers, Madame de, smallpox after inoculation, 495, 500

=Bowel-hive=, meaning of, 758 _note_

Boyle, Robert, influenza not due to the weather, 399, hypothesis of subterraneous miasmata, 400-2, 408, agues rare in Scotland, 341

Boylston, Zabdiel, inoculations at Boston, 483, 485

Brest, malignant typhus in 1757, 113

Bridgenorth, epidemic agues in 1784, 368

Bright, Richard, enteric fever in London in 1825-6, 186

Bristol, fever in 1696 46, types of the fever of 1817-19, 173, fever-cases in general wards, 179, type of fever in 1834, 201, cholera of 1832, 828, of 1849, 846 _note_

Bromfeild, William, against Sutton’s inoculations, 499, abandons inoculation, 515

Bromley, malignant sore-throat in 1746, 696

Brown, Andrew, fevers of the seven ill years in Scotland, 48

Browne, Sir Thomas, urn-burial and Norwich churchyards, 38

Brownrigg, William, nature of Leyden fever of 1669, 19 _note_, contagion of fever in ships of war, 114

Buchanan, Andrew, state of the poor in Glasgow 1830, 598, Edinburgh New Town epidemic of 1828, 788 _note_

Buchanan, Sir G., desires definition of “influenza proper,” 397 _note_

Buckie, cholera of 1832, 815

Budd, William, epidemic fever of 1839 at North Tawton, 196

=Burial= in relation to plague, 36-39

Burke, Edmund, dearth of 1795, 158 _note_

Burns, Robert, distress and fever of 1783, 154 _note_

Bury St Edmunds, smallpox in 1824, 593

Butter, William, infantile remittent fever, 7

=Buying the smallpox=, in Wales, 471, in Africa, 473, in Poland, 473

Caithness, inoculation in, 510, 542

Calabria, earthquakes and disease, 413, 419

Cambridge, plague of 1666, 34 _note_, gaol fever, 96, false rumour of smallpox, 458, inoculations near, 592

Cameron, James, scarlatina from milk, 734 _note_

Campbell, David, typhus in cotton-mills, 151, few children die of typhus, 152

Canterbury, smallpox in 1824, 581, inoculations, 584

Cardiff, diphtheria, 742, cholera of 1849, 845, 847

Carleton, William, tales of Irish famines, 254 _note_

Carlisle, typhus in 1781, 147, smallpox of infants, 538, rate of fatality, 555, measles, 646, scarlatina, 712, 723, cholera of 1832, 829

Carnbroe, winter cholera in a mining township, 837

Carrick, Dr, fevers of Bristol, 201

Carter, H. W., smallpox and inoculation at Canterbury 1824, 581, 584

Castlebar, gaol-fever in 1847, 292

=Cats=, throat-distemper of in 1798, 719

Ceely, Robert, cowpox near Aylesbury, 561 and _note_

=Cellar dwellings= make typhus in Liverpool, 141, in Manchester, 149, in Whitehaven, 151

=Cerebro-spinal fever=, question of diagnosis of in Irish epidemic of 1771, 247, at Cork and Dublin in 1864, 297, two recent periods of, 863, statistics of valueless, 863, instance of its being overlooked after autopsy and inquest, 863

Chalmers, Thomas, state of Glasgow in 1819, 599

Chambers, W. F., enteric fever in London 1826, 185

Chandler, John, throat-distemper of 1739, 692

Charles II., patronizes Talbor, 319, 322, his ague treated by bark, 323, his fatal illness, 324, visits his mistress after smallpox, 454

Charleston, inoculation at in 1738, 486, 490, fatal measles, 645

Chelmsford, Sutton’s trial at, 499, 608

Cheshire, epidemic agues, 313, 368

Chester, public health in plague-times and after, 40-42, typhus among military prisoners in 1716, 60, 96, typhus endemic in suburbs, 143, smallpox in 1634, 436, inoculation, 508, 511, 516, smallpox in 1774, 537, 544 _note_, compared with Warrington, 551-555, cholera in 1866, 857

Cheyne, George, on fevers in 1701, 52

Chichester, mild smallpox in 17th cent., 455, smallpox in 1821, 581, inoculation and vaccination in 1821-22, 591

=Children=, nervous fever of in 1661, 5-8, epidemics among after the Great Plague, 18, typhus in, 152, 276, 571-2, smallpox of in 17th century, 434, 436, alleged mildness of same, 441-2

=Cholera, Asiatic=, Anglo-Indian writings on before 1831, 793, preparations for, 794, diagnosis of from cholera nostras in 1831, 795-6, first case of in England, 797, the Sunderland epidemic, 797-802, extension to the Tyne, 802-5, to Scotland, 805, the Glasgow epidemic in 1832, 808, the Edinburgh epidemic, 812, table of the epidemic in Scotland, 813, among the fishing population, 814, the 1832 epidemic in Ireland, 816, table of same, 819, the outbreak in London, 820, table of 1832 epidemic in England, 821, exempted towns, 823, Bilston, 824, in Liverpool shipping, 826, at Manchester, 826, exemption of cotton mills, 827, microbic hypothesis in 1832, 827 _note_, chief season of, 830, season of in Paris, 831 _note_, localities of, 830, susceptible persons, 831, question of contagion, 831, means of transmission, 832, sanitary lessons, 833, revivals of in 1833-34 and 1837, 834

Second epidemic 1848-9: Outbreak at Edinburgh, 835, at Springburn, Glasgow, 836, great mortality at Glasgow in mid winter, 837, in mining townships, 837, summer epidemic in Dundee, 838, in Ireland, 839, great outbreak delayed in London till July 1849, 841, chief London localities of, 841, many deaths from collapse at outset, 842, mixed with much cholera nostras, 842, prevalence in institutions, 841, 843, table for England, 843, in Merthyr Tydvil, 845, in Hull, 845, in Airedale, 846, exempted places, 846, influence of locality, 847, law of altitude, 847, carried in surface water, 848

Third epidemic 1853-4: Outbreak at Newcastle and Gateshead, 849, Commissioners’ report on, 849, suspected water-supply, 850, the epidemic partial in England in 1854, 851, table of same and of 1866 epidemic, 852, supposed connexion with water in South London, 853, and in Soho, 854, the epidemic in Scotland, 855, in Ireland, 856

Fourth epidemic: Outbreak at Southampton in 1865, 856, Liverpool &c. in 1866, 857, chiefly in the East End of London, 857, table of four epidemics in the parishes of London, 858, main drainage incomplete at East End in 1866, 859, slight Scotch epidemic in 1866, 859, no subsequent epidemic, 859

In India before 1817, 860, causes of endemicity since 1817, 861

=Cholera infantum=, _see_ Diarrhoea.

=Cholera nostras=, fatal to adults chiefly in old age, 769, historical references to, 770, distinction of from bilious colic, 771 _note_, Willis’s symptoms of, 772, in and near Leeds in 1825, 773, diagnosis from Asiatic in 1831, 795-6

Christison, Sir Robert, relapsing fever of 1819, 174, 177, fever cases in general wards, 179, relapsing fever of 1827-29, 182, heat of 1826, 185, rarity of enteric fever in Edinburgh, 187, relapsing fever of 1842, 203, agues at Kelso dispensary 18th cent., 370, ague in 1827, 378, dysentery in and near Edinburgh, 787, 791

Christleton, village smallpox, 556

Churchill, Fleetwood, influenza in Dublin 1847, 389

Circassia, procuring of smallpox in, 472, Voltaire’s legend of, 473 _note_

Clanny, W. R., Sunderland cholera, 798, 801 _note_

Clark, John, ship fever, 117, Newcastle typhus, 142, influenza of 1782, 364, agues, 369, inoculation of infants, 507, scarlet fever of 1778, 713, dysentery, 784

Clarke, James, typhus at Nottingham in 1807, 165, ague in 1808, 378 _note_, gangrene in measles, 706

Clayton, Mr, describes cowpox in the cow, 560

Cleghorn, George, influenza in Minorca, 352, mild and severe smallpox, 547

Clemow, F., origin of influenza in 1889, 393 _note_

Cleveland, miliary fever or scarlatina in 1760, 127, 703

Clifton, _see_ Bristol

Clouston, T. S., dysentery in asylum, 791

Clowes, William, calls _variola_ measles, 633

Cloyne, dysentery in 1741, 241

Clutterbuck, Henry, excremental effluvia in houses, 87 _note_, 170

Cobbett, William, the potato in Ireland, 285

Cockburn, William, on “little fever,” 68, sickness in navy, 103

Cockermouth, typhus, 114, cholera, 846

=Coffins=, at Tewkesbury to prevent plague, 36, supersede cerecloths, 37, advantages of, 38, burials without in a Scots parish, 51, and in cholera, 814 _note_, 818

Coke family, typhus in, 31, 53, smallpox in, 435

Colden, Cadwallader, throat-distemper in New York, 689

Coleridge, S. T., merits of inoculation and vaccination as poetic subjects, 588 _note_

=Colic, bilious=, distinguished from cholera nostras, 771 _note_

Collieston, cholera of 1832, 815, 833 _note_

=Comatose fever=, 5, 20, 75

Connemara, famine and fever of 1821-22, 268

Constantinople, inoculation at 463-467, 475

Copenhagen, adult smallpox in 1833, 612

Cork, types and causes of fever 18th cent., 234-6, state of workhouse in 1846, 286, fever of 1864, 297, cholera of 1832, 816, of 1849, 839

Cormack, John Rose, relapsing fever, 204

=Cotton mills=, typhus in, 152, effects of on married women, 767, adverse to cholera, 827

=Country disease=, name of dysentery in Ireland, 226-7

Coventry, infantile diarrhoea, 765 and _note_

Covey, John, formal inoculation, 505

Cowan, Robert, Glasgow typhus, 191, little smallpox among Irish adults, 601

=Cowpox=, matter from used to inoculate with, 558, Jenner’s advocacy of, 558, its properties used by Adams to illustrate phagedaena, 559, accounts of by Jenner, Pearson and Clayton, 560, circumstances of its origin in a cow, 561, case of in a milkmaid, 562, obsolete opinions concerning, 562, called by Jenner “smallpox of the cow,” 563, attempts to manufacture it out of smallpox, 564, _see_ also Vaccination

Cox, Daniel, fever of 1741, 83 _note_

Craigie, David, Edinburgh enteric fever, 187, cholera at Newburn 1832, 804, at Edinburgh, 812, history of cholera, 860 _note_

Cromarty, cholera of 1832, 814

Cromwell, Oliver, dies of epidemic ague, 303

Crook, John, sells bark in 1658, 320

Crookshank, Edgar, describes cowpox, 561 _note_, witnesses contamination of milk, 735

Cross, John Green, Norwich smallpox, 578, inoculation in 1819, 591

=Croup=, name for diphtheria in Bucks 1793, 716, in Glasgow in 1819, 738 _note_

Croydon, scarlatina from blood &c., 735, increase of diphtheria, 742

=Cucumbers=, theory of in fever of 1624, 32

Cupar Fife, crystalline smallpox, 575

Cullen, William, definitions of scarlatina and cynanche, 737, rickets congenital, 767

Currie, James, typhus in Liverpool, 141, inoculation, 508, 511, cold affusions in scarlatina, 723

Darlington, enteric fever and water-supply, 221, cholera nostras 18th cent., 772

Darwin, Charles, quantity of seminal particles, 608 _note_

Deal, supposed typhoid in 1806, 165

=Dearths= in England, 78, 125-6, 132, 159, in Scotland, 30, 50, 82, 154, 599

Deering, Charles, Nottingham smallpox in 1736, 522, mild smallpox, 845

Defoe, Daniel, the Plague and the Fire of London, 42

=Dengue=, an analogy for influenza, 424

Denman, Thomas, diphtheria of infants, 714

=Depuratory fevers=, 21

Dewar, Henry, smallpox of 1817, 575

=Diarrhoea, infantile=, called “griping in the guts” 17th cent., 747, Harris on mortality from in London 17th cent., 749, London statistics of in 17th and 18th cent., 750-755, less of in provincial cities, 757, first described by Rush, 758, modern statistics of, 758-762, has declined in London since 18th cent., 763, modern prevalence in provincial towns, 765, in infants of workwomen, 766, a congenital risk, 767-8

Dillon, Dr, gaol-fever at Castlebar, 292

Dimsdale, Baron, re-inoculation, 505, opposes infant inoculations, 507, general inoculations, 509

Dingle, escapes famine of 1817, 262, cholera of 1849, 840

=Diphtheria=, identified in 18th cent., 679, 691 _note_, 702, 737 _note_, called croup in 1793, 716, reappears in 1856, 736, details of the epidemic of 1858-9, 739, incidence of on town and country, 741, on London, 742, on age and sex, 743, favouring conditions of, 744

=Dispensaries= in London, 16, 135

Dixon, Joshua, Whitehaven fevers, 152, 571

Dobson, Dr, Liverpool smallpox 1772-4, 537

=Dogs= attacked by influenza, 354, 361, 371 _note_, 372, 398

Donoughmore, fever in 1836, 277

Dorset, epidemic agues in 1780, 369

Douglas, James, post-mortem on case of fever, 55

Douglass, William, smallpox and inoculation at Boston 1721, 486, danger of inoculated smallpox, 607, throat-distemper of New England 1735-6, 686-9

Dover, Thomas, fever at Bristol 1696, 46, agues in Glo’stershire, 74, treated for smallpox by Sydenham, 446 _note_, his success in smallpox in 1720, 449, mildness of measles, 641 _note_

Drage, William, epidemic agues of 1658, 315, transplantation of agues, 474 _note_, incubation of measles, 655 _note_

Drogheda, dysentery at siege of, in 1649, 227, cholera in 1832, 88, in 1849, 839

=Drunkenness= in London 18th cent., 84

Dublin, Black Assizes of 1776, 98, question of enteric fever in 1826, 187, typhus in 1682, 228, nervous fever in 1734, 239, relapsing fever in 1738-9, 240, dysentery and fever 1740-41, 241-2, relapsing fever in 1746-8, 245, putrid fevers in 1754-62, 245-6, fevers of 1799-1802, 249-50, dysentery and relapsing fever 1825-26, 271, intermittent fever in 1827, 273, typhus in 1837, 277, fever of 1864-5, 297, recent enteric fever, 299, influenza of 1688, 336, of 1693, 337, horse-colds, 345, 354, malignant smallpox, 549, mild and severe scarlatina, 722, 724, cholera of 1832, 816, of 1849, 839

Dundalk, camp sickness, 230

Dundee, typhus of 1836, 192-3, relapsing and typhus in 1842, 204, hospital cases of typhus, 210, dysentery, 789, cholera of 1832, 814, of 1849, 838, of 1853, 855, of 1866, 859

=Dunkirk rant=, 340

Dunse, smallpox in 1733, 527, inoculation revived, 590

Duvillard, M., on saving of life by vaccination, 629

=Dysentery=, four degrees of epidemic prevalence, 774, severe during plague in London, 774, names of in bills of mortality, 775, London epidemics of 1669-72, 776, in Scotland 1731-37, 777, in London in 1762, 778, symptoms of in Newcastle in 1758-9, 780-1, Akenside’s theory of its pathology, 782, epidemic period of 1779-85, 783, in a Scots fishing village in 1789, 784, epidemic period 1800-2, 785, in Glasgow in 1827-29, 786, in Edinburgh 1828, 787, in Wakefield Asylum, 787, occasions of in 1827-29, 787, in Scotland in 1836, 789, at Taunton workhouse in 1837, 790, at Penzance in 1848, 790-1, during the cholera of 1849, 791, 842, relation of to typhus fever, 792

Earlsoham, malignant fever in a farmhouse, 161

=East Indiamen=, fevers in, 117

Edinburgh, mortality bills of 1740-41, 82, 523, fevers of 1699, 49, worm fever in 1731-32, 75, relapsing fever in 1735, 76, state of the poor in 1818, 174, types of fever 1817-19, 174-5, fever cases in general wards of Infirmary, 179, relapsing fever of 1827-29, 182, little enteric fever, 187, 199-200, 202, typhus of 1836-39, 192, relapsing fever of 1843-44, 204, Irish fever of 1846-48, 208, typhus and enteric of 1864, 210, relapsing of 1870, 211 _note_, influenza of 1733, 346, of 1743, 351, of 1758, 353, of 1775, 361, smallpox in 18th cent., 523, in 1817, 575, in 1830-31, 600, measles in 1735, 642, in 1740-41, 643, in 1808, 651-2, whooping-cough in 1740-41, 670, scarlatina in 1684, 681, in 1733, 684, Cullen’s experiences of the same, 737, in 1804-5, 721, in 1832-33, 725, dysentery in 1734, 777, in 1828, 787, the “New-Town Epidemic” of 1828, 788, cholera of 1832, 807, 812, of 1848, 835, of 1853-4, 855

Ellenborough, Lord Chief Justice, opposes Vaccination Bill, 609

Ellenborough, second Earl of, brings in Vaccination Bill, 606

Elliotson, John, agues in 1826-28, 378

Elyot, Sir Thomas, infantile maladies of 16th cent., 666

Ennis, chief months of fever 1846-48, 288

=Enteric Fever=, epidemic of 1661 identified as, 8 _note_, “little fever” identified as, 70, probable cases of in 1804-10, 165, in London in 1826, 183-6, alleged at North Tawton in 1839, 196 _note_, at Anstruther in 1835-39, 199, at Edinburgh, 199-200, Lombard on proportion of in Britain, 201, prevalence of since 1869, 211, favouring conditions of, 217, highest English death-rates, 218, explosions of, 220, age-incidence fatality and predisposition to, 222-3, Edinburgh New Town epidemic of 1828, 788 _note_

=Epidemic Constitutions= copied by Sydenham from Hippocrates, 10

Evelyn, John, the winter of 1653-4, 23, Norwich graveyards, 38, bark prescribed for Charles II., 323, last illness of Charles II., 324, “new fever” of 1678, 330, attack of ague, 331 _note_, treated in smallpox, 445

Exeter, influenza of 1729, 345, of 1775, 360, of 1837, 386, smallpox of 1837, 604, measles in 1824, 662, cholera of 1832, 829, cholera and water-supply, 854

Faröe Islands, strangers’ cold, 432

Farr, William, endorses Watt’s doctrine of displacement, 658, cholera and elevation of ground, 847, cholera and Newcastle drinking-water, 850

=Febricula= or “little fever” of 1720-30, 67-70

Feckenheim, camp sickness, 108

Ferguson, Dr, of Aberdeen, measles in 1808, 651-2

Ferguson, Robert, favours inoculation in 1825, 592

Ferriar, John, typhus severe in migrants to towns, 101, fevers in Manchester, 149, need for fever-hospitals, 158, troubles of a young couple, 552

Ferryden, cholera in 1833, 815, 834

=Fever Hospitals=, committee on in 1818, 178

=Fire of London=, alleged effect on plague, 42

Fletcher, Andrew, state of Scotland end of 17th cent., 49

“=Flox and Smallpox=,” meaning of, 436 _note_

Forbes, Sir John, inoculation in Sussex, 591

Fordyce, John, miliary fever, 130

Fordyce, Sir William, malignant sore-throat in 1773, 707, prevalence of rickets, 756

Foster, Sir Michael, Old Bailey Black Assizes, 93

Foster, Sir Walter, on cerebro-spinal fever diagnosed as typhoid, 863

Fothergill, Anthony, influenza of 1775, 359, in horses, 361

Fothergill, John, fevers of 1751-55, 122, collective inquiry on influenza of 1782, 360, smallpox of 1751, 453, 529, objections to the Parish Clerks’ bills, 530, 638 _note_, epidemic sore-throat 1746-48, 696, 737

Fothergill, Samuel, scarlatina in 1814, 723

Fowler, Thomas, arsenic in ague, 368

Freind, John, Sydenham’s varieties of fever, 27 _note_, petition to Commons on drink, 84, sickness of Peterborough’s expedition 1705, 106, adverse to inoculation, 478

Frewen, Thomas, methods of inoculation, 492, Boerhaave’s antidotes, 494 _note_

Fuller, Thomas, inoculation, 489 _note_

Gaddesden, John of, uses “mesles” for _morbilli_, 632

Gairloch, fevers in 18th cent., 155

Galway, plague of 1649, 227, fever of 1741, 243, fever of 1821-22, 269, gaol fever in 1848, 291, cholera of 1832, 816, of 1849, 839

=Gaol Fever=, 90-95, Howard’s discoveries of, 95-97, Lettsom’s cases, 97, infection of in ships, 114, in 1783-55, 153, Neild’s inquiries, 628

Gaskell, Mrs, the fever episode in ‘Jane Eyre,’ 181 _note_, distress of the working class in Manchester in 1839-41, 197

Gateshead, fever in 1790, 142, cholera in 1832, 803, cholera in 1853, 849

Gatti, Angelo, method and results of inoculation, 495-7

Gaulter, Henry, Manchester cholera of 1832, 826

Geach, Francis, influenza and astrology, 405, dysentery of, 1781, 783

Geary, W. J., the Limerick poor in 1836, 275, age-incidence of typhus, 276

Geneva, vital statistics of, 443 _note_, 623

George I. sanctions inoculation, 468-9

George Ham, epidemic pneumonia (?) in 1747, 355

Germany, names of influenza in 1712, 339, apparent extinction of smallpox, 612, re-vaccination, 612

Gibraltar, ship fever at, 115, influenza of 1837, 388

Gilchrist, Ebenezer, nervous fever of 1735, 75, inoculations at Dumfries, 509

Gladstone, rt. hon. W. E., on dearth of 1767, 132 _note_

Glasgow, fever statistics from 1795, 164, fever of 1816-19, 175, fever of 1827-28, 181, spotted typhus after 1835, 189, 193, public health 1831-39, 191, fatality of typhus in adults, 193, fevers of 1842-44, 204, fevers of 1847-48, 208, influenza of 1831, 379, smallpox in end of 18th cent., 539, 557, decline of smallpox 1801-12, 569, statistics of vaccination 1801-18, 582, revival of smallpox 2nd quarter 19th cent., 597-601, immunity from same of Irish in, 602, age-incidence of smallpox compared with same at Paris 1850-51, 611, measles in 1808 etc., 652, comparative table with London 1783-1812, 655, substitution of measles for smallpox, 657, ages of fatal measles, 661, whooping-cough, 670, 672, relation of same to measles, 675, scarlatina 1835-39, 725, milk scarlatina, 734 _note_, “bowel-hive,” 758, dysentery of 1827-28, 786, of 1836, 789, cholera of 1832, 808, of 1848-9, 836, of 1853-4, 855, of 1866, 859

Gloucester, Duke of, dies of smallpox, 438

Gloucester, agues in 1727-29, 74

Goodsir, John, enteric fever at Anstruther, 199

Goole, infantile diarrhoea, 762, 765 _note_

Grainger, James, anomalous fever in 1753, 123

Grant, William, pestilential fever in London, 137, influenza of 1775, 359, fever and sore-throat, 707

Graunt, John, exactness of the early bills of mortality, 653 _note_

Graves, Robert J., typhus fatal to the well-to-do, 102, fever in Galway, 270, jaundice in relapsing fever, 272, spotted typhus a new type, 277, typhus begins like a cold, 278 _note_, failure of blooding in influenza, 282, mild and fatal scarlatina, 722, 724, type of scarlatina not affected by treatment, 725, writings on cholera, 831 _note_

Gray, Edward, collective inquiry on influenza of 1782, 363, 365

Greenock, high typhus death-rates, 209, cholera of 1832, 813

Gregory, George, compares London smallpox of 1825 with great 18th cent. epidemics, 593-5, advocates re-vaccination, 612

Gregory, James, follows course of influenza in 1775, 361

Griffin, Daniel, infantile mortality in Limerick, 602

Grimsby, cholera in 1893, 860

Grimshaw, T. W., fever and rainfall in Dublin, 298, relation of whooping-cough to measles, 676 _note_

_Grippe, la_, 339 _note_

Guide, Philip, on Talbor, 319

Guilford, Lord, his fever treated by bark, 321

Gull, Sir William W., report on cholera, 846 _note_

Haeser, Heinrich, identities of 18th cent. throat-distempers, 691 _note_

Hague, The, ages in 18th cent. smallpox, 623

Hales, Stephen, ventilation of Newgate, 94, ventilation of ships, 119

Halifax, semi-rural industries of, 145, smallpox at in 1681, 458, inoculation at, 483

Hamilton, Sir David, case of fever in London in 1709, 55, factitious miliary fever, 128, fever and sore-throat in 1704, 704 _note_

Hamilton, dysentery in 1801, 785, cholera of 1848-9, 838

Hampstead, agues in 1781, 367, scarlatina in 1786, 713

Hampton, U. S., throat-distemper in 18th cent., 690

Harris, Walter, influenza of 1688, 336, mildness of smallpox in infants, 441, reference to inoculation in 1721, 467, whooping-cough, 667, summer diarrhoea fatal to London infants, 749, 763

Harty, William, Irish epidemic of 1817-19, 264, affinities of dysentery, 782, cholera in Dublin prisons, 816

Hastings, smallpox in 1731, 521

Haverfordwest, buying the smallpox, 471, diphtheria in 1849, 738 _note_

Haviland, Alfred, the Hippocratic “constitutions,” 10 _note_, village epidemic of ague in 1858, 393

Hawkins, Bisset, cavils at Watt, 658

Hawkins, Caesar, inoculator, 504, 515

Haygarth, John, typhus in Chester, 41, 143, miliary fever, 130, influenza of 1803, 376, procuring the smallpox, 477, census of Chester after smallpox in 1774, 544 _note_, infantile deaths at Chester, 553-4, letter on Jenner’s cowpox project in 1794, 559

Heberden, William, junior, supposed decrease of dysentery, 747, 774

Heberden, William, senior, smallpox least dangerous to infants, 442, a failure of inoculation, 498, measles in 1753, 644, scarlatina and angina, 712 _note_

Hecker, J. F. C., identity of throat-epidemics, 691 _note_, 704 _note_

Hecquet, Ph., reasons against inoculation, 479 _note_

Helmont, J. B. van, ridiculed by Barker, 450 _note_

Henry, Thomas, smallpox in different parts of Manchester, 556 _note_

Hertford, smallpox in 1722, 519

Hewett, Cornwallis, cases of enteric fever, 185

Heysham, John, Carlisle typhus, 147, smallpox, 538, 555, 570, measles, 646, scarlatina, 712, 723

Hillary, William, Ripon fevers, 72-3, copious bloodings, 74 _note_, nervous fever in Barbados, 127, influenza in Barbados, 352, 412, volcanic waves at Bridgetown, 411, smallpox mild there, 548

Hippocrates, epidemic constitutions, 9

Hirsch, August, identity of 18th cent. throat-distempers, 691 _note_, 737 _note_, history of infantile diarrhoea, 758, degrees of epidemic dysentery, 774

Holland, Sir Henry, advises re-vaccination, 613, “hypothesis of insect life” in cholera, 827 _note_

Holy Island, ship typhus, 109

Hongkong fever, resembles influenza, 423 _note_

=Horses= attacked by influenza in 1658, 313, in 1688, 337, in 1727-29, 345, in 1732, 348, in 1737, 348, in 1758, 353, in 1743 and 1750, 354, in 1760, 355, in 1775, 361, in 1783, 371 _note_, in 1788, 372

Howard, John, effects of the window-tax, 88, discoveries of gaol-fever, 95, smallpox in three gaols, 544

Hull, infantile diarrhoea, 762, 765 _note_, cholera of 1832, 823, of 1849, 845, of 1854, 851

Hume, David, influence of climate etc., 224

Hunter, John, M.D., typhus in London, 15, 134, 138

Hutchinson, James, change in fevers since 17th cent., 3

Hutchinson, Jonathan, vaccinal syphilis, 562 _note_

Huxham, John, Plymouth fevers 1727-29, 73-4, worm fever in 1734, 75, typhus, 76-77, ship fever, 78, gaol fever at Launceston in 1742, 93, influenza in 1729, 345, horse-cold in 1727, 345, influenza of 1733, 347, influenza and horse-cold of 1737, 348-9, influenza of 1743, 351, smallpox of 1724-25, 520, smallpox of 1751, 529, malignant measles 1749, 656, anginose fever of 1734, 684, epidemic sore-throat of 1751, 695, 699

Iceland, dust clouds from volcanic action, 414

India, cholera before 1817, 860, creation of the endemic area, 861

=Industrial Revolution=, the, 145

=Infantile Remittent Fever=, 5-8

=Influenza=, historically mixed with epidemic ague, 300, probable etymology of, 304, names of before 1743, 305, retrospect of influenzas to 1659, 306-313, influenza of 1675, 326, of 1679, 328, of 1688, 335, of 1693, 337, of 1712, 339, of 1729, 343, probable in 1728, 346, of 1733, 346, of 1737, 348, of 1743, 349, of 1758, 353, of 1759 in Peru, 354, of 1762, 356, of 1767, 358, of 1775, 359, of 1782, 362, of 1788, 370, of 1803, 374, of 1831, 379, of 1833, 380, of 1837, 383, of 1847-48, 389, minor epidemics, 391, of 1889-94, 393, antiquity and sameness of, 398, views of Willis and Sydenham, 399, miasmatic hypothesis of Boyle, 399-402, theory of Arbuthnot, 402, theory of Noah Webster, 405, a phenomenal cause needed, 407, relation to epidemic agues, 409, the epidemic of 1761 at Barbados and the earthquake, 409, the earthquake of Lisbon and influenzas, 411, earthquakes and the influenza of 1782, 413, miasmatic sickness following earthquakes in Jamaica, 415, in Amboina, 418 _note_, and in Sicily, 419, possible sources of miasmata of influenza in 1693, 420, epidemic of 1688 and the earthquake of Lima, 421, possible sources of S. American epidemic in 1720, direction in which the true theory lies, 425, outbreaks at sea, 425-431, strangers’ colds, 431-433. See also Horses.

=Inoculation= of smallpox, a Greek practice, 463, begun in London, 467, popular origins of, 471, Voltaire’s legend of Circassian, 472 _note_, probably grew out of transplantation of disease, 474, religious symbolism of inoculation, 475, etymology of, 476, not an antidote, 477, controversy on in England, 477, reality of as practised by Nettleton, 482, at Boston, New England, 485, cases of failure, 487, cases of death from, 489, revival of in 1741, 489, at Charleston in 1738, 490, as practised by Frewen, 492, by Kirkpatrick, 493, the blister method of, 494, Gatti’s practice in, 495, Sutton’s practice in, 498, opposition to Sutton’s method of, 499, Watson’s experiment in, 500, Mudge’s experiment in, 501, tests of its validity, 502, extent of in England in 18th cent., 504-9, in Scotland, 509, value of, 511, at Blandford, 513, at the Foundling Hospital, 514, known failures of, 515, testimonies to value of, 516, advocates of in 19th cent., 586, Lipscomb’s poem on, 587, preference of populace for, 589, practised by Walker as vaccination, 590, extent of, 590-2, made penal, 606, history of the doctrine that it was a nuisance, 607-10, did not contain the principle of re-vaccination, 610

=Intermittent Fevers=, Sydenham’s view of, 11, in Ireland after the relapsing fever of 1826, 273, and of 1847-9, 297. See also =Ague=.

Inverness, typhus at, 110, cholera of 1832, 814, of 1849, 838

Ipswich, ship typhus at, 110, scarlatina in 1771, 708

Jamaica, sickness after earthquake, 416

Jenner, Edward, relapsing fever in his house, 156, inoculates with crude matter, 502, collects failures of inoculation, 515, inoculates with swinepox, 558, proposes to inoculate with cowpox, 558, indicates ulcerous characters of cowpox, 560, his opinion on origin of smallpox and cowpox, 562, calls cowpox _variolae vaccinae_, 563, tests the virtue of cowpox, 565, makes interest with the great, 566, demands prohibition of inoculation, 609, opposes Watt’s doctrine of measles, 657

Jenner, J. C., epidemic ague in 1784, 369, general inoculation, 509, why smallpox malignant, 550

Jenner, Sir William, diagnosis of continued fevers, 4, 183, diphtheria, 739 _note_, rickets a diathesis, 767

Jesty, Benjamin, inoculates with cowpox, 558

Johnstone, James, Kidderminster fevers 1752-56, 124, sequelae of measles, 660 _note_, sore-throat and fever, 702, 704, the scarlet eruption, 710

Johnstone, James, junior, dies of gaol fever, 153, writes on the scarlatina of 1778, 710

=Jolly rant=, name of influenza in 1675, 327 _note_, 328

Jones, John, fevers of the Greeks not in our climate, 301, agues of 1558, 307

Jones, John, dysentery in Wales, 777

Jurin, James, arguments for inoculation, 479, his authority, 480, biographical sketch of, 481 _note_

Kanturk, incidents at in famine of 1818, 265

Katharine, Queen of Charles II., her fever in 1663, 13

Kell, John Butler, cholera at Sunderland 1831, 798

Kellwaye, Simon, measles and smallpox, 633

Kelso, agues in 18th cent., 369, cholera in 1848-9, 838

Kendal, vaccination 1819-21, 584

Kennedy, Henry, type of Dublin fever in 1847, 289, in 1862, 298

Kennedy, Peter, inoculation at Constantinople, 464, procuring smallpox in Scotland, 471

Kerr, George, fever in Aberdeen, 176

Kidderminster, fevers in 1727-29, 124 _note_, in 1751-56, 124, sequelae of measles, 660, sore-throat and fever in 1748, 701, 704, in 1778, 710

Kilgour, Alexander, typhus one of the exanthemata, 189, ratio of spotted cases, 193

Kilkenny, sickness in 1846, 282

Kilmarnock, 18th cent. smallpox, 526, cholera of 1832, 814, of 1849, 838

Kiltearn, paupers in 1697, 51 _note_, smallpox in 18th cent., 541

Kingsley, Charles, cholera of 1854, 851 _note_

=Kink=, old name of whooping-cough, 666

Kirkmaiden, smallpox and fever in 18th cent., 528

Kirkpatrick, or Kilpatrick, J., inoculates at Charleston, 90, in London, 491, 493

Kite, Charles, second inoculations, 503, failures of inoculation, 515

La Condamine, M. de, case of Timoni’s daughter, 488 _note_, advocates inoculation, 494, estimates saving of life by same, 516

La Motraye, M. de, procuring smallpox in Circassia, 472

Lamport, John, fever in Hampshire 1680, 21, his success in smallpox, 453

Lamprey, Jones, types of famine sickness in Skull 1846, 287, 288

Lancaster, typhus in 1782, 151

Langton, William, opposes formal inoculation, 500

Lansdowne, Marquis of, inoculation and vaccination, 606, 607

Launceston, gaol typhus, 93, 97, diphtheria, 740

Laurie, J. Adair, statistics of Glasgow cholera hospital in 1832, 811

Laycock, Thomas, influenza at York, 389 _note_

Le Cat, Claude Nicolas, the Rouen fever of 1753, 121

Leeds, typhus in 18th cent., 146, in 1802, 160, statistics of fever hospital, 164, fever in 1817, 171, notification at in 1804, 180 _note_, typhus in 1847, 207 _note_, influenza in 1675, 327, smallpox in 1689-99, 458, general inoculations, 510, smallpox in 1781, 538, 555, cholera nostras in 1825, 773, dysentery in 1849, 791, 842, cholera in 1849, 847

Leith, cholera of 1832, 814, of 1848, 836

Lettsom, John Coakley, gaol fever, 97, London fevers in 1773, 135, inoculation of infants, 507, general inoculation at Ware, 511 London smallpox more than in the Bills, 534, smallpox in 1808, 570, inoculation not contagious, 608, saving of life in typhus, 628, scarlatina in 1793, 718

Levett, Robert, amateur in medicine, 134

Levison, George, scarlatina in 1777, 708

Leyburn, fever in 1813, 167

Limerick, famine of 1741, 242, statistics of fever hospital, 258, pauperism of 1836, 275, statistics of fever, 276, of infantile mortality, 602, cholera of 1832, 818, of 1849, 839

Lind, James, desires history of British fevers, 1, ventilation of gaols, 95, ship fever, 111, Sutton’s pipes, 119, smallpox in the ‘Royal George,’ 543, cholera nostras at Portsmouth, 772

Linnaeus, Carolus, as nosologist, 670

Lipscomb, G., his prize poem on Inoculation, 588

Lisbon, ship fever at, 105

Liskeard, diphtheria in 1748, 694

Liverpool, typhus in 18th cent., 140, enteric in 1836, 201, the Irish fever of 1847, 206, recent typhus, 214, influenza atmosphere in 1837, 388, general inoculations, 504, 508, 511, 18th cent. smallpox, 537, age-incidence of same in 1837, 624, diarrhoea, 765, dysentery in the Irish fever, 790, cholera of 1832, 826, of 1849, 847, of 1854, 851, of 1866, 857

Livingston, Dr, Aberdeen sore-throat in 1790, 718, dysentery in 1789, 784

Lombard, H. C., enteric fever in Britain, 188 _note_, 201

London, Asiatic cholera of 1832, 820, of 1833, 834, supposed in 1837, 835, epidemic of 1848-9, 841, 847, of 1854, 853, of 1866, 857

London, cholera nostras in, in Sydenham’s time, 769, every autumn, 770, in 1669-70, 771, described by Willis, 772

London, diphtheria in 741-2

London, dysentery in, names of in the Bills, 774, symptoms of in 1669, 776, epidemic of 1762, 779, of 1779-81, 783

London, fever in, endemic, 13, in Sydenham’s time, 18-22, epidemic of 1685-6, 22, identified as typhus, 27, statistics of to end of 17th cent., 43, epidemic of 1694, 45, statistics of 1701-20, 54, epidemic of 1709-10, 54, 57, sample case of, 55, a case of relapsing in 1710, 57, epidemic of 1714, 59, in 1718, 64, statistics of 1720-40, 65, weekly maxima 1726-29, hysteric or little, 67, relapsing, 69, identified as enteric, 70, epidemic typhus of 1741-42, 78-81, in Marshalsea prison, 91, at Old Bailey in 1750, 93, in gaols, 97, slow remittent of 1751-55, 122, typhus from 1770 to 1800, 133-140, localities of, 140 _note_, hospital for in 1802, 160, slight prevalence of from 1803 to 1816, 163, possible enteric cases in 1808, 165, epidemic of 1816-19, 168, bred by insanitary state of houses, 170, relapsing in 1817, 172, cases of mixed in general hospitals, 178, relapsing in 1826-28, 182, enteric in 1826, 183, change of type to spotted, 188, purely typhus in 1837-38, 194, epidemic typhus of 1847, 205, in part relapsing, 208, relapsing in 1868, 211, ratios of typhus and enteric at Fever Hospital, 213, season of enteric, 217

London, Fire of, supposed effect on plague, 42

London, infantile diarrhoea in, entered as “griping in the guts,” 747, Harris on in 1689, 749, weekly bills of in 17th cent., 750, 752, 753, annual deaths 1667-1720, 753, some 18th cent. weekly bills, 754, 755, conditions favouring, 756, 19 cent. statistics, 759-60, recent death-rates moderate, 761, reasons of greater fatality in former times, 763

London influenza weekly mortalities, of 1580, 310, of 1675, 326, of 1679, 329, of 1688, 336, of 1693, 338, of 1729, 343, of 1733 and 1737, 349, of 1743, 350, of 1762, 356, of 1775, 359 _note_, of 1782, 363, of 1803, 375, of 1831, 379, of 1833, 380, of 1837, 384, of 1847, 390, of 1890-94, 394

London, measles in, deaths from in 17th cent., 634, 635, 640, epidemic of 1670, 653, epidemic of 1674, 656, indirect effects of same contrasted with those of smallpox, 658-9, deaths from in 18th cent., 641, 643, epidemic of 1705-6, 641, fatalities one-tenth those of smallpox, 644, ratio of to all deaths, 647, epidemic of 1807-8, 650-1, compared with Glasgow, 655, deaths from 1813 to 1837, 660, in 1837-39, 662, two seasonal maxima, 664

London, sanitary state of under George II., 84, improvement in after 1766, 133, of workmen’s houses in 1819, 170

London, scarlatina or diphtheria in, Morton’s cases, 682, cases 1739, 692, Fothergill’s cases, 696, Fordyce’s cases, 707, Levison’s cases, 708, Sims’ cases, 713, Willan’s cases, 714, in 1796-1802, 719, Bateman’s notes of, 722, mild in 1822, 723, recent range of fatality, 730, fatalities at home and in hospital, 730, seasonal maximum, 731

London, smallpox of 1628 in, 435, annual deaths 1629-61, 436-437, epidemic of 1641, 437, after the Restoration, 437, ratio of adult cases 17th cent., 444, mild type in 1667-9, 452, compared with that of 1751, 455, estimate of proportion of faces marked by, 454, epidemic of 1694, 458, of 1710, 461, annual deaths 1701-20, 461, private hospitals for, 463, public hospital for, 505, 533, prevalence in middle of 18th cent., 529, table of weekly deaths in 1752, 532, smaller mortality of infants from than in provincial towns, 534, annual deaths 1761-1800, 535, in the Foundling Hospital, 550, annual deaths 1801-37, 568, epidemic of 1817-19, 580, in Christ’s Hospital in 1818, 581, epidemic of 1825, 593, annual deaths 1837-1893, 613, excessive incidence of from 1871 to 1885, 616, age, sex and fatality of in epidemic of 1871-72, 618, varying fatality of from 1871 to 1893, 619, fatality at each age-period in 1893, 619, ages at death from in 1845, 624

London, whooping-cough, ratio of to all deaths 1731-1831, 647, annual mortality 1701-1782, 669, same from 1783 to 1812, 655

Londonderry, sickness in siege of, 229, cholera in 1832, 818

Louis, P. Ch. A _fièvre typhoide_, 196 _note_

Lower, Richard, against bark in fever, 323, his advice to Queen Mary, 459

Lucas, James, typhus in Leeds, 146, smallpox and inoculation, 510, 555

Lucretius, air-borne infection, 408

Lynn, smallpox in 1819, 580

Lynn, Walter, opposes blooding in smallpox, 449, smallpox in 1710-14, 462

Macaulay, Lord, on the Soho plague-pit, 38, eloquent on smallpox, 454, on the death of Queen Mary, 460 _note_

McCarthy, Alexander, state of Skibbereen in 1826, 274

Maidstone, gaol fever at, 153, diphtheria and ground-water, 744

Maitland, Charles, inoculator, 467-71

Mallet, Mr, catalogue of earthquakes, 407

Malthus, T. R., population and potatoes, 253, 284, 285 _note_, one infection will replace another, 629

Manchester, miliary fever becomes rare, 131, increase of population, 146, typhus in end of 18th cent., 149, statistics of fever hospital, 164, distress and typhus 1839-41, 197, amount of enteric fever in 1836, 201, typhus in 1847, 207, in 1863-5, 209, smallpox in 18th cent., 536, extent of early vaccination, 583, mortality by smallpox in 1826, 593, measles in 18th cent., 644, scarlatina in 1805, 722, cholera nostras in 1794, 773, cholera in 1832, 826, in 1849, 846

Manningham, Sir Richard, on “little” or hysteric fever, 70

Mapletoft, Dr, his experience of smallpox, 546

Mary, Queen of William III, dies of smallpox, 459

=Marsh fevers= distinct from epidemic agues, 302, 367, 369

=Marshalsea prison=, state of in 1729, 91

Mason, Simon, on ague-curers, 325

Massey, Isaac, smallpox seldom fatal in schoolboys, 545

Mather, Cotton, instigates to inoculation, 485

Maty, M. defends Gatti’s inoculations, 496, proposes general inoculation of infants, 506

May, William, fever and influenza in Cornwall, 373

Mead, Richard, the Dunkirk rant, 340, no failures of inoculation, 487, 488

=Measles=, etymology of, 632, _variolae_ translated by, 633, in 17th cent., 634, 640, Sydenham on, 635, indirect mortality from in 1674, 636, in 18th cent., 641, at Manchester, 644, at Northampton, 645, in the Foundling Hospital, 646, increased fatality at end of 18 cent., 647, anomalous at Uxbridge, 649, the great epidemic of 1807-8, 651, the epidemic in Glasgow, 652, comparison of in London and Glasgow, 655, Watt’s doctrine of substitution, 655-7, reception of same, 657, sequelae of, 659, recent statistics of, 660, recent highest death-rates from, 663, progression of epidemics, 663, season of, 664, age-incidence of, 664, an illustrative epidemic of, 665

Merthyr Tydvil, enteric fever, 219, cholera in 1849, 844-5, 847, in 1854, 851, in 1866, 857

=Miasmatic infection=, Sydenham’s and Boyle’s doctrine of, 29, 400, of enteric fever, 222-3, of endemic ague, 302, of influenza in, 401-5, after earthquakes, 415-20, of dengue, 424, not excluded in scarlatina, 732, of diphtheria, 745, of dysentery, 788, of cholera, 842

Middlesborough, enteric fever, 221

=Miliary fever=, 72, 76, 124, 127, 128-131

=Milk=, a vehicle of enteric fever, 222, of scarlatina, 734, of diphtheria, 745

Millar, Dr, isolation of fever patients, 178

Miller, Hugh, Cromarty cholera, 814

Molyneux, Dr, influenza of 1688, 336, of 1693, 337

Minorca, localized influenza of 1748, 352, mild and severe smallpox, 547

Missenden, Great, inoculation revived, 592

Moir, D. M., Musselburgh cholera, 806

Monro, Alexander, primus, influenza of 1762, 357 _note_, procuring the smallpox in Scotland, 471, inoculation in same, 509

Monro, A. Campbell, measles at Jarrow, 663

Monro, Donald, war typhus, 110

Montagu, Lady Mary Wortley, favours inoculation, 467-8, referred to in prize poem, 588

Moore, John, on “putrid” fevers, 130, improved health of London, 133

Morley, Christopher Love, epidemic agues and influenzas of 1678-79, 329, 332

Morton, Richard, worm fever, 7, scale of malignity in fevers, 16, fevers of 1678-80, 21, smallpox not fatal to infants, 441, opposed to the cooling regimen in do., 448, fourteen things that make smallpox severe, 451-2, pock-pits, 456, measles of 1674, 657, his view of scarlatina, 682, cholera nostras, 771, dysentery infective, 772

Moryson, Fynes, dietetic habits of Irish, 226

Moseley, Benjamin, practice of vaccination in 1808, 586

Moss, Mr, Liverpool public health 18th cent., 141 _note_, 368

Mudge, John, experiment in inoculation, 501, 558

Mulgrave, Lord, vaccination among rich and poor, 589

Murchison, Charles, enteric fever in Edinburgh, 200, cause of increase of same in London, 202, history of relapsing fever 1842, 203, enteric of 1846, 206 _note_, table of typhus in hospitals, 210, confuses marsh agues with epidemic agues, 303-4 _note_, cerebro-spinal fever a variety of typhus, 863

=Murre=, old name of influenza, 305, 432

Musselburgh, cholera in 1832, 806

Nairn, war typhus in 1746, 109, cholera in 1832, 813-14

=Navy=, health of in 17th cent., 102, in 18th cent., 104, Smollett on, 107 _note_, in the Seven Years’ War and American War, 111-117, improvement in, 119

Neath, high scarlatina death-rate, 728, cholera in 1849, 845, in 1866, 857

=Nervous= fever, of Willis in 1661, 5, or hysteric, 67, 70, of Wintringham and Hillary, 72, of Gilchrist, 75, of Huxham, 76, or putrid, 120-128

Nettleton, Thomas, pioneer of inoculation, 470, inspires Jurin, 479, gives a real smallpox, 483, his theory of inoculation, 483-4, ceases to inoculate, 485, his statistics of smallpox fatality, 518

=New= acquaintance, 308, ague, 306, 307, delight, 332, disease, 312-13, 344, Boyle on, 313 _note_, distemper of 1688, 335, fever of Sydenham, 23, 27

Newburn, cholera of 1832, 804

Newcastle-on-Tyne, typhus in 18th cent., 142, 156 _note_, in 1816-19, 172, “jolly rant” of 1675, 327 _note_, agues of 1780, 369, inoculation of infants, 507, no smallpox statistics, 539, comparison of inoculations and vaccinations, 582, scarlatina in 1778-9, 712, in 1779-1802, 720, in 1802-27, 723, dysentery 18th cent., 780, 784, cholera of 1831-2, 802, cholera of 1853, 849

Newcastle-under-Lyme, cholera of 1849, 847

Newhaven, cholera of 1848, 835

Newman, John Henry, priests in the Irish fever, 207 _note_, “chemists for our cooks,” 280

Newton Stewart, smallpox of 1816, 574

Norfolk Island, strangers’ cold of, 432

North, Roger, his fever in 1661, 8, on Lord Guildford’s fever, 321, fashion of blood-letting, 325 _note_

Northampton, smallpox statistics in 1747, 524, vital statistics, 525, measles and whooping-cough 18th cent., 645, infantile diarrhoea, 765

Norwich, high mortality of 1740-42, 82, smallpox beginning of 19th cent., 569, 578, epidemic of 1819, 578, vaccinations at, 585, inoculations at, 591, smallpox in 1838-9, 605, infantile diarrhoea, 766

=Notification= at Leeds in 1804, 180 _note_, and incorrect diagnosis, 864

Nottingham, fever in 1808, 165, 18th cent. smallpox, 522, infantile diarrhoea, 761-2

O’Brien, John, Dublin dysentery in 1825, 271, relapsing fever in 1826, 272, intermittents in 1827, 273, 297

O’Brien, W. Smith, native resources of Ireland, 281

O’Connell, Daniel, export of Irish corn in famine, 280

O’Connell, Maurice, Irish famine of 1740, 241, dysentery from it, 242, the mortality from it, 244

O’Connor, Dennis, types of fever in Cork 1849-65, 297

O’Rourke, Rev. John, history of the Irish famine of 1847, 279 _note_

Ogle, William, influenza mortality, 395, progression of measles epidemics, 663, age and sex in scarlatina deaths, 729, diarrhoea and heat, 762

Oglethorpe, General, reports on state of gaols, 91

=Old Bailey=, black assize of 1750, 93

Ormerod, E. L., relapsing fever with miliaria, 129, 208

Oxford, fevers of children in 1655 and 1661, 5-7, epidemic fever in Wadham College, 59, typhus in 1785, 153, smallpox in 1649 and 1654, 437, in 1661, 439, usually mild, 444, cholera of 1854, 851 _note_

Paderborn, sickness in British troops, 110

Painswick, typhus in 1785, 154, epidemic agues, 369, general inoculation, 509, smallpox fatal during typhus, 550

Paisley, an epidemic of fever in 1811, 165, cholera of 1831-2, 813

Palatinate, war typhus of 1621, 32

=Parish Clerks of London=, the bills of become inadequate, 385, 594, 596, statistics of smallpox from in 1628, 435, scarlatina appears in, 725

Paris, type of fever in 1700, 53, smallpox of adults in 1825, 593, same compared with Glasgow in 1850-51, 601, 611, whooping-cough in 1578, 666, cholera of 1832, 821, 830 _note_

Parkin, John, epidemics and electricity, 406 _note_, cholera water-borne, 832

Parsons, H. Franklin, reports on influenza of 1890-92, 396 _note_

Peacock, T. B., influenza of 1847, 391

Pearson, George, nature of cowpox, 560, cowpox not smallpox of the cow, 563, second infection with cowpox impossible, 610

Peel, Sir Robert, policy in Irish famine of 1817, 266, in famine of 1845-46, 279

=Peninsular War=, decline of fevers in Britain during, 162-64, 557, 569

Pepys, Samuel, fever of 1661, 9, of the queen in 1663, 13, of 1694, 44, duchess of Richmond’s smallpox, 454

Percival, Thomas, decline of miliary fever, 131, Manchester public health, 146, statistics of smallpox, 536, of measles, 644

Perkins, W. L., nosology of putrid sore-throats, 712 _note_

Perth, fever of 1622, 30, enteric fever in 1864, 210, cholera of 1832, 813-14

Peru, influenza of 1759, 354, earthquake of 1687, 421, influenza of 1720, 422

=Pestilential fever=, 16, 22, 30, 67, in London in 1773, 137

Peterborough, plague in 1666-7, 34

Pettenkofer, Max von, infection in the subsoil, 403, English officials prejudiced against his doctrine, 859

=Peyer’s patches=, theoretical relation of to ague, 2, found diseased in London fevers, 186, in Anstruther fevers, 189

Philadelphia, measles brought to by Irish, 649

=Physicians, College of=, memorial against drink, 84, 756, inquiry on influenza of 1782, 363, their Dispensary, 462 _note_, declare inoculation in 1754 to be salutary, 516, 608, but in 1807 to be mischievous, 609, inquiries on cholera of 1849, 846 _note_

=Plague=, extinction of, 34-43, effects of upon Chester, 40, alarm of in 1710, 58, rumour of in London in 1799, 140

Plot, Robert, smallpox mild, 444

Plymouth, 18th cent. types of fever, 74, worm fever, 75, malignant fever, 77, ship fever, 78, anginose fever, 125, 699, dysentery and fever after Corunna, 166, influenza of 1729, 345, horse-colds, 345-6, influenza of 1733, 347, of 1743, 351, of 1788, 371, influenza in the fleet in 1782, 426, smallpox of 1724-25, 520, malignant sore-throat, 695, 699, recent measles and scarlatina, 720, dysentery, 778, cholera of 1832, 829

Pockpitted faces, in 17th cent. London, 454, the Vaccine Board on decrease of, 456 _note_

Poland, buying the smallpox in, 473

Popham, John, Cork workhouse in 1846, 286

=Population=, increase of North of Trent, 144, in Ireland, 250, after potato famine, 283, principle of, 657

Port Royal, earthquake of 1692, 415

Portsmouth, dysentery in crews in 1696, 104, ship fever in 1779, 116, influenza in new arrivals in 1788, 372, agues and fluxes, 772

=Posse=, old name of influenza or catarrh, 305 _note_, 308 _note_

=Potatoes=, in Ireland, 241, 252, 284

Preston, infantile diarrhoea, 705, suffers little from cholera, 823

=Prices=, in 18th cent., 62, 131, in 1801, 159, in second half of French war, 162, 256-7, effects of fall of in Ireland, 268

Prichard, J. C., Bristol fever 1817-19, 173, cases not isolated, 179

Pringle, Sir John, ventilation of Newgate, 94, war dysentery and typhus, 108-10, nosology of continued fevers, 130, improved state of London, 133, little smallpox in campaigns, 545, dysentery rarely epidemic in London, 779 _note_

=Prisons=, state of early in 18th cent., 90-92, Howard’s visitations of, 95, Lettsom’s cases of fever in, 97, fever in 1785-88, 153, little smallpox in, 544, Neild’s reforms of, 628

Pulteney, R., Blandford, smallpox, 513

=Purples=, meaning of, 680

=Putrid fever=, in the sense of Willis, 16, in 18th century sense, 120-8, 129-30, 683, 700

=Putrid measles=, 705

Pylarini, Jacob, on transplantation of smallpox, 465, 476

=Quarantine=, for plague pressed on the Ministry by Swift, 58 _note_, in the cholera of 1831-32, 794, 798, 799, 814, 820

Queensferry North, vaccinations during an epidemic, 585

Radcliffe, John, attends Queen Mary in smallpox, 460 _note_ Ranby, John, his pamphlet against Jurin, 481 _note_, his inoculation practice, 504

Reid, John, enteric fever at Edinburgh, 199

Reid, Seaton, relapsing synocha, 177

=Relapsing fever=, case of in London 1710, 57, in 1727-29, 69, 74, at Edinburgh 1735, 76, in Gloucestershire in 1794, 156, in London in 1817, 168, 172, affinities of, 177, in Scotland in 1817-19, 174, in 1827-28 181, in London, 182, in Scotland in 1842-44, 203, in 1847, 208, in 1869-71, 210, in Dublin in 1738, 239, in 1746-48, 243, in Ireland in 1799-1801, 450, in 1817-19, 266, in 1826, 271-2, in 1846-7, 289, not always associated with want, 211

=Remittent fever=, 68, 69 _note_, 72, in London in 1751-55, 122, Cormack on, 392 _note_

Reynolds, Revell, epidemic agues of 1780, 366

=Rheumatic fever=, its relation to dysentery, 782

=Rickets= in London 18th cent., 756, relation of to infantile diarrhoea, 766

Rigby, Edward, vaccinations at Norwich, 584

Ripon, fevers at in 1726-28, 72

Roberton, John, vaccination at Manchester, 583, smallpox after vaccination, 597 _note_, measles in Edinburgh 1808, 651, criticism of Watt, 658

Robertson, Robert, ship fever, 114, influenza of 1782 in the fleet, 426, no fatalities in smallpox, 546

Rochdale, fever of 1818, 171

Rogan, Francis, slaughter-houses not noxious, 236 _note_, population in Tyrone 1817, 253, cottiers in same, 255, famine of 1817, 257, dysentery and fever of, 258-260, ratio of attacks, 263, smallpox in the famine of 1817, 573

Rogers, James E. Thorold, starvation wages 18th cent., 62, Malthus and high standard of living, 285 _note_

Rogers, Joseph, criticism of Sydenham, 10, epidemic in Wadham College, 59, fevers in Cork 18th cent., 234

=Roseola=, epidemic, supposed the scarlatina of Sydenham, 681

Rouen, epidemic fever of 1753-4, 121

Royston, William, epidemic agues of 1780 and 1808, 378 _note_

Rumsey, Henry, epidemic sore-throat in Chesham, 715, “the croup” in the same, 716

Rush, Benjamin, smallpox after inoculation, 488, infantile diarrhoea, 758

Russell, Lord John, cost of Irish potato famine, 282

Russell, James B., scarlatina from cows’ milk, 734 _note_

Ruston, Thomas, antidotes to smallpox, 494 _note_

Rutty, John, “putrid” fevers in Dublin, 127, 245, nervous and relapsing fevers, 239, 240, 243, famine fever of, 1740 244, agues and horse-colds, 354, smallpox in Ireland, 543, malignant during typhus, 549, throat-distemper of 1743, 693

Ryan, Dennis, dysentery in transports, 784

St Andrews, smallpox in 1818, 575, dysentery in 1736, 778

St Kilda, strangers’ cold, 431

Salford, infantile diarrhoea, 761-2, 765 _note_, cholera of 1832, 828

Salisbury, smallpox in 18th cent., 528, cholera in 1832, 829, in 1849, 847

Sanderson, J. B., diphtheritic membrane, 740 _note_

Sauvages, F. B. de, his nosology, 670, 678

=Scarlatina= and diphtheria, 18th cent., 678, simplex of Sydenham, 680, of Sibbald, 681, perhaps epidemic roseola, 681 _note_, Morton’s view of, 682, anginosa at Edinburgh, 684, at Plymouth, 684, popular name of epidemic sore-throat, 687, 697, 701, Cotton’s name for epidemic sore-throat in 1748, 698, called miliary, 688, 703, diagnosis from anomalous measles, 649, 705, mild at Ipswich in 1771, 708, anginosa in London in, 1777 708, Withering on, 711, Heberden on, 712 _note_, Willan’s statistics 1786, 714, Rumsey on, 715, epidemic period 1796-1805, 719, mildness of type 1805-31, 722-5, modern statistics of, 726, incidence on age and sex, 729, range of fatality, 730, fatalities at home and in hospital, 730, alleged influence of drought, 731, maximum in late autumn, 731, question of miasma, 732, uncertainty of its contagion, 733, in children’s hospitals, 733, from cows’ milk, 734, as a septic disease, 735

Schacht, Lucas, fevers of Leyden, 332

Schultz, Simon, buying the smallpox, 473

=Scurvy=, supposed prevalence of on land in 17th cent., 1, 317, 319

Sedgley, cholera of 1832, 825

=Seven ill years=, fevers of in Scotland, 47-52

=Sewerage= of London 858, of Lancashire towns, 209, defects of in new mining townships, 220, 845

Shapter, Thomas, influenza contagious, 387, Exeter, cholera in 1832, 829

Sharkey, Edmond, Asiatic cholera in 1837 at Berehaven, 834 _note_

Sheffield, vital statistics of 17th cent., 58, epidemic sore-throat 18th cent., 696, 704, diarrhoea during cholera, 842 _note_, cholera in 1849, 848

=Ships=, cholera in, 826, 857, fever in, _see_ Navy, influenza in, 425-31

Short, Thomas, scarlatina in 1759, 704

Sibbald, Sir Robert, diseases of Scots 17th cent., 48, bleeding in smallpox, 447, scarlatina, 681

Simon, Sir John, inquiry on diphtheria, 739, general principles of sanitation, 834, report on Newcastle cholera in 1853, 849

=Simple continued fever=, a common form in the epidemic of 1817-19, 168-174, relation of to relapsing fever, 177, 272, in London 1826-28, 182, in Bristol, 189 _note_, 176, recent statistics of, 212, 216, 296

Simpson, Sir J. Y., cholera of 1832, 815 _note_

Simpson, William, choleraic season of 1678, 333

Sims, James, London typhus in 1786, 138, Tyrone fevers 18th cent., 127, 246, smallpox, 543, London scarlatina in 1786, 713, in 1798, 719

Skibbereen, dysentery in 1826, 273, exports of food from, 280, sicknesses of the great famine, 286, 287, 288

Slatholm, Dr, against blooding and cooling in smallpox, 447, smallpox transferred to a sheep, 475

Sligo, cholera of 1832, 818

Sloane, Sir Hans, Jamaica earthquakes, 415, procures account of inoculation, 465, advises the king on same, 469

=Smallpox=, references to before 1660, 434, after the Restoration, 437, alleged increase of fatality, 439, alleged mildness in infants, 441, largely a disease of adults in 17th cent., 443, the cooling regimen in, 445, Morton on the causes of a severe type, 451, marks of a recent epidemic visible, 454, estimate of the numbers marked by in 17th cent., 455, London deaths by from 1661 to 1700, 456, in the country at end of 17th cent., 458, death of Queen Mary from haemorrhagic form of, 458, epidemic in 1710, 461, a trouble in great houses, 462, houses for, kept by nurses, 463, at Boston, New England, in 1721, 485, 626, at Charleston, 490, hospital in London for, 505, at Blandford, 513, in the Foundling Hospital, 514, table of epidemics of from 1721 to 1729, 518, at Hertford in 1721, 519, at Plymouth in 1724, 520, at Aynho, 520, at Hastings, 521, at Nottingham, 522, at Edinburgh 18th cent., 523, at Northampton, 524, at Boston, 525, 540, at Kilmarnock, 526, intervals between epidemics of, 527, various epidemics 1751-53, 529, London deaths 1721-60, 531, weekly deaths in 1752, 532, among London infants, 533, London deaths 1761-1800, 535, 18th cent. statistics of Manchester, Liverpool, Chester, Carlisle and Glasgow, 536-40, in parishes of Scotland 18th cent., 541, in Ireland, 543, in the army and navy, 543, wide range of fatality, 544, comparison of epidemics at Chester and Warrington, 550, summary of 18th cent. history, 556, London deaths by from 1801 to 1837, 568, Glasgow deaths 1801-1812, 569, epidemic of 1817-19, 571, the crystalline form of, 574-7, at Norwich in 1819, 578, in Christ’s Hospital, 581, the epidemic of 1825-26, 593, so-called “secondary,” 597, a generation of in Glasgow, 597, in Limerick 1830-40, 601, the epidemic of 1837-40, 604, legislation for in 1840, 606, ages of at Paris and Glasgow compared, 611, more adults attacked abroad than in Britain, 612, London deaths by from 1837 to 1893, 613, table for England, 614, comparison of the epidemics of 1837-40 and 1871-72, 615, has almost ceased in rural parts, 616, London’s recent share of, 617, recent rates of fatality from, 618, in Ireland since 1864, 620, in Scotland since 1855, 622, varying ratios of children and adults attacked at various periods of history, 622-7, reason why fewer children attacked in epidemic of 1871-72, 627, Watt’s doctrine of substitution applied to, 629

Smollett, Tobias, sick bay of the ‘Cumberland,’ 107 _note_

Snow, John, water-borne cholera, 852, 854

Southampton, a 17th cent, autopsy at, 316

Spalding, diphtheria, 739, 740

Spelman, Sir Henry, on burials, 37

=Spotted fever= in 17th and 18th cent., 13, universal in 1623, 31, cases in Archbishop’s family, 64, Arbuthnot on, 67, return of after 1831, 188, 277

Stark, James, sex-fatality in whooping-cough, 672 _note_

Stewart, Frances, her beauty after smallpox, 453

Stokes, William, Dublin enteric fever in 1826, 187 _note_

Story, Rev. George, camp sickness at Dundalk, 230-2

Stow, John, irregular building of London out-parishes, 85-6

Strabane, a congested district in 1817, 253, fever and dysentery in, 259-60, 263, smallpox in 1817, 573

Stranraer, smallpox in 1829, 600

Streater, Aaron, ague curer, 316

Streeten, R. J. N., influenza of 1837, 387 _note_

Strother, Edward, London fevers of 1727-29, 68-70

Stroud, tests of cowpox at, 565

Sturges, Octavius, whooping-cough mimetic, 677

Sudell, Nicholas, ague curer, 317

Sunderland, recent typhus in, 214, 217, cholera begins at, in 1831, 796

=Surfeit=, meaning of, 775

Sutherland, John, reports on cholera of 1848-49, 837-8, 840

Sutton, Daniel, his method of inoculation, 498

=Sweat, the=, late reference to by Shakespeare, 311 _note_

Sweden, early statistics of whooping-cough, 670

Swift, Jonathan, urgent for quarantine, 58 _note_, the stinks in his London lodging, 87, state of Ireland in 1729, 238, on an ague curer, 325

Sydenham, Thomas, on succession of epidemic types, 4, 631, his epidemic constitutions, 9, on intermittents, 11, 302, 314, on comatose fever, 20, on depuratory fever, 21, on the “new fever” of 1685-6, 22, 24, 27, his theory of subterranean miasmata, 29, 80, a Scotch disciple of, 48, on marsh agues, 302, his position in the bark controversy, 320, 321-2, on influenza of 1675, 327, of 1679, 329, on epidemic agues of 1678-80, 331, his view of influenza, 399, his practice in smallpox, 445, smallpox most fatal to the rich, 450, on measles in 1670 and 1674, 655, on pertussis, 677, on scarlatina, 680, on diarrhoea in infants, 749, on cholera nostras, 770, on dysentery, 776

Symonds, John Addington, Bristol cholera in 1832, 828

Tain, cholera in 1832, 814

Talbor, Sir Richard, ague curer, 318, his use of bark, 319, 322

=Tar-water=, in fever, 242, in smallpox, 546

Taunton, dysentery in 1837, 790

Tavistock, cholera in 1849, 847

Tawton, North, epidemic fever of 1839, 196

Tees valley, enteric fever in, 221

Tewkesbury, burial in coffins, 36

Thackrah, Charles T., Leeds cholera nostras in 1825, 773

Theydon Bois, cholera in 1865, 857

Thompson, Theophilus, his ‘Annals of Influenza,’ 360 _note_

Thomson, John, smallpox of 1817-19, 575-6

Thoresby, Ralph, on influenza of 1675, 327, loses his children by smallpox, 458

Thorne, Richard Thorne, diphtheria from cow’s milk, 745 _note_

Thorp, Dr, Leeds fevers in 1802, 160

=Throat distemper=, _see_ Scarlatina

Timoni, Emanuel, first writer on inoculation, 463, visited by La Motraye, 472 _note_, his inoculated daughter dies of smallpox, 488

Tiverton, fever of 1741, 80

Torbay, influenza on board ships in, 426

Torthorwald, 18th cent. fevers, 154, vital statistics, 542

Torrington, strange experience of, in the influenza of 1782, 364

Toynbee, Arnold, the industrial revolution, 145

Tralee, typhus, 259, cholera in 1849, 840

Trallianus, Alexander, dysenteria rheumatica, 782

Tranent, cholera in 1832, 806

=Transplantation= of disease, 474

Tristan d’Acunha, strangers’ colds, 431

Tronchin, Theodore, inoculation by blister, 493

Trotter, Thomas, ship fever, 117, Northumberland fevers 18th cent., 156 _note_, smallpox in the navy, 544

Turner, John, influenza of 1712, 340

Tullamore, panic at, from fever of 1817, 262

Tynemouth, cholera in 1849, 846, in 1853, 850, in 1854, 851

=Type, change of=, in continued fever, 2, 189, 203, 277, in scarlatina, 724, 730

=Typhoid fever= _see_ Enteric

=Typhus=, _see_ also Simple Continued, Nervous, Putrid, Miliary, Pestilential, War, Gaol, Ship and Workhouse fevers. Perennial in London in 17th and 18th cent., 13, 67, epidemic of 1685-6 identified as, 27, the type of universal fever in 1623-4, 31, corresponds to the malignant fever of 1694, 44, among children at Bristol in 1696, 47, in Scotland at end of 17th cent., 48, 49, at Paris in 1700, 53, a case in London in 1709, 53, in Chester Castle in 1716, 60, or _synochus_ at York in 1718, 63, in 1728, 73, at Plymouth in 1735, 77, the type in the English epidemic of 1741-42, 83, and in the Irish, 243, circumstances of severe type of, 98-102, 290, relation of to dysentery, 108, 231, 792, in Lettsom’s dispensary practice, 136, identified by Hunter in London with gaol or hospital fever, 138, described by Sims in 1786, 138, by Willan in 1799, 139, by Currie at Liverpool, 141, at Newcastle, 142, 156 _note_, at Chester, 143, at Leeds, 146, 160, at Carlisle, 147, at Manchester, 149, 157, at Lancaster, 151, at Whitehaven, 152, in England generally 1782-85, 153, in Scotland, 154, 161, reference to by Robert Burns, 154 _note_, epidemic of 1799-1802, 160, in Ireland, 248, epidemic of in fiction in 1811, 162 _note_, decline of in second period of French war, 163, 167, epidemic of 1817-19, in England, 168, rare in the Scotch epidemic of same years, 175, in the Irish epidemic, 258, in Galway in 1822, 270, the common type of continued fever from 1831 to 1848, 188-198, the epidemic of 1847 in England, 205, in Scotland, 208, 839 _note_, in Ireland, 289-92, of the Lancashire cotton famine, 209, prevalence of relative to enteric, 211, recent decrease of, 214, 606, recent highest death-rates, 214, 217, mistaken for typhoid, 214, table of for Scotland, 216, for Ireland, 296

Tyrone, over-population in, 254, effects of the famine of 1817-19, 264

Ulverston, smallpox in 1816, 573

Uxbridge, measles in 1801, 649

=Vaccinal Syphilis=, real nature of, 562 _note_

=Vaccination=, rival of inoculation, 557, its pathological nature, 559-562, tests of its efficacy, 564, approved by the State, 567, extent of its practice to 1825, 582-6, Gregory on the effect of upon the London smallpox of, 1825 595, reasons for treating it as irrelevant to the epidemiology of smallpox, 596, prejudices of working class against, 606-7, made compulsory in 1853 on the precedent of 1840, 610, of adults, or re-vaccination, common on the Continent sooner than in Britain, 611-3 _see_ also Cowpox

=Vagrancy= in Irish famines, 244, 261, 267

“=Variolae Vaccinae=,” figurative name of cowpox, 563

=Ventilation= of gaols, 94, of ships, 118. _See_ also Window-tax.

Verdier, Jean, vaccination incorrect in principle, 587

=Vibrios= in cholera, 827 _note_

Virchow, Rudolph, dysentery and typhus, 108 _note_, season of epidemic typhoid in Berlin, 217

Voltaire, M. de, his mythical account of inoculation in Circassia, 473 _note_

Wagstaffe, William, objects to inoculation, 478, 607

Wakefield, dysentery in asylum, 787

Wakley, James, carries Bill against inoculation, 607

Walker, George A., London graveyards, 87

Walker, John, “vaccinates” with smallpox, 590

Walker, Patrick, sickness in the seven ill years, 50, epidemic agues in Scotland, 341

Wall, John, fever of 1741, 83, epidemic sore-throat of 1748, 701-2, relation of same to murrain, 736 _note_

Wall, Martin, Oxford typhus in 1785, 153

Walpole, Horace, on middle-class comfort, 60, suffers from nervous fever, 71 _note_, influenza of 1743, 350, horse-cold of 1760, 355, deaths by sore-throat in 1760, 703

=War typhus= at Chester in 1716, 60, at Feckenheim in 1743, 108, in 1746, 109, at Paderborn in 1761, 110, from Peninsular War, 166

Ward, T. Ogier, Wolverhampton cholera, 825

Ware, inoculation after an epidemic, 511

Warren, Dr, of Boston, two forms of influenza in successive seasons, 398 _note_

Warren, H., scarlatina anginosa in Barbados 1736, 684

Warrington, fevers at in 1773, 148, smallpox in 1773, 537, 553, comparison of with Chester as regards infant mortality, 551-5, cholera of 1832, 829 _note_

=Water= from reservoirs, a source of enteric fever, 220 _note_, 221, and _note_, 222 _note_, a source of cholera, 832, 848, at Newcastle in 1853, 550, in London, 853, 859

=Water= from wells, a source of enteric fever, 219 _note_, source of dysentery, 791, source of cholera, 848, the Broad St pump, 854, Theydon Bois, 857

=Water= in the subsoil, relation to enteric fever, 217, 221, Arbuthnot on its relation to influenza, 403-4, 408, relation to scarlatina years or season, 731, to diphtheria at Maidstone, 744, to cholera at Bilston, 824, 830, to cholera in east of London 1866, 859, to cholera in the endemic area of Bengal, 861

Waterford, fever hospital founded in 1799, 249, statistics of fever 1817-19, 266

Watson, Sir Thomas, epidemic fever of 1837-39 all typhus, 194, “threw the agy off his stomach,” 318 _note_, cause of intestinal irritation in scarlatina, 697 _note_, rarity of dysentery, 790

Watson, Sir William, peeling of skin after influenza, 351, inoculation trials at the Foundling, 500, 503, smallpox in the Foundling, 514, 550, putrid measles in same, 705, dysentery in 1762, 779

Watt, Robert, Glasgow vital statistics, 539, 569, 654, vaccination no direct effect on measles fatality, 583, decline of smallpox, 597, its place taken by measles, 629, 653-8, statistics of whooping-cough, 675, meaning of “bowel-hive,” 758 _note_

Watts, Giles, mildness of Sutton’s inoculation, 499

Webster, Noah, his theory of influenza, 405-7, influenza of 1781 in America, 410, influenza at sea, 428, fatality of measles, 645, insanitary state of American towns, 685, angina of cats in Philadelphia &c., 719 _note_

West, Charles, nature of infantile remittent fever, 5, exanthematic typhus, 189, no enteric cases in 1837-8, 194

West Ham, diphtheria, 742

Wharekauri, strangers’ cold, 432

Whitaker, Tobias, smallpox more fatal after the Restoration, 439, blooding in smallpox, 447, prevention of pock-pits, 456

White, J., fevers in the navy 17th cent., 104

White, William, public health of York improves, 63

Whitehaven, gaol and ship fever, 114, fevers, 152, 156, few children die of them, 571, fatality of smallpox, 538, 547, vaccination supersedes inoculation, 582, 586, cholera in 1832, 829

Whitmore, H., influenzas and agues of 1658-9, 313, 362, opposes blooding in influenza, 381 _note_

=Whooping-cough= called “the kink” in medieval book, 666, little regarded till 18th cent., 668, apparent increase of London deaths, 669, nosologically recognized in Sweden, 670, various British statistics 18th cent., 670, recent statistics, 671, probable cause of higher fatality in females, 672, now heads list of its class, 673, as a sequel of other diseases, 674, its pathology, 676,

## partly contagious by mimicry, 677

Whytt, Robert, influenza of 1758, 353, smallpox fatal in 1758, 547

Wick, cholera of 1832, 815

Wilde, Sir W. R., census of Ireland after the famine, 292

Willan, Robert, London typhus in 1796-99, 139, agues, 373, measles, 648, 18th cent. throat distempers all scarlatinal, 679, 737, the Foundling epidemic of 1763, 705, scarlatina of 1786, 713, of 1796-1801, 719, uncertainty of scarlatinal contagion, 733, dysentery in 1800, 785

Williams, Robert, on 17th cent. agues and dysenteries in London, 304 _note_, electrical theory of influenza, 406 _note_

Willis, Thomas, epidemic fever of 1661, 4-7, cases and postmortem of, 6, scale of malignity in fevers, 16, epidemic agues of 1657-58, 314, refers to bark in 1660, 320, smallpox at Oxford in 1649 and 1654, 437, less danger from smallpox in childhood, 441, opinion on Duke of York’s children, 451, whooping-cough left to nurses, 667, convulsions, 749, cholera nostras of 1670, 772, symptoms of dysentery, 776

Wilson, Andrew, bilious colic, 771 _note_, Newcastle dysentery, 780

=Window-tax=, effects of on health, 88, history of, 88

Wintringham, Clifton, typhus in Yorkshire in 1718, 63, nervous fevers, 72, 73, agues, 341, influenza of 1729, 345, measles, 642, angina and miliary fever, 683

Withering, William, describes scarlatina anginosa in 1778, 710-12

Witney, fever in 1818, 170

Wolverhampton, cholera in 1832, 825, in 1849, 845

Woodward, John, treatment of smallpox, 449

Woodville, William, history of the Inoculation Hospital, 505, value of inoculation, 516, recent vaccination does not keep off smallpox, 565

Worcester, gaol typhus, 153, epidemic sore-throat, 701, infantile diarrhoea, 765-6

=Workhouses= fever in English, 47, 79, 126, 137, 154, 168; established in Ireland, 267, fever in, 286, 289, 293

Wordsworth, William, distress of 1794, 156

=Worm fever=, 7, 75, 111, 247

Worthing, enteric fever in 1893, 220

=Yellow fever= in the navy, 17th cent., 102

York, improved public health 18th cent., 63

Youghal, cholera in 1837, 835 _note_

Young, Arthur, prices and wages in 1801, 159, potatoes in Ireland, 252, potatoes as the English staple food, 284, Warrington industry, 551

Ystradyfodwg, enteric fever, 220

Cambridge: PRINTED BY C. J. CLAY, M.A. AND SONS, AT THE UNIVERSITY PRESS.

FOOTNOTES:

[1] James Lind, M.D., _Two Papers on Fevers and Infection_. Lond. 1763, p. 79.

[2] _Observations on Fevers and Febrifuges._ Made English from the French of M. Spon. London, 1682.

[3] James Hutchinson, M.D., _De Mutatione Febrium e tempore Sydenhami, etc._ Edin. 1782. Thesis.

[4] _Observationes Medicae_, 3rd ed. 1676, I. 2. § 23. English by R. G. Latham, M.D.

[5] Reports of Whitehaven Dispensary (Dixon) and of Nottingham General Hospital (Clarke), cited in the sequel.

[6] Rilliet, _De la Fièvre Typhoïde chez les Enfants_, Thèse, Paris, _2 Janv. 1840_, based on 61 cases; West, _Diseases of Infancy and Childhood_, 3rd ed. Lond. 1854.

[7] “Febris epidemicae cerebro et nervoso generi potissimum infestae, anno 1661 increbescentis descriptio,” in _Pathologia Cerebri_, Cap. VIII, “De Spasmis universalibus qui in febribus malignis” etc., Eng. transl. p. 51.

[8] “Itaque ventrem inferiorem primo aperiens, viscera omnia in eo contenta satis sana et sarte tecta inveni”--the small intestine being telescoped in several places.

[9] Elsewhere he says the first case of the series was “circa solstitium hyemale anno 1655.”

[10] _De Febribus_, chapter “De febribus pestilentibus.”

[11] _Treatise on the Infantile Remittent Fever._ London, 1782.

[12] _Pyretologia_, 2 vols. Lond. 1692-94, i. 68, at the end of “Synopsis Febrium”:--“Febris verminosa, quae nulli e specibus memoratis praecisé determinari potest.”

[13] Häser gives a reference to an essay in which Willis’s fever of 1661 is compared to enteric fever: C. M. W. Rietschel, _Epidemia anni 1661 a Willisio et febris nervosa lenta ab Huxhamio descriptae, etc. cum typho abdominali nostro tempore obvio comparantur_. Lips. 1861. Not having found this essay, I cannot say on what grounds the comparison is made.

[14] _Lives of the Norths._ New ed. by Jessopp. 3 vols. 1890, iii. 8, 21.

[15] _Diary of John Evelyn, Esq., F.R.S., 1641-1706_, under the date of 18 Sept.

[16] _Diary of Samuel Pepys, Esq., F.R.S., 1659-69._

[17] An analysis of the four Hippocratic constitutions, with modern illustrative cases, is given by Alfred Haviland, _Climate, Weather, and Disease_. London, 1855.

[18] _Epist. I. Respons._ § 57. Greenhill’s ed. p. 298.

[19] Tillison to Sancroft, 14 Sept. 1665. Cited in former volume, p. 677: “One week full of spots and tokens, and perhaps the succeeding bill none at all.”

[20] H. Clutterbuck, M.D., _Obs. on the Epidemic Fevers prevailing in the Metropolis_. Lond. 1819, pp. 58-60.

[21] Horace Walpole’s _Letters_ give two instances: he himself had never set foot in Southwark; a small tradesman in the City had never heard of Sir Robert Walpole.

[22] _Transactions of the College of Physicians_, iii. 366.

[23] Willis, Op. ed. 1682, Amstelod. p. 110. “De febribus pestilentibus”: “Etenim vulgo notum est febres interdum populariter regnare, quae pro symptomatum vehementia, summa aegrorum strage, et magna vi contagii, pestilentiae vix cedant; quae tamen, quia putridarum typos innotantur, nec adeo certo affectos interemunt aut alios inficiunt haud _pestis_ sed diminutiori appellatione _febris pestilens_ nomen merentur. Praeter has dantur alterius generis febres, quarum et pernicies et contagium se remissius habent, quia tamen supra putridarum vires infestae sunt, et in se aliquatenus τὸ θεῖον Hippocratis continere videntur, tenuiori adhuc vocabulo _febres malignae_ appellantur.”

The war-typhus of 1643, which was sometimes bubonic, and was succeeded by plague in 1644, is given as an example of _febris pestilens_; the epidemic of 1661 as an example of _maligna_.

[24] _Pyretologia_, i. 68.

[25] C. L. Morley, _De morbo epidemico, in 1678-9, narratio_. Lond. 1680.

[26] Guido Fanois, _De morbo epidemico hactenus inaudito, praeterita aestate anni 1669 Lugduni Batavorum vicinisque locis grassante_. Lugd. Bat. 1671.

[27] Brownrigg cites the Leyden epidemic of 1669, which he calls an intermitting fever, as an instance of the effects of changes in the ground water; it was “powerfully aggravated by the mixture of salt water with the stagnant water of the canals and ditches. This fever happened in the month of August, 1669, and continued to the end of January, 1670.” “Observations on the Means of Preventing Epidemic Fevers.” Printed in the _Literary Life of W. Brownrigg, M.D., F.R.S._ By Joshua Dixon, Whitehaven, 1801.

[28] _Obs. Med._ 3rd ed., v. 2.

[29] _Epist. I. Respons._ §§ 56, 57.

[30] _Pyretologie_, i. 429.

[31] John Lamport _alias_ Lampard, _A direct Method of ordering and curing People of that loathsome disease the Smallpox_. Lond. 1685, p. 28.

[32] _Hist. MSS. Com._ v. 186. Duke of Sutherland’s historical papers.

[33] _Schedula Monitoria I._ “De novae febris ingressu.” §§ 2, 3.

[34] _Ibid._ § 46.

[35] In the Belvoir Letters (_Hist. MSS. Com. Calendar_) Charles Bertie writes from London to the Countess of Rutland, 26 January, 1685, that “many are sick of pestilential fevers.” Evelyn says that the winter of 1685-6 was extraordinarily wet and mild, but does not mention sickness until June, 1686, when the weather was hot and the camp at Hounslow Heath was broken up owing to sickness.

[36] Evelyn’s _Diary_, which gives other particulars, including a description of the ice-carnival on the Thames.

[37] Thomas Short, M.D. of Sheffield, _New Observations on City, Town and Country Bills of Mortality_. London, 1750.

[38] Freind (_Nine Commentaries upon Fever, &c._, engl. by Dale, Lond. 1730, p. 4) has the following general criticism upon Sydenham’s varying constitutions of fevers: “I believe also I may truly affirm that those very fevers which Sydenham explains as distinct species, according to the various temperature of the seasons, do not differ much from one another. For, if perhaps you should except the _Petechiae_, they differ rather in degree than in kind. There hardly ever appeared a fever in any season where the signs so constantly answered one another, that those which you found collected in one person should unite after the same manner in another; however upon this account you would not deny their labouring under the same distemper.”

[39] _Tractatus de Podagra_, § 35. Greenhill’s edition, p. 428.

[40] _Chronicle of Perth_ (Maitland Club) under date 14 Oct. 1621.

[41] Thorold Rogers, _Hist. of Agric. and Prices_, sub anno.

[42] _Extracts from Kirk Session Records._ Spalding Club, 1846.

[43] _Chronicle of Perth._

[44] _History of the Burgh of Dumfries._ By W. MacDowall. 2nd ed. Edin. 1873, p. 381.

[45] _Court and Times of James I._, ii. 331.

[46] _Ibid._, under date 25 Oct. 1423.

[47] _Ibid._, ii. 439.

[48] _Cal. Coke MSS._ (Hist. MSS. Com.) i. 158.

[49] _C. and T. James I._, ii. 469.

[50] Mayerne, _Opera Medica_, Lond. 1700.

[51] _Ibid._, ii. 473.

[52] Janus Chunradus Rhumelius, _Historia morbi, qui etc._ Norimb. 1625.

[53] W. D. Cooper, _Archæologia_, XXXVII. (1857) p. 1. I had overlooked this important paper on English plagues in my former volume. The chief additional facts that it contains are the very severe plague at Cambridge in the summer of 1666, the deaths of 417 by plague at Peterborough in 1666, and of 8 more in the first quarter of 1667, and the slightness of the Nottingham outbreak, which was in August, 1666 (p. 22).

[54] _London Gazette_, 17-21 June, 1675, repeated in the number for 28 June-1 July.

[55] Brand, _Hist. of Newcastle_, II. 509. Report contradicted on 18 Dec.

[56] “The habitations of the poor within or adjoining to the City,” says Willan, “have suffered greatly; and some, I am informed, have been almost depopulated, the infection having extended to every inmate. The rumour of a plague was totally devoid of foundation.”

[57] Rudder, _A New History of Gloucestershire_, 1779, P. 737.

[58] Spelman, _De Sepultura_. English ed. 1641, p. 28. He cites the burial fees paid to the parson as twice as much for coffined as for uncoffined corpses. This agrees on the whole with the evidence adduced in the former volume of this history, p. 335.

[59] 18 and 19 Car. II. cap. 4; 30 Car. II. (1), cap. 3. These Acts were repealed by 54 Geo. III., cap. 108.

[60] _History of England_, I. 359.

[61] He has one or two relevant remarks: “But while we suppose common worms in graves, ’tis not easy to find any there; few in churchyards above a foot deep, fewer or none in churches, though in fresh-decayed bodies. Teeth, bones, and hair give the most lasting defiance to corruption. In an hydropsical body, ten years buried in the churchyard, we met with a fat concretion [adipocere] where the nitre of the earth and the salt and lixivious liquor of the body had coagulated large lumps of fat into the consistence of the hardest Castille soap, whereof part remaineth with us. The body of the Marquis of Dorset seemed sound and handsomely cereclothed, that after seventy-eight years was found uncorrupted. Common tombs preserve not beyond powder: a firmer consistence and compage of parts might be expected from arefaction, deep burial, or charcoal.”

[62] One may allege poverty on general grounds, as well as on particular. Thus, in 1636, the mayor was unpopular: “He was a stout man and had not the love of the commons. He was cruel, and not pitying the poor, he caused many dunghills to be carried away; but the cost was on the poor--it being so hard times might well have been spared.” Ormerod, I. 203.

[63] Printed plague-bill, with MS. additions, Harl. MS. 1929.

[64] Haygarth, _Phil. Trans._, LXVIII. 139.

[65] Cotton Mather’s _Magnalia_. Ed. of 1853, I. 227.

[66] _History of England &c._, IV. 707. Evelyn (_Diary, 21 May, 1696_) says the city was “very healthy,” although the summer was exceeding rainy, cold and unseasonable.

[67] Thomas Dover, M.B., _The Ancient Physician’s Legacy_. London, 1732, p. 98.

[68] Broadsheet in the British Museum Library.

[69] Tooke, _Hist. of Prices_, Introd.

[70] _Scotia Illustrata._ Edin. 1684. Lib. II. p. 52.

[71] Fynes Morryson, _Itinerary_, 1614. Pt. III. p. 156.

[72] Edinburgh, 1691, p. 67.

[73] _The Epilogue to the Five Papers, etc._ Edin. 1699, p. 22. This title refers to a controversy on the use of antimonial emetics in fevers. See Dr John Brown’s essay on Dr Andrew Brown, in his _Locke and Sydenham_, new ed. Edinb., 1866.

[74] He adds that “the fever has several times before been in my family and among my servants and children.” In mentioning the case of the Master of Forbes in August, 1691, whom he cured, he remarks that “the malicious said he was under no fever”; to disprove which Dr Brown refers to the symptoms of frequent pulse, watching and raving, continual vomiting, frequent fainting, and extreme weakness.

[75] Andrew Fletcher, _Two Discourses_. 1699.

[76] The English Government took off the Customs duty upon victual imported from England to Scotland, and placed a bounty of 20_d._ per boll upon it.

[77] Patrick Walker, _Some Remarkable Passages in the Life and Death of Mr Daniel Cargill, &c._ Edinb. 1732. (Reprinted in _Biographia Presbyteriana_. Edinb. 1827, II. 25.)

[78] Sir John Sinclair’s _Statistical Account of Scotland_. 1st ed. III. 62.

[79] _Ibid._ II. 544.

[80] _Ibid._ VI. 122.

[81] In the remote parish of Kilmuir, Skye, the famine is referred to the year 1688, “when the poor actually perished on the highways for want of aliment.” (_Ibid._ II. 551.) In Duthil and Rothimurchus, Invernessshire, the famine is referred to 1680, “as nearly as can be recollected:” “A famine in this and the neighbouring counties, of the most fatal consequence. The poorer sort of people frequented the churchyard to pull a mess of nettles, and frequently struggled about the prey, being the earliest spring greens.... So many families perished from want that for six miles in a well-inhabited extent, within the year there was not a smoke remaining.” (_Ibid._ IV. 316.) In the Kirk session records of the parish of Kiltearn, Rossshire, which I have seen in MS., there are various entries in the year 1697 relating to badges of lead to be worn by those licensed to beg from door to door: on 12 April, 34 such persons are named, and on 19 April, Robert Douglas was reimbursed for the cost of 35 badges. On 2 Aug., the number of poor who were to receive each from the heritors ten shillings Scots reads like “nighentie foure.”

[82] John Freind, M.D., _Nine Commentaries on Fevers_, transl. by T. Dale. London, 1730.

[83] _Cal. Coke MSS._ II. 405.

[84] Joannes Turner, _De Febre Britannica Anni 1712._ Lond. 1713, p. 3. “Vere proximè elapso, per Gallias passim ingravescere coeperunt febres mali moris in nobiles domos, et regiam praecipue infestae; quò Ludovicum Magnum ipsa infortunia ostenderent Majorem, et patientia Christianissima Maximum.”

[85] From London, on 25 February, 1701, we hear of the illness from a violent fever of Mr Brotherton, at his house in Chancery Lane; he was member for Newton, and Mr Coke was advised to look after his seat. A letter of 18 April, 1701, from Chilcote, in Derbyshire, says that it has been a sickly time in these parts and that a certain lady and her daughter were both dead and to be buried the same day. In the same correspondence, cases of fever in London are mentioned on 18 June and 4 December the same year (1701). _Cal. Coke MSS._ II. 421, 424, 429, 441.

[86] _Tractatus Duplex._ Lond. 1710. Engl. transl. 1737, p. 253.

[87] W. Butter, M.D., _A Treatise on the Infantile Remittent Fever_. Lond. 1782.

[88] Philip Guide, M.D., _A Kind Warning to a Multitude of Patients daily afflicted with different sorts of Fevers_. Lond. 1710.

[89] One death from “malignant fever,” two from scarlet fever.

[90] Hunter’s _Hallamshire_, ed. Gatty.

[91] Brand, _Hist. of Newcastle_, II. 308. Swift writes to Stella on 8 December, 1710: “We are terribly afraid of the plague; they say it is at Newcastle. I begged Mr Harley [the Lord President] for the love of God to take some care about it, or we are all ruined. There have been orders for all ships from the Baltic to pass their quarantine before they land; but they neglect it. You remember I have been afraid these two years.” The orders referred to were probably the Order of Council of 9 Nov. 1710. Parliament met on the 25th Nov. and passed the first Quarantine Act (9 Anne, cap. II.). Swift had a good deal to say with Ministers on many subjects, and it is not impossible, however absurd, that his had been the first suggestion to Harley of a quarantine law. I had purposed including a history of quarantine in Britain, but can find no convenient context for it. I shall therefore refer the reader to the historical sketch which I have appended to the Article “Quarantine” in the _Encyclopaedia Britannica_, 9th ed.

[92] _Essay on Epidemic Diseases._ Dublin, 1734, p. 34.

[93] Dr Guide, a Frenchman, who had been in practice in London for many years, says in his _Kind Warning to a Multitude of Patients daily afflicted with different sorts of Fevers_ (1710) “the British physicians and surgeons are lately fallen into an unhappy and terrible confusion and mixture of honest and fraudulent pretenders.” Another writer of 1710, Dr Lynn, quoted in the chapter on Smallpox, implies that physicians were taking an unusually cynical view of their business. The most interesting essay of the time on fevers is by J. White, M.D. (_De recta Sanguinis Missione &c._ Lond. 1712), a Scot who had been in the Navy and afterwards in practice at Lisbon; but it throws no light upon the London fevers.

[94] Elizabeth, Lady Otway, to Benj. Browne, Dec. 1st and 15th, 1715, and Feb. 16, 1716. _Hist. MSS. Com._ X. pt. 4, p. 352; Hemingway’s _Hist. of Chester_, II. 244.

[95] _Letters_, ed. Cunningham, I. 72.

[96] Lecky, _History of England in the Eighteenth Century_, VI. 204:--“All the evidence we possess concurs in showing that during the first three-quarters of the century the position of the poorer agricultural classes in England was singularly favourable. The price of wheat was both low and steady. Wages, if they advanced slowly, appear to have commanded an increased proportion of the necessaries of life, and there were all the signs of growing material well-being. It was noticed that wheat bread, and that made of the finest flour, which at the beginning of the period had been confined to the upper and middle classes, had become before the close of it over the greater part of England the universal food, and that the consumption of cheese and butter in proportion to the population in many districts almost trebled. Beef and mutton were eaten almost daily in villages.”

[97] _Six Centuries of Work and Wages_, pp. 398-415.

[98] _Gentleman’s Magazine_, 1766.

[99] Short.

[100] Clifton Wintringham, M.D., _Commentarium nosologicum, morbos epidemicos et aeris variationes in urbe Eboracensi locisque vicinis ab anno 1715 usque ad finem anni 1725 grassantes, complectens_. Londini, 1727.

[101] W. White, M.D., _Phil. Trans._ LXXII. (1782), p. 35. The annual deaths under the old _régime_ exceeded by a good deal the annual births: in the seven years 1728-35, according to the figures from the parish registers in Drake’s _Eboracum_, the burials from all causes were 3488, and the baptisms 2803, an annual excess of 98 deaths over the births in an estimated population of 10,800 (birth-rate 37 per 1000, death-rate 46 per 1000). But in the seven years, 1770-76, the balance was the other way: the population had increased by two thousand (to 12,800), and the births were on an average 20 in the year more than the deaths (474 births, 454 deaths), the birth-rate being still 37 per 1000, and the death-rate fallen to 35 per 1000. But the correctness of these rates depends on the population being exactly given.

[102] “There has been very great mobbing by the weavers of this town, as they pretend, because they are starved for want of trade; and they pull the calico cloaths off women’s backs wherever they see them. The Trainbands have been up since last Friday, and they were forced to fire at the mobb in Moor Fields before they would disperse, and four or five were shott and as many wounded.” (Benjamin Browne to his father, 16 June, 1719: Mr Browne’s MSS. _Hist. MSS. Com._ X. pt. 4, p. 351.) The calicoes which the London weavers tore from the backs of women were doubtless the Indian fabrics brought home by the ships of the East India Company. These imports were so injurious to home manufactures that an Act had been passed in 1700 prohibiting (with some exceptions) the use in England of printed or dyed calicoes or any other printed or dyed cotton goods. This prohibition was re-enacted in 1721, two years after the rioting at Moorfields. (7 Geo. I. cap. 7). Blomefield (_Hist. of Norfolk_, III. 437) says that at Norwich also there was tearing of calicoes, “as pernicious to the trade” of that city. On the 20th of September, 1720, a great riot arose there, the rabble cutting several gowns in pieces on women’s backs, entering shops to seize all calicoes found there, beating the constables, and opposing the sheriff’s power to such a degree that the company of artillery had to be called out.

[103] Ambrose Warren to Sir P. Gell, 16 Sept. 1718, _Hist. MSS. Com._ IX. pt. 2, p. 400 _b_.

[104] The sudden rise was due to influenza; but the fever mortality was high for weeks before and after.

[105] John Arbuthnot, M.D., _Essay concerning the Effects of Air on Human Bodies_. Lond. 1733, p. 187.

[106] Edward Strother, M.D., _Practical Observations on the Epidemical Fever which hath reigned so violently these two years past and still rages at the present time, with some incidental remarks shewing wherein this fatal Distemper differs from Common fevers; and more particularly why the Bark has so often failed: and methods prescribed to render its use more effectual. In which is contained a very remarkable History of a Spotted Fever._ London, 1729. This book was written before the influenza of the end of 1729. At p. 126 the author was writing on the 24th of May, 1728. The preface is undated.

[107] Bernard de Mandeville, M.D., _A Treatise of the Hypochondriack and Hysteric Diseases_, 3rd ed. 1730, 1st ed. 1711. It contains nothing about the “little fever.”

[108] Richard Blackmore, M.D., _A Discourse upon the Plague, with a prefatory account of Malignant Fever_. London, 1721, p. 17.

[109] W. Cockburn, M.D., _Danger of improving Physick, with a brief account of the present Epidemick Fever_. London, 1730.

[110] I am the more persuaded of the identity with relapsing fever of much that was called remittent in Britain, and even intermittent, after reading the highly original treatise by R. T. Lyons on _Relapsing or Famine Fever_, London, 1872, relating to the epidemics of it in India.

[111] Huxham, _On Fevers_, chap. VIII.

[112] Murchison, _Continued Fevers of Great Britain_, 2nd ed. Lond. 1873, p. 423.

[113] Sir Richard Manningham, Kt., M.D. _Febricula or Little Fever, commonly called the Nervous or Hysteric Fever, the Fever on the Spirits, Vapours, Hypo, or Spleen_. 1746.

[114] It is clear that the nervous fever established itself as a distinct type in England in the earlier part of the 18th century, both in medical opinion and in common acceptation: thus Horace Walpole, writing from Arlington Street on 28 January, 1760, says: “I have had a nervous fever these six or seven weeks every night, and have taken bark enough to have made a rind for Daphne: nay, have even stayed at home two days.” _Letters of Horace Walpole_, ed. Cunningham, iii. 281.

[115] _Commentar. Nosol._ u. s.

[116] William Hillary, M.D., “An Account of the principal variations of the Weather and the concomitant Epidemical Diseases from 1726 to 1734 at Ripon.” App. to _Essay on the Smallpox_, Lond. 1740.

[117] Brand, _History of Newcastle_, ii. 517, says that the magistrates of that town made a collection for the relief of poor housekeepers in the remarkably severe winter of 1728-29, the sum raised being £362. 18_s._

[118] Tooke, _History of Prices from 1793 to 1837_. Introd. chap. p. 40.

[119] _Ancient Physician’s Legacy._ Lond. 1733, p. 144.

[120] “In the year 1727,” says Hillary, “I ordered several persons to lose 120 to 140 ounces of blood at several times in these inflammatory distempers, with great relief and success; whereas, in this winter [1728] I met with few, and even the strong and robust, who could bear the loss of above 40 or 50 ounces of blood, at three or four times; but, in general, most of the sick could not bear bleeding oftener than twice, and then not to exceed 30 or 34 oz. at most, at two or three times; and especially those who had been afflicted with, and debilitated by, the intermitting fever in the autumn before,--these could not bear blooding oftener than once, or twice at most, and in very small quantities too, though the acuteness of the pain, and the other symptoms in all, seemed at first to indicate much larger evacuations that way; but the first bleeding often sunk the pulse and strength of the patient so much that I durst not repeat it more than once, and in some not at all.” Hillary, u. s. p. 26.

[121] _Edin. Med. Essays and Obs._ I-VI. This annual publication was the original of the _Transactions_ of the Royal Society of Edinburgh.

[122] _Ibid._ I. 40; II. 27; II. 287 (St Clair’s case); IV.

[123] Huxham, _De aere et morbis_.

[124] Ebenezer Gilchrist, M.D., “Essay on Nervous Fevers.” _Edin. Med. Essays and Obs._ IV. 347, and VI. (or V. pt. 2), p. 505.

[125] _Ibid._ V. pt. 1, p. 30.

[126] _Obs. de aere et morbis_; also his essay _On Fevers_.

[127] Hillary, App. to _Smallpox_, 1740, pp. 57, 66.

[128] Mr Lecky (_History of England in the 18th Century_), II., says that the famine and fever of 1740-41, which he describes as an important event in the history of Ireland, “hardly excited any attention in England.” It was severely felt, however, in England; and if it excited hardly any attention, that must have been because there were so many superior interests which were more engrossing than the state of the poor.

[129] _Gent. Magaz._ X. (1740), 32, 35. Blomefield, for Norwich, says that many there would have perished in the winter of 1739-40 but for help from their richer neighbours.

[130] W. Allen, _Landholder’s Companion_, 1734. Cited by Tooke.

[131] _An Inquiry into the Nature, Cause and Cure of the present Epidemic Fever ... with the difference betwixt Nervous and Inflammatory Fevers, and the Method of treating each_, 1742, p. 54.

[132] John Altree, _Gent. Magaz._ Dec. 1741, p. 655.

[133] White, _ibid._ 1742, p. 43.

[134] Dunsford, _Historical Memorials of Tiverton_. The accounts of the great weaving towns of the South-west are not unpleasing until we come to the time when they were overtaken by decay of work and distress, from about 1720 onwards. The district, says Defoe, was “a rich enclosed country, full of rivers and towns, and infinitely populous, in so much that some of the market towns are equal to cities in bigness, and superior to many of them in numbers of people.” Taunton had 1100 looms. Tiverton in the seven years 1700-1706 had 331 marriages, 1116 baptisms, 1175 burials (a slight excess), and an estimated population of 8693, which kept nearly at that level for about twenty years longer (from 1720 to 1726 the marriages were 284, the baptisms 1070 and the burials 1175).

[135] _Gent. Magaz._ XI. (1742), p. 704.

[136] Blomefield, _History of Norfolk_ III. 449.

[137] Arnot, _History of Edinburgh_, 1779, p. 211.

[138] _Gent. Magaz._ 1741, p. 705.

[139] _Edin. Med. Essays and Obs._ I. Art. 1.

[140] _Gent. Magaz._ 1742, p. 186.

[141] John Wall, M.D., _Medical Tracts_, Oxford, 1780, p. 337. See also _Obs. on the Epid. Fever of 1741_, 3rd ed., by Daniel Cox, apothecary, with cases.

[142] _Edin. Med. Essays and Obs._ VI. 539.

[143] “And here I cannot but observe how many ignorant conceited coxcombs ride out, under a shew of business, with their lancet in their pocket, and make diseases instead of curing them, drawing their weapon upon every occasion, right or wrong, and upon every complaint cry out, ‘Egad! I must have some of your blood,’ give the poor wretches a disease they never might have had, drawing the blood and the purse, torment them in this world,” etc.--_An Essay on the present Epidemic Fever_, Sherborne, 1741. The practice of blood-letting in continued fevers received a check in the second half of the 18th century, but it was still kept up in inflammatory diseases or injuries. Even in the latter it was freely satirized by the laity. When the surgeon in _Tom Jones_ complained bitterly that the wounded hero would not be blooded though he was in a fever, the landlady of the inn answered: “It is an eating fever, then, for he hath devoured two swingeing buttered toasts this morning for breakfast.” “Very likely,” says the doctor, “I have known people eat in a fever; and it is very easily accounted for; because the acidity occasioned by the febrile matter may stimulate the nerves of the diaphragm, and thereby occasion a craving which will not be easily distinguishable from a natural appetite.... Indeed I think the gentleman in a very dangerous way, and, if he is not blooded, I am afraid will die.”

[144] Munk, _Roll of the College of Physicians_, II. 53.

[145] _Gentleman’s Magaz._ III. 1733, Sept., p. 492.

[146] _Effects of Air on Human Bodies_, 1733, pp. 11, 17. His excellent remarks on the need of fresh air in the treatment of fevers, two generations before Lettsom carried out the practice, are at p. 54. The curious calculation above cited was copied by Langrish, and usually passes as his.

[147] “Also without the bars both sides of the street be pestered with cottages and alleys even up to Whitechapel Church, and almost half a mile beyond it, into the common field: all which ought to be open and free for all men. But this common field, I say, being sometime the beauty of this city on that part, is so encroached upon by building of filthy cottages, and with other purprestures, enclosures and laystalls (notwithstanding all proclamations and Acts of Parliament made to the contrary) that in some places it scarce remaineth a sufficient highway for the meeting of carriages and droves of cattle. Much less is there any fair, pleasant or wholesome way for people to walk on foot, which is no small blemish to so famous a city to have so unsavoury and unseemly an entrance or passage thereunto.” Stow’s _Survey of London_, section on “Suburbs without the Walls.”

[148] The line of an old field walk can still be followed from Aldermanbury Postern to Hackney, Goldsmiths’ Row being one of the wider sections of it.

[149] Luttrell’s _Diary_ 10 June, 1684.

[150] Roger North’s “Autobiography,” in _Lives of the Norths_, new ed. 3 vols., 1890, III. 54.

[151] Willan, 1801: “The passage filled with putrid excremental or other abominable effluvia from a vault at the bottom of the staircase.” See also Clutterbuck, _Epid. Fever at present prevailing_. Lond. 1819, p. 60. Ferriar, of Manchester, writing of the class of houses most apt to harbour the contagion of typhus, says, “Of the new buildings I have found those most apt to nurse it which are added in a slight manner to the back part of a row, and exposed to the effluvia of the privies.”

[152] C. Davenant to T. Coke, London, 14 Dec. 1700. _Cal. Coke MSS._, II. 411, “I heartily commiserate your sad condition to be in the country these bad weeks; but I fancy you will find Derbyshire more pleasant even in winter than the House of Commons will be in a summer season. For, though it be now sixteen years ago [1685], I still bear in memory the evil smells descending from the small apartments adjoining to the Speaker’s Chamber, which came down into the House with irresistible force when the weather is hot.”

[153] _Report on the Diseases in London, 1796-1800._ Lond. 1801.

[154] John Ferriar, M.D., _Medical Histories and Reflections_. London 1810, II. 217.

[155] Heysham, _Jail Fever at Carlisle in 1781_. Lond. 1782, p. 33.

[156] John Howard, _State of the Prisons_.

[157] _Notes and Queries_, 4th ser. XII. 346. Jenkinson, who was a Minister under George II., was reputed to have set an example of stopping up windows in his mansion near Croydon:

You e’en shut out the light of day To save a paltry shilling.

Others had boards painted to look like brickwork, which could be used to cover up windows at pleasure.

[158] Petition, undated, but placed in a collection in the British Museum among broadsides of the years 1696-1700. In 1725 the imprisoned debtors at Liverpool petitioned Parliament for relief, alleging that they were reduced to a starving condition, having only straw and water at the courtesy of the serjeant. _Commons’ Journals_, XX. 375.

[159] _Commons’ Journals_, 20 March, 1728/29, 14 May, 1729, 24 March, 1729/30.

“Mrs Mary Trapps was prisoner in the Marshalsea and was put to lie in the same bed with two other women, each of which paid 2_s._ 6_d._ per week chamber rent; she fell ill and languished for a considerable time; and the last three weeks grew so offensive that the others were hardly able to bear the room; they frequently complained to the turnkeys and officers, and desired to be removed; but all in vain. At last she smelt so strong that the turnkey himself could not bear to come into the room to hear the complaints of her bedfellows; and they were forced to lie with her on the boards, till she died.”

[160] _Political State of Great Britain_, XXXIX. April, 1730, pp. 430-431, 448.

[161] _Gent. Magaz._, XX. 235. This authority is twenty years after the event, the incident having been recalled in 1750, on the occasion of the Old Bailey catastrophe.

[162] Huxham.

[163] See the former volume of this History, pp. 375-386.

[164] _A Report &c. and of other Crown Cases._ By Sir Michael Foster, Knt., some time one of the Judges of the Court of King’s Bench. 2nd ed. London, 1776, p. 74.

[165] The _Gentleman’s Magazine_ however says (1750, p. 235): “There being a very cold and piercing east wind to attack the sweating persons when they came out of court.”

[166] See Bancroft, _Essay on the Yellow Fever, with observations concerning febrile contagion etc._ Lond. 1811.

[167] _Gent. Magaz._ 1750, p. 274: “Many families are retired into the country, and near 12,000 houses empty”--an impossible number.

[168] Sir John Pringle, _Observations on the Nature and Cure of the Hospital and Jayl Fever_. Letter to Mead, May 24. London, 1750.

[169] One of the cases was that of an apprentice: “Some of the journeymen working in Newgate had forced him to go down into the great trunk of the ventilator in order to bring up a wig which one of them had thrown into it. As the machine was then working, he had been almost suffocated with the stench before they could get him up.” Pringle, “Ventilation of Newgate,” _Phil. Trans._ 1753, p. 42.

[170] Thomas Stibbs to Sir John Pringle, Jan. 25, 1753. _Ibid._ p. 54.

[171] “Ventilators some years since when first introduced, it was thought, would prove an effectual remedy for and preservative against this infection in jails; great expectations were formed of their benefit, but several years’ experience must now have fully shewn that ventilators will not remove infection from a jail.” Lind, _Means of Preserving the Health of Seamen in the Royal Navy_. New ed. Lond. 1774, p. 29.

[172] J. C. Lettsom, M.D., _Medical Memoirs of the General Dispensary in London, 1773-4_. Lond. 1774.

[173] _Gent. Magaz._ 1776, April 22. p. 187.

[174] Lind, _Two Papers on Fevers and Infection_. Lond. 1763. pp. 90, 106. Many cases had buboes both in the groins and the armpits.

[175] Carmichael Smyth, _Description of the Jail Distemper among Spanish Prisoners at Winchester_ in 1780. Lond. 1795.

[176] _Cal. Coke MSS._ Hist. MSS. Commiss. i. 218.

[177] _Med. Hist. and Reflect._ ut infra.

[178] The following case, which happened five or six years ago, shows disparity of conditions in a twofold aspect. A lady from a city in the north of Scotland travelled direct to Switzerland to reside for a few weeks at one of the hotels in the High Alps. Within an hour or two of the end of her journey she began to feel ill, and was confined to her room from the time she entered the hotel. An English physician diagnosed the effects of the sun; the German doctor of the place, from his reading only, diagnosed typhus fever, which proved to be right, the patient dying with the most pronounced signs of malignant typhus. An explanation of the mystery was soon forthcoming. The lady had been a district visitor in an old and poor part of the Scotch city; she had, in particular, visited in a certain tenement-house in a court, from which half-a-dozen persons had been admitted to the Infirmary with typhus (an unusual event) at the very time when she was ill of it on the Swiss mountain.

[179] Blane, _Select Dissertations_. London, 1822, p. 1.

[180] Mather’s _Magnalia_. 2 vols. Hartford, 1853, i. 226 “Life of Sir William Phipps.” “Whereof there died, ere they could reach Boston, as I was told by Sir Francis Wheeler himself [‘but a few months ago’], no less than 1300 sailors out of 21, and no less than 1800 soldiers out of 24.” He had brought 1800 troops with him from England to Barbados in transports.

[181] Churchill’s Collection, VI. 173.

[182] W. Cockburn, M.D. _An Account of the Nature, Causes, Symptoms and Cure of the Distempers that are incident to Seafaring People._ 3 Parts. London, 1696-97.

[183] J. White, M.D. _De recta Sanguinis Missione, or, New and Exact Observations of Fevers, in which Letting of Blood is shew’d to be the true and solid Basis of their Cure, &c._ London, 1712. His chief point, that the strongest and lustiest were most obnoxious to malignant fevers, had been urged by Cockburn in 1696.

[184] Lind (_Two Papers on Fevers and Infection_, London, 1763, p. 113) gives an instance where the poisonous effluvia of the ship’s well did not spread through the ’tween decks: “The following accident happened lately [written in 1761] in the Bay of Biscay. In a ship of 60 guns, by the carpenter’s neglecting to turn the cock that freshens the bilge-water, which had not been pumped out for some time, a large scum, as is usual, or a thick tough film was collected a-top of it. The first man who went down to break this scum in order to pump out the bilge-water was immediately suffocated. The second suffered an instantaneous death in like manner. And three others, who successively attempted the same business, narrowly escaped with life: one of whom has never since perfectly recovered his health. Yet that ship was at all times, both before and after this accident, remarkably healthy.” It was the contention of Renwick, a naval surgeon who wrote in 1794, that it was the stirring of the bilge-water in being discharged from the ship’s well, or the adding of fresh water to the foul, that caused the offensive emanations. “Hence the first cause of febrile sickness in all ships recently commissioned.” Renwick made so much of the foul bilge-water as a cause that he thought the fevers ought to be termed “bilge-fevers.” _Letter to the Critical Reviewer_, p. 42.

[185] These particulars are not given in Freind’s special work on Peterborough’s campaign, which deals only with the military and political history, but in his _Nine Commentaries on Fever_ (Engl. ed. by Dale, London, 1730), and in a Latin letter to Cockburn, dated Barcelona, 9 Sept. 1706, which was first printed in _Several Cases in Physic_. By Pierce Dod, M.D. London, 1746.

[186] Smollett joined the ‘Cumberland’ as surgeon’s mate in 1740, before she sailed with the fleet sent out under Vernon and others to Carthagena. His account in _Roderick Random_ of the sick-bay of the ‘Thunder’ as she lay at the Nore is doubtless veracious: “When I observed the situation of the patients, I was much less surprised that people should die on board, than that any sick person should recover. Here I saw about fifty miserable distempered wretches, suspended in rows, so huddled one upon another that not more than fourteen inches space was allowed for each with his bed and bedding; and deprived of the light of the day, as well as of fresh air; breathing nothing but a noisome atmosphere of the morbid steams exhaling from their own excrements and diseased bodies, devoured with vermin hatched in the filth that surrounded them, and destitute of every convenience necessary for people in that helpless condition.” Chap. XXV. He wrote a separate account of the fatal Carthagena expedition in a compendium of voyages.

[187] Coxe’s _Life of Marlborough_. Bohn’s ed. I. 183.

[188] Grainger’s essay, _Historia febris anomalae Bataviae annorum, 1746, 1747, 1748, etc._ Edin. 1753, is chiefly occupied with an anomalous “intermittent” or “remittent” fever with miliary eruption, and with dysentery.

[189] For a full discussion of the relation of dysentery to typhus, see Virchow, “Kriegstypus und Ruhr.” _Virchow’s Archiv_, Bd. LII. (1871), p. 1.

[190] Sir John Pringle, _Obs. on the Nature and Cure of Hospital and Jayl Fever_, Lond. 1750 (Letter to Mead); and his _Obs. on Diseases of the Army_, Lond. 1752 (fullest account).

[191] Pringle, _Diseases of the Army_, pp. 40-45.

[192] _Ibid._ p. 68.

[193] Donald Monro, M.D. _Diseases of British Military Hospitals in Germany, from Jan. 1761 to the Return of the Troops to England in 1763._ Lond. 1764. The same campaign called forth also Dr Richard Brocklesby’s _Œconomical and Medical Observations from 1758 to 1763 on Military Hospitals and Camp Diseases etc._ London, 1764.

[194] _Essay on Preserving the Health of Seamen_, Lond. 1757; _Two papers etc._ u. s.

[195] In 1755 a pestilential sickness raged in the North American fleet, the ‘Torbay’ and ‘Munich’ being obliged to land their sick at Halifax.

[196] The _Gentleman’s Magazine_ for December, 1772 (p. 589), records the following: “The bodies of two Dutchmen who were thrown overboard from a Dutch East Indiaman, where a malignant fever raged, were cast up near the Sally Port at Portsmouth; they were so offensive that it was with difficulty that anyone could be got to bury them.”

[197] W. Brownrigg, M.D. _Considerations on preventing Pestilential Contagion._ London, 1771, p. 36.

[198] Lind writes in his book on the Health of Seamen, “The sources of infection to our armies and fleets are undoubtedly the jails: we can often trace the importers of it directly from them. It often proves fatal in impressing men on the hasty equipment of a fleet. The first English fleet sent last war to America lost by it alone two thousand men.”

[199] R. Robertson, M.D. _Observations on Jail, Hospital or Ship Fever from the 4th April, 1776, to the 30th April, 1789, made in various parts of Europe and America and on the Intermediate Seas._ London, 1789. New edition.

[200] Given by Blane in a Postscript to his paper “On the Comparative Health of the British Navy, 1779-1814” in _Select Dissertations_, London, 1822, p. 62.

[201] Blane, u. s. p. 47, from information supplied by Dr John Lind, of Haslar Hospital.

[202] _Diseases incident to Seamen_, p. 18.

[203] _Ibid._ p. 34.

[204] Trotter, _Medicina Nautica_, I. 61. His general abstracts of the health of the fleet in the first years of the French War, 1794-96, give many instances of ship-typhus.

[205] John Clark, M.D. _Observations on the Diseases which prevail in Long Voyages to Hot Countries, &c._ London, 1773. 2nd ed. 2 vols., 1792.

John Lorimer, M.D., published in _Med. Facts and Observations_, VI. 211, a “Return of the ships’ companies and military on board the ships of the H. E. I. C. for the years 1792 and 1793.”

+---------------------------------------------------------------+ | | Outward voyages | Homeward voyages | | | |-----------------|------------------| In port | | | Crew | Military | Crew | Invalids | | |----------------|------|----------|-------|----------|---------| | Number of men | 2657 | 3919 | 2701 | 1075 | -- | | Sick | 1253 | 1751 | 1058 | 282 | 1533 | | Dead | 28 | 50 | 51 | 27 | 96 |

[206] _Reflections and Resolutions for the Gentlemen of Ireland_, p. 28. Cited by Lecky.

[207] Sutton, “Changing Air in Ships,” _Phil. Trans._ XLII. 42; W. Watson, M.D. _ibid._ p. 62; H. Ellis, _ibid._ XLVII. 211.

[208] _Ibid._ XLIX. 332, “Ventilation of a Transport.”

[209] _Ibid._ pp. 333, 339.

[210] Lind, _Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy_. New Ed. London, 1774, p. 29.

[211] Blane, _Diseases incident to Seamen_, 1785, p. 243.

[212] _Id._ “On the Comparative Health of the British Navy from the year 1799 to the year 1814, with Proposals for its farther Improvement.” _Select Dissertations_, 1822, p. 1.

[213] Le Cat, _Phil. Trans._ XLIX. 49.

[214] “Its cause seemed to be something contagious mixed with the contents of the stomach and intestines, especially the bile and alvine faeces, which absorbed thence contaminates the whole body and affects especially the cerebral functions.” _Gent. Magaz._, Article signed “S,” 1755, p. 151.

[215] James Johnstone, M.D., senior, _Malignant Epidemic Fever of 1756_. London, 1758.

[216] Nash, _Hist. of Worcestershire_, II. 39, found evidence in the Kidderminster registers that the fevers of 1727, 1728 and 1729 had “very much thinned the people, and terrified the inhabitants.” Watson, “On the Medical Topography of Stourport,” _Trans. Proc. Med. Assoc._, II., had heard or read somewhere that fever was so bad in Kidderminster in the first part of the 18th century that farmers were afraid to come to market.

[217] Huxham, _Dissertation on the Malignant Ulcerous Sore-Throat_. Lond. 1757, p. 60.

[218] Tooke, _History of Prices_. Introduction.

[219] In Shrewsbury gaol, in 1756, thirty-seven colliers were confined for rioting during the dearth. Four of them died in gaol, ten were condemned to death, of whom two were executed. Phillips, _History of Shrewsbury_, 1779, p. 213.

[220] Johnstone, u. s. Short says: “a slow, malignant, putrid fever in some parts of Yorkshire, Cheshire, Worcestershire and the low parts of Leicestershire, which carried off very many.” In October, 1757, it set in at Sheffield and raged all the winter.

[221] Short, _Increase and Decrease of Mankind in England, etc._ London, 1767, p. 109.

[222] Charles Bisset, _Essay on the Medical Constitution of Great Britain_, 1 Jan. 1758, to Midsummer, 1760. Together with a narrative of the Throat-Distemper and the Miliary Fever which were epidemical in the Duchy of Cleveland in 1760. London, 1762, pp. 265, 270, &c.

[223] James Sims, M.D., _Obs. on Epid. Disorders_. Lond. 1773, p. 181.

[224] W. Hillary, M.D., _Changes of the Air and Concomitant Epid. Disorders in Barbadoes_. 2nd ed., Lond. 1766.

[225] _Tractatus duplex de Praxeos Regulis et de Febre Miliari_, Lond. 1710. Engl. transl. of the latter, Lond. 1737.

[226] Ormerod, _Clin. Obs. on Continued Fever_. London, 1848.

[227] _Historia Febris Miliaris, et de Hemicrania Dissertatio._ Auctore Joanne Fordyce, M.D., Londini, 1758. Symptoms at p. 16. In an Appendix Dr Balguy makes the following curious division of the miliary vesicles: the white in malignant continued fever, the dull red in remittent fever, the “almost efflorescent” in intermittent. Fordyce makes them to appear as early as the third day, and to begin to disappear in four or six days in favourable cases.

[228] London, 1773, p. 9. See also Sir W. Fordyce’s essay of the same year.

[229] John Moore, M.D., _Medical Sketches_, Lond. 1786. Part II. “On Fevers.” Referring to the “putrid” fever in particular, he says that certain unbelievers, of whom he was probably one, “assert that mankind are tenacious of opinions, when once adopted, in proportion as they are extraordinary, disagreeable and incredible.” Dr Moore is best known as the author of _Zeluco_.

[230] Haygarth, _Phil. Trans._ LXIV. 73.

[231] Percival, _ibid._ LXIV. 59.

[232] Hutchinson, u. s.

[233] _Annual Register_, 1766, p. 220. The King’s Speech on 11 Nov. was chiefly occupied with the dearth. The use of wheat for distilling was prohibited by an order of Council of 16 Sept. 1766. _Gent. Magaz._ p. 399. To show the hardships of the rural population at this time, Mr Gladstone, in a speech at Hawarden in 1891, read the following words copied from a stone set up in the park of Hawarden to commemorate the rebuilding of a mill: “Trust in God for bread, and to the king for protection and justice. This mill was built in the year 1767. Wheat was within this year at 9_s._, and barley at 5_s._ 6_d._ a bushel. Luxury was at a great height, and charity extensive, but the poor were starved, riotous, and hanged.”

[234] Lecky, III. 115.

[235] _Gent. Magaz._, series of letters by various hands in 1766. See also a long essay in the _Annual Register_ for 1767 (then edited by Edmund Burke), “On the Causes and Consequences of the present High Price of Provisions,” p. 165. The evidence of a rise in the standard of living, in the matter of dress and luxuries as well as of food, is equally clear from Scotland in the articles written by the parish ministers for the ‘Statistical Account.’

[236] For a judicious estimate of the value of the Parish Clerks’ bills of mortality see the elaborate paper by Dr William Ogle, _Journ. Statist. Soc._ LV. (1892), 437.

[237] _Diseases of the Army._ New ed. 1775, pp. 334-5. Pringle admitted, however, that “in some of the lowest, moistest and closest parts of the town, and among the poorer people, spotted fevers and dysenteries are still to be seen, which are seldom heard of among those of better rank living in more airy situations.”

[238] _Medical Sketches_, Lond. 1786, p. 464.

[239] Lecky, _History of England in the Eighteenth Century_, II. 636, generalizes the facts as follows: “The wealthy employer ceased to live among his people; the quarters of the rich and of the poor became more distant, and every great city soon presented those sharp divisions of classes and districts in which the political observer discovers one of the most dangerous symptoms of revolution.”

[240] “This disease, as it appears in jails and hospitals, has been well described by Sir John Pringle; and other authors have given accounts of it on board of ships, especially crowded transports and prison-ships, but I do not find that its originating in the families of the poor in great cities during the winter has been taken notice of.” _Med. Trans. Coll. Phys._ III. 345.

[241] He has been immortalised by Johnson’s verses:

“Well tried through many a varying year See Levett to the grave descend, Officious, innocent, sincere, Of every friendless name the friend. In misery’s darkest cavern known His ready help was ever nigh;” etc.

[242] John Coakley Lettsom, M.D., _Medical Memoirs of the General Dispensary in London, April 1773 to March 1774_. London, 1774.

[243] Nothing could be clearer than Dr John Arbuthnot’s reasoning and advice on this matter half a century before.

[244] London, 1775.

[245] _Med. Trans. of the Coll. Phys. Lond._ III. (1785), 345: “Observations on the Disease commonly called the Jail or Hospital Fever.” By John Hunter, M.D., physician to the army.

[246] James Sims, M.D., “Scarlatina anginosa as it appeared in London in 1786,” _Mem. Med. Soc. Lond._ I. 414. Willan, who saw the same epidemic of scarlatinal sore-throat in London in 1786, believed that the angina was also “connected with a different species of contagion, namely, that of the typhus or malignant fever originating in the habitations of the poor, where no attention is paid to cleanliness and ventilation.” _Cutaneous Diseases_, 1808, p. 333.

[247] The rumour of London fevers seems to have reached Barker, who kept an epidemiological record at Coleshill. Referring to the winter of 1788-89, he says: “At this time there were dreadful fevers in London, fatal to many, and a very infectious one in Coventry, of which many among the poor died, most of them being delirious, and many phrenetical.”

[248] Robert Willan, M.D., _Reports on the Diseases of London,

## particularly during the years 1796-97-98-99 and 1800_. London, 1801.

[249] He names specially some streets of St Giles’s parish, the courts and alleys adjoining Liquorpond Street, Hog-Island, Turnmill Street, Saffron Hill, Old Street, Whitecross Street, Golden Lane, the two Bricklanes, Rosemary Lane, Petticoat Lane, Lower East Smithfield, some parts of Upper Westminster, and several streets of Southwark, Rotherhithe, etc. “I recollect a house in Wood’s Close, Clerkenwell, wherein the fomites of fever were thus preserved for a series of years; at length an accidental fire cleared away the nuisance. A house, notorious for dirt and infection, near Clare-market, afforded a farther proof of negligence: it was obstinately tenanted till the wall and floors, giving way in the night, crushed to death the miserable inhabitants.”

[250] _Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and other Diseases._ 2nd ed., 1798. It need hardly be explained that Dr Currie was competent on fevers, his use of the clinical thermometer marking him as a man of precision. He is best known to the laity as the biographer of Robert Burns and the generous helper of the poet’s widow and family.

[251] “If it be supposed,” says Currie, “that some cases may be denominated typhus by mistake, let it be considered how many cases of this disease do not appear in the books of the Dispensary, though occurring among the poor, being attended by the surgeons and apothecaries of the Benefit Clubs to which they belong.”

[252] Moss (_A Familiar Medical Survey of Liverpool_, 1784), who had not the same means of knowing the prevalence of typhus in Liverpool as Currie, declares that “there has been but one instance of a _truly_ malignant fever happening in the town for many years; it was in the autumn of 1781, and appeared in Chorley Street, which is one of the narrowest and most populous streets in the town, and nine died of it in one week; it was only of short duration, and did not spread in any other part of the town.” He admits that the habitations of the poorer class were confined, being chiefly in cellars; yet the diet of the _sober_ and _industrious_ is wholesome and sufficient, the comfortable artizans being ship-carpenters, coopers, ropers and the like.

[253] John Clark, M.D., _Observations on the Diseases which prevail in Long Voyages_, &c. 2nd ed., Lond. 1792; _Account of the Newcastle Dispensary from its Commencement in 1777 to March 1789_, Newcastle, 1789; and subsequent Annual Reports.

[254] Haygarth, _Phil. Trans._ LXIV. 67; Hemingway, _History of Chester_, I. 344 _seq._

[255] Arnold Toynbee, _Lectures on the Industrial Revolution of the 18th Century, etc._ London, 1884.

[256] Toynbee (u. s.) says of the time before the mills were built: “The manufacturing population still lived to a very great extent in the country. The artisan often had his small piece of land, which supplied him with wholesome food and healthy recreation. His wages and employments too were more regular. He was not subject to the uncertainties and knew nothing of the fearful sufferings which his descendants were to endure from commercial fluctuations, especially before the introduction of free trade.”

[257] Percival, “Population of Manchester.” _Phil. Trans._ LXIV. 54.

[258] James Lucas, “Remarks on Febrile Contagion.” _London Medical Journal_, X. 260.

[259] In Appendix to Hutchinson’s _Cumberland_, 1794. Reprinted in Appendix to Joshua Milne’s _Valuation of Annuities_, Lond. 1815.

[260] John Heysham, M.D., _Account of the Jail Fever, or Typhus Carcerum, as it appeared at Carlisle in 1781_. London, 1782.

[261] Aikin, _Phil. Trans._ LXIV. 473.

[262] John Aikin, M.D., _The Country from 30 to 40 miles round Manchester_. Lond. 1795, p. 584.

[263] John Ferriar, M.D., _Medical Histories and Reflections_. 4 vols., 1810-13, I. 172.

[264] Ferriar, I. 261.

[265] _Ibid._ I. 234.

[266] _Ibid._ II. 213-20.

[267] _Ibid._ I. 153-6; and II. 57.

[268] Ferriar, I. 166-8.

[269] This is perhaps the first numerical evidence of the slight fatality of typhus in children. A more elaborate proof of the same was given long after by Geary for Limerick. An early age-table for Whitehaven is given under Smallpox, _infra_.

[270] David Campbell, M.D., _Observations on the Typhus or Low Contagious Fever_. Lancaster, 1785.

[271] Joshua Dixon, M.D., _Annual Reports of the Whitehaven Dispensary, 1795 to 1805_. Details for 1773-4 in his note in _Memoirs of Lettsom_, III. 353.

[272] Dixon, _Literary Life of Dr Brownrigg_, pp. 238-9.

[273] Aikin, _Country round Manchester_. Lond. 1795, p. 616.

[274] _Nature and Origin of the Contagion of Fevers._ Hull, 1788.

[275] _Account of a Contagious Fever at Aylesbury._ Aylesbury, 1785.

[276] Thomas Day, _Some Considerations ... on the Contagion in Maidstone Jail_, 1785.

[277] See Barnes, in _Mem. Lit. Phil. Soc. Manchester_, II. 85. Dr Samuel Parr wrote his epitaph in the Cathedral. Also Johnstone sen. to Lettsom, _Memoirs_, III. 241.

[278] Martin Wall, M.D., _Clin. Obs. on the Use of Opium in Low Fevers and in the Synochus_. Oxford, 1786.

[279] J. C. Jenner, in _Lond. Med. Journal_, VII. 163.

[280] _Gent. Magaz._ 1785, I. 231, March 1.

[281] This is the period and the district to which Robert Burns refers, under date of 21 June, 1783, in a letter to his cousin, James Burness, of Montrose: “I shall only trouble you with a few particulars relative to the wretched state of this country. Our markets are exceedingly high, oatmeal 17_d._ and 18_d._ per boll, and not to be got even at that price. We have, indeed, been pretty well supplied with quantities of white peas from England and elsewhere; but that resource is likely to fail us, and what will become of us then, particularly the very poorest sort, heaven only knows.” The lately flourishing silk and carpet weaving had declined during the American War, and the seasons had been adverse to farmers. The lines in Burns’ poem, “Death and Dr Hornbook”:

‘This while ye hae been mony a gate At mony a house.’ ‘Ay, Ay,’ quoth he, and shook his head.--

are explained by a note, “An epidemical fever was then raging in the country.”

[282] Account by Rev. Geo. Skene Keith, _Statist. Act._ II. 544.

[283] Also Banff, _ibid._ XX. 347.

[284]

“Not twenty years ago, but you I think Can scarcely bear it now in mind, there came Two blighting seasons, when the fields were left With half a harvest. It pleased heaven to add A worse affliction in the plague of war, &c.”

Trotter, _Medicina Nautica_, I. 182, 1797, gives these real cases:--“During the short time that I attended the dispensary at Newcastle, just at the beginning of the [French] war, I was sent for to a poor man in a miserable and low part of the town called Sandgate. He was ill with what is called a spotted fever.” Six children were standing round his bed, the oldest not more than nine. They had been ill first, then his wife, who was recovered and had gone out to pawn the last article they had to buy meal for the children. The man worked on the quay at 1_s._ 2_d._ per diem. Again, “When I practised as a surgeon and apothecary at the end of the late [American] war in a small town in Northumberland, with an extensive country business, some similar scenes came under my view. Two servants of two opulent farmers applied to me for relief. The first had seven children, who took the fever one by one till the whole became sick. His wages were 1_s._ per diem. His master, a rich man, thought himself charitable by allowing them to pull turnips from his field for food. The other servant was a shepherd; but his herding, as the saying is, was a poor one. The first and second of six children were able to work a little, till they got a fever in a severe winter, and down they fell, one after another, the father and mother at last.” They wanted to sell the cow; but some charitable ladies raised a small subscription, by which means the comforts of wine and diet came within their reach; their master, for his part, sent them the carcase of a sheep, which had been found dead in a furrow, with a request that the skin should be returned.

[285] Jenner to Shrapnell, Baron’s _Life of Jenner_, I. 106-7.

[286] John Barker, _Epidemicks_, pp. 201-6.

[287] The dearth of 1794-95 called forth one notable piece, the ‘Thoughts and Details on Scarcity,’ drawn up by Mr Burke, from his experience in Buckinghamshire, originally for the use of Mr Pitt, in November, 1795. Burke takes an optimist line, and preaches the economic doctrine of _laissez faire_: “After all,” he asks, “have we not reason to be thankful to the Giver of all good? In our history, and when ‘the labourer of England is said to have been once happy,’ we find constantly, after certain intervals, a period of real famine; by which a melancholy havock was made among the human race. The price of provisions fluctuated dreadfully, demonstrating a deficiency very different from the worst failures of the present moment. Never, since I have known England, have I known more than a comparative scarcity. The price of wheat, taking a number of years together, has had no very considerable fluctuation, nor has it risen exceedingly within this twelvemonth. Even now, I do not know of one man, woman, or child, that has perished from famine; fewer, if any, I believe, than in years of plenty, when such a thing may happen by accident. This is owing to a care and superintendence of the poor, far greater than any I remember.... Not only very few (I have observed that I know of none though I live in a place [Beaconsfield] as poor as most) have actually died of want, but we have seen no traces of those dreadful exterminating epidemicks, which, in consequence of scanty and unwholesome food, in former times not unfrequently wasted whole nations. Let us be saved from too much wisdom of our own, and we shall do tolerably well.” The last sentence is his favourite principle of “a wise and salutary neglect” on the part of Government.

[288] A labourer at Bury St Edmunds, receiving a weekly wage of five shillings, was able to buy therewith at the old prices:

Cost of same in 1801 £ _s._ _d._ {A bushel of wheat 0 16 0 {A bushel of malt 0 9 0 5_s._{A pound of butter 0 1 0 {A pound of cheese 0 0 4 {Tobacco, one penny 0 0 1 ----------- £1 6 5 {Weekly wage in 1801, 9_s._ {Parish bonus 6_s._ 15 0 ---------- 0 11 5 deficiency

[289] _Loidis and Elmete_, 1816, p. 85.

[290] Thorp, Tract of 1802, cited by Hunter, _Ed. Med. Surg. Journ._ April, 1819, p. 239.

[291] Currie, _Med. Phys. Journ._ X. 213.

[292] Beddoes.

[293] Goodwin, _Med. Phys. Journ._ IX. 509. Cf. Gervis, _Med. Chir. Trans._ II. 236.

[294] Elizabeth Hamilton, _The Cottagers of Glenburnie_, Edin. 1808: “The only precaution which the good people, who came to see him [the farmer] appeared now to think necessary, was carefully to shut the door, which usually stood open.... The prejudice against fresh air appeared to be universal.... The doctor did not think it probable that he would live above three days; but said, the only chance he had was in removing him from that close box in which he was shut up, and admitting as much air as possible into the apartment.... While the farmer yet hovered on the brink of death, his wife and Robert, his second son, were both taken ill.... Peter MacGlashan had taken to his bed on going home and was now dangerously ill of the fever.... All the village indeed offered their services; and Mrs Mason, though she blamed the thoughtless custom of crowding into a sick room, could not but admire the kindness and good nature with which all the neighbours seemed to participate in the distress of this afflicted family.”

[295] Charlotte Brontë’s story of _Shirley_ falls in this period and turns upon the industrial crisis in Yorkshire; but it is on the whole a happy idyllic picture. Harriet Martineau wrote in _Household Words_, vol. I. 1850, Nos. 9-12, a story entitled “The Sickness and Health of the People of Bleaburn,” a Yorkshire village supposed to have been Osmotherly. It is, in substance, an account of a terrible epidemic of fever in the year 1811, the story opening with the news of the victory of Albuera and the rejoicings thereon. It appears to have been constructed very closely from the real events of the plague of 1665-66 in the village of Eyam, in the North Peak of Derbyshire, and had probably a very slender foundation in any facts of fever in Yorkshire or elsewhere in the year 1811. “Ten or eleven corpses,” says the novelist, “were actually lying unburied, infecting half-a-dozen cottages from this cause.” Cf. infra, Leyburn, p. 167.

[296] T. Bateman, M.D., _Reports on the Diseases of London ... from 1804 to 1816_. Lond. 1819.

[297] Parl. Committee’s Report on Contag. Fev. 1818, p. 33. Table by P. M. Roget.

[298] Adam Hunter, _Ed. Med. Surg. Journ._, April, 1819.

[299] Cleland, _Glasgow and Clydesdale Statist. Soc. Transactions_, Pt. I. Nov. 2, 1836.

[300] Sutton, _Account of a Remittent Fever among the Troops in this Climate_. Canterbury, 1806.

[301] In the first three months of 1811 a singular fever occurred among working people in part of a suburb of Paisley, one practitioner having 32 cases in 13 families. It was marked by rigors at the onset, pain in the back, headache, dry skin, loaded very red tongue, quick fluttering pulse, watchfulness, delirium-like fatuity, abdominal pain in many, foetid stools, great prostration, gradual recovery after fifteen or sixteen days without manifest crisis, and relapses in some. In this fever Murchison discovers enteric or typhoid. Its limitation to a part of one of the suburbs of Paisley is, of course, in the manner of enteric fever; on the other hand, only one of those 32 cases died, which is a rate of fatality perhaps not unparalleled in typhoid but much more often matched in typhus or relapsing fever of young and old together; while the length of the fever, fifteen or sixteen days or sometimes more, is too great for the abortive kind of enteric and too little for enteric fever completing both its first and second stages. James Muir, _Edin. Med. and Surg. Journ._ VIII. 134. Murchison, _Continued Fevers_, p. 428.

[302] James Clarke, M.D., “Medical Report for Nottingham from March 1807 to March 1808,” _Edin. Med. and Surg. Journ._ IV. 422. His account of the unwholesome state of the weavers’ houses is as bad as any of those already given.

[303] McGrigor, “Med. Hist. of British Armies in Peninsula,” _Med. Chir. Trans._ VI. 381.

[304] Richard Hooper, “Account of the Sick landed from Corunna,” _Edin. Med. and Surg. Journ._ V. (1809), p. 398. See also Sir James McGrigor, _ibid._ VI. 19.

[305] James Johnson, _Influence of Tropical Climates_, p. 20.

[306] J. Terry, in _Ed. Med. and Surg. Journ._, Jan. 1820, p. 247.

[307] Bateman, _Account of the Contagious Fever of this Country_. Lond. 1818.

[308] The following from the “Observations on Prevailing Diseases,” Oct.-Nov., 1818 (perhaps by Dr Copland), in the _London Medical Repository_, X. 525, shows that the relapses in the earlier part of this epidemic had been commonly remarked in London: “Fevers are still prevalent.... Relapses have been noticed as of frequent occurrence in the instances of the late epidemic. To what are these to be attributed? Are we to ascribe them to the influence of the atmosphere, to anything in the nature of the disorders themselves, or to the vigorous plans of treatment which are adopted for their removal? These relapses are more common in hospital than in private practice.... It has recently become the fashion to consider the state of recovery from fever as one which will do better without than with the interposition of the cinchona bark. Has the prevalence of this negative practice anything to do with the admitted fact of frequent relapse?”

[309] _Report of the Select Committee of the House of Commons on Contagious Fever_, Parl. Papers, 1818.

[310] _On the Epidemic Fever at present prevailing._ Lond. 1819, p. 40.

[311] J. B. Sheppard, “Remarks on the prevailing Epidemic.” _Edin. Med. Surg. Journ._, July 1819, p. 346. Also for Taplow, Roberts, _Lond. Med. Repos._ XIV. 186.

[312] W. Hamilton, M.D., _Med. and Phys. Journ._, June 1817, p. 451.

[313] _Laws and Phenomena of Pestilence_, Lond. 1821, p. 39. Christison says: “All great towns, with the exception it is said of Birmingham.”

[314] Adam Hunter, _Edin. Med. Surg. Journ._, Apr. 1819, p. 234, and Apr. 1820.

[315] Wood, “Cases of Typhus.” _Edin. Med. Surg. Journ._, April, 1819.

[316] Adam Hunter, u. s.

[317] T. Barnes, _Edin. Med. Surg. Journ._, April, 1819.

[318] H. Edmonston, _ibid._ XIV. (1818), p. 71.

[319] T. McWhirter, _ibid._ April, 1819, p. 317.

[320] J. C. Prichard, M.D., _History of the Epidemic Fever which prevailed in Bristol, 1817-19_. Lond. 1820.

[321] _Obs. on the Cure and Prevention of the Contagious Fever now in Edinburgh._ Edin. 1818.

[322] _Edin. Med. Surg. Journ._ XVI. 146.

[323] Benj. Welsh, _Efficacy of Bloodletting in the Epidemic Fever of Edinburgh_. Edin. 1819.

[324] _Life of Sir Robert Christison_, Edin. 1885, I. 142:--“I had been scarcely three weeks at my post in the fever hospital when I was attacked suddenly--so suddenly, that in half-an-hour I was utterly helpless from prostration. I had nearly six days of the primary attack, then a week of comfort, repose and feebleness, and next the secondary attack, or relapse, for three days more. My pulse rose to 160, and continued hard and incompressible even at that rate. My temperature under the tongue was 107° &c.” He was bled to 30 oz. and next day to 20 oz. more. Before the end of the epidemic, in August, 1819, he had another attack of relapsing fever, for which he was bled to 24 oz. and a third, after exposure to chill, the same autumn, which last was a simple five-days’ fever without relapse, also treated by the abstraction of 24 oz. of blood. In 1832 he had two attacks of the same _synocha_ without relapses, and throughout the rest of his life many more: e.g. 16 June, 1861, “I have had something like the relapsing fever of my youth”--a five-days’ fever with a relapse on the 18th day; and again, on 19 March, 1868, “Incomprehensible return of mine ancient enemy.” These experiences coloured Christison’s view of relapsing fever, the so-called relapses being, in his opinion, comparable to the returning paroxysms of ague.

[325] Cleland.

[326] Report signed A. Brebner, provost, printed in Harty, _Historic Sketch of the Contagious Fever in Ireland, 1817-19_. Dublin, 1820, Appendix, p. 110.

[327] _Memoir concerning the Typhus Fever in Aberdeen, 1818-19._ By George Kerr, Aberdeen, 1820.

[328] William Gourlay, “History of the Epidemic Fever as it appeared in a Country Parish in the North of Scotland.” _Edin. Med. and Surg. Journ._, July, 1819, p. 329, dated 20 Nov. 1818.

[329] _Trans. K. and Q. Cal. Phys. Ireland_, V. 527.

[330] _Dub. Q. J. Med. Sc._ VIII. 297.

[331] A succession of thirty-one cases of relapsing typhoid at Charing Cross Hospital in 1877-78 were made the subject of an able essay by J. Pearson Irvine, M.D., _Relapse of Typhoid Fever_, London, 1880.

[332] Cited in Aberdeen Report, 17 Dec. 1818, in Harty, App. p. 110.

[333] _Report of Select Committee_, u. s. p. 6, and minutes of evidence.

[334] Prichard, pp. 74, 88.

[335] Christison, _Month. J. Med. Sc._ X.; Bennett, _Princip. and Pract. of Med._ 944-5.

[336] See above, p. 110-11.

[337] A complementary measure, namely, notification of contagious sickness to the authorities, was put in practice at Leeds in 1804 on the opening of the House of Recovery there. The Leeds House of Recovery, with fifty beds, was opened on 1 November, 1804, the epidemic of fever being then about over. One of its officers was an inspector, whose duty was “to detect the first appearance of infection, to cause the removal of the patient to the House of Recovery, and to superintend the fumigating and whitewashing of the apartment from which he is removed. So great is the solicitude of the physicians to promote early removal that rewards are offered to such as shall first give information of an infectious fever in their neighbourhoods.” It was claimed that this had been a great success, Leeds having been for twelve years previous to the epidemic of 1817 nearly exempted from two of the most infectious and fatal diseases, namely, typhus and scarlet fever. (It happened, however, that the whole of England, Scotland and even Ireland were exempted to the same remarkable, and of course gratifying degree.) Whitaker, _Loidis and Elmete_, 1816, p. 85.

[338] A strange epidemic of the early summer of 1824 in a semi-charitable girls’ school at Cowan Bridge, between Leeds and Kendal, which is the subject of a moving chapter in ‘Jane Eyre,’ was inquired into by Mrs Gaskell, the biographer of Charlotte Brontë. Forty girls were attacked with fever. A woman who was sent to nurse the sick, saw when she entered the school-room from twelve to fifteen girls lying about, some resting their heads on the table, others on the ground; all heavy-eyed and flushed, indifferent and weary, with pains in every limb, the atmosphere of the room having a peculiar odour. The symptoms, so far as known, and the circumstances of the school, point more to relapsing fever than to typhus, which is the name given to it by Charlotte Brontë. None died of the fever (it is otherwise in the tale), but one girl died at home of its after-effects. Dr Batty, of Kirby, who was called in, did not consider the type of fever to be alarming or dangerous. The dietary of the school had undoubtedly been most meagre for growing girls, and its discipline severe. The house was old and unsuited for the purposes of a boarding-school.

[339] Cowan, _Journ. Statist. Soc._ III. (1840) p. 271; _Glas. Med. Journ._ III. 437.

[340] Some of these were treated at the extra fever-hospital in Spring Gardens.

[341] From the table by Christison, _Edin. Med. Journ._, Jan. 1858, p. 581.

[342] _Life of Christison_, “Autobiography.”

[343] John Burne, M.D., _Pract. Treatise on the Typhus or Adynamic Fever_. London, 1828.

[344] To show the effect of emotion in causing a relapse, he gives an instance, almost the only concrete illustration in all his book: An Irishwoman, Ann McCarthy, aged 26, was admitted to Guy’s Hospital on 20 June, 1827, with “adynamic fever of the second degree,” having been already ill for two weeks: the course of her fever was favourable and she was “soon convalescent.” While still in the ward mending her strength, she lent her bonnet to another female patient to go out with; finding that her kindness had been abused by the woman forgetting to return the bonnet, she became exceedingly angry, relapsed into the fever on the 10th of July, was wildly delirious for several days, and died on the 19th of July. At this time it was the practice at Guy’s to examine the bodies after death; but permission was refused in the case in question, so that Burne was unable to say “whether the bowels were affected.” The case, therefore, may have been one of relapsing enteric fever. A similar ambiguity is discussed by Hughes Bennett in his _Principles and Practice of Physic_ (p. 923), and decided in favour of relapsing fever proper, or relapsing synocha.

[345] Sir William Jenner, M.D., _Lectures and Essays on Fevers and Diphtheria_, 1849 to 1879. London, 1893.

[346] Christison, _Life_, u. s. I. 341.

[347] “Cases showing the frequency of the occurrence of Follicular Ulceration in the Mucous Membrane of the Intestine during the progress of Idiopathic Fever, with Dissections, and Observations on its Pathology.” _Lond. Med. and Physical Journ._, Aug. 1826, p. 97.

[348] _Ibid._ p. 351.

[349] Burne, u. s.

[350] Richard Bright, M.D., _Reports of Medical Cases_. Part I., 1827.

[351] _Life of Sir Robert Christison_, I. 144. Also in _Trans. Soc. Sc. Assn._ 1863, p. 104.

[352] _Edin. Med. Journ._, Jan. 1858, p. 588. Cf. _infra_, under Dysentery, 1828.

[353] Reid, _Trans. K. and Q. Coll. of Phys. in Ireland_, V.; O’Brien, _ibid._

[354] Writing in 1839, Dr Stokes, of Dublin, made the following remarkable assertion (_Dub. Journ. Med. and Chem. Sc._ XV. p. 3, note): “In the epidemic of 1826 and 1827 we observed the follicular ulceration (dothienenteritis of the French) in the greater number of cases.” As the epidemic of 1826-27 was almost wholly one of relapsing fever, the statement is at least puzzling. It was made twelve years after the epidemic, at a time when the discrepancies between British and French observers, as to the occurrence of ulceration of the ileum in continued fever, were much discussed. Dr Lombard, of Geneva, having visited Glasgow, Dublin and other places, and confirmed the fact that the characteristic lesion of enteric fever was at that time only occasional, went on to say that Irish typhus was a species of disease by itself, a _morbus miseriae_. Whereupon the editor of the ‘Dublin Journal of Medical Science’ (XII. 503, in a review of Cowan’s Glasgow Statistics) gave the following truly Irish reply: “Had Dr Lombard made more inquiries, he would have found that Ireland is not so sunk in misery and debasement but that she can produce occasionally a fever which, in abdominal ulcerations, can compete with the sporadic diseases of her wealthier and more enlightened neighbours.” It may have been in the same patriotic spirit that Stokes declared “the greater number of cases” in the epidemic of 1826 and 1827 to have had follicular ulceration.

[355] G. L. Roupell, M.D., _Some Account of a Fever prevalent in 1831_. Lond. 1837.

[356] In addition to what has been said on this point already, for

## particular epidemics, I shall give a statement for ordinary years by Dr

Carrick, of Bristol, in his ‘Medical Topography’ of that city: _Trans. Prov. Med. Assocn._ II. (1834), p. 176. “Continued fever is common enough, but nine-tenths of the cases are of a simple character, terminating for the most part within seven days, and unaccompanied with anything more serious than slight catarrhal or rheumatic disorder. Typhus gravior is rare--much more so than might be expected.”

[357] Charles West, M.D., “Historical Notices designed to illustrate the question whether Typhus ought to be classed among the Exanthematous Fevers.” _Edin. Med. and Surg. Journ._ 1840, April, p. 279.

[358] Alexander Kilgour, M.D., _ibid._ Oct. 1841, p. 381.

[359] Cowan, “Vital Statistics of Glasgow,” _Journ. Statist. Soc._ III.

[360] Cases at Mile-End Fever Hospital.

[361] Including 906 male fever-patients at Albion Street temporary hospital.

[362] _Blackwood’s Magazine_, March, 1838, p. 289.

[363] In 1819 the Irish in Glasgow had been estimated at 1 in 9·67: in 1831 the Irish part of the population had risen to 1 in 5·69. Dr Cowan, however, said of them: “From ample opportunities of observation, they appear to me to exhibit much less of that squalid misery and habitual addiction to the use of ardent spirits than the Scotch of the same grade.”

[364] Robert Cowan, M.D., “Statistics of Fever in Glasgow for 1837.” _Lancet_, April 10, 1839.

[365] James Arrott, M.D., _Edin. Med. and Surg. Journ._, Jan. 1839, p. 121.

[366] Craigie _ibid._ April, 1837.

[367] Christison, _Monthly Journ. Med. Sc._ X. 1850, p. 262.

[368] Kilgour, u. s.

[369] Cowan, _Journ. Statist. Soc._ III. 1841.

[370] Arrott, u. s.

[371] Craigie, u. s.

[372] _Edin. Med. and Surg. Journ._ July, 1838.

[373] _Principles and Practice of Physic_, 3rd ed. 1848, II. 742, 732.

[374] _First Report of the Registrar-General_, London, 1839.

[375] The district registrars had hardly organised their work in the first two or three years of registration. Some gave much more complete returns than others. There was a reluctance to register births, and the marriages were not all registered. But the totals of deaths came out very nearly as the actuaries had expected.

[376] The Third Report of the Registrar-General gives the mortality in all parts of England from typhus in 1839 (as well as from scarlatina) in an elaborate table of the registration districts and sub-districts.

[377] W. Budd, M.D., _Lancet_, 27 Dec. 1856, and 2 July, 1859. Dr Budd, who had been studying in Paris and seeing much typhoid fever, but little or no typhus, in the service of Louis at La Pitié hospital, took the whole of these cases for enteric or typhoid, and insisted, in his later life, on the ground of his North Tawton experiences in 1839, that typhoid fever spread by contagion. He published numerous papers on this theme (_Lancet_, 27 Dec. 1856, another series in the same journal from 2 July to Nov. 1859, _Brit. Med. Journ._ Nov.-Dec. 1861, and, finally, a volume of reprints with additions, _Typhoid Fever, its Nature, Mode of Spreading and Prevention_, London, 1873). But he published no clinical cases nor post-mortem notes, to make good his 1839 diagnosis, on which the whole matter turned, contenting himself with an assurance that he knew typhoid well from studying it under Louis (who, at that time, believed that the typhus of armies, gaols, &c. and of the British writers, was the same as the fever which he, and others after him, named typhoid). He also made the following six statements, as if he were making affidavit: (1) that the great majority of the cases had early diarrhoea, (2) that three had profuse intestinal haemorrhage, (3) that more or less of tympanitis was almost universal in the epidemic, (4) that in nearly every case he found the rose-coloured lenticular spots, (5) that one case, which was the only one examined post-mortem, had the characteristic ulceration of the intestine, and (6) that one fatal case had the symptoms of perforation of the gut. This summary manner, asking in effect to be taken on trust, is not usually accepted from innovators, none of the great discoverers having resorted to it. Hitherto, however, no one has thought proper to question Budd’s diagnosis of the epidemic fever in his North Tawton practice, nor even to remark upon his strange error of treating the epidemic of 1838-39 all over Britain as purely one of typhoid (_Lancet_, 27 Dec. 1856). But everyone knew that typhoid fever did not spread in the way that he described (doubtless correctly for the above cases). After the publication of his book in 1873 an attempt was made by an influential layman in the _Times_ (9 Nov. 1874) to popularize Budd’s fallacies or paradoxes on the contagiousness of typhoid. “How,” it was asked, after a summary of the North Tawton epidemic in 1839, “could a disease whose characters are so severely demonstrable, have ever been imagined to be non-contagious? How could such a doctrine be followed, as it has been, to the destruction of human life?”

[378] “For three years past trade had been getting worse and worse, and the price of provisions higher and higher. This disparity between the amount of the earnings of the working classes and the price of their food occasioned, in more cases than could well be imagined, disease and death. Whole families went through a gradual starvation. They only wanted a Dante to record their sufferings. And yet even his words would fall short of the awful truth; they could only present an outline of the tremendous facts of the destitution that surrounded thousands upon thousands in the terrible years 1839, 1840, and 1841. Even philanthropists who had studied the subject were forced to own themselves perplexed in their endeavour to ascertain the real causes of the misery; the whole matter was of so complicated a nature that it became next to impossible to understand it thoroughly.... The most deplorable and enduring evil that arose out of the period of commercial depression to which I refer, was this feeling of alienation between the different classes of society. It is so impossible to describe, or even faintly to picture, the state of distress which prevailed in the town [Manchester] at that time, that I will not attempt it; and yet I think again that surely, in a Christian land, it was not known even so feebly as words could tell it, or the more happy and fortunate would have thronged with their sympathy and their aid. In many instances the sufferers wept first, and then they cursed. Their vindictive feelings exhibited themselves in rabid politics. And when I hear, as I have heard, of the sufferings and privations of the poor, of provision shops, where ha’porths of tea, sugar, butter, and even flour, were sold to accommodate the indigent--of parents sitting in their clothes by the fireside during the whole night for seven weeks together, in order that their only bed and bedding might be reserved for the use of their large family--of others sleeping upon the cold hearthstone for weeks in succession, without adequate means of providing themselves with food or fuel--and this in the depth of winter--of others being compelled to fast for days together, uncheered by any hope of better fortune, living, moreover, or rather starving, in a crowded garret, or damp cellar, and gradually sinking under the pressure of want and despair into a premature grave; and when this has been confirmed by the evidence of their careworn looks, their excited feelings, and their desolate homes--can I wonder that many of them, in such times of misery and destitution, spoke and acted with ferocious precipitation?” Mrs Gaskell, _Mary Barton_.

[379] John Goodsir, “On a Diseased Condition of the Intestinal Glands,” _Lond. and Edin. Monthly Journ. of Med. Science_, April, 1842. He does not enter on the question “as to whether the subject of the present paper constitutes a distinct species of disease, or be merely a form of the ordinary continued fever”; but he appears to recognize that a certain district may have a form of fever special to it, as Reid had probably told him.

[380] John Reid, M.D., “Analysis and Details of Forty-seven Inspections after Death,” _Edin. Med. and Surg. Journ._, Oct. 1839, p. 456.

[381] Reid, u. s., from Home’s records.

[382] Murchison, _Continued Fevers_, 2nd ed. 1873, p. 444.

[383] Lombard, in _Dublin Journal of Med. Sc._ X. (1836), p. 17. He bore witness, also, to the rarity of the bowel-lesion in the Glasgow fevers. This was confirmed by Dr Perry, of that city, _Ibid._ X. 381. See also Julius Staberoh, M.D., “Researches on the Occurrence of Typhus in the Manufacturing Cities of Great Britain,” _Ibid._ XIII. 426.

[384] _Trans. Prov. Med. Assoc._ II. (1834), p. 176.

[385] _Continued Fevers_, 2nd ed. 1873, p. 443.

[386] Christison, “On the Changes which have taken place in the Constitution of Fevers and Inflammations in Edinburgh during the last forty years.” Paper read at Med. Chir. Soc. Edin. 4 March, 1857. _Edin. Med. Journ._ Jan. 1858, p. 577.

[387] _Continued Fevers_, under the head of “Typhus,” p. 47.

[388] See especially John Rose Cormack, M.D., _Natural History, Pathology and Treatment of the Epidemic Fever at present prevailing in Edinburgh and other towns_. Lond. 1843; and the papers by Wardell, _Lond. Med. Gaz._ N. S. II-V.

[389] Dr Betty, of Lowtherstown, Fermanagh, _Dubl. Quart. Journ. Med. Sc._ VII. 125.

[390] Murchison says that the enteric fever of the end of 1846 was prevalent at many places in England where the epidemic of typhus never made its appearance, and that in Edinburgh (according to an unpublished essay by Waters) most of the enteric cases not only occurred prior to the outbreak of the epidemic of Irish fever, but came from localities in the neighbouring country and from the best houses of the New Town--not from the crowded courts of the Old Town, to which the later epidemic of typhus and relapsing fever was restricted. Murchison, u. s. p. 49. The following papers relate to the autumnal typhoid of 1846 in England: Sibson, “Fever at Nottingham and neighbourhood in Summer and Autumn of 1846,” _Med. Gaz._ XXXIX.; Taylor, “Fever at Old and New Lenton in 1846,” _Med. Times_, XV. 159 and _Med. Gaz._ XXXVIII. 127; Turner, “Fever at Minchinhampton in Autumn 1846,” _Med. Gaz._ XLII. 157; Brenchley, “Fever in Berkshire in 1846,” _Med. Gaz._ XXXVIII. 1082; Bree, “Epidemic Fever at Great Finborough in Autumn of 1846,” _Prov. Med. and Surg. Journ._ 1847, p. 676.

[391] In the _Report of the Registrar-General for the year 1847_.

[392] This was the occasion which furnished Father Newman with a famous argument for the _bona fides_ of his co-religionists: “The Irish fever cut off between Liverpool and Leeds thirty priests and more young men in the flower of their days, old men who seemed entitled to some quiet time after their long toil. There was a bishop cut off in the North; but what had a man of his ecclesiastical rank to do with the drudgery and danger of sick calls, except that Christian faith and charity constrained him?” John Henry Newman, D.D., _History of My Religious Opinions_, London, 1865, p. 272.

[393] Leigh, in _Report Reg.-Gen. for 1847_, X. p. xx.

[394] H. M. Hughes, “On the Continued Fever at present existing in the southern districts of the metropolis,” _Lond. Med. Gaz._ Nov. 1847; Laycock, “Unusual prevalence of Fever at York,” _Lond. Med. Gaz._ Nov. 1847; Bottomley, “Notes on the Famine Fever at Croydon in 1847,” _Prov. Med. and Surg. Journ._ 1847; Ormerod, _Clinical Observations on Continued Fever at Bartholomew’s Hospital_, Lond. 1848; Art. in _Brit. and For. Med. Chir. Rev. 1848_, I. 285; Duncan, _Journ. Pub. Health_, I. 200 (Liverpool); Paxton, _Prov. Med. Journ._ 1847, pp. 533, 596 (Rugby).

[395] The following papers relate to the epidemic in Scotland in 1847: Orr, “Historical and Statistical Sketch of the progress of Epidemic Fever in Glasgow during 1847,” _Edin. Med. and Surg. Journ._ LXIX.; Stark, “On the Mortality of Edinburgh and Leith for 1847,” _Ibid._ and LXXI.; R. Paterson, “Account of the Epidemic Fever of 1847-8” in Edinburgh, _Ibid._ LXX.; W. Robertson, “Notes on the Epidemic Fever of 1847-8,” _Month. Journ. of Med. Sc._ IX. 368; J. C. Steele, “View of the Sickness and Mortality in the Glasgow Royal Infirmary during 1847,” _Edin. Med. and Surg. Journ._ LXX.; J. C. Steele, “Statistics of the Glasgow Infirmary for 1848,” _Ibid._ LXXII. 241; J. Paterson, “Statistics of the Barony Parish Fever Hospital of Glasgow in 1847-8,” _Ibid._ LXX. 357.

[396] Buchanan, _Report Med. Officer Privy Council for 1864_, and _Trans. Epid. Soc._ 1865, II. 17; Hamilton, _Lancet_, II. 1867, p. 608 (Liverpool); Martyn, _Brit. Med. Journ._ July, 1863; Davies, _Med. Times and Gaz._ II. 1867, p. 427 (Bristol); Thompson, _St George’s Hosp. Reports_, I. (1866), p. 47 (London); Allbutt, _ibid._ p. 61 (Leeds).

[397] Buchanan, _Report Med. Off. Privy Council for 1865_, p. 210.

[398] James Stark, M.D., “Remarks on the Epidemic Fever of Scotland during 1863-64-65” etc., _Trans. Epidem. Soc._ N. S. II. 312. See also Russell, _Glasg. Med. Journ._ July, 1864, and R. Beveridge (for Aberdeen), _Lancet_, I. 1868, p. 630.

[399] Weber, _Lancet_, I. 1869, pp. 221, 255; Murchison, _ibid._ II. 1869, pp. 503, 647; Gee (Liverpool), _Brit. Med. Journ._ II. 1870, p. 246; Robinson (Leeds), _Lancet_, I. 1871, p. 644; Muirhead (Edinburgh), _Edin. Med. Journ._ July, 1870, p. 1; Rabagliati (Bradford), _ibid._ Dec. 1873; Tennant (Glasgow), _Glasgow Med. Journ._ May, 1871, p. 354; Armstrong (Newcastle), _Lancet_, I. 1873, p. 48.

[400] Muirhead (l. c.) says: “In no single instance which came under my observation could starvation be said to be the immediate cause of the disease. Not one of those individuals could be said to be emaciated.... On strict and repeated inquiry, not one of them would confess to having been in destitute circumstances.” During the winter of 1870-71 I attended from the Edinburgh New Dispensary several relapsing-fever patients at their homes, and can clearly remember having been surprised at the condition of decency and comfort in which I found them. The appearance of comfort was certainly due in part to the district visitors, who were numerous and

## active during the epidemic.

[401] Spear, “Typhus Fever in various parts of England, 1886-87.” _Rep. Med. Off. Loc. Gov. Bd._ N. S. XVI. p. 169.

[402] 2303 of these fever deaths in 1864 occurred in the eight principal towns of Scotland, classified as follows: typhus, 1450, relapsing fever, 371, gastric, enteric, or typhoid, 382.

[403] G. B. Longstaff, M.D., _Trans. Epid. Soc._ 1884-5, p. 72, reprinted in his _Studies in Statistics_, Lond. 1891, p. 402. The seasonal curve for the typhoid admissions to the London Fever Hospital over a longer period is nearly the same, as well as that of the registered deaths by typhoid in all London, 1869-84.

[404] The following large registration districts besides those in the Table, had enteric-fever death rates of ·5 and upwards per 1000 persons living, in the ten years 1871-80; in nearly all of them there has been a marked decline in the ten years 1881-90:--Durham, Hartlepool, Easington, Houghton-le-Spring, Darlington, Gateshead (county Durham); Morpeth (Northumberland); Aysgarth, Todmorden, Dewsbury, Pontefract, Barnsley, Rotherham (Yorkshire); Dudley, Leigh, Ormskirk (Lancashire); Crickhowell (Wales); Worksop, Radford (Nottingham); Shrewsbury; Peterborough; Portsea Island (Hants). Of the London districts, Hackney had the highest enteric fever, 0·46 per 1000 in a general death-rate of 20·78. The high rate of a decennium is not unfrequently brought up by one great explosion. In many of the Lancashire, Yorkshire and Midland towns, with rates about ·4 per 1000 persons, the rate has been somewhat steady from year to year. In the decennium 1871-80, many special outbreaks, some of them in villages, were reported on by the inspectors of the Medical Department, and traced for the most part to water-supplies tainted by the percolation of excrement.

[405] The Registration District of Middlesborough was carved out of Stockton and Guisborough in 1875.

[406] Registration District containing a population of 72,707 on a mean between the census of 1871 and that of 1881. In 1891 the population was 146,812.

[407] F. W. Barry, M.D., in _Rep. Med. Off. Loc. Gov. Board for 1882_, p. 72. The contention of the inspector was that the water-supply had been tainted by enteric-fever evacuations from a case which began on 22 May in a cottage some half-mile distant from the reservoir but in communication with it through ditches and brooks. The area of the water-supply did not correspond with the area of the fever.

[408] The report for the Medical Department by F. W. Barry, M.D. (_Enteric Fever in the Tees Valley_, 1890-91, Parl. papers, Nov. 1893), is an elaborate argument to prove that the flooded state of the Tees was indeed the relevant antecedent, not as indexing the rise of the ground-water in the respective towns, but as dislodging and sweeping down the slops, sewage and dry refuse of the market town of Barnard Castle, in upper Teesdale, whereby the water taken in from the Tees two miles above Darlington to the tanks, filters and reservoirs of the Darlington Corporation, and of the Stockton and Middlesborough Water Board, was tainted in some unusual degree--a hypothesis the more remarkable that the refuse, such as it was, had been suspended or dissolved in an unusual volume of water, that little refuse could have collected between the first floods and the second, and that no cases of enteric fever were known in the upper valley of the Tees. This judicial deliverance has not been accepted by the authorities of Darlington, Stockton and Middlesborough, nor by the Royal Commission on Water Supply, before whom it was laid.

[409] Besides the epidemic at Worthing in 1893, which is still _sub judice_, the best known instance of typhoid following a certain water-supply is the explosion at Redhill and Caterham in Jan.-Feb. 1879, _Rep. Med. Off. Loc. Gov. Board, for 1879_, Parl. papers, 1880, p. 78. The first instance alleged of the distribution by milk was the Islington explosion in July-August 1870 (Ballard, _Med. Times and Gaz._ 1870, II. 611). It was soon followed by the Marylebone explosion in the summer of 1873 (_Rep. Med. Off. L. G. B._, N. S. II. 193); but such instances have become less common, while instances of scarlatina and diphtheria following a milk-supply have become more common.

[410] _Second Letter to Sir Hercules Langrishe_, May, 1795.

[411] Berkeley’s _Querist_, Q. 362.

[412] Radulphus de Diceto, _Imag. Histor._ Eng. Hist. Soc. ed. I. 350.

[413] “Topogr. Hiberniae” in _Opera_, Rolls ed. V. 67. This and the preceding reference had escaped the notice of Dr John O’Brien, in the historical introduction to his _Observations on the Acute and Chronic Dysentery of Ireland_. Dublin, 1822.

[414] _Polychronicon_, Rolls ed. I. 332-3.

[415] “Many of the English-Irish have by little and little been infected with the Irish filthinesse, and that in the very cities, excepting Dublin and some of the better sort in Waterford, where the English continually lodging in their houses, they more retain the English diet.” And again: “In like sort the degenerated citizens are somewhat infected with the Irish filthinesse, as well in lowsie beds, foule sheetes, and all linnen, as in many other particulars.... Touching the meere or wild Irish, it may truely be said of them, which was of old spoken of the Germans, namely, that they wander slovenly and naked, and lodge in the same house (if it may be called a house) with their beasts.” Fynes Moryson, _Itinerary_, Pt. IV. p. 180.

[416] _Ireland’s Natural History, &c._ Written by Gerard Boate, late Doctor of Physick to the State in Ireland. And now published by Samuel Hartlib, Esquire. Lond. 1652. The author died at Dublin, shortly after his arrival there, on 9/19 January 1650/49. His information would seem to have come in part from his brother Arnold Boate, resident in Ireland.

[417] Hardiman, _History of Galway_, p. 126 _seq._ The plague from July 1649 to Lady Day 1650 is said to have swept away 3700 of the inhabitants, including 210 of the most respectable burgesses and freemen, with their families. The capitulation on 5 April, 1652, was followed by famine throughout the country, and by a revival of plague for two years, “during which upwards of one-third of the population of the province was swept away.”

[418] _Cromwell’s Letters and Speeches_, II. 55, 77.

[419] Edmund Borlase, _History of the Reduction of Ireland to the Crown of England_. 1675, p. 172.

[420] Boyle’s _Works_, fol. Lond. 1744, V. 92.

[421] The war-pestilence at Londonderry in 1689 is the third recorded epidemic of the kind there, not including what may have happened in the capture of the town by the Catholics in O’Neill’s rebellion, when Derry was destroyed, to be rebuilt in 1613 by the London Companies with a new charter under the name of Londonderry. The first historical occasion of sickness was in 1566. The troops of Elizabeth were landed on Loch Foyle in October and built their huts on the site of the old monastery. In the course of the winter the greater part of a force of 1100 men perished by dysentery and the infection which it breeds (see former volume, p. 372). On 12 Dec. 1642, a year after the outbreak of the Rebellion of Confederate Catholics, a petition of the agents of the distressed city of Londonderry to the Commons represented that there were 6059 persons in the city, whereof 5123 were women and children, or sick, aged or impotent; only 2000 were inhabitants of the city, the rest having fled there for safety. Spotted fever had broken out. (_Hist. MSS. Comis._ V. “MSS. of the House of Lords.”)

[422] With the exception of the last quoted piece of information, the most minute particulars of the siege of Londonderry are in an essay by an army chaplain, John Mackenzie, _A Narrative of the Siege of Londonderry_, London, 1690, which was written to correct and augment _A True Account of the Siege of Londonderry_ by the Rev. Mr George Walker, rector of Donoghmoore in the county of Tyrone, and late Governor of Derry. London, 1689.

[423] See former volume, pp. 634-43.

[424] Minute particulars of it are given in _An Impartial History of the Wars in Ireland_ [1689-1692]. By George Story, Chaplain to Sir Thomas Gower’s Regiment. London, 1693. Part I.

[425] Gangrene of the extremities was one of the symptoms of the “plague of Athens” as described by Thucydides. There is no need to invoke ergotism for an explanation of it, as some have done.

[426] At that time there was little systematic knowledge of military hygiene. Nearly two generations after, the experiences of Pringle, Donald Monro and Brocklesby in the campaigns of 1743-48 and 1758-63 in Germany and the Netherlands, yielded many valuable hints, some of which Virchow made use of in compiling his “Rules of Health for the Army in the Field,” in the Franco-Prussian War of 1870-71. See his _Gesammelte Abhandlungen aus dem Gebiete der öffentlichen Medicin und Seuchenlehre_.

[427] Bde. Berlin, 1879, II. 193.

[428] Joseph Rogers, M.D. _Essay on Epidemic Diseases._ Dublin, 1734.

[429] In further illustration of the power of morbid effluvia, he says: “We see how small a portion of a putrid animal juice, taken into the blood by inoculation, like a most active _leaven_ sets all in a ferment; and in a very short time brings the whole juices of a sound body into an equal state of corruption with itself,”--instancing war-typhus, plague from cadaveric corruption (according to Paré), the Oxford gaol fever, and “a later instance at Taunton not more than five or six years ago.”

[430] Dr Rogan of Strabane, in his _Condition of the Middle and Lower Classes in the North of Ireland_, 1819, was of a different opinion (p. 90): “No police regulations exist in Strabane to prevent the slaughtering of cattle in any part of the town. The butchers, therefore, most of whom live in the narrow streets near the shambles, have their slaughter-houses immediately behind their dwellings. The garbage is thrown into a large pit, which is generally cleaned but once in the year, at the season when the manure is required for planting potatoes, and at this time an offensive smell pervades the whole town, and is perceptible for a considerable distance around. The families exposed constantly to the effluvia arising from these heaps of putrid offal might have been expected to suffer severely from fever; but on the contrary, they were found to be much less liable to it than others in the same rank of life. This was no doubt owing to their living chiefly on animal food, and thus escaping the debility induced by deficient nourishment, which certainly had the chief share in creating a predisposition to the disease.”

[431] Bp. Nicholson to Archbp. of Canterbury, cited by Lecky (II. 216) from _Brit. Mus. Add. MS. 6116_.

[432] Cited by O’Rourke, _History of the Great Irish Famine of 1847_. Dublin, 1875, from pamphlet in the Halliday Collection of the Royal Irish Academy.

[433] See Boulter’s _Letters to the English Ministers_.

[434] Wakefield’s _Ireland_, II. 6, cited by Barker and Cheyne.

[435] John Rutty, M.D. _Chronological History of the Weather and Seasons and prevailing Diseases in Dublin during Forty Years._ London, 1770.

[436] Maurice O’Connell, M.D. _Morborum acutorum et chronicorum Observationes._ Dublin, 1746.

[437] Boulter’s _Letters_. Oxford, 1769, I. 226.

[438] Lecky, II. 217.

[439] Berkeley’s _Works_. Ed. Fraser, Oxford, 1871, III. 369.

[440] Lord John Russell used these historical parallels from England and Scotland in his great speech in the House of Commons, during the debate on Ireland, 25th January, 1847.

[441] Fraser, “Life and Letters of Berkeley,” in _Works_, IV. 262.

[442] Berkeley to Prior, Feb. 8 and 15, 1740/1.

[443] He published the receipt in a Dublin journal.

[444] Berkeley to Thomas Prior, in “Life and Letters,” u. s., p. 265. Some attempts at relief-works had been made the year before, two of which are still to be seen in the obelisks on Killiney Hill near Dublin and on a hill near Maynooth (“Lady Conolly’s Folly.” O’Rourke, u. s.).

[445] Rutty, p. 93.

[446] (Dublin, 1741).

[447] Cited by O’Rourke. Short, a contemporary, also says that the fever in Galway was like a plague.

[448] Dutton, _Statistical Survey of the County of Galway_. Dublin, 1824, p. 313: “1741. A fever raged this year that occasioned the judges to hold the assizes in Tuam. Numbers of the merchants of Galway died this year, and multitudes of poor people, caused partly by fever and by the scarcity, as wheat was 28_s._ per cwt.”

[449] The author of _The Groans of Ireland_ (Dublin, 1741) says: “On my return to this country I found it the most miserable scene of distress that I ever read of in history: want and misery in every face; the rich unable to relieve the poor; the road spread with dead and dying bodies; mankind of the colour of the docks and nettles which they fed on; two or three, sometimes more, on a car going to the grave for want of bearers to carry them, and many buried only in the fields and ditches where they perished.” Skelton, a Protestant clergyman, says: “Whole parishes in some places were almost desolate; the dead have been eaten in the fields by dogs, for want of people to bury them.” Skelton’s _Works_, Vol. V. Cited by Lecky.

[450] Report by Dr Phipps to Baron Wainwright, 10 March, 1741. Cited by F. C. Webb, _Trans. Epidem. Soc._ 1857, p. 67.

[451] Smith’s _Kerry_, p. 77. He adds that many were excused the hearth-tax on account of their poverty, by certificate of the magistrates; so that the decrease in 1744 may mean a greater proportion excused the tax, as well as a depopulation.

[452] How near the verge of want the people were is brought out by an experience in Galway county in 1745: a great fall of snow smothered vast numbers of cattle and sheep, which caused a great many farmers to surrender their lands. Wheat rose from six to eighteen shillings the hundredweight, while, after the distress, the best land in Connaught could be rented for five shillings an acre. Dutton’s _Galway_, p. 313.

[453] For Kinsale, Cork and Bandon, see Marjoribanks, _Med. Press and Circ._ 1867, II., 8.

[454] James Sims, M.D. _Observations on Epidemic Disorders, with Remarks on Nervous and Malignant Fevers._ London, 1773, p. 10. The preface is dated from London, whither Sims had removed from Tyrone. He rose to eminence in the London profession.

[455] _A Letter to a Member of the Irish Parliament relative to the present State of Ireland._ By Philo-Irene. London, 20 May, 1755. The turning of hundreds of acres into one dairy-farm had caused the depopulation which Goldsmith described in the _Deserted Village_: “By this unhappy policy several villages have been deserted at different times by the inhabitants, and numbers of them set a-begging,” p. 6.

[456] Sims, u. s. pp. 164-5.

[457] F. Barker and J. Cheyne, _Account of the Fever lately epidemical in Ireland_, 2 vols. London, 1821. This work relates mainly to the epidemic of 1817-19, but there is a short retrospect, the valuable part of which is for the years 1797-1802.

[458] The history of the Limerick and Belfast fever-hospitals is carried back to a few years before the founding of the Waterford hospital; but the latter was the first that was formally organised as a fever-hospital.

[459] “The fever in 1800 and 1801 very generally terminated on the fifth or seventh day by perspiration; the disease was then very liable to recur. The poor were the chief sufferers by it; and it was much more fatal amongst the middling and upper classes in proportion to the number attacked.” Barker and Cheyne, _op. cit._ p. 20.

[460] Smith’s _Kerry_. Dublin, 1756, p. 77.

[461] Smith’s _Kerry_, p. 88.

[462] _A Tour in Ireland ... in 1776-78._ London, 1780.

[463] The forty-shillings freeholder of Ireland was a life-renter whose farm was worth forty shillings annual rent more than the rent reserved in his lease.

[464] Malthus, _Essay on the Principle of Population_. Bk. II. chap. 10, Bk. III. chap. 8, and Bk. IV. chap. 11.

[465] Francis Rogan, M.D., _Observations on the Condition of the Middle and Lower Classes in the North of Ireland, as it tends to promote the diffusion of Contagious Fever; with the History and Treatment of the late Epidemic Disorders_. London, 1819.

[466] William Carleton, the _vates sacer_ of the Irish peasantry, was born, in 1798, in one of those Tyrone thatched cottages, in the parish of Clogher. His father had changed his holding three times before William, the youngest child, was fourteen years old; the last of the four was a farm of sixteen or eighteen acres in the north of Clogher parish, and “nearer the mountains.” Carleton says that he “lived among the people as one of themselves” until he was twenty-two, which would have been until the year 1820; so that he probably saw the famine and fever of 1817-18 among that very Tyrone peasantry whom Dr Rogan brings before us from the medical side. The scenes of famine and fever in the ‘Black Prophet’ are those “which he himself witnessed in 1817, 1822, and other subsequent years,” having been recalled by him in the form of a tale which was published in 1846, at the beginning of the Great Famine of that and the following year. His early recollections of famine and fever come into other tales, such as the ‘Clarionet,’ the ‘Poor Scholar’ and ‘Tubber Derg,’ in which last is related the almost inevitable reduction to poverty and at length to beggary of a most upright and industrious farmer owing to the fall of prices, without fall of rents, after the Peace of 1815. Carleton’s work has always the quality of fidelity, and he may be credited when he says that the scenes of famine and fever are not exaggerated.

[467] Rogan, u. s. p. 95: “A farmer within my knowledge, who holds fifteen acres of arable land, with nearly an equal quantity of cut-out bog, for which he pays £28 per annum, has erected six cabins for labourers. They are built with mud, instead of lime, and are thatched, so that they cannot each have cost more than three or four pounds. For some time he received from three of his tenants six guineas per annum, and from the others two guineas each, the latter only holding a cottage and a small garden [the former three having also grazing for a milch cow, half a rood of land for flax, and half an acre for oats, with privileges of cutting turf and planting as many potatoes as they could each provide manure for]; but they have been all so reduced in circumstances by the late scarcity as to be now unable to keep a cow, and for the two last years have rented their cabins and potato gardens alone. All the straw raised on the farm would scarcely suffice to keep the houses water-fast if applied solely to this purpose.” One of the first things that the Marquis of Abercorn did in the epidemic of 1817 was to call upon the subletting farmers on his manors to repair the roofs of their cottiers’ cabins.

[468] Carleton, in one of his tales, has given a vivid picture of the lurid or gloomy appearance of the country in the late autumn of 1816, as if it foreboded the distress of the following spring.

[469] Probably their cattle had been impounded for rent and tithe. The author of the pamphlet _Lachrymae Hiberniae_ (Dublin, 1822), a resident on the western coast, says (p. 8), with reference to the seizures for rent and tithe: “Oh what scenes of misery were exhibited in Ireland in this way during the years 1817, ’18 and ’19; by that time the people were left without cattle; after this their potatoes and corn were seized and sold, and in some cases their household furniture, even to their blankets.” The hardness of landlords in general is alleged by Dr Rogan, with an exception in favour of the Marquis of Abercorn in his own district.

[470] There was dysentery also in the autumn of 1818. Cheyne, _Dubl. Hosp. Rep._ III. 1.

[471] Rogan, p. 31.

[472] The following is an instance, from Boyle, in Roscommon: “In the middle of June, 1817, or a little earlier, a soup-shop was established here by subscription, where soup was daily given out to one thousand persons, who, naturally anxious to procure it in time, crowded together during its distribution, though every pains was taken to keep order amongst them. From the 16th to the 23rd of that month the weather became suddenly and unusually hot, and the disease about that period spread rapidly among those persons, the greater number of whom attributed the origin of their complaint to attendance at the soup-shop; among that crowd, many of whom I have seen faint from absolute want during exposure to the sun, there were persons from houses where the disease existed.” Report by Dr Verdon of Boyle, 26 June, 1818, in Barker and Cheyne, I. 325.

[473] Dr King of Tralee (Barker and Cheyne, I. p. 177) wrote as follows: “It is a custom in this country for very poor persons, living in the country parts, and possessing a miserable hovel with a small garden, after they have sowed their potatoes, to shut up their hut and carrying their families with them, to roam about the country, trusting to the known hospitality of the towns and villages for shelter and subsistence till the time for digging the potatoes shall have arrived.”

[474] Barker and Cheyne, I. 60.

[475] In Carleton’s tale of ‘The Poor Scholar,’ it is related how the hay-mowers stopped in their work to erect a hut for the fever-stricken youth, and a much larger hut not far from the first for the numerous persons who ministered to his wants under a kind of quarantine arrangement. The stealing of milk from rich men’s cows for the sick youth is the subject of a dialogue between the Roman Catholic bishop and the leader of the kindly party of mowers, in which the latter shows a skill in casuistry creditable to his religious instructors.

[476] William Harty, M.D., _Historic Sketch of the Contagious Fever Epidemic in Ireland during 1817-19_. Dublin, 1820. This work contains information collected by a circular of queries addressed to practitioners in the several provinces. It was undertaken by Dr Harty at the instance of Sir John Newport, M.P. for Waterford. The work by Barker and Cheyne on the same epidemic took longer to prepare, having been published in 1821. See also Cheyne, _Dubl. Hosp. Rep._ II. 1-147.

[477] Barker and Cheyne, p. 65. A similar incident comes into Carleton’s tale of ‘The Clarionet’: “At length, out of compassion, the few neighbours who feared not to attend a feverish death-bed, acting on the popular belief that children under a certain age are not liable to catch a fever, placed the boy in her arms.” This popular belief was well founded.

[478] Accounts from various places in Barker and Cheyne, and in Harty. Rogan (u. s. p. 45) says: “The cases of typhus gravior were infinitely more numerous among the rich and well-fed than among the poor; and with them also the head was most frequently the seat of diseased action.”

[479] _Report on the Present State of the Distressed District in the South of Ireland: with an Enquiry into the Causes of the Distresses of the Peasantry and Farmers._ Dublin, 1822.

[480] _Lachrymae Hiberniae, or the Grievances of the Peasantry of Ireland, especially in the Western Counties._ By a Resident Native. Dublin, 1822 (September). The author, a resident of the west coast, was concerned in the distribution of relief, and positively asserts the saving of thousands “from his own personal knowledge.”

[481] Robert James Graves, M.D., “Report on the Fever lately prevalent in Galway and the West of Ireland.” _Trans. K. and Q. Col. Phys._ IV. (1824), p. 408.

[482] John O’Brien, M.D., “On the Epidemic Dysentery which prevailed in Dublin in the year 1825.” _Trans. K. and Q. Col. Phys._ V. (1828) p. 221; Burke, _Ed. Med. Surg. Journ._ July, 1826, p. 56; Speer, _Med. Phys. Journ._ N. S. VI. 199.

[483] John O’Brien, “Med. Rep. of the H. of Recovery, Cork Street, Dublin, for the year ending 4 Jan. 1827.” _Trans. K. and Q. Col. Phys._ V. 512.

[484] Graves, _Clinical Medicine_, 1843. Lect. XVIII.

[485] O’Brien, u. s.

[486] “Remarks on the Epidemic Dysentery of the Autumn of 1826 in the South of Ireland.” By Alexander McCarthy, M.D. _Edin. Med. and Surg. Journ._ April, 1827, p. 289.

[487] “It is a melancholy picture of society to witness the increase of wealth and luxury on one side, and the greatest want and wretchedness on the other; to meet famine and exhaustion in the great body of the people, in a country that produces as much food as would afford a full supply for once and a half its present population; to see the granaries full of corn and flour, and the great body of the people scarcely existing on a half supply of bad potatoes. Such is the miserable situation of the Irish, a race of people distinguished for their intellect, and above all for their resignation and patience under afflictions the most trying.”

[488] _Dub. Quart. Journ. Med. Sc._ XI. 385.

[489] W. J. Geary, M.D., “Report of the St John’s Fever and Lock Hospitals.” _Dub. Quart. Journ. Med. Sc._ XI. 378: XII. 94.

[490] Various descriptions of these exist, of which that by Carleton in the tale ‘Barney Branagan,’ is probably not overdone.

[491] The Report of the Roscrea Fever Hospital for 1827 says: “In March, when the dung is being removed from the back yards for the purpose of planting the potatoes, the number of patients becomes double in the Fever Hospital.” _Dublin Medical Press_, Jan. 1846, p. 235.

[492] Babington, “Epidemic Typhous Fever in Donoughmore.” _Dub. Quart. Journ._ X. 404.

[493] G. A. Kennedy, “Report of Cork St. Fever Hosp. 1837-38.” _Ibid._ XIII. 311. Graves, _Ibid._ XIV. 363.

[494] Lynch, _Ibid._ N. S. VII. 388, gives some particulars of it also at Loughrea, Galway, in 1840.

[495] _System of Clinical Medicine._ Dublin, 1843, p. 57. The “change of type,” with special reference to treatment, is discussed more fully in Lecture XXXIV. pp. 492-500. See also _Dub. Quart. Journ. Med. Sc._ XIV. 502, where a letter on the changed character of fever at Sligo is cited.

[496] _The Census of Ireland_, 1841, Parl. Papers, 1843. “Report on the Table of Deaths,” by W. R. Wilde. The deaths in the family, with their causes, &c., in each of the previous ten years were entered on the census paper by the head of the family, or by the parish priest for him. These returns were, of course, far from exhaustive or correct.

[497] Graves, _Clinical Medicine_, 1843, p. 46. Remarking on the much greater frequency of fever in Ireland than in England, he says (p. 47): “Nothing can be more remarkable than the facility with which a simple cold (which in England would be perfectly devoid of danger), runs into maculated fever in Ireland, and that, too, under circumstances quite free from even the suspicion of contagion--in truth, except when fever is epidemic, catching cold is its most usual cause.”

[498] The principal work on the general circumstances of the Irish famine of 1846-47 is _The History of the Great Irish Famine of 1847, with notices of Earlier Irish Famines_. By Rev. John O’Rourke, P.P., M.R.I.A. Dublin, 1875.

[499] Joseph Lalor, M.D., _Dub. Quart. Journ. Med. Sc._ N. S. III. 38.

[500] Cited by O’Rourke, p. 152.

[501] _The Census of Ireland_, 1851. Part V. Table of deaths, vol. I. Dublin, 1856, p. 235.

The following are a few instances of depopulation between 1841 and 1851.

Union of Loughrea, Co. Galway. 1841 65,636 1851 38,698

Union of Clonakilty, Co. Cork. 1841 52,185 1851 31,473

Union of Kanturk, Co. Cork. 1841 61,238 1851 41,801

Parish of Kanturk. 1841 4,096 1851 6,754

Union of Portumna, Co. Galway. 1841 30,714 1851 19,747

Union of Skibbereen, Co. Cork. 1841 57,439 1851 37,283

Parish of Skibbereen. 1841 9,557 1851 8,931

Union of Skull, Co. Cork. 1841 26,620 1851 16,866

Parish of Skull. 1841 2,895 1851 3,226

[502] _Essay on the Principle of Population._ Bk. IV. chap. XI. Thorold Rogers has in many passages emphasized the advantages of the English practice from medieval times of living on the dearest kind of corn; but he seems to have overlooked the priority of Malthus throughout the whole of the eleventh chapter of his fourth book. In _Six Centuries of Work and Wages_ (p. 62), Rogers says: “Hence a high standard of subsistence is a more important factor in the theory of population than any of those checks which Malthus has enumerated.”

[503] Cited in Thomas Doubleday’s _Political Life of Sir Robert Peel_. London, 1856, II. 398 _note_.

[504] It is a doctrine of economics that the higher standard of living checks population. Thus Marshall says of England: “The growth of population was checked by that rise in the standard of comfort which took effect in the general adoption of wheat as the staple food of Englishmen during the first half of the 18th century.” _Economics_, p. 230.

[505] Vol. VII. (1849) pp. 64-126, 340-404, and Vol. VIII. pp. 1-86, 270-339 of the _Dublin Quart. Journ. of Medical Science_, N. S. contain numerous reports collected by the editors from all parts of Ireland, and published either in abstract or in full. These are the chief medical sources. Some particulars are given also in the _Dublin Med. Press_, 1846 to 1849 in several papers on dysentery.

[506] John Popham, M.D., _Dub. Quart. Journ. Med. Sc._ N. S. VIII. 279.

[507] Cited by Dr Jones Lamprey, _Dub. Quart. Journ._ VII. 101.

[508] Lamprey, _Dub. Quart. Journ._ VII. 101.

[509] O’Rourke.

[510] Ormsbey, _Dub. Quart. Journ._ VII. 382.

[511] Pemberton, _ibid._ VII. 369.

[512] Lalor, u. s.

[513] This epidemic called forth two pamphlets on the relation of famine to fever, one by Dominic Corrigan, M.D., _On Famine and Fever as Cause and Effect in Ireland_ (“no famine, no fever”), and a reply to it by H. Kennedy, M.D., _On the Connexion of Famine and Fever_.

[514] Pains resembling those of rheumatism were common in the fever of 1817-18 at Limerick. Barker and Cheyne, I. 432.

[515] Lamprey, u. s.

[516] Dr Kelly of Mullingar compared the smell of relapsing fever to that of burning musty straw. _Dub. Quart. Journ. Med._, Aug. 1863, p. 341.

[517] Cusack and Stokes, _ibid._ IV. 134.

[518] Barker and Cheyne, Harty, and Rogan have been cited to this effect for earlier epidemics. Graves (_Clin. Med._ pp. 59-60) says: “In the epidemics of 1816, 1817, 1818 and 1819, it was found by accurate computation that the rate of mortality was much higher among the rich than among the poor. This was a startling fact, and a thousand different explanations of it were given at the time.” He cites Fletcher (_Pathology_, p. 27) an Edinburgh observer, as follows: “The rich are less frequently affected with epidemic fevers than the poor, but more frequently die of them. Good fare keeps off diseases, but increases their mortality when they take place.”

[519] _Dub. Quart. Journ. Med. Sc._ N. S. VII. 388.

[520] _Census of Ireland_, 1851.

[521] _The Census of Ireland of 1851._ Part V. Table of Deaths. 2 vols. Dublin, 1856. Upwards of two hundred pages are occupied with a chronological “Table of Cosmical Phenomena, Epizootics, Epiphitics, Famines and Pestilences in Ireland” from the earliest times. This retrospect, which is very replete but tedious and uncritical, is followed by a summary report of twenty pages on “The Last General Potato Failure, and the Great Famine and Pestilence of 1845-50,” and by a long series of tabulated extracts from contemporary writings on all matters relating to the famine.

[522] Of this total, 18,430 deaths were from dysentery and 7,264 from diarrhoea.

[523] The increase in 1849 was doubtless owing to choleraic diarrhoea during the epidemic of Asiatic cholera, the deaths from dysentery being one-half of the total.

[524] R. Mayne, M.D., “Observations on the late Epidemic Dysentery in Dublin.” _Dub. Quart. Journ. Med. Sc._ VII. 294. See also papers in _Dubl. Med. Press_, 1849.

[525] 17th and 26th Reports of the Regr.-Genl. Ireland.

[526] Review of Murchison in _Dub. Quart. Journ. Med. Sc._, Aug. and Nov. 1863, pp. 169 and 339: “We are able, from extensive opportunities of observing the epidemic [of 1846-48] in Dublin, to verify the statement of Dr H. Kennedy as to the infrequency of enteric fever.”

[527] _Dub. Quart. Journ. Med. Sc._ Nov. 1865, p. 285.

[528] See p. 273, _supra_.

[529] O’Connor, u. s. p. 286, “Typhoid has scarcely appeared in this locality, which cannot boast of the excellence of its sewerage.”

[530] “On Atmospheric Conditions influencing the Prevalence of Typhus Fever.” _Dub. Quart. Journ. Med. Sc._, May, 1866, p. 309.

[531] H. Kennedy, M.D., “Further Observations on Typhus and Typhoid Fevers as seen in Dublin.” _Ibid._, Aug. 1862, p. 50.

[532] Nearly one-half of all the enteric fever deaths in Ulster and Leinster come respectively from Belfast and Dublin:

Year Belfast Dublin

1889 236 231 1890 190 168 1891 156 185

[533] Higden’s _Polychronicon_. Rolls Series, I. 332.

[534] _Dyall of Agues._ London, [1564].

[535] _Essay on Epidemic Diseases._ Dublin, 1734.

[536] _Dissert. Epistol._ § 93. Greenhill’s ed. p. 378.

[537] One regrets to find the above mistake in the learned pages of Murchison (p. 8). The following by Dr Robert Williams (_Morbid Poisons_, II. 423) is absolutely erroneous: “In Sydenham’s time, intermittent fever and dysentery were constantly endemic in London; and the mortality from the former cause alone averaged, in a comparatively small population, from one to two thousand persons annually.” What Sydenham says is that dysentery was endemic in Ireland (on the authority of Boate, no doubt), that it was epidemic in London in the end of 1669 and in the three years following, and that for the space of ten years it had appeared quite sparingly (_quae per decennium jam parcius comparuerat_). As to intermittents, he says they were absent from London for thirteen years, from 1664 to 1677, except in sporadic or imported cases. In the London bills the deaths from “agues” are sometimes distinguished from “fevers,” and are then seen to be only some dozen or twenty in two thousand.

[538] It is used in the Latin title of an Edinburgh graduation thesis, “De Catarrho epidemio, vel Influenza, prout in India occidentali sese ostendit,” by J. Huggar, which is assigned in Häser’s bibliography to the year 1703. Having been unable to find the thesis, I have not verified the date.

[539] _Annales Monastici_ (St Albans), Rolls Series, No. 191, under the year 1427; _Hist. MSS. Commiss._ IX. pt. 1, p. 127, records of Canterbury Abbey.--An epidemic in Ireland a century before, in 1328, has been given by Sir W. R. Wilde, and by Dr Grimshaw following him, under the name of “murre,” as if that had been its name at the time. The explanation seems to be that the contemporary Irish name _slaedan_ was rendered by Macgeoghegan, in his translation of the Annals of Clonmacnoise, by the 15th century English term “murre.” The “mure” of 1427 was a universal influenza; but the word was afterwards used for a common cold, along with poss, as in Gardiner’s _Triall of Tabacco_, 1610, fol. 12 and 15: “stuffings in the head, murres and pose, coughs”; and “the poze, murre, horsenesse, cough” etc.

[540] _Cal. Cecil. MSS._ I. under the dates.

[541] Munk, _Roll of the College of Physicians_, I. 32.

[542] Cited in Southey’s _Commonplace Book_, from Fuller’s _Pisgah Sight_, p. 54.

[543] Southey, _Commonplace Book_, from Strype’s _Memorials of Cranmer_, p. 284.

[544] Thoresby, _Ducatus Leodiensis_, ed. Whitaker, App. p. 152.

[545] Baines, _Lancashire_, II. 679: 39 deaths from 17 to 24 August, 1551, set down to “plague,” i.e. sweat.

[546] Lest it may be supposed that there has been adequate discussion of the differences between epidemic agues and influenzas, I quote from Hirsch’s _Handbuch der historisch-geographischen Pathologie_ the passage in which these epidemics or pandemics of “malarial fever” are referred to: “These epidemics of malaria, which extend not unfrequently over large tracts of country, and sometimes even over whole divisions of the globe, forming true pandemics, correspond always in time with a considerable increase in the amount of sickness at the endemic malarious foci, whether near or distant; they either die out after lasting a few months, or they continue--and this applies particularly to the great pandemic outbreaks--for several years, with regular fluctuations depending on seasonal influences. On the very verge of the period to which the history of malarial epidemics can be traced back, we meet with a pandemic of that sort, in the years 1557 and 1558, which is said to have overrun all Europe (Palmarius, _De morbis contagiosis_. Paris, 1578, p. 322).... It is not until the years 1678-82 that we again meet with definite facts relating to an epidemic extending over a great part of Europe....” (Eng. Transl. I. 229.)

[547] _Queen Elizabeth and her Times._ Ed. Wright, 2 vols. Lond. 1838, I. 113. Sir W. Cecil writing from Westminster to Sir T. Smith on 29th December [1563] says: “The cold here hath so assayled us that the Queen’s majestie hath been much troubled, and is yet not free from the same that I had in November, which they call a pooss, and now this Christmas, to keep her Majestie company, I have been newly so possessed with it as I could not see, but with somewhat ado I wryte this. We have had perpetuall frosts here sence the 16th of this month. Men doo now ordinarily pass over the Thamiss, which I thynk they did not since the 8th yere of the reign of King Henry the VIII.” _Ibid._ I. 157. For “poss,” see note p. 305.

[548] _Ephemer. Meteorol. anni 1561_ [for the latitude of Brabant]. Antwerp, 1561: “Tusses numero infinitae atque tanta contagionis vi praestabunt ut pauci immunes reliquant, praecipuè circa mensis finem.” The almanacks of those times must have been constructed on the same principle as the weather forecasts of our own time--namely, that of using the experience of one year for the next, just as the weather of one day is an indication for the next. In 1575 Dr Richard Foster (who became president of the College of Physicians in 1601) issued an almanack in which he foretold “sweating fevers” for the month of July (_Ephemer. meteorol. ad ann. 1575._ Lond. 1575). Cogan says that Francis Keene, an astronomer, also prophesied the return of the sweating sickness in 1575, “wherein he erred not much, as there were many strange fevers and nervous sickness.”

[549] Johan Boekel, Συνοψις _novi morbi quem plerique medicorum catarrhum febrilem, vel febrem catarrhosam vocant, qui non solum Germaniam, sed paene universam Europam graviss. adflixit_. Helmstadtii, 1580.

[550] Hoker’s “Irish historie ... to the present year 1587,” p. 165a in Holinshed’s _Chronicles_.

[551] This very moderate increase of the deaths in London in 1580 may be compared with the probably fabulous figures which Webster (I. 163) gives for continental cities the same year: Rome, 4000 deaths, Lübeck, 8000 deaths, Hamburg, 3000 deaths. I have given the weekly deaths and baptisms in London for five years, 1578-82, in my former volume, p. 341.

[552] There is a curious reference to “the sweat” in Shakespeare’s _Measure for Measure_, Act I. scene 2, where the bawd, in an aside, says: “Thus, what with the war, what with the sweat, what with the gallows, and what with poverty, I am custom-shrunk.” It is known that Shakespeare adapted and condensed his play from Whetstone’s _Promus and Cassandra_, printed in 1578, who took it from an Italian romance. But Whetstone’s dialogue, which is pointless and verbose beside Shakespeare’s, gives an entirely different speech to the bawd at the same place in the action, making no reference to “the sweat.” The date of _Measure for Measure_ is not certain; but it seems to belong to the earlier period of Shakespeare’s work, when he was adapting old plays most freely. Whatever its date, the war, the sweat, the gallows and poverty are evidently topical allusions pointed enough for the audience to have taken up.

[553] The year 1610 is mentioned by Short as a season of universal catarrhal fever abroad; but that epidemic is not in the modern chronologies of influenza.

[554] Chamberlain to Carleton in _Court and Times of James I._ I.

[555] Same to same 4 Nov. 1612. _Ibid._ I. p. 201.

[556] _Court and Times of James I._ I. p. 206.

[557] _Ibid._ p. 208.

[558] _Court and Times of James I._ p. 197.

[559] _Ibid._ p. 237.

[560] _Ibid._ Letter of 25 Nov. 1613.

[561] _Cal. Coke MSS._ I. 83.

[563] Graunt, _Obs. upon the Bills of Mortality_, 1662.

[564] Robert Boyle did not attach much importance to the name of “new disease.” “The term _new disease_,” he says, “is much abused by the vulgar, who are wont to give that title to almost every fever that, in autumn especially, varies a little in its symptoms or other circumstances from the fever of the foregoing year or season.” (Boyle’s _Works_. 6 vols. 1772, V. 66.) But it was the name commonly given to the epidemics of catarrhal fever among others, and it does not appear, when the history is examined closely, that it was ever given except to some epidemic separated by several years from the last of the kind.

[565] Sir R. Leveson’s Letters. _Hist. MSS. Commiss._ V. 146.

[566] Pp. 568-577.

[567] Πυρετολογια _sive Gulielmi Dragei Hitchensis_ Ιατρου καὶ Φιλοσοφου _Observationes ab Experientia de Febribus Intermittentibus_. Londini, 1665.

[568] His tract is dated 1641.

[569] By Nicholas Sudell, licentiate in physick and student in chimistry. London, 1669.

[570] Πυρετολογια. _A rational account of the Cause and Cure of Agues, with their signs, Diagnostick and Prognostick. Also some Specified Medicines prescribed for the Cure of all sorts of Agues, &c. Whereunto is added a short account of the Cause and Cure of Feavers and the Griping in the Guts._ Authore Rto. Talbor, Pyretiatro. Londini, 1672.

[571] Sir Thomas Watson (_Practice of Physic_, I. 725) has a story which shows how long these fancies, encouraged by quacks, may linger: “A coachman by whose side I sat while travelling from Broadstairs to Margate was speaking of the rarity of ague in that part of the Isle of Thanet. His father, he said, once had the complaint, and a fit came on while he was on a visit to him, the coachman, at Ramsgate. The son administered to his suffering parent a glass of brandy; whereupon ‘he threw the agy off his stomach; and it looked for all the world like a lump of jelly.’”

[572] Philip Guide, M.D., _A Kind Warning, &c._ Lond. 1710.

[573] The best summary of the “history of the use of Peruvian bark” is by Sir George Baker, in _Trans. Col. Phys._ III. (1785), 173.

[574] Cited by Baker, _l. c._ p. 190.

[575] _Lives of the Norths._ New ed. by Jessopp. Lond. 1890, III. 188.

[576] He fell into a kind of decline and died at his country house on 5 September, Dr Radcliffe having been summoned from London without avail.

[577] Baker, _l. c._, “Had not physicians been taught by a man whom they, both abroad and at home, vilified as an ignorant empiric, we might at this day have had a powerful instrument in our hands without knowing how to use it in the most effectual manner.” This was written at a time when physicians spoke of “throwing in the bark”--throwing it in “with a shovel,” as an Edinburgh professor used to say.

[578] John Barker, M.D., of Sarum, and afterwards physician to the forces, says in 1742 (in his essay on the epidemic fever of 1741, u. s. p. 112) that he had Sydenham’s letter in manuscript before him, and that it was written in October, 1677.

[579] Cited by Baker, _Trans. Col. Phys._ III. 208.

[580] Beaufort MSS. _Histor. MSS. Com._ XII. App. 9, p. 85.

[581] Evelyn’s _Diary_, under the date of 29 Nov. 1694.

[582] Evelyn; Luttrell, I. 327.

[583] _Hist. MSS. Com._ V. 186. Sutherland correspondence.

[584] _The Diary of John Evelyn_, under the date 4 Feb. 1685.

[585] The popular imagination at the time appears to have been most impressed by Dr King’s promptitude in whipping out his lancet. Roger North must have had it incorrectly in his mind when he wrote: “About the time of the death of Charles II., it grew a fashion to let blood frequently, out of an opinion that it would have saved his life if done in time.”

[586] _Obs. Med._ 3rd ed. 1675, V. 5.

[587] Ralph Thoresby, _Ducatus Leodiensis_, ed. Whitaker, App. p. 151. Brand, _Hist. of Newcastle_, under the year 1675, says that “the jolly rant” caused 724 deaths in that town, the authority given being Jabez Cay, M.D., who left his papers to Thoresby. The number given is probably the mortality from all causes.

[588] Patrick Walker’s _Life of Cargill_, pp. 29, 30.

[589] _Synopsis Nosologiae._ 3rd ed. Edin. 1780, II. 173.

[590] _Epist. respons. ad R. Brady_, § 42.

[591] Luttrell (_Diary_, I. 23) enters under Oct. 1629: “About the middle of this month vast great rains fell which have been very prejudiciall to many persons.”

[592] Christopher Love Morley, M.D., _De Morbo Epidemico tam hujus quam superioris Anni, id est 1678 et 1679 Narratio_. Preface dated London, 31 Dec. 1679.

[593] Lady Chaworth to Lord Roos, _Calendar of the Belvoir MSS._ II. 47.

[594] _Lives of the Norths. Ed. cit._ III. 143.

[595] Luttrell’s _Historical Relation_. Oxford, 1857, I. 19.

[596] Luttrell, _loc. cit._ I. 20, 21, 44.

[597] On 16 March, the illness of “little Frank ... hath made me suspect some kind of aguish distemper; but, if it be, it is so little that we neither perceive coming nor going.” On 7 July, another child is recovered of her feverish distemper. On 5 October, “all my little ones are very well, but some of my servants have quartan agues.” _Lives of the Norths_, Letters of Anne, Lady North.

[598] An authentic case of these lingering epidemic agues was that of John Evelyn in the beginning of 1683. On 7th February, 1687, he writes: “Having had several violent fits of an ague, recourse was had to bathing my legs in milk up to the knees, made as hot as I could endure it; and sitting so in a deep churn or vessel, covered with blankets, and drinking carduus posset, then going to bed and sweating. I not only missed that expected fit, but had no more, only continued weak that I could not go to church till Ash Wednesday, which I had not missed, I think, so long in twenty years”--in fact, since his “double tertian” in 1660, which kept him in bed from 17th February to 5th April.

[599] Ralph Thoresby caught it at Rotterdam, suffered from it, in the tertian form, for several weeks of October and November, 1678, and brought it home with him to Leeds. He gives a good account of the illness in his _Diary_ (2 vols. Lond. 1830).

[600] _The History of this present Fever, with its two products, the Morbus Cholera and the Gripes._ By W. Simpson, Doctor in Physick. London, 1678.

[601] _Cal. Belvoir MSS._ II. 120. June, 1688. Bridget Noel to the Countess of Rutland.

[602] Walter Harris, M.D., _De morbis acutis infantum_. Lond. 1689. English transl. by Cockburn, 1693, p. 88.

[603] “Historical Account of the late General Coughs and Colds, with some Observations on other Epidemical Distempers.” _Phil. Trans._ XVIII. (1694), p. 109.

[604] “’Twas very remarkable that in England as well as this kingdom a short time before the general fever, a slight disease, but very universal, seized the horses too: in them it showed itself by a great defluxion of rheum from their noses; and I was assured by a judicious man, an officer in the army of Ireland, which was then drawn out and encamped on the Curragh of Kildare, there were not ten horses in a regiment that had not this disease.” Molyneux, u. s.

[605] Evelyn says nothing of a great epidemic cold in this season, but makes the following remarks on the weather: “Oct. 31. A very wet and uncomfortable season. Nov. 12. The season continued very wet, as it had nearly all the summer, if one might call it summer, in which there was no fruit, but corn was very plentiful.”

[606] Molyneux, _Phil. Trans._ XVIII. (1694), p. 105.

[607] “An universal cold that appeared in 1708, and was immediately preceded by a very sudden transition from heat to cold in Dublin and its vicinity.” Molyneux’s _Memoirs_.

[608] _La Grippe_ may, of course, be taken literally to mean seizure; but the common use of the word seems to have been figurative for some fancy that seized many at once and became the fashion.

[609] Joannes Turner, M.D., _De Febre Britannica Anni 1712_. Lond. 1713, pp. 3, 4.

[610] Mead, _Short Discourse concerning Pestilential Contagion_. Lond. 1720, p. 8. But Short, who wrote in 1749, places the “Dunkirk rant” under the year 1710: (_Air, Weather, &c._ I. 455).--“March 1, began and reigned two months an epidemic which missed few, and raged fatally like a plague in France and the Low Countries, and was brought by disbanded soldiers into England, namely a catarrhous fever called the Dunkirk rant or Dunkirk ague.... It lasted eight, ten, or twelve days. Its symptoms were a severe, short, dry cough, quick pulse, great pain of the head and over the whole body, moderate thirst, and sweating. Diuretics were the cure.”

[611] “The effects and evidences of God’s displeasure appearing more and more against us since the incorporating union [1707], mingling ourselves with the people of these abominations, making ourselves liable to their judgments, of which we are deeply sharing; particularly in that sad stroke and great distress upon many families and persons, of the burning agues, fevers never heard of before in Scotland to be universal and mortal.” _Life and Death of Alexander Peden._ 3rd ed. 1728. _Biog. Presb._ I. 140.

[612] Boyle’s _Works_. Ed. 1772, V. 725.

[613] _Ibid._ V. 49.

[614] _Scotia Illustrata._ Edin. 1684. Lib. II. “De Morbis,” p. 52.

[615] _Commentar. Nosolog._ Lond. 1727.

[616] _The Method and Manner of curing the late raging Fevers, and of the danger, uncertainly and unwholesomeness of the Jesuit’s bark._ Dated 6 Dec. 1728: “You see that intermitting fevers, when they come to be chronical (and you may see it almost everywhere) make room for a great many distempers, and those very difficult to cure.” p. 49.

[617] _An Enquiry into the Causes of the Present Epidemical Diseases, viz. Fevers, Coughs, Asthmas, Rheumatisms, Defluxions, &c._ By the author of “The Family Companion for Health.” London, 1729, pp. 6, 7.

[618] “Variations of the weather and Epid. Diseases, 1726-34 at Ripon.” Appendix to _Essay on the Smallpox_. Lond. 1740, p. 35.

[619] _Comment. Nosol._ p. 142.

[620] This epidemic appears to have made a much greater impression in Italy. The _Political State of Great Britain_ for 1730, p. 172, under the date of 12th January, N. S. speaks of “the influenza, a strange and universal sickness and lingering distemper,” as causing thirty deaths a day in the public hospital of Milan, as well as fatalities at Rome, Bologna, Ferrara and Leghorn, including the deaths of two cardinals.

[621] _Chronological History_, p. 10.

[622] _Edinburgh Medical Essays and Observations_, II. p. 22, Art. 2. “An Account of the Diseases that were most frequent last year in Edinburgh” (June, 1832 to May, 1833): There had been tertian agues throughout the month of June, 1732, and from August to October an epidemic in the suburbs and villages near Edinburgh, of a slow fever, having symptoms like the “comatose” fever of Sydenham, or the remittent of children.

[623] _Op. cit._ p. 47.

[624] John Arbuthnot, M.D., _Essay concerning the Effects of Air on Human Bodies_. London, 1733, p. 193. His remarks upon the “hysteric” maladies that were common after the wave of influenza in Jan.-Feb. 1733, are referred to in the chapter on Continued Fevers, along with the corresponding information from Hillary, of Ripon.

[625] _Gent. Magaz._ 1733, Jan. p. 43.

[626] Huxham, _Obs. de aere et morbis epidemicis_, 1728-52, _Plymuthi factae_.

[627] _De Aere, &c._ pp. 3, 136-8.

[628] Rutty, _Chronol. Hist. of Diseases in Dublin_. Lond. 1770.

[629] Pringle, _Diseases of the Army_, p. 16.

[630] _Letters of Horace Walpole_, ed. Cunningham, I. 235.

[631] _Gent. Magaz._ XIII. May 1743, p. 272.

[632] R. Chambers, _Domestic Annals of Scotland_, III. 610.

[633] Rutty, u. s. under the year 1743. In an earlier passage, he says that the influenza of 1743 raised the Dublin weekly bills to a highest point of 67, so that it must have been very slight in that city.

[634] Huxham, _Obs. de aere etc._, 2nd ed. 3 vols. Lond. 1752-70, II. 99.

[635] W. Watson, _Phil. Trans._ LII. 646.

[636] _Cleghorn, Observations on the Epidemical Diseases in Minorca, 1744-49_, p. 132.

[637] This influenza was observed in the North American Colonies. It is noteworthy that Huxham, of Plymouth, records under October, 1752, that hundreds of people at once had cough, sore throat, defluxions from the nose, eyes and mouth, attended with a slight fever, and more or less of a rash, several having a great flux of the belly.--_On Ulcerous Sore Throat_, 1757, p. 13.

[638] W. Hillary, M.D., _Obs. on ... Epid. Diseases in Barbadoes_. Lond. 1760.

[639] It is not described for England, unless a reference by Bisset for Cleveland, Yorkshire, should apply to it. Short says, under the year 1758 (_Increase and Decrease of Mankind in England, &c._ 1767): A healthy year in general, “only in the harvest was a very sickly mortal time among the poor, of a putrid slow fever, which carried off many. An epidemic catarrh broke out in November, and made a sudden sweep over the whole kingdom.” Barker, of Coleshill, says, in his _Putrid Constitution of 1777_ (Birmingham, 1779, p. 49): “In the remarkable intermittents of 1758 or 9 ... the early and consequently injudicious use of the bark was attended with such fatal effects that a few doses only sometimes totally oppressed the head, brought on a most rapid delirium, and cut off persons in half-an-hour.”

[640] Robert Whytt, M.D., “On the Epidemic Disorder of 1758 in Edinburgh and other parts of the South of Scotland.” _Med. Obs. and Inq. by a Society of Physicians_, 6 vols. Lond. II. (1762), p. 187. With notices by Millar, of Kelso, and Alves, of Inverness.

[641] Archibald Smith, M.D., “Notices of the Epidemics of 1719-20 and 1759 in Peru,” &c. from the Medical Gazette of Lima, on the authority of Don Antonio de Ulloa. _Trans. Epid. Soc._ II. pt. 1, p. 134.

[642] Horace Walpole’s _Letters_, ed. Cunningham, III. 281.

[643] C. Bisset, _Essay on the Medical Constitution of Great Britain, 1 Jan. 1758, to Midsummer 1760_. Lond. 1762, p. 279.

[644] Extract from the parish register printed by Dr G. B. Longstaff in an appendix to his _Studies in Statistics_. Lond. 1891, p. 443.

[645] _Increase and Decrease of Mankind in England &c._ London, 1767.

[646] Rutty, _op. cit._ p. 275. Compare Watson, _supra_, p. 351.

[647] G. Baker, _De Catarrho et de Dysenteria Londinensi epidemicis, 1762_, Lond. 1764; W. Watson, “Some remarks upon the Catarrhal Disorder which was very frequent in London in May 1762, and upon the Dysentery which prevailed in the following autumn.” _Phil. Trans._ LII. (1762), p. 646.

[648] Professor Alexander Monro, _primus_, of Edinburgh, describes his own attack in a letter to his son, Dr Donald Monro, 11 June, 1766 (_Works of Alex. Monro, M.D. with Life_, Edin. 1781, p. 306): “My case is this: in May, 1762, I had the epidemic influenza, which affected principally the parts in the pelvis; for I had a difficulty and sharp pain in making water and going to stool. My belly has never since been in a regular way, passing sometimes for several days nothing but bloody mucus, and that with considerable tenesmus” &c. Dysentery was epidemic in 1762 as well as influenza.

[649] Donald Monro, M.D., _Diseases of the British Military Hospitals in Germany, &c._ Lond. 1764, p. 137.

[650] _Med. Trans. published by the College of Physicians in London_, I. 437. Heberden’s paper was read at the College, Aug. 11, 1767.

[651] The nearest approach to Heberden’s London influenza of 1767 is an epidemic that Sims observed in Tyrone in the autumn of 1767; a season remarkable for measles and acute rheumatism. At the same time that the acute rheumatism prevailed, a fever showed itself, like it; the patients for two or three days were languid, chilly, with pains in the bones, headache, stupor, dry tongue, costiveness. It was marked by remissions, was by no means mortal, and usually ended by a sweat from the 14th to the 17th day, followed by a copious deposit in the urine. James Sims, _Obs. on Epidemic Disorders_, Lond. 1773, p. 84.

[652] Anthony Fothergill, _Mem. Med. Soc._ III. 30. This paper is not included in John Fothergill’s series. There is also a separate Dublin essay, _Advice to the People upon the Epidemic Catarrhal Fever of Oct. Nov. Dec. 1775_. By a Physician.

[653] I have not found the weekly bills for this year in London; but the following averages, taken from the four-weekly or five-weekly totals in the _Gentleman’s Magazine_, will show how slight the rise was:

1775. October weekly average 323 births 345 deaths November " " 334 " 447 " December " " 369 " 449 "

[654] W. Grant, M.D., _Observations on the late Influenza as it appeared at London in 1775 and 1782_. Lond. 1782. Also, by the same, _A Short Account of the Present Epidemic Cough and Fever, in a letter &c._ First printed at Bath, and afterwards at London, 1776.

[655] MS. Infirmary Book.

[656] The reports collected by Dr John Fothergill (_Med. Obs. and Inquir._ VI. 340) were by himself, and by Pringle, Baker, Heberden and Reynolds, of London; Cuming, of Dorchester; Glass, of Exeter (long account): Ash, of Birmingham; White, of York; Haygarth, of Chester; Pulteney, of Blandford; Thomson, of Worcester; Skene, of Aberdeen; and Campbell, of Lancaster. The papers of this collective inquiry, as well as the two collections in 1782, the collection of Simmonds in 1788, that of Beddoes in 1803 (in a digest) and the Report of the Provincial Medical Association in 1837, together with some other extracts from books or papers, were brought together in a volume, without much editing, by Dr Theophilus Thompson, under the title of _The Annals of Influenza in Great Britain from 1510 to 1837_. London, 1852. This has been reprinted and brought down to date by Dr Symes Thompson, 1891.

[657] _Mem. Med. Soc._ III. 34.

[658] _Life of Sir Robert Christison_, 2 vols. Edin. 1885, vol. I. (Autobiography), p. 82.

[659] For the year 1730, under the date 12 January, p. 172.

[660] “An Account of the Epidemic Catarrh of the Year 1782; compiled at the request of a Society for promoting Medical Knowledge.” By Edward Gray, M.D., F.R.S., _Medical Communications_, I. (1784), p. 1.

[661] “An Account of the Epidemic Disease called the _Influenza_, of the Year 1782, collected from the observations of several physicians in London and in the Country; by a Committee of the Fellows of the Royal College of Physicians in London.” _Medical Transactions published by the Coll. of Phys. in London_, III. (1785), p. 54. Read at the College, June 25, 1783.

[662] John Clark, M.D., _On the Influenza at Newcastle_. Dated 26 May, 1782; Arthur Broughton, _The Influenza or Epid. Catarrh in Bristol in 1782_. London, 1782; W. Falconer, _Account of the Influenza at Bath in May-June, 1782_. Bath, 1782.

[663] Gregory, cited by Christison, _Life &c._ I. 84: “I have been told of the haymakers attempting to struggle with the sense of fatigue, but being obliged in a few minutes to lay down their scythes and stretch themselves on the field.”

[664] Gray, u. s. p. 107.

[665] _The London Medical Journal_, III. (1783), 318.

[666] College of Physicians’ Report: “A family which came in the Leeward Islands fleet in the end of September, 1782, was attacked by it in the beginning of October. This family afterwards told the physician who attended them that several of their acquaintances, who came over in the same fleet with them, had been attacked at the same time and in the same manner as themselves.”

[667] He had another experience not quite the rule: “Children and old people either escaped this influenza entirely, or were affected in a slight manner.”

[668] R. Hamilton, M.D., “Some Remarks on the Influenza in Spring, 1782,” _Mem. Med. Soc._ II. 422. This author had some difficulty in deciding where the influenza ended and the epidemic ague began.

[669] _Trans. Col. Phys._ “On the late Intermittent Fevers,” III. 141. Read at the College, 10 Jan., 1785.

[670] _Ibid._ p. 168.

[671] _Febris Anomala, or the New Disease._ Lond. 1659, p. 1.

[672] “Remarks on the Treatment of Intermittents, as they occurred at Hampstead in the Spring of 1781.” By Thomas Hayes, Surgeon. _Lond. Med. Journ._ II. 267.

[673] _Epidemicks_ (1777-95), pp. 58, 72, 75, &c. Barker’s annals from 1779 to 1786 are full of references to agues, “bad burning fevers” and the like, but are on the whole too confused to be of much use for history. See the Boston bills under Smallpox.

[674] W. Moss, _Familiar Medical Survey of Liverpool_. Liverpool, 1784, p. 117. This writer’s object is to show that Liverpool escaped most of the epidemic diseases that troubled other places, including typhus fever. As to the influenzas he says: “The influenza of 1775, so universal and very fatal in many parts, was less fatal here; and also that much slighter complaint, distinguished by the same title, which appeared in the spring of 1783.”

[675] _Gent. Magaz._ LIII. pt. 2, p. 920. Letter dated from “Pontoon.”

[676] William Coley, _Account of the late Epidemic Ague in the neighbourhood of Bridgenorth, Shropshire, in 1784 ... to which are added some observations on a Dysentery that prevailed at the same time_. Lond. 1785.

[677] Baker, u. s.

[678] “An Account of the Effects of Arsenic in Intermittents.” By J. C. Jenner, surgeon at Painswick, Gloucestershire. _Lond. Med. Journ._ IX. (1788), p. 47.

[679] _Ibid._ VII. (1786), p. 163.

[680] Table compiled by Dr Mackenzie, and printed by Christison, _Trans. Soc. Sc. Assoc._ Edin. Meeting, 1863, p. 97. Christison pointed out very fairly the difficulties in the way of accepting the drainage-theory for the decline of ague (p. 98), but he had not realized the fact that the disease used to come in epidemics at long intervals.

[681] e.g. parish of Dron, Perthshire (IX. 468): “The return of spring and autumn never failed to bring along with them this fatal disease [ague], and frequently laid aside many of the labouring hands at a time when their work was of the greatest consequence and necessity.” That had now ceased, owing to drainage. See also Cramond parish, I. 224, and Arngask, Perthshire, I. 415.

[682] The following extracts are from Barker’s book, _Epidemicks_, Birmingham [1795]: 1782. Influenza in the latter end of spring. Nine out of ten in Lichfield and other towns had violent defluxions of the nose, throat and lungs, bringing on violent sneezings, soreness of the throat, coughs, &c. attended with a pestilential fever, of which many were relieved by perspiration.... Some had swelled faces, and violent pains in the teeth.... Some, giddiness and violent headaches, accompanied with a slow fever, and even loss of memory.... By its running through whole families it appeared also to be communicable by infection.

1783. The influenza also began to appear again; and those who had coughs last year began now to be afflicted with them again, the disorder at length frequently ending in a consumption. Also dogs in this year and the next had running at the eyes and a loss of the use of their hind legs, which in the end killed most of those that were seized with it. Horses also suffered.

1786. In the middle of this season the influenza returned, and colds and coughs were epidemical.

1788 [spring]. A species of influenza of the pestilential kind, akin to that of 1782, has almost constantly returned in spring and autumn since that time ... [summer] A species of influenza, as in the spring, and it is also at Edinburgh.

1789 [spring]. Influenza returned. Even dogs affected.

1791. Influenza very bad, especially in London.

[683] Samuel Foart Simmons, M.D., F.R.S., “Of the Epidemic Catarrh of the year 1788.” _Lond. Med. Journ._ IX. (1788), p. 335.

[684] Vaughan May, surgeon to H. M. Ordnance, “Observations on the Influenza as it appeared at Plymouth, in the summer and autumn of the year 1788.” Duncan’s _Med. Commentaries_, Decade 2, vol. iv. p. 363.

[685] Falconer, “Influenzae Descriptio, uti nuper comparebat in urbe Bathoniae, mensibus Julio, Augusto et Septembri A.D. 1788.” _Mem. Med. Soc._ III. 25.

[686] George Bew, M.D., physician at Manchester, “Of the Epidemic Catarrh of the year 1788.” _Lond. Med. Journ._ IX. (1788), p. 354. “The influenza has been _very_ prevalent,” writes Withering, of Birmingham, to Lettsom, 19 Aug. 1788. _Mem. of Lettsom_, III. 133.

[687] Related to Dr Simmons (1. c. p. 346), by Mr Boys, surgeon, of Sandwich, who was told it by his son, a lieutenant on board the ‘Rose.’

[688] In a note to Simmons’ paper, u. s., p. 342.

[689] “An Account of an Epidemic Fever that prevailed in Cornwall in the year 1788.” _Lond. Med. Journal_, X. p. 117 (dated Truro, Jan. 26, 1789).

[690] Bew, u. s., p. 365. Carmichael Smyth has a similar remark on the influenza of 1782: “This epidemic distemper very soon declined. But it seemed to leave behind it an epidemical constitution which prevailed during the rest of the summer; and the fevers, even in the end of August and beginning of September, assumed a type resembling, in many respects, the fever accompanying the influenza.”

[691] A solitary reference occurs to an influenza in 1792, which I have not succeeded in verifying:--B. Hutchinson, “An Account of the Epidemic Disease commonly called the Influenza, which appeared in Nottinghamshire and most other parts of the kingdom in the months of November and December, 1792.” _New. Lond. Med. Journ._, Lond. 1793, II. 174. Cited in the Washington Medical Catalogue.

[692] Robert Willan, M.D., _Reports on the Diseases in London,

## particularly during the years 1796, ’97, ’98, ’99 and 1800_. London, 1801,

pp. 76, 253.

[693] Published in the _Med. and Phys. Journal_ from August to December, 1803.

[694] _Memoirs of the Medical Society_, vol. VI.

[695] R. Hooper, M.D., _Obs. on the Epidemic Disease now prevalent in London_. London, 1803. R. Pearson, M.D., _Obs. on the Epid. Catarrhal Fever or Influenza of 1803_. Lond. 1803.

[696] J. Herdman, _The prevailing Epid. Disease termed Influenza_. Edin. 1803.

[697] W. Falconer, M.D., _The Epidemic Catarrhal Fever commonly called the Influenza, as it appeared at Bath &c._ Bath, 1803.

[698] John Nott, M.D., _Influenza as it prevailed in Bristol in Feb.-April, 1803_. Bristol, 1803.

[699] _Med. and Phys. Journ._ X. 104.

[700] Dr Currie of Chester, _Med. and Phys. Journ._ X. 213.

[701] _Ib._ X. 527, quoted by Beddoes from memory, the letter from Navan having been lost.

[702] Alvey, _Mem. Med. Soc._ VI. 462.

[703] Dr Carrick, of Bristol, in Duncan’s _Annals of Med._ III. Compare the report for Fraserburgh in 1775, supra, p. 360.

[704] Frazer, _Med. and Phys. Journ._ X. 206, dated 12 June, 1803.

[705] Hirsch cites authorities for influenza in Edinburgh, London, Nottingham and Newcastle in the winter of 1807-8. In Roberton’s monthly reports from Edinburgh (_Med. and Phys. Journ._ XXI.), and Bateman’s quarterly reports from London, I find only common colds recorded. Clarke for Nottingham (_Ed. Med. Surg. Journ._ IV. 429) says catarrh was so general “as to have acquired the name of influenza; but there was no reason to suppose it contagious.”

[706] W. Royston, “On a Medical Topography,” _Med. and Phys. J._ XXI. 1809, (Dec. 1808), p. 92: “After the unusual heat of the last summer, the frequency of intermittents in the autumn was increased in the fens of Cambridgeshire to an almost unprecedented degree; and even quadrupeds were not exempt, for distinctly marked cases of _tertian_ were observed in horses. In the year 1780 a similar prevalence of this disease occurred in the same part; and though in an interval of 28 years many and frequent sporadic cases have arisen, yet its universality during that period was suspended. We have to regret that a correct record of the constitution of the year 1780, as applying to this particular district, has not been preserved in such a manner as to admit of a direct comparison with that of 1808. If it were possible, from authentic documents to compare the history of these two seasons, much light might be thrown on the obscure cause of intermittents.” Clarke, of Nottingham, (l. c.) says there were some cases of irregular ague among a few privates of the regiment there, who had all come from a marshy quarter, some of them with the fever on them. The paroxysms came at unusually long intervals. Bark increased the fever.

[707] Lecture on Agues, in the _Lond. Med. Gaz._ IX. 923-4, 24 March, 1832.

[708] _Lancet_, s. d., p. 438.

[709] _Lond. Med. Gazette_, 2 July, 1831.

[710] John Burne, M.D., _Ibid._ VIII. (1831), p. 430.

[711] G. Bennett, _Lond. Med. Gaz._ 23 July, 1831.

[712] Bellamy, _Ibid._

[713] “Report of Diseases among the Poor of Glasgow,” _Glas. Med. Journ._ IV. 444.

[714] McDerment, _ibid._ V. 230: “In June and July to an extent unequalled” etc.

[715] During the last general election before the passing of the Reform Bill, which was held in the month of June, 1831, a number of the Aberdeen radicals went out on a hot and dusty day to meet the candidate of their party who was posting from the south. It was remarked that all those who had been of this company “caught cold,” unaccountably but as if from some common cause. The date would correspond to the prevalence of influenza elsewhere.

[716] Mr Kingdon, reported in the _Lancet_, s. d.

[717] Venables, _Lancet_, II. May, 1833.

[718] Hingeston, _Lond. Med. Gaz._ XII. 199.

[719] _Gent. Magaz._, April, 1833, p. 362.

[720] Whitmore, _Febris anomala, or the New Disease, etc._, London, 1659, p. 109:--“And for a plethora or fulness of blood, if that appears (though this may seem a paradox yet ’tis certain) that it is so far in this disease from indicating bleeding that it stands absolutely as a contradiction to it and vehemently prohibits it. And whereas they think the heat, by bleeding, may be abated and so the feaver took off, they are mistook, for by that means the fermentation through the motion of the blood is highly increased, so as sad experience hath manifested in a great many: upon the bleeding they have within a day or two fallen delirious and had their tongues as black as soot, with an intolerable thirst and drought upon them.... Petrus a Castro, who rants high for letting blood, at last as if he had been humbled with the sad success, saith etc.”

[721] _A System of Clinical Medicine_, Dublin, 1843, pp. 500-501. Lecture delivered in the session 1834-35.

[722] Rawlins, _Lond. Med. Gaz._ s. d.

[723] _Ed. Med. Surg. Journ._ XLIII. 1835, p. 26.

[724] Parsons, “Report of Outcases, Birmingham Infirmary, 1 Jan. to 31 Dec. 1833.” _Trans. Provin. Med. Surg. Assoc._ II. 474.

[725] In the report upon the influenza of 1837 by a Committee of the Provincial Medical Association, the preceding epidemic is uniformly referred to the year 1834. Graves, in a clinical lecture upon that of 1837, speaks two or three times of the last as that of 1834, and, in another place, he calls it the epidemic of 1833-34. But these, I think, are mere laxities of dating, of which there are many other instances where the date is recent and not yet historical.

[726] As early as 1612 a proposal had been made to James I. for “a grant of the general registrarship of all christenings, marriages and burials within this realm.” _State Papers_, Rolls House, Ja. I. vol. LXIX. No. 54. It was a device for raising money.

[727] The account in the _Gentleman’s Magazine_ for February, 1837, p. 199, is almost identical with the paragraph in the number for April, 1833: “An influenza of a peculiar character has been raging throughout the country, and particularly in the Metropolis. It has been attended by inflammation of the throat and lungs, with violent spasms, sickness and headache. So general have been its effects that business in numerous instances has been entirely suspended. The greater number of clerks at the War Office, Admiralty, Navy Pay Office, Stamp Office, Treasury, Post-Office and other Government Offices have been prevented from attending to their daily avocations.... Of the police force there were upwards of 800 incapable of doing duty. On Sunday the 13th the churches which have generally a full congregation presented a mournful scene &c. ... the number of burials on the same day in the different cemeteries was nearly as numerous as during the raging of the cholera in 1832 and 1833. In the workhouses the number of poor who have died far exceed any return that has been made for the last thirty years.”

[728] Graves, u. s., p. 545.

[729] Robert Cowan, M.D., _Journ. Stat. Soc._ III. 257.

[730] Peyton Blakiston, _A Treatise on the Influenza of 1837, containing an analysis of one hundred cases observed at Birmingham between 1 Jan. and 15 Feb._ Lond. 1837.

[731] These and some former particulars are from the “Report upon the Influenza or Epidemic Catarrh of the winter of 1836-37,” compiled by Robt. J. N. Streeten, M.D. for the Committee of the Provincial Medical Association. _Trans. Prov. Med. Assoc._ VI. 501.

[732] Streeten’s Report, u. s., p. 505.

[733] _Statist. Report on Health of Navy_, 1837-43.

[734] Jackson, _Dubl. Med. Press_, VIII. 69; Brady, _Dubl. Journ. Med. Sc._ XX. (1842), 76.

[735] Laycock, _Dubl. Med. Press_, VII. 234. Several cases of sudden and great enlargement of the liver and of suppression of urine were judged to be part of the epidemic.

[736] Ross, _Lancet_, 1845, I. p. 2.

[737] Report of Holywood Dispensary for 1842, _Dublin Med. Press_, IX. 204.

[738] Hall, _Prov. Med. Journ._ 1844, p. 315.

[739] M’Coy, _Med. Press_, XI. 133.

[740] Fleetwood Churchill, _Dubl. Quart. Journ._, May, 1847, p. 373.

[741] Farr, in _Rep. Reg.-Gen._

[742] Farr, in the _Report of the Registrar-General for 1848_. He cites (p. xxxi) Stark for Scotland, that it “suddenly attacked great masses of the population twice during November”--on the 18th, and again on the 28th.

[743] A curious trace of the temporary interest excited by influenza in 1847-8 remains in a great book of the time, Carlyle’s _Letters and Speeches of Cromwell_, the third edition of which, with new letters, was then under hand. One of the new letters related to the death of Colonel Pickering from the camp-sickness among the troops of Fairfax at Ottery St Mary in December, 1645. Carlyle’s comment is: “has caught the epidemic ‘new disease’ as they call it, some ancient _influenza_ very prevalent and fatal during those wet winter operations.” “New disease” was the name given by Greaves to the war-typhus in Oxfordshire and Berkshire in 1643, but neither that nor the sickness at Ottery (which is not called “new disease” in the documents) had anything of the nature of influenza.

[744] But Dr Rose Cormack, who had known relapsing fever well in Edinburgh, wrote from Putney, near London, in October, 1849: “For some months past the majority of cases of all diseases in this neighbourhood have ... presented a well-marked tendency to assume the remittent and intermittent types.” “Infantile Remittent Fever,” _Lond. Journ. of Med._, Oct. 1849, reprinted in his _Clinical Studies_, 2 vols., 1876.

[745] T. B. Peacock, M.D., _On the Influenza, or Epidemic Catarrhal Fever of 1847-8_. London, 1848.

[746] Haviland, _Journ. Pub. Health_, IV. 288, (94 cases in June-Aug. in a village).

[747] See F. Clemow, M.D., of St Petersburg, “The Recent Pandemic of Influenza: its place of origin and mode of spread.” _Lancet_, 20 Jan. and 10 Feb. 1894. These papers bring together and discuss the Russian opinions, official and other. The Army Medical Report favoured the view that the birthplace of this pandemic in the autumn of 1889 was an extensive region occupied by nomadic tribes in the northern part of the Kirghiz Steppe. There is evidence of its rapid progress westwards over Tobolsk to the borders of European Russia. Influenza is said to be constantly present in many parts of the Russian Empire; but the circumstances that have, on four or five occasions in the 19th century, set the infection rolling in a great wave westwards from the assumed source are wholly unknown.

[748] The collective inquiry on the epidemics was made by the medical department of the Local Government Board, the result being given in two reports: _Report on the Influenza Epidemic of 1889-90, Parl. Papers_, 1891, and _Further Report and Papers on Epidemic Influenza, 1889-92, Parl. Papers_, Sept. 1893. By H. Franklin Parsons, M.D. Statistical tables comparing the epidemics in London with those in some other capitals were published by F. A. Dixey, M.D., _Epidemic Influenza_, Oxford, 1892.

[749] The notable difference between the type of this epidemic and that of the epidemics of 1833, 1837 and 1847, from which the conventional notion of “influenza cold” was derived, is perhaps the explanation of the following apt and erudite remark by Buchanan, on “influenza proper,” in his introduction to the first departmental report, 1891: “It would be no small gain to get more authentic methods of identifying influenza proper from among the various grippes, catarrhs, colds and the like--in man, horse, and other animals--that take to themselves the same popular title” (p. xi).

[750] The volume by Julius Althaus, M.D., _Influenza: its Pathology, Complications and Sequelae_, 2nd ed., Lond. 1892, includes a summary and bibliography of recent observations.

[751] Noah Webster, _Brief History of Epidemick Diseases_, I. 288; Warren, of Boston, to Lettsom, 30 May, 1790, _Lettsom’s Memoirs_, III. 238: “whether this [the second] is a variety of influenza, or a new disease with us, I am at a loss to determine.”

[752] In Twysden’s _Decem Scriptores_, col. 579.

[753] Boyle’s _Works_, 6 vols., London, 1772, V. 52.

[754] Seneca, _Nat. Quaest._ § 27, cited by Webster. After earthquakes, “subitae continuaeque mortes, et monstrosa genera morborum ut ex novis orta causis.” The passage cited from Baglivi (p. 530) looks like a repetition of this: “imo nova et inaudita morborum genera ... post terraemotus.”

[755] Cited by Horace E. Scudder, in _Noah Webster_. New York and London, 1881, p. 105.

[756] _Brief History of Epidemic and Pestilential Diseases_, 2 vols., Hartford, 1799.

[757] _Brief History of Epidemic and Pestilential Diseases_, II. 15.

[758] _Id._ II. 34, 84. Dr Robert Williams, in his work on _Morbid Poisons_ (II. 670) argues for Webster’s electrical theory of influenza without knowing, or at least without saying, that it was Webster’s. The much-advertised writings of Mr John Parkin on _The Volcanic Theory of Epidemics_ (or other title) follow Webster very closely both in the main idea and in its ramifications, but without acknowledgment to the American _philosophe_. Milton’s rule was that one might take from an old author if one improved upon him; but neither Williams nor Parkin has improved upon Webster.

[759] _Ibid._ II. 30.

[760] “Catalogue of Recorded Earthquakes from 1606 B.C. to A.D. 1850.” _British Assocn. Reports_, 1852-54.

[761] Abraham Mason, _Phil. Trans._ LII. Part 2, p. 477.

[762] Webster, I. 150.

[763] Hillary, _Changes of the Air, etc._, p. 82.

[764] Hillary, _Changes of the Air, etc._, p. 80.

[765] Webster, I. 250.

[766] Hamilton, _Phil. Trans._ LXXIII. 176.

[767] Mallet’s Catalogue, u. s.

[768] Holm, _Vom Erdbrande auf Island im Jahre 1783_, Kopenhagen, 1784, says: “Since the outbreak began, the atmosphere of the whole country has been full of vapour, smoke and dust, so much so that the sun looked brownish-red, and the fishermen could not find the banks.... Old people, especially those with weak chests, suffered much from the smell of sulphur and the volcanic vapours, being afflicted with dyspnoea. Various persons in good health fell ill, and more would have suffered had not the air been cooled and refreshed from time to time by rains,” pp. 57, 60. The real sickness of Iceland in those years had been before the volcanic eruptions, in 1781 and 1782, when some parts of the island were almost depopulated by the famine and pestilential fevers that followed the unusual seasons.

[769] _Phil. Trans._ II. (1667), p. 499.

[770] _Ibid._ March-Apr. 1694, p. 81. Sloane had himself felt several shocks at Port Royal on the 20th October, 1687, between four and six o’clock in the morning, which were due to the same earthquake that destroyed Lima in Peru.

[771] _Phil. Trans._ XVIII. p. 83 (March-April, 1794). Series of reports from Jamaica collected by Sloane.

[772] A few cases have been exceptionally seen at Spanish Town, six miles from the head of the bay, the infection of which was supposed to have been brought from the shore by sailors, and it has also prevailed in the barracks on the high ground of Newcastle not far from the shore.

[773] Without seeking to argue for the connexion between particular earthquakes and influenzas, but merely to illustrate the possibilities, I append here an instance that ought not to be overlooked. On the 1st of November, 1835, there was a great earthquake in the Moluccas, which so completely changed the soil of the island of Amboina, that it became notably subject to deadly miasmatic or malarious fevers from that time forth. For three weeks before the earthquake the atmosphere had been full of a heavy sulphurous fog, so that miasmata were rising from the soil by some unwonted pressure before the actual cataclysm. There is no doubt at all that Amboina became “malarious” in a most marked degree from the date of the earthquake; it is a classical instance of the sudden effect of great changes in the earth’s crust upon the frequency and malignity of remittent and intermittent fevers, according to the testimony of physicians in the Dutch East Indian service. The influenza nearest to the earthquake was about a year after, at Sydney, Cape Town, and in the East Indies, during October and November, 1836. The epidemic appeared about the same time in the north-east of Europe, spread all over the continent, and reached London in January, 1837. There was again influenza in Australia and New Zealand in November, 1838, two years after the last outbreak in that region.

[774] _Phil. Trans._ for the year 1694, p. 5.

[775] Mallet, “First Report on the Facts of Earthquake Phenomena.” _Trans. Brit. Assoc. for 1850_, Lond. 1851. Cited from von Hoff.

[776] Archibald Smith, M.D., “Notices of the Epidemics of 1719-20 and 1759 in Peru,” etc. _Trans. Epid. Soc._ II. pt. 1, p. 134. From the _Medical Gazette of Lima_, 15 March, 1862.

[777] Bell’s Travels, in Pinkerton, VII. 377.

[778] See an article “Railways--their Future in China,” by W. B. Dunlop, in _Blackwood’s Magazine_, March, 1889, pp. 395-6. A letter in the _Pall Mall Gazette_, dated 23 May, 1891, and signed “Shanghai,” recalled the outbreak of Hongkong fever, “the symptoms of which bore a curious resemblance to the influenza epidemic,” at the time when much building was going on upon the slope of Victoria Peak: “It was said at the time--I do not know with what truth--that in this turning-up of the soil, several old Chinese burying-places were included.”

[779] _Essay on the Most Effective Means of preserving the Health of Seamen in the Royal Navy._ London, 1757, p. 83.

[780] See _The Eruption of Krakatoa and subsequent phenomena_. Report of the Krakatoa Committee of the Royal Society.... Edited by G. J. Symons, London, 1888.

[781] _Edin. Med. Essays and Obs._ II. 32.

[782] _Trans. Col. Phys._ III. 62.

[783] _Gent. Magaz._ 1782, p. 306.

[784] R. Robertson, M.D., _Observations on Jail, Hospital or Ship Fever from the 4th April, 1776, to the 30th April, 1789_. Lond. 1789, New ed., p. 411.

[785] Trotter, _Medicina Nautica_, I. 1797, p. 367.

[786] Notes of a lecture on Influenza, by Gregory, taken by Christison about the year 1817, in the _Life of Sir Robert Christison_, I. 82.

[787] College of Physicians’ Report, _Trans. Col. Phys._ III. 63.

[788] This is inferred from the varying number of ships in the two fleets in the several notices of their movements in the _Gentleman’s Magazine_, for May and June, 1782.

[789] Brian Tuke to Peter Vannes, 14 July, 1528: “For when a whole man comes from London and talks of the sweat, the same night all the town is full of it, and thus it spreads as the fame runs.” _Cal. State Papers, Henry VIII._ IV. 1971.

[790] Webster, II. 63.

[791] College of Physicians’ Report. _Trans. Col. Phys._ III. (1785), p. 60-61. “Information has been received” of the incident.

[792] _Statist. Report of Health of Navy, 1837-43._ Parl. papers, 1 June, 1853, p. 8.

[793] _Ibid._ p. 14.

[794] _Ibid._ s. d.

[795] _Report on Health of Navy, 1857_, p. 69.

[796] _Ibid._ p. 41.

[797] _Ibid._ p. 131.

[798] _Ibid._ p. 112.

[799] _Report for 1856_, p. 100.

[800] Chaumezière, _Fievre catarrhals épidemique, observée à bord du vaisseau ‘Le Duguay-Trouin’ aux mois de Fevr. et Mars, 1863_. Paris, 1865. Cited by Hirsch.

[801] Dr Guthrie, of Lyttelton.

[802] Macdonald, _Brit. Med. Journ._, 14 July, 1886.

[803] _Cruise of H.M.S. ‘Galatea’ in 1867-8._

[804] R. A. Chudleigh, in _Brit. Med. Journal_, 4 Sept. 1886. The experiences are not altogether recent, for they were noted for “the Chatham Islands and parts of New Zealand” by Dieffenbach, in his German translation of Darwin’s _Naturalist’s Voyage round the World_. See English ed. 1876, p. 435 _note_.

[805] _Pall Mall Gazette_, 11 Dec. 1889.

[806] Hirsch, _Geograph. and Histor. Pathol._ I. 29. Engl. Transl.

[807] See the chapter on Sweating Sickness in the first volume of this History, p. 269, and the author’s other writings there cited.

[808] See the first volume, pp. 456-461. I shall add here a reference to smallpox among young people in Henry VIII.’s palace at Greenwich in 1528. Fox, newly arrived from a mission to France, writes to Gardiner, 11 May, 1528 (Harl. MS. 419, fol. 103): The king “commanded me to goe unto Maystress Annes chamber, who at that tyme, for that my Lady prynces and dyvers other the quenes maydenes were sicke of the small pocks, lay in the gallerey in the tilt yarde.”

[809] _Selections from the Records of the Kirk Session, Presbytery and Synod of Aberdeen._ Edited by John Stuart, for the Spalding Club, Aberd. 1846, I. 427.

[810] Mead to Stutteville, in _Court and Times of Charles I._, I. 359. Joan, Lady Coke to Sir J. Coke, 26 June, 1628. _Cal. Coke MSS._

[811] Lord Dorchester to the Earl of Carlisle, 30 Aug. 1628, in _C. and T. Charles I._: “Your dear lady hath suffered by the popular disease, but without danger, as I understand from her doctor, either of death or deformity.”

[812] Gilbert Thacker to Sir J. Coke at Portsmouth, 9 June, 1628; Thomas Alured to the same, 21 June; Richard Poole to the same, 23 June. _Cal. Coke MSS._, I. Thomas Alured’s house “hath been visited in the same kind, once with the measles and twice with the smallpox, though I thank God we are now free; and I know not how many households have run the same hazard.”

[813] Harl. MS., No. 2177.

[814] The original heading in the Bills of Mortality was “flox and smallpox.” “Flox” meant flux, or confluent smallpox, which was so distinguished, as if in kind, from the ordinary discrete form, seldom fatal. Huxham, in 1725, _Phil. Trans._ XXXIII. 379, still used these terms: “When the pustules broke out in less than twenty-four hours from the seizure, they were always of the flux kind, as is commonly observed.... Pocks which at first were distinct would flux together during suppuration.” Dover, _Physician’s Legacy_, 1732, p. 101, has “the flux smallpox, or variolae confluentes,” as one of the varieties: and again, pustules “fluxing in some parts, in others distinct.”

[815] Having been omitted by Graunt in his table. _Op. cit._ 1662.

[816] _Cal. State Papers_, under the dates. The epidemic seems to have revived in 1642. An affidavit among the papers of the House of Lords, excusing the attendance of a witness, states that Thomas Tallcott has recently lost his wife and one child by smallpox, and that he himself, six of his children and three of his servants are now visited with the same disease. 13 July, 1642, _Hist. MSS. Com._ V. 38. The Mercurius Rusticus, 1643, says that Bath was much infected both with the plague and the smallpox. Cited in Hutchins, _Dorsetshire_, III. 10.

[817] _Remaining Works._ Transl. by Pordage. Lond. 1681. “Of Feavers,” p. 142. In one of his cases Willis was at first uncertain as to the diagnosis, because “the smallpox had never been in that place.”

[818] _Histor. MSS. Commis._ V. 156-154. Sutherland Letters.

[819] Sutherland Letters, u. s. Andrew Newport to Sir R. Leveson at Trentham.

[820] Mary Barker to Abel Barker, 26 May and 2 June, 1661. _Hist. MSS. Com._ V. 398: “There is many dy out in this town, and many abroad that we heare of”; the squire’s mother is living “within a yard of the smallpox, which is also in the house of my nearest neighbour”; her own children had whooping cough, but do not appear to have taken smallpox.

[821] _Hactenus Inaudita, or Animadversions upon the new found way of curing the Smallpox._ London, 1663. Dated 10 July, 1662. The burden of his own complaint is of a prominent personage in the smallpox who was killed, as he maintains, by enormous doses of diacodium, an opiate with oil of vitriol, much in request among the partisans of the cooling regimen.

[822] His first book was Περὶ ὑδροποσίας, or _A Discourse of Waters, their Qualities and Effects, Diaeteticall, Pathologicall and Pharmacuiticall_. By Tobias Whitaker, Doctor in Physicke of Norwich. Lond. 1834. In 1638, being then Doctor in Physick of London, he published _The Tree of Humane Life, or the Bloud of the Grape. Proving the Possibilitie of maintaining humane life from infancy to extreame old age without any sicknesse by the use of wine._ An enlarged edition in Latin was published at Frankfurt in 1655, and reprinted at the Hague in 1660, and again in 1663. The passages cited in the text occur in his _Opinions on the Smallpox_. London, 1661.

[823] His only reference to the deaths in the royal family, which were currently set down to professional mismanagement, comes in where he opposes the prescription of Riverius to bathe the hands and feet in cold water: “this hath proved fatall,” he says, “in such as have rare and tender skins, as is proved by the bathing of the illustrious Princess Royal. Therefore I shall rather ordain aperient fomentations in their bed, to assist their eruption and move sweat.”

[824] _Pyretologia_, II. 94, 112.

[825] Walter Harris, M.D., _De morbis acutis infantum_, 1689. There were several editions, some in English.

[826] Jurin, _Letter to Cotesworth_. Lond. 1723, p. 11.

[827] Speaking of malignant sore-throat, he says: “The younger the patients are, the greater is their danger, which is contrary to what happens in the measles and smallpox.” _Commentaries on Diseases_, p. 25.

[828] Andrew’s _Practice of Inoculation impartially considered_. Exeter, 1765, p. 60.

[829] Duvillard (_Analyse et Tableaux de l’Influence de la Petite Vérole sur la Mortalité à chaque Age._ Paris, 1806) gives the ages at which 6792 persons died of smallpox at Geneva from 1580 to 1760, according to the registers of burials:

Total at all ages. 0-1, -2, -3, -4, -5, -6, -7, -8, -9, -10, -15, -20, -25, -30.

6792 1376 1300 1290 898 603 381 301 189 109 78 126 54 39 31

The public health of Geneva altered very much for the better in the course of two centuries from 1561 to 1760. From 1561 to 1600, in every hundred children born, 30·9 died before nine months, on an annual average, and 50 before five years. From 1601 to 1700 the ratios were 27·7 under nine months, and 46 before five years. From 1701 to 1760 the deaths under nine months had fallen to 17·2 per cent., and under five years to 33·6 per cent. (Calculated from a table in the _Bibliothèque Britannique_, Sciences et Arts, IV. 327.) Thus, with an increasing probability of life, the age-incidence of fatal smallpox may have varied a good deal within the period from 1580 to 1760. It is given by Duvillard separately for the years 1700-1783 (inclusive of measles): during which limited period a smaller ratio died under nine months, and a larger ratio above the age of five years, than in the aggregate of the whole period from 1580 to 1760. Whatever may have been the rule at Geneva, it cannot be applied to English towns; for, while some 30 per cent. of the smallpox deaths were at ages above five in the Swiss city (1700-1783), only 12 per cent. were above five in English towns such as Chester and Warrington in 1773-4.

[830] _Pyretologia_, 2 vols. Lond. 1692-94, vol. II.

[831] _Natural History of Oxfordshire._ Oxford, 1677, p. 23.

[832] In his _Diary_, under the year 1646, homeward journey from Rome.

[833] The physician was “a very learned old man,” Dr Le Chat, who had counted among his patients at Geneva such eminent personages as Gustavus Adolphus and the duke of Buckingham.

[834] Dr Dover has left us an account of Sydenham’s practice in the smallpox as he himself experienced it: “Whilst I lived with Dr Sydenham, I had myself the smallpox, and fell ill on the twelfth day. In the beginning I lost twenty ounces of blood. He gave me a vomit, but I find by experience purging much better. I went abroad, by his direction, till I was blind, and then took to my bed. I had no fire allowed in my room, my windows were constantly open, my bedclothes were ordered to be laid no higher than my waist. He made me take twelve bottles of small beer, acidulated with spirit of vitriol, every twenty-four hours. I had of this anomalous kind to a very great degree, yet never lost my senses one moment.” _The Ancient Physician’s Legacy._ London, 1732, p. 114.

[835] _Scotia Illustrata._ Lib. II., cap. 10.

[836] _De Febribus &c._, Lond. 1657: cap. ix. “De Variolis et Morbillis,” p. 141.

[837] “First of all,” he says, “let the patient be kept with all care and diligence from cold air, especially in winter, so that the pores of the skin may be opened and the pocks assisted to come out. Therefore let him be kept in a room well closed, into which cold air is in no manner to enter, and let him be sedulously covered up in bed.... I desire the more to admonish my friends in this matter, for that Robert Cage, esquire, my dear sister’s husband,” etc.

[838] Besides cases to show the ill effects of blooding, vomits, purges and cooling medicines such as spirit of vitriol, he gives examples as if to refute Sydenham’s favourite notion that salivation, diarrhoea and menstrual haemorrhage were relieving or salutary. Morton’s chief object was to bring out the eruption, and to get it to maturate kindly; an eruption which languished, or did not rise and fill, was for him the most untoward of events. Sydenham, on the other hand, argued that the danger was in proportion to the number of pustules and to the total quantity of matter contained in them; and he sought, accordingly, to restrain cases which threatened to be confluent by an evacuant treatment or repressive regimen.

[839] Walter Lynn, M.B., _A more easy and safe Method of Cure in the Smallpox founded upon Experiments, and a Review of Dr Sydenham’s Works_, Lond. 1714; _Some Reflections upon the Modern Practice of Physic in Relation to the Smallpox_, Lond. 1715. F. Bellinger, _A Treatise concerning the Smallpox_, Lond. 1721.

[840] Letter from Woodward to the _Weekly Journal_, 20 June, 1719, in Nichols, _Lit. Anecd._ VI. 641.

[841] Rev. Dr Mangey to Dr Waller, 4 March, 1720, London. Nichols’ _Lit. Anecd._ I. 135.

[842] Huxham, _Phil. Trans._ XXXII. (1725), 379.

[843] _Gent. Magaz._, Sept. 1752.

[844] John Barker, M.D., _Agreement betwixt Ancient and Modern Physicians_, Lond. 1747. Also two French editions. It is on Van Helmont that Barker pours his scorn for “breaking down the two pillars of ancient medicine--bleeding and purging in acute diseases.” That upsetting person forbore to bleed even in pleurisy; the only thing that he took from the ancient medicine was a thin diet in fevers; “and yet this scheme, as wild and absurd as it seems, had its admirers for a time.”

[845] Lynn (u. s. 1714-15) agrees as to the matter of fact, namely, that the mortality from smallpox was greater among the richer classes, who were too much pampered and heated in their cure, than among the poorer, who had not the means to fee physicians and pay apothecaries’ bills.

[846] He was under the tutelage of John Churchill, duke of Marlborough, who does not give a name to the malady (Coxe’s _Life of Marlborough_). Dr James Johnstone, junr., of Worcester, in his _Treatise on the Malignant Angina_, 1779, p. 78, claims the death of the Duke of Gloucester as from that cause, on the evidence of Bishop Kennet’s account.

[847] In the _Gentleman’s Magazine_, under the dates.

[848] _A Direct Method of ordering and curing People of that Loathsome Disease the Smallpox, being the twenty years’ practical experience of John Lamport alias Lampard_, London, 1685. The writer was probably an empiric, “Practitioner in Chyrurgery and Physick,” dwelling at Havant, and attending the George at Chichester on Mondays, Wednesdays and Fridays, the Half Moon at Petersfield on Saturdays. He says: “One great cause of this disease being so mortal in the country is because the infection doth make many physicians backward to visit such patients, either for fear of taking the disease themselves or transferring the infection to others.” He has another fling at the regular faculty: “Do not run madding to Dr Dunce or his assistance to be let bloud.” Empirics, although they were commonly right about blood-letting, were under the suspicion of not speaking the truth about their cures.

[849] Macaulay, _History of England_, IV. 532. The moving passage on the former horrors of smallpox, _à propos_ of the death of Queen Mary in 1694, is familiar to most, but it may be cited once more in the context of a professional history: “That disease, over which science has since achieved a succession of glorious and beneficent victories, was then the most terrible of all the ministers of death. The havoc of the plague had been far more rapid: but plague had visited our shores only once or twice within living memory; and the smallpox was always present, filling the churchyards with corpses, tormenting with constant fears all whom it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover.” It is not given to us all to write like this; but it is possible that the loss of picturesqueness may be balanced by a gain of accuracy and correctness.

[850] Kellwaye, u. s., 1593.

[851] Dr Richard Holland in 1730 (_A Short View of the Smallpox_, p. 75), says: “A lady of distinction told me that she and her three sisters had their faces saved in a bad smallpox by wearing light silk masks during the distemper.”

[852] As I do not intend to come back to the subject of pockmarked faces, I shall add here that I have found nothing in medical writings of the 18th century, nor in its fiction or memoirs, to show that pockpitting was more than an occasional blemish of the countenance. At that time most had smallpox in infancy or childhood, when the chances of permanent marking would be less. The disappearance of pockpitted faces was discovered long ago. The report of the National Vaccine Board for 1822 says: “We confidently appeal to all who frequent theatres and crowded assemblies to admit that they do not discover in the rising generation any longer that disfigurement of the human face which was obvious everywhere some years since.” The members of this board were probably seniors who remembered the 18th century; and it is quite true that the first quarter of the 19th century was singularly free from smallpox in England except in the epidemic of 1817-19. But the above passage became stereotyped in the reports: exactly the same phrase, appealing to what they all remembered “some years since,” was used in the report for 1825, a year which had more smallpox in London than any since the 18th century, and again in the report for 1837, the first year of an epidemic which caused forty thousand deaths in England and Wales. These stereotyped reminiscences are apt to be as lasting a blemish as the pockholes themselves.

[853] Collinson, _Hist. of Somerset_, III. 226, citing Aubrey’s _Miscellanies_, 33.

[854] Blomefield, _Hist. of Norfolk_, III. 417.

[855] Thoresby, _Ducatus Leodiensis_, ed. Whitaker. App. p. 151.

[856] _Cal. Le Fleming MSS._ p. 408 (_Hist. MSS. Com._). There are also many references to smallpox from 1676 onwards in the letters of the Duke of Rutland at Belvoir, lately calendared for the Historical MSS. Commission.

[857] In the _London Gazette_ of 11-14 May, 1674, the Vice-Chancellor and two doctors of medicine of the University of Cambridge contradicted by advertisement a report that smallpox and other infections were prevalent in the university.

[858] Marquis of Worcester to the Marchioness, [London] 8 June, 1675 (Beaufort MSS. _Hist. MSS. Commis._ XII. App. 9, p. 85): “They will have it heere that the smallpox and purple feaver is at the Bath, and the Dutchesse of Portsmouth puts off her journey upon it. The king askt me about it as soon as I came to towne. Pray enquire, and lett me know the truth.” The _London Gazette_ of 17-21 June and 28 June-1 July, 1775, had advertisements “that it hath been certified under the hands of several persons of quality” that Bath and the country adjacent was wholly free of the plague or any other contagious distempers whatsoever.

[859] Burnet, _History of his own Time_, IV. 240.

[860] Walter Harris, M.D., _De morbis acutis infantum_. Ed. of 1720, p. 161.

[861] John Cury, M.D., _An Essay on Ordinary Fever_. Lond. 1743, p. 40.

[862] See p. 438.

[863] Macaulay hardly realized the anomalous character of the queen’s attack of smallpox. “The physicians,” he says, “contradicted each other and themselves in a way which sufficiently indicates the state of medical science in that day. The disease was measles; it was scarlet fever; it was spotted fever; it was erysipelas.... Radcliffe’s opinion proved to be right.” There had been some doubt on the first appearance of the eruption whether it would turn to measles or smallpox. Sydenham says that it was often difficult to make the diagnosis at that stage, and in the queen’s case the first signs were anomalous as well. Next day, however, the eruption all over the body became “smallpox in its proper and distinct form.” But it did not long remain so; the livid spots, into which the pustules subsided, again raised doubts in the minds of some of the physicians whether it was not measles after all; and there was undoubtedly erysipelas of the face. Harris took the middle course of diagnosing “smallpox and measles mingled,” a name by which the form that we now call haemorrhagic smallpox had been known from the early part of the seventeenth century. It was at this late and ominous stage of the illness that Radcliffe was called in; it is not correct to say, as the historian says, that he was the first to pronounce “the more alarming name of smallpox.” The diagnosis was then a matter of little moment, for the queen was dying. He declared that “her majesty was a dead woman, for it was impossible to do any good in her case when remedies had been given that were so contrary to the nature of her distemper; yet he would endeavour to do all that lay in his power to give her ease.” (Munk’s _Roll of the College of Physicians_, II. 458.) For some unexplained reason Radcliffe was made to bear the blame of the queen’s death, an accusation which he deserved as little as he deserved the credit given him by the historian of having been the only physician to make the correct diagnosis.

Macaulay is equally unfortunate in his remark that smallpox “was then the most terrible of all the ministers of death,” in his comparison of it to plague, and in his rhetoric generally. The haemorrhagic form, of which the queen died, was rare. Dover adds it as a fourth variety, but admits that he had seen only five cases of it. Ferguson, of Aberdeen, as late as 1808, in a paper on measles (_Med. and Phys. Journal_, XXI. 359), described a haemorrhagic case of smallpox which he once saw, without knowing that it was a recognized variety of smallpox at all. However terrible a minister of death smallpox may sometimes have been, it happened that there was comparatively little of it in London during the period covered by Macaulay’s history; and it certainly did not “fill the churchyards,” as he might have found out by referring to that not altogether recondite source, the bills of mortality. From 1694 to 1700 fevers caused three and a half times more deaths than smallpox. In the year 1696, when “the distress of the common people was severe,” the smallpox deaths in London were 196, or about one-hundredth part of the mortality from all causes.

[864] Blomefield, III. 432. The following are two cases from the London epidemic of 1710: June, 15.--“Lord Ashburnham’s brother has the smallpox, and the first, concluding he had had it, went to him, and now himself very ill of them. Doctor Garth, who says none has them twice, examined the servants, and they tell him he was but six days ill then; so he concludes that was not the smallpox.” _Cal. Belvoir MSS._, II. 190.

[865] Lynn, u. s. He recalls a remark made by a writer in 1710 that the severity of that epidemic “was not due to a peculiar state of the air, but to a defect in some of our great physicians, who, being too fully employed, could not give due attendance to all or even to any of their patients through the multiplicity of them: for want of which, and the severity of their injunctions, which hindered others from applying anything in their absence, many persons were lost who might otherwise have been saved with due care.”

[866] John Woodward, M.D., _The State of Physick and Diseases, with an inquiry into the causes of the late increase of them, but more

## particularly of the Smallpox; with some considerations on the new practice

of purging in that disease_. London, 1718.

[867] See the account of the Dispensary of the College of Physicians in Warwick Lane, in Munk’s _Roll of the Coll. of Phys._ II. 499, under the head of Sir Samuel Garth. The dispensary was started in 1687 and languished until 1724. The General Dispensary in Aldersgate Street was opened in 1770 with Dr Hulme as physician, and Dr Lettsom as additional physician in 1773.

[868] Letter of 27 March, year not given. _Hist. MSS. Com._ V. 618. See also the letter of 4 March, 1720, from Mangey to Waller, cited above, p. 450.

[869] Dr Philip Rose, of Bedfordbury (“over against a baker, next door to the Old Black Horse, two doors from Chandos Street, St Martin’s parish”), having been called by Lady Wyche to see her butler, pronounced him to be in the smallpox; whereupon the lady informed the physician that “she knew an eminent nurse who had managed above twenty of my Lord Cheyney’s servants in the smallpox, and every one of them had recovered.” Her butler was accordingly carried to this nurse’s house in a by street near Swallow Street. _An Essay on the Smallpox._ By Philip Rose, M.D. Lond. 1724, p. 18.

[870] “An Account or History of the Procuring the Small Pox by Incision, or Inoculation; as it has for some time been practised at Constantinople.” Being the Extract of a Letter from Emanuel Timonius, Oxon. et Patav. M.D., S.R.S., dated at Constantinople, December, 1713. Communicated to _Phil. Trans._ XXIX. (Jan.-March, 1714) 72, by Dr Woodward, Gresham Professor of Physic. Timoni had been in England in 1703, and had been incorporated a doctor of medicine at Oxford on his Padua degree: hence, perhaps, his correspondence.

[871] _An Essay on External Remedies_, Lond. 1715, p. 153. Kennedy settled in practice in London as an ophthalmic surgeon, and appears to have enjoyed the patronage of Arbuthnot. His other work, _Ophthalmographia, or Treatise of the Eye and its Diseases, with appendix on Diseases of the Ear_, Lond. 1723, which is dedicated to Arbuthnot, shows a knowledge of optics and of the structure of the parts concerned in operations on the eye.

[872] Sloane, _Phil. Trans._ XLIX. (1756), p. 516, “An Account of Inoculation given to Mr Ranby to be published, anno 1736.”

[873] Jacobus Pylarinus, _Nova et Tuta Variolas excitandi per Transplantationem Methodus, nuper inventa et in usum tracta, qua rite peracta immunia in posterum praeservantur ab hujusmodi contagio corpora_. Venetiis, 1715. Privilege dated 10 Nov., 1715. Reprinted in _Phil. Trans._ XXIX. (Jan.-March, 1716), p. 393.

[874] _A Dissertation concerning Inoculation of Smallpox._ By W. D[ouglass], Boston, 1730.

[875] _loc. cit._

[876] Published under the initials J. C., M.D.

[877] _De Peste dissertatio habita Apr. 17, 1721, cui accessit descriptio inoculationis Variolarum_, a Gualt. Harris, Lond. 1721.

[878] _Phil. Trans._ XLIX. 104.

[879] Sloane, u. s., 1736.

[880] Jurin, _Account of the Success of Inoculating the Smallpox_. Annual reports from 1723 to 1726.

[881] Alexander Monro, primus, _An Account of the Inoculation of the Smallpox in Scotland_. Edin. 1765 (Reply to circular of queries issued by the dean and delegates of the Faculty of Medicine of Paris).

[882] _Phil. Trans._ 1722: papers by Perrot Williams, M.D. (p. 262), and Richard Wright (p. 267).

[883] _Voyages du Sr. A. de la Motraye._ Tome II. La Haye, 1727, Chap. III. p. 98. He saw Timoni at Constantinople on his return from the Caucasus. Timoni used “a three-edged surgeon’s needle,” which is more intelligible than three needles tied together. La Motraye’s travellers’ tales have not enjoyed the best credit. But this of the inoculation in Circassia has been made by Voltaire the sole basis of his spirited account of inoculation as the national practice of that country (_Lettres sur les Anglais_, Lettre XI. “Sur l’insertion de la petite-vérole,” 1727, reprinted as the article “Inoculation” in his _Dict. Philosophique_, 1764). There has never been a grosser instance of a myth constructed in cold blood. The fable does not need refutation because it is mere assertion, in the manner of a _philosophe_. But the British ambassador at Constantinople made inquiries concerning the alleged Georgian or “Circassian” practice in 1755, at the instance of Maty, the foreign secretary of the Royal Society (_Phil. Trans._ XLIX. 104). A Capuchin friar, “a grave sober man” who had returned shortly before from a sixteen years’ residence in Georgia and “gives an account of the virtues and vices, good and evil, of that country with plainness and candour,” solemnly declared to Mr Porter that he never heard of inoculation “at Akalsike, Imiritte or Tiflis,” and was persuaded that it had never been known in the Caucasus. It was impossible that either the public or private practice of inoculation could have been concealed from him, as he went in and out among the people practising physic. He had often attended them in the smallpox, which, he said, was unusually severe there. On the other hand La Motraye says: “I found the Circassians becoming more beautiful as we penetrated into the mountains. As I saw no one marked with the smallpox, it occurred to me to ask if they had any secret to protect them from the ravages which this enemy of beauty makes among all nations. They told me, Yes; and gave me to understand that it was inoculating, or communicating it to those whom they wished to preserve by taking the matter from one who had it and mixing the same with the blood at incisions which they made. On this I resolved to see the operation, if it were possible, and made inquiry in every village that we passed through if there was anyone about to have it done. I soon found an opportunity in a village named Degliad, where I heard that they were going to inoculate a young girl of four or five years old just as we were passing.” This was published fifteen years after, Timoni’s account being given in an Appendix.

[884] _Travels_, IV. 484. See also for Algiers, _Lond. Med. Journ._ XI. 141. In those cases there was no inoculation by puncture or otherwise.

[885] _Miscell. Curiosa s. Ephemer. Med.-Phys. Acad. Nat. Curios._ Decuria I., An. 2, Obs. CLXV. 1671. D. Thomae Bartholini, “Febris ex Imaginatione.” Scholion by D. Henr. Vollgnad, Vratislaviae practicus.

[886] _Miscell. Curiosa_, _l. c._ 1677.

[887] See Drage, _Pyretologia_. Lond. 1665.

[888] Nuremberg, 1662, p. 529.

[889] La Condamine cites Bartholin’s essay on Transplantation as if it really contained the germ of inoculation, which it does not, the single reference in it to smallpox being in a passage where the contagion of that, as well as of plague, syphilis and dysentery, is said to be capable of being turned aside from one to another.

[890] Drage (_Pyretologia_) gives a case where an ague passed from one person to another in the fumes of blood drawn in phlebotomy. He says also (_Sicknesses and Diseases from Witchcraft_, 1665, p. 21) that a witch could be made to take back a disease by scratching her and drawing blood.

[891] _De Transplantatione Morborum._ Hafniae, 1673, p. 24.

[892] _De Febribus_, u. s. In the plague, a live cock applied to the botch was thought to draw the venom; the cock was then to be buried. Also crusts of hot ryeloaf hung in the room where one had died of plague absorbed the venom. Gabelhover, _The Boock of Physicke_, Dort, 1599, p. 298. Bread was used for the same purpose in fevers as late as 1765. Muret, _Mém. par la Société Econom. de Berne_, 1766.

[893] _Dissertationes in Inoculationem Variolarum_, a J. à Castro, G. Harris, et A. le Duc. Lugd. Bat. 1722.

[894] Gardiner’s _Triall of Tabacco_. London, 1610, fol. 38.

[895] _Ibid._ fol. 43. _The City Remembrancer_, 1769, a work claiming to be Gideon Harvey’s, says that in the Great Plague of London, 1665, some low persons contracted the French pox of purpose to keep off the infection of plague.

[896] _Inquiry how to prevent the Smallpox_, Chester, 1785:--“No care was taken to prevent the spreading; but on the contrary there seemed to be a general wish that all the children might have it.” Cited from Mr Edwards, surgeon, of Upton, near Chester. Again (_Sketch of a Plan, &c._, 1793, p. 491), “They neither feared it nor shunned it. Much more frequently, by voluntary and intentional intercourse, they endeavoured to catch the infection.”

[897] _History of Physic_, Lond. 1725-26, II. 288. This was written at a time when the novelty of inoculation had passed off, and may be taken as Freind’s mature opinion. Douglass, of Boston, writing in 1730, implies that Freind’s objections had been overcome; which may mean no more than he says in general: “Yet from repeated tryals the Anti-Inoculators do now acknowledge that inoculation, generally speaking, is a more easy way of undergoing the smallpox.” Condamine, in his French essay of 1755, counts Freind among the original supporters of inoculation, and ridicules the opposition to it. Munk, in citing the title of Wagstaffe’s _Letter to Dr Freind showing the danger and uncertainty of Inoculating the Smallpox_ (London, 1722), omits the words “to Dr Freind,” at the same time describing the pamphlet as “specious.” There seems no reason to doubt that Freind shared Wagstaffe’s views.

[898] Hecquet, of Paris, who is supposed to have been the original of Dr Sangrado in ‘Gil Bias,’ gave the following reasons against inoculation (_Raisons de doutes contre l’Inoculation_): “Its antiquity is not sufficiently ascertained: the operation rests upon false facts: it is unjust, void of art, destitute of rules: ... it doth not prevent the natural smallpox: ... it bears no likeness to physic, and savours strongly of magic.”

[899] James Jurin, M.D., _Account of the Success of Inoculation_, 1724, p. 3.

[900] G. Baker, M.D., _Oratio Harveiana_, 1761, p. 24.

[901] _Sloane, Phil. Trans._ XLIX. 516.

[902] They are given in Maitland’s _Vindication_, 1722, and in one of Jurin’s papers.

[903] In regard to the last of them, when Frewen in 1759 was controverting the fancy of Boerhaave and Cheyne that smallpox might be hindered from coming on in a person exposed to contagion by a timely use of the Aethiops mineral, he said there was a fallacy in the evidence, because many persons ordinarily escape smallpox “who had been supposed to be in the greatest danger of taking it.” Huxham also pointed out that a person might be susceptible at one time but not at another, or insusceptible altogether; and the elder Heberden wrote: “Many instances have occurred to me which show that one who had never had the smallpox may safely associate, and even be in the same bed with a variolous patient for the first two or three days of the eruption without any danger of receiving the infection.” William Heberden, sen., M.D., _Commentaries on Disease_, 1802, p. 437.

[904] Dr James Jurin was educated at Cambridge, and elected a fellow of Trinity College. He became a schoolmaster at Newcastle, where he also gave scientific lectures. Coming to London, with a Leyden medical degree, he devoted himself to the Newtonian mathematics and was made one of the secretaries of the Royal Society, Newton being the president. He was one of the original physicians of the new hospital founded in the Borough by Guy, the rich bookseller. He made a fortune by medical practice, and was elected president of the College of Physicians a few weeks before he died. In medicine his name is associated with the inoculation statistics, the idea of which, as well as most of the substance, he got from Nettleton, and with “Jurin’s Lixivium Lithontripticum,” or solvent for the stone, the idea of which belonged originally to Mrs Johanna Stevens, and was sold by her to the State for five thousand pounds on the 16th of June, 1739, the prescriptions having been made public in the _London Gazette_ of 19th June. On the 15th of December, 1744, Jurin was called to see the Earl of Orford (Sir Robert Walpole), who was suffering from stone, either renal or vesical. He began administering his alkaline solvent, “four times stronger than the strongest capital soap-lye,” and during the six weeks of his attendance had given his patient thirty-six ounces of it. Horace Walpole made him angry by arguing on the medicine: “It is of so great violence that it is to split a stone when it arrives at it, and yet it is to do no damage to all the tender intestines through which it must first pass. I told him I thought it was like an admiral going on a secret expedition of war with instructions which are not to be opened till he arrives in such a latitude.” (_Letters of Horace Walpole_, Cunningham, I. 339.) His services were at length dispensed with, and the earl, whose case was probably hopeless before, died in a few weeks. A war of pamphlets followed, Ranby, the serjeant-surgeon, maintaining that the patient had “died of the lixivium.” Mead, also, expressed himself strongly upon the attempt to use a modification of Mrs Stevens’s solvent.

[905] The fatalities are given somewhat fully in Jurin’s annual accounts of the _Success of Inoculation_, 1723-27.

[906] John Wreden, body-surgeon to the Prince of Wales, author of _An Essay on the Inoculation of the Smallpox_ (Lond. 1779), may also be counted among those who gave a more real smallpox. See especially his cases at Hanover.

[907] H. Newman, “Way of Proceeding in the Smallpox Inoculation in New England.” _Phil. Trans._ XXXII. (1722), p. 33.

[908] Thomas Nettleton, Letter to Whitaker. _Ibid._ p. 39.

[909] _Phil. Trans._ _l. c._ p. 46. A remark follows which is not quite clear: “There is one observation which I have made, tho’ I would not yet lay any great stress upon it, that in families where any have been inoculated, those who have been afterwards seized never had an ill sort of smallpox, but always recovered very well.”

[910] _Phil. Trans._ 1722, p. 209. Dated from Halifax, 16 Dec. 1722.

[911] Dr William Douglass to Dr Cadwallader Colden, 28 July, 1721, and 1 May, 1722, in _Massachu. Hist. Soc. Collections_, Series 4, vol. II. pp. 166-9. Also _A Dissertation concerning Inoculation of Smallpox_. By W. D[ouglass]. Boston, 1730; and _A Practical Essay concerning the Smallpox_. By William Douglass, M.D. Boston, 1730.

[912] Boylston, _Account of the Smallpox inoculated in New England_. London, 1726.

[913] This was admitted, in a manner, for the great Boston epidemic of 1752, by the Rev. T. Prince, _Gent. Magaz._ Sept. 1753, p. 414. The epidemic attacked 5545 (in a population of 15,684), and cut off 569. The numbers inoculated were 2124 (including 139 negroes), of which number 30 died and were included in the total of 569. Many of the inoculated, says Prince, were not careful to avoid catching the infection in the natural way; “for I have known some, as soon as inoculated, receive visits from their friends, who had been with the sick of the same disease and ’tis likely carried infection with them; it seems highly probable that the inoculated received the infection from them into their vitals.” It may be supposed that the inoculated who were more careful formed a part of the 1843 who “moved out of town.” More than a third of the population took natural smallpox in some four months (April to July) of 1752, more than a third had had it before, a severe epidemic having occurred in 1730 as well as in 1721.

[914] Clinch, _Rise and Progress of the Smallpox, with an Appendix to prove that Inoculation is no Security from the Natural Smallpox_. 2nd ed. 1725.

[915] C. Deering, M.D., _An Account of an Improved Method of treating the Smallpox_. Nottingham, 1736, p. 27. Woodville appears to accept this case as authentic.

[916] Pierce Dod, M.D., F.R.S., _Several Cases in Physic_. London, 1746.

[917] Kirkpatrick, and after him Woodville, treat the alleged experience of Jones as pure fiction.

[918] La Condamine, of Paris, an amateur enthusiast for inoculation, did all he could to upset the case. He got his friend Dr Maty, foreign secretary of the Royal Society, to make inquiry through the British ambassador to the Porte. It happened that Angelo Timoni, son of the inoculator, was at that time an interpreter at the British Embassy; he applied to his mother, who re-affirmed the facts as to the inoculation of her child in infancy, and her death by the natural smallpox twenty-four years after. The only defence left was that the inoculation had not been done by Dr Timoni’s own hand. La Condamine, _Mémoires pour servir à l’Histoire de l’Inoculation_. 2me Mémoire. Paris, 1768.

[919] Rush to Lettsom, Philadelphia, 17 June, 1808, in Pettigrew’s _Memoirs of Lettsom_, III. 201.

[920] Fuller, in his _Exanthematalogia_, makes a somewhat late defence of it in 1729. But Richard Holland, who published in 1730 _A Short View of the Smallpox_, does not mention inoculation, and in the following passage he writes of smallpox as if the extravagant hopes of the preceding years had vanished: “This last season having afforded too many melancholy instances of the fatal effects of the distemper, though under the care and direction of the most eminent physicians, since the disease, notwithstanding the plainness of its symptoms, is become the _opprobrium medicinae_,” _&c._ (p. 3).

[921] _Phil. Trans._ Jan.-March, 1722: “The way of proceeding in the Small Pox inoculated in New England.” Communicated by Henry Newman, Esq. of the Middle Temple, p. 33, § 3: “Yet we find the variolous matter fetched from those that have the inoculated smallpox altogether as agreeable and effectual as any other.”

[922] _An Essay on Inoculation: occasioned by the Smallpox being brought into S. Carolina in the year 1738._ By J. Kilpatrick. London, 1743, p. 50. The essay had been “first printed in South Carolina,” the London edition of 1743 having an Appendix dealing historically with the Charleston epidemic of 1738.

[923] Thomas Frewen, M.D., _The Practice and Theory of Inoculation_. London, 1749.

[924] J. Kirkpatrick, M.D., _Analysis of Inoculation, with a consideration of the most remarkable appearances in the Small Pocks_. Lond. 1754.

[925] Kirkpatrick, _Analysis_.

[926] La Condamine, _Mémoires pour servir, &c._ (Deuxième Discours), 1768, p. 91. It matters little what Lobb may or may not have done. But it does not appear that Boerhaave ever tried to get rid of the eruption of smallpox by means of drugs. In the chapter of his _Aphorisms_, “De Variolis” (§ 1392) he says that he imagines a specific might be found, in the class of antidotes, to correct and destroy the variolous virus, indicating antimony and mercury as likely agents for the purpose owing to certain physical properties of the medicinal preparations of them. Ruston (_An Essay on Inoculation_, 3rd ed. 1768) says that Boerhaave, who died in 1738, “never practised it himself; nor seems to have understood the manner in which these medicines operate to produce their salutary effects.” However they were known as the Boerhaavian antidotes to smallpox, and were used in Rhode Island, it is said with great success and as a secret. Ruston used them in England, and discovered by an analysis that Sutton’s secret powders were the same. They seem also to have been used by Cheyne to prevent the development of smallpox in persons who had been exposed to contagion and had presumably taken the contagion. Frewen, in 1759, published a pamphlet to show the improbability of antimony and mercury having any such action, and the fallacy of the claims made for their success.

[927] The Duchess gave the following account of her own case (_Gent. Magaz._ Nov. 1765, p. 495, sent by Gatti to a friend in London): “On the 12th of March, 1763, I was inoculated for the smallpox, and about four or five days afterwards a redness appeared round the orifice, which Mons. Gatti called an inflammation, and assured me was a sign that the smallpox had taken effect: these were the very terms he used. The redness or inflammation increased every day, and about the seventh or eighth day, the wound began to suppurate. There appeared also about the wound six small risings, or pimples, which successively suppurated and disappeared the next day. Mons. Gatti, upon their appearance, again assured me that the smallpox had taken effect. In the afternoon of the eleventh or twelfth day of my inoculation I felt a general uneasiness and emotion, a pain in my head and my back, and about my heart, in consequence of which I went to bed sooner than ordinary. I slept well, however, and rose without any disorder in the morning. These symptoms Mons. Gatti assured me were the forerunners of the eruption. The next day a pretty large rising or pimple appeared in my forehead, turned white, and then died away, leaving a mark which continued many days.

“The wound in my arm continued to suppurate seven or eight days, and Mons. Gatti now assured me that I had nothing to fear from the smallpox; and upon this assurance I relied without the least doubt, and continued in perfect confidence of my security till the natural smallpox appeared. I continued very well during the whole time of my inoculation, except one day, as mentioned above, and I went out every day.

“Monmorency, D. de Boufflers.”

[928] Gibbon’s _Autobiography_. It was to Dr Maty that Gibbon, in 1759, submitted his French essay on the Study of Literature, having had a fair copy of it transcribed by one of the French prisoners at Petersfield. Of Maty he says: “His reputation was justly founded on the eighteen volumes of the _Journal Britannique_, which he had supported almost alone, with perseverance and success. This humble though useful labour, which had once been dignified by the genius of Bayle and the learning of Le Clerc, was not disgraced by the taste, the knowledge and the judgment of Maty.”

[929] Angelo Gatti, M.D., _New Observations on Inoculation_. Translated from the French by M. Maty. Lond. 1768. The French edition was published at Brussels in 1767.

[930] John Andrew, M.D., _The Practice of Inoculation impartially considered_. Dated 17 June, 1765, Exeter, p. 61.

[931] _La Pratique de l’Inoculation._ Paris, An. VII. (1798), p 51.

[932] Andrew, u. s. p. 53.

[933] “I am sorry to have found that this operation has not always secured the patient from having the smallpox afterwards, if the eruptions have been imperfect without maturation. I attended one in a very full smallpox, which ran through all its stages in the usual manner; yet this patient had been inoculated ten years before, and, on the 5th day after inoculation, began to be feverish, with a headache, followed by a slight eruption, which eruption soon went off without coming to suppuration; the place of inoculation had inflamed and remained open ten days, leaving a deep scar, which I saw.” William Heberden, Senr., M.D., _Commentaries on Disease_ (p. 436). This was published in 1802, after the author’s death; but as he was in the height of his practice from 1760 onwards, the case, which is undated, may be taken as illustrating Heberden’s position in the Suttonian controversy.

[934] Benj. Chandler, M.D., _An Essay on the Present Method of Inoculation_. Lond. 1767.

[935] _Method of Inoculating the Smallpox._ Lond. 1766. Baker thought he was “an enemy of improvement and no philosopher,” who stood upon the antecedent improbability of securing the patient by a minimal inoculation such as Sutton used.

[936] Giles Watts, M.D., _Vindication of the Method of Inoculating_. London, 1767.

[937] William Bromfeild, _Thoughts on the Method of treating Persons Inoculated for the Smallpox_. Lond. 1767. He was a Court surgeon and a man of some eminence. Morgagni dedicated one of the books of his _De Sedibus et Causis Morborum_ to him as representing the Royal Society.

[938] W. Langton, M.D., _Address to the Public on the present Method of Inoculation_. London and Salisbury, 1767. Dr Thomas Glass, of Exeter, replied in 1767 to Bromfeild and Langton, in _A Letter to Dr Baker on the Means of procuring a Distinct and Favourable Kind of Smallpox_. Lond. 1767, and in a _Second Letter to Dr Baker_, 1767.

[939] W. Watson, M.D., _An Account of a Series of Experiments instituted with a view of ascertaining the most successful Method of Inoculating the Smallpox_. London, 1768.

[940] John Mudge, Surgeon at Plymouth, _A Dissertation on the Inoculated Smallpox_. London, 1777. A copy of this essay was found in the library of Dr Samuel Johnson. The Doctor was a friend of the author’s father, the Rev. Archdeacon Mudge, whose published sermons he has characterized in one of his most amusing balanced sentences of praise qualified with blame. Johnson stood godfather to one of John Mudge’s children. Notes on “Dr Johnson’s Library,” by A. W. Hutton.

[941] Edward Jenner, M.D., _Inquiry into the Causes and Effects of the Variolae Vaccinae, or Cowpox_. Lond. 1798, p. 56. See also his _Further Observations on the Cowpox_. 1799.

[942] Langton cites the following advertisement put out on 18 June, 1767, in his own district by Messrs Slatter and Duke, surgeons, of Ringwood, Hants: “The first objection I shall take notice of is that the disorder being in general so light, it is imagined there is danger of a second infection [i.e. a natural attack]. Whenever this has been supposed to have happened, I am certain the operation has failed, which not being discovered by the operator, proves to me that he was not experienced in the practice; for it may always be determined in four, five, or six days, sometimes sooner; and if there is the least reason to doubt, it is very easy to inoculate a second, third or fourth time, which may be done without the least inconvenience. I have inoculated several patients three or four times for their own satisfaction, having very little or perhaps no eruption.”

[943] _Mem. Med. Soc. Lond._ IV. 114.

[944] John Covey, of Basingstoke, 8 May, 1786, in _London Medical Journal_, VII. p. 180.

[945] _Address to the Inhabitants of Liverpool on the subject of a General Inoculation for the Smallpox._ 1 September, 1781.

[946] The account of the London charity is taken from the _History of Inoculation in Great Britain_ (1796) by Woodville, who became physician to it in 1791.

[947] _Med. Obs. and Inquiries_, III. (1767), p. 287. The passage quoted (p. 306, _note_) is almost exactly in the words of Hufeland long after, with reference to the probable extinction of smallpox by cowpox. See his _Journal_, X. pt. 2, p. 189.

[948] J. C. Lettsom, _A Letter to Sir Robert Barker, F.R.S. and G. Stacpoole, Esq. upon General Inoculation_. London, 1778.

[949] _A Plan of the General Inoculating Dispensary, &c._ Lond. (no date).

[950] T. Dimsdale, _Thoughts on General and Partial Inoculation_. Lond. 1776. _An Introduction to the Plan of the Inoculation Dispensary._ 1778. _Remarks on Dr Lettsom’s letter to Barker and Stacpoole._ 1779.

[951] Lettsom, _Obs. on Baron Dimsdale’s Remarks, &c._ 1779; and other pamphlets on both sides.

[952] Clark, _Report of the Newcastle Dispensary_. 1789.

[953] Currie to Haygarth, 28 Nov. 1791, in _Sketch of a Plan, etc._, pp. 451, 207.

[954] J. C. Jenner, “An Account of a General Inoculation at Painswick.” _Lond. Med. Journ._ VII. 163-8.

[955] _Gent. Magaz._ April, 1788, reported by the Hon. and Rev. Mr Stuart, who was a grandson of Lady Mary Wortley Montagu.

[956] Monro, _Account of Inoculation in Scotland_, 1765; in his _Works_. Edin. 1781, p. 693.

[957] _Statistical Account of Scotland._ 1791-99, III. 376.

[958] _Ibid._ IV. 130. It was about the year 1782 that the College of Physicians of Edinburgh appointed a committee to inquire into the mode of conducting the gratis inoculations of the poor, which had been tried at Chester, Leeds, Liverpool, &c. in 1781-82. Haygarth, u. s. 1784, p. 207.

[959] _Ibid._ III. 582.

[960] _Ibid._ XX. 502-7.

[961] _Ibid._ XX. 348. Account by Rev. Abercromby Gordon, who gives in a note (p. 349) the following instance of professional zeal: “A surgeon in the north, presuming that self-interest has a stronger hold on man than superstition, has lately opened a policy of insurance for the smallpox! If a subscriber gives him two guineas for inoculating his child, the surgeon in the event of the child’s death pays ten guineas to the parent; for every guinea subscribed, four guineas, for half a guinea, two guineas, and for a crown one guinea.”

[962] James Lucas, _Lond. Med. Journ._ X. 269.

[963] Currie to Haygarth, 28 Nov. 1791, in the latter’s _Sketch of a Plan, &c._ p. 453.

[964] _A Conscious View of Circumstances and Proceedings respecting Vaccine Inoculation._ Bath, 1800. The author was probably James Nooth, senior surgeon to the Bath Hospital, who removed to London and practised in Queen Anne Street, holding the appointment of surgeon to the Duke of Kent. He wrote on cancer of the breast.

[965] _Tracts on Inoculation._ London, 1781.

[966] R. Pulteney, M.D., in a letter of 21 June, 1766, to Dr G. Baker, given in his _Inquiry into the Merits of a Method of Inoculating the Smallpox_. Lond. 1766.

[967] Pulteney, “Births, Deaths and Marriages of Blandford Forum, 1733-1772.” _Phil. Trans._ LXVIII. 615.

[968] Pulteney to Baker, App. to _Inquiry into the method of Inoculating_. 1766; Hutchins, _Dorsetshire_, I. 217.

[969] On 23 July, 1785, the apothecary makes a note in his book: “Some inspectors are not sufficiently careful to send information to the Hospital when children have had the smallpox.” MS. Records.

[970] _Experiments, &c._ 1768.

[971] Sir W. Watson, M.D., F.R.S., “On the Putrid Measles of London, 1763 and 1768.” _Med. Obs. and Inquiries_, IV. 153.

[972] Charles Kite, surgeon, Gravesend, “An Account of some anomalous Appearances consequent to Inoculation of Smallpox.” _Memoirs Med. Soc. Lond._ IV. (1794), p. 114.

[973] Fosbroke, _Lond. Med. Repository_. June, 1819, p. 466.

[974] Jenner to James Moore, in Baron’s _Life of Jenner_, II. 401: “Is not that a precious anecdote for your new work?” See also _Court and Private Life of Queen Charlotte_ (Journals of Mrs Papendiek). Lond. 1887, I. 41, 70, 270.

[975] In Baron, u. s.

[976] _A Conscious View, &c._ u. s.

[977] Earle, in Jenner’s _Further Observations_. 1799.

[978] T. Adams to Richard Pew, M.D., of Sherborne. _Lond. Med. and Phys. Journ._ April, 1829.

[979] John Forbes, M.D., “Some Account of the Smallpox lately prevalent in Chichester and its vicinity.” _Lond. Med. Reposit._ Sept. 1822, p. 218.

[980] _Discourse on Inoculation._ Eng. Transl. 1755.

[981] _A Series of Experiments, &c._ 1768.

[982] John Haygarth, M.B., _Inquiry how to prevent the Smallpox_. Chester, 1784, p. 154.

[983] _History of Inoculation in Britain._ Vol. I. London, 1796, p. 33.

[984] _History of Edinburgh._ Edin. 1779, p. 260.

[985] W. Hillary, _Rational and mechanical Essay on the Smallpox_. Lond. 1735.

[986] J. Barker, _The Nature of Inoculation explained and its Merits stated_. London, 1769, p. 33. He taught that a depraved habit, by ill diet, &c., “serves for a nidus wherein the variolous matter rests.” If the variolous matter to be expelled is small, “by reason of natural health, temperance, or the power of preparation,” the disease is of the distinct kind; when large, of the confluent. “And wise indeed must he be who can find out any laws respecting the reception and expulsion of diseases superior on the whole to those which are original.” p. 9.

[987] “I have taken an account in this town [Halifax], and some parts of the country, and have procured the same from several other towns hereabouts, where the smallpox has been epidemical this last year, with as much exactness as was possible.” _Phil. Trans._ XXXII. 211.

[988] “A small neighbouring market town.”

[989] “More than usually mortal.”

[990] “A small market town in Lancashire, including two neighbouring villages.”

[991] Account taken “by a person of credit” and sent to Dr Whitaker. Jurin says, more generally: “Taken in several places by a careful enquiry from house to house.” _Account, &c._ 1724, p. 7.

[992] “At Uxbridge and in the neighbourhood, the smallpox having been exceedingly fatal all thereabouts.”

[993] _Mr Maitland’s Account of Inoculating the Smallpox vindicated._ 2nd ed. Lond. 1722.

[994] _Phil. Trans._ XXXIII. 379. “A short account of the Anomalous Epidemic Smallpox beginning at Plymouth in August, 1724, and continuing to the month of June, 1725, By the learned and ingenious Dr Huxham, physician at Plymouth.”

[995] The totals are given in Jurin’s _Account_ for 1725. The ages are in the original communication of the Rev. Mr Wasse, among the MS. papers which Jurin had deposited with the Royal Society.

[996] The most singular thing in the Aynho experience is that there should have been no cases in infants under two years. It was observed, however, some two generations after this, that smallpox attacked children at the earliest ages in the great towns (Haygarth, _Sketch of a Plan, &c._, 1793, p. 31), and even in the worst conditions of infancy it has attacked relatively few in the first three months of life. Again, it is nearly as remarkable that there should have been only three cases at Aynho in the third year of life and only four in the fourth. However, the fewness of cases in the five first years of life must be taken as exceptional, even for a village epidemic. If Nettleton, who made the first of these censuses of smallpox epidemics and suggested to Jurin that they should be carried out elsewhere, had given the ages, he would certainly have included some in infancy, for he mentions, in the course of his inoculation experiences,

## particular cases at nine months, eighteen months, etc.

[997] Frewen, _Phil. Trans._ XXXVII. 108.

[998] See above, pp. 485-6 and 490-1.

[999] Deering, _Nottingham vetus et nova_. 1751, pp. 78, 82. He says, in an essay on smallpox (_Improved Method of treating Smallpox._ Nottingham, 1737) that he treated fifty-one cases in the epidemic of 1736, of which only three proved fatal.

[1000] _Gent. Magaz._ 1741, p. 704.

[1001] Alex. Monro, primus, in his Report to the Dean of the Faculty of Medicine of Paris on Inoculation in Scotland, 1765. Reprinted in his _Works_. Edin. 1781, p. 485. He does not give ages, but an inspection of the burial registers is said to show that they were nearly all under five.

[1002] _Gent. Magaz._ 1742, p. 704. Blomefield gives 1710 and 1731 as great smallpox years in Norwich.

[1003] _Ibid._ 1747, p. 623. The population of Northampton in 1746 was 5136. Price, _Revers. Payments_. 4th ed. I. 353.

[1004] Part of the account extracted from the parish registers by the Rev. Samuel Partridge, F.S.A., vicar of Boston, and sent to Dr George Pearson, who published it in the _Report of the Vaccine Pock Institution for 1800-1802_. London, 1803, p. 100.

[1005] J. C. M’Vail, M.D. in _Proc. Philos. Soc. Glasgow_, XIII. 1882, p. 381, from a MS. register kept by the session clerk of Kilmarnock, now in the General Register House, Edinburgh. The baptisms and burials have not been extended from the MS. for more years than the table shows.

[1006] _Statist. Acct. of Scotland._

[1007] _Sketch of a Plan, &c._ 1793, pp. 33-34.

[1008] The following is the Ackworth bill given by Price, _Phil. Trans._ LXV. 443.

1747-57 1757-67 Christened 127 212 Buried 107 156 ---------------------------- Consumption 23 38 Dropsy 5 3 Fevers 35 23 Infancy 13 13 Old age 24 30 Smallpox 1 13 Chincough -- 2 Convulsions -- 6 Dysentery -- 2 Measles -- 2 Sundries 6 24 ---------------------------- Total deaths in ten years 107 156

[1009] The following are some examples of rural fecundity and health: Middleton, near Manchester, 1763-72, births 1560, deaths 993, average of 4·75 children to a marriage. Tattenhall, near Chester, 1764-73, births 280, deaths 130; Waverton, same county and years, births 193, deaths 84. Stoke Damerel (now the dockyard near Plymouth), in 1733 (in part an influenza-year), births 122, deaths 62, population 3361. Landward townships of Manchester in 1772, births 401, deaths 246. Darwen, in 1774-80, births 508, deaths 233, population 1850. From Papers in _Phil. Trans._ by Percival and others.

[1010] _Statist. Acct. of Scot._ I. 155.

[1011] Hoare’s _Wiltshire_, VI. 521. There had been a general inoculation to the number of 422, from 13 August, 1751, to February, 1752, just before the epidemic. Brown to Watson, in _Phil. Trans._ XLVII. 570.

[1012] Huxham, _Ulcerous Sore-throat_, 1757.

[1013] _Gent. Magaz._ 1751, Supplement, p. 577. See also June, 1751, p. 244, and letter of “Devoniensis,” _ibid._ 1752, p. 159. The subject had been raised by Corbyn Morris in his _Observations on the past growth and present state of London_, and was discussed, from an actuary’s point of view, by Dodson in _Phil. Trans._ XLVII. (Jan. 1752), p. 333.

[1014] The weekly average deaths for eight weeks of September and October is 30·5 from two to five years and 11·1 from five to ten, which are about half the average at each age period during the maximum prevalence of smallpox.

[1015] W. Black, M.D. (_Observations Medical and Political on the Smallpox, etc._ London, 1781, p. 100) says: “I am induced by various considerations to believe that whatever share of smallpox mortality takes place in London amongst persons turned of twenty years of age, is almost solely confined to the new annual settlers or recruits, who are necessary to repair the waste of London, and the majority of whom arrive in the capital from twenty to forty years of age.”

[1016] Maddox, bishop of Worcester, preaching a sermon in 1752 for the Smallpox and Inoculation Charity, enforced his pleading by relating the recent case of “a poor man sick of this distemper, of which his wife lay dead in the same room, with four children around her catching the dreadful infection, but destitute of all relief, till they found _some_ in that too narrow building which now importunately begs your compassionate bounty to enlarge its dimensions.”

[1017] The _Gent. Magaz._ Sept. 1752, p. 402, contains a long letter to refute the very prevailing notion among many people that there is very little occasion for doctors and apothecaries in smallpox, but that a good nurse is all the assistance that is usually wanted. “Whence this notion took its rise I cannot conceive, unless it was from the disease being visible, so that every one who has been at all used to it knows it when they see it.”

[1018] This was an argument used in the first writings on Inoculation, so as to prove the real hazard of dying by the natural smallpox. Thus, Maitland in his _Vindication_ of 1722, which Arbuthnot is said to have had a hand in, deducts a quarter of the annual London deaths before he begins to estimate the ratio of smallpox among them, for the reason that eight out of nine infants who die in their first year are “non-entities” _quâ_ smallpox, other causes of death having had the priority (p. 19). Jurin used the same argument for the same purpose in his _Letter to Caleb Cotesworth, M.D._, 1723, p. 11: “It is notorious that great numbers, especially of young children, die of other diseases without ever having the smallpox”; and again, “very young children, or at most not above one or two years of age,” including the stillborn, abortives and overlaid, chrisoms and infants, and those dead of convulsions. “It is true, indeed, that in all probability some small part of these must have gone through the smallpox, and therefore ought not to be deducted out of the account”; but he does deduct 386 in every 1000 London deaths before he estimates the ratio of smallpox deaths, which so comes out 2 in 17.

[1019] Percival, _Med. Obs. and Inquiries_, V. 1776, p. 287; population in _Phil. Trans._ LXIV. 54.

[1020] Haygarth, _Inquiry how to prevent the Smallpox_, 1784.

[1021] Haygarth, _Sketch of a plan to exterminate the Natural Smallpox_. Lond. 1793, p. 139.

[1022] John Heysham, M.D. “An Abridgement of Observations on the Bills of Mortality in Carlisle, 1779-1787,” in Hutchinson’s _History of Cumberland_. 2 vols. Carlisle, 1794, and separate reprint, Carlisle, 1797; also reprinted in Appendix to Joshua Milne’s _Treatise on the Valuation of Annuities_. London, 1815, pp. 733-752.

[1023] See Loveday’s _Diary of a Tour_, 1732, p. 120.

[1024] _Gent. Magaz._ 1755, p. 595. In a parish near Glasgow, Eaglesham, eighty children are said to have died of smallpox in 1713. Chambers, _Domest. Annals_, III. 387.

[1025] Robert Watt, M.D., _Treatise on the History, Nature and Treatment of Chincough ... to which is subjoined an Inquiry into the relative mortality of the Principal Diseases of Children, and the Numbers who have died under ten years of age in Glasgow during the last thirty years_. Glasgow, 1813.

[1026] This high mortality was probably caused by the epidemic agues of 1780, which specially affected Lincolnshire.

[1027] In 1802 the smallpox epidemic recurred, with 33 deaths. In 1801 there was one death.

[1028] Barker and Cheyne, u. s.

[1029] James Sims, M.D., _Observations on Epidemic Disorders_. London, 1773.

[1030] _Two papers on Fever and Infection_, 1763, p. 112.

[1031] _Medicina Nautica._

[1032] Haygarth, _Sketch of a Plan, &c._, 1793, p. 32.

[1033] Gaol at Bury St Edmunds: In the winter of 1773, five died of the smallpox. No apothecary then. Leicester County Gaol: In 1774 three debtors and one felon died of the smallpox. “Of that disease, I was informed, few ever recover in this gaol.” Oxford Castle: In 1773 eleven died of the smallpox. In 1774 that distemper still in the gaol. In 1775 one debtor died of it in May, three debtors and a petty offender in June; three recovered. No infirmary, no straw to lie on. _State of the Prisons._

[1034] I append Haygarth’s full table of the Chester smallpox epidemic, 1774:

Recovd. from Died of Not had Parish Families Persons smallpox smallpox smallpox

{St Oswald 924 4027 321 40 350 Suburbs {St John 774 3187 284 52 218 {St Mary 583 2392 240 45 205 {Trinity 330 1605 127 24 97

Old {St Peter 193 920 52 6 39 Parishes{St Bridget 154 623 52 6 35 {St Martin 154 611 47 18 35 {St Michael 135 575 15 2 31 {St Olave 134 536 42 8 43 {Cathedral 47 237 3 1 7 ---- ---- ---- --- ---- 3428 14713 1183 202 1060

[1035] Isaac Massey, _Remarks on Dr Jurin’s last yearly Account of the Success of Inoculation_. Lond. 1727, p. 6. Huxham held that children might be “prepared” for the natural smallpox, as it was then the custom to prepare them for the inoculated disease, so that few of them need have it severely: “I am persuaded, if persons regularly prepared were to receive the variolous contagion in a natural way, far the greater part would have them in a mild manner.” _On Fevers._ 2nd ed. 1750, p. 133.

[1036] C. Deering, M.D., _Account of an improved Method of treating the Smallpocks_. Nottingham, 1737.

[1037] John Lamport alias Lampard, u. s.

[1038] _Obs. on Ship Fever, &c._ New ed. Lond. 1789, p. 448.

[1039] Thomas Phillips, “Journal of a Voyage,” &c. in Churchill’s _Collection of Voyages_, VI. 173.

[1040] Berkeley’s claim for tar-water in smallpox was a double one, as a preventive or modifier, and as a cure. Of the former he says: “Another reason which recommends tar-water, particularly to infants and children, is the great security it brings against the smallpox to those that drink it, who are observed, either never to take that distemper, or to have it in the gentlest manner.” _Further Thoughts on Tar-water_, 1752. In his _Second Letter to Thomas Prior, Esq._ 1746 (in _Works_. 4 vols. Oxford, 1871, III. 476) he gives the famous case of curing by it:--“the wonderful fact attested by a solemn affidavit of Captain Drape at Liverpool, whereby it appears that, of 170 negroes seized at once by the smallpox on the coast of Guinea one only died, who refused to drink tar-water; and the remaining 169 all recovered, by drinking it, without any other medicine, notwithstanding the heat of the climate and the incommodities of the vessel. A fact so well vouched must, with all unbiassed men, outweigh, &c.”

[1041] Prince, _Gent. Magaz._ Sept. 1753, p. 414.

[1042] Walter Lynn, u. s. 1715, _ad init._

[1043] _Reports, &c._ 1819.

[1044] Whytt, _Med. Obs. and Inquiries_, II. (1762), p. 187.

[1045] Cleghorn, _Diseases of Minorca_. London (under the years).

[1046] Hillary, _Changes of the Air, and Epidemical Diseases of Barbados_.

[1047] Muret, _Mém. par la Société Économique de Berne_, 1766. “Population dans le pays de Vaud”: p. 102, “J’ai vu à Veney, la petite vérole être générale dans toute la ville, des centaines d’enfans attaqués de cette maladie, et qu’à peine il en mouroit sept ou huit.”

[1048] _Gent. Magaz._ 1753, p. 114. Letter from Sam. Pegge, rector, 17 Feb. 1753.

[1049] Haygarth, _Phil. Trans._ LXV. 87.

[1050] Morton, _Pyreologia_, II. 338: “Et quidem omnes haereditario quasi jure benignis istis variolis tentabantur, quae (Deo favente) eventum secundum habuerunt; nunquam enim quemquam meâ vel conjugis meae stirpe ortum hoc morbo periisse memini.” The case of hereditary tendency to fatal smallpox is No. 53, p. 470: “Domina Theodosia Tytherleigh, virgo elegans ac formosa, stirpe celeberrima (sed cui hic morbus jure quasi haereditario funestus esse solebat)” &c. She died in a late stage of the disease.

[1051] _Cal. Coke MSS._ (Hist. MSS. Commis.) II. 429.

[1052] Rutty, _Chronological History of the Weather and Seasons, and prevailing Diseases in Dublin during forty years_. London, 1770, under the dates.

[1053] Short (_Comparative History of the Increase and Decrease of Mankind in England, &c._ Lond. 1767) has found somewhere a statement that in 1717 there was “a most fatal continual fever in the West of Scotland, in January and February, and not less fatal confluent smallpox in March and April.”

[1054] _Lond. Med. Journ._ VII. 163.

[1055] W. Watson, in _Medical Observations and Inquiries by a Society of Physicians in London_, IV. (1771), p. 153. Whether the epidemic that preceded the smallpox was measles or scarlatina is a question that was raised by Willan, and is referred to in the chapter on “Scarlatina and Diphtheria.”

[1056] _Annals of the Lords of Warrington and Bewsey from 1587._ By W. Beamont. Manchester, 1873, p. xix.

[1057] John Aikin, M.D., _Descriptions of the Country from thirty to forty Miles around Manchester_. London, 1795, p. 302.

[1058] Taken out of the register by Aikin at the request of Dr Richard Price, and published by the latter in the 4th ed. of his _Obs. on Reversionary Payments_. Lond. 1783, II. 5, 100.

[1059] Arthur Young, _Six Months Tour through the North of England_. 4 vols. London, 1770-71, III. 163.

[1060] Percival, _Phil. Trans._ LXV. 328.

[1061] Beamont, u. s. p. 116-17.

[1062] Ferriar, _Med. Obs. and Reflections_.

[1063] Price, _Reversionary Payments_. 4th ed. II.

[1064] Aikin, _Phil. Trans._ LXIV. (1774), p. 438; Haygarth, _ibid._ LXVIII. 131.

[1065] “Almost ended at the winter solstice, only 19 remaining ill in January, 1775.”

[1066] Percival, for Warrington, _Med. Obs. and Inquiries_, V. (1776), p. 272 (information from Arkin); Haygarth, for Chester, _Phil. Trans._ LXVIII. 150. Haygarth (_Sketch of a Plan, &c._ p. 141) gives the following table of the smallpox deaths and the deaths from all causes at several ages of children up to ten years at Chester from 1772 to 1777 inclusive:

Under one 1-2 2-3 3-5 5-10 Total

Smallpox deaths 91 75 83 86 34 369 All other deaths 392 155 68 68 53 736

[1067] _Sketch of a plan, &c._ p. 31.

[1068] Heysham, _Obs. on Bills of Mortality in Carlisle_, 1779-1787. Carlisle, 1797. Reprinted from App. Vol. II. of Hutchinson’s _Cumberland_.

[1069] _Lucas, Lond. Med. Journ._ X. 260: “The number of those who were still uninfected was found on a survey to be 700.”

[1070] Dr Henry, of Manchester, to Haygarth, 20 March, 1789, in the latter’s _Sketch of a Plan, &c._ p. 369: “In large and populous places such as Manchester, the smallpox almost always exists in some parts of the town. I have known it strongly epidemic in one part without any appearance of it in others.... At present it is prevalent and fatal in the outskirts, but very rarely occurs in the interior parts of the town.”

[1071] “Most of them [Jenner’s colleagues] had met with cases in which those who were supposed to have had cowpox had subsequently been affected with smallpox.” Baron, _Life of Jenner_, I. 48.

[1072] Haygarth to Worthington, 15 April, 1794, in Baron’s _Life of Jenner_, I. 134.

[1073] See the cases and remarks by John Hunter, Sir W. Watson, Lettsom and others.

[1074] Joseph Adams, _Observations on Morbid Poisons, Phagedaena and Cancer_. 1st ed. Lond. 1795. Preface, 31 March.

[1075] I have collected all the scattered references in Jenner’s writings to cowpox in the cow or in infected milkers in my _Natural History of Cowpox and Vaccinal Syphilis_. London, 1887, pp. 53-57.

[1076] G. Pearson, _Inquiry concerning the History of Cowpox_. Lond. 1798.

[1077] Beddoes’ _Contributions to Physical and Medical Knowledge_. Bristol, 1799, p. 387.

[1078] See my _Natural History of Cowpox, &c._ u. s. 1887. The most systematic descriptions, both for cows and milkers, are by Ceely, in _Trans. Provinc. Med. and Surg. Assocn._ VIII. (1840) and X. (1842). Professor E. M. Crookshank has reproduced these valuable memoirs, with the coloured plates, in his _History and Pathology of Vaccination_. 2 vols. London, 1889. The plates are in vol. I., the memoirs in vol. II. Crookshank’s volumes, which are a convenient repertory of the more important earlier writings on cowpox, contain also the author’s original observations (with plates), of cowpox in Wiltshire in 1887-88.

[1079] In my essay of 1887 (u. s.) I maintained, as an original opinion, that the true affinity of cowpox was to the great pox of man, and that the occasional cases of so-called vaccinal syphilis were not due to the contamination of cowpox with venereal virus but to inherent (although mostly latent) properties of the cowpox virus itself. This opinion was at first received with incredulity, but is now looked upon with more favour. See Hutchinson, _Archives of Surgery_, Oct. 1889, and Jan. 1891, p. 215. The concessions hitherto made are only for cases that have arisen since my book was published, such as the case at the Leeds Infirmary in 1889. I believe that my explanation of vaccinal “syphilis” will at length be accepted for all cases, past or future.

[1080] _An Inquiry, &c._ 1798. “Remarks on the term Variolae Vaccinae.”

[1081] That Dr Jenner foresaw this line of proof, and dismissed it as irrelevant, is made clear by G. C. Jenner, _Monthly Magazine_, 1799, p. 671, in reply to Dr Turton, of Swansea: “It is possible that variolous virus inserted into the nipples of a cow, might produce inflammation and suppuration, and that matter from such a source might produce some local affection on the human subject by inoculation. But all this tends only to show, what was well known before, that virus taken from one ulcer is capable of producing another by its being inserted into any other part of the body.”

[1082] Jenner, _Further Observations on the Variolae Vaccinae_, 1799.

[1083] Thornton, in Beddoes’ _Contributions to Physical and Medical Knowledge_. Bristol, 1799.

[1084] Hughes, _Med. and Phys. Journ._ I. (1799), p. 318. Many other tests, English and foreign, are detailed in my book, _Jenner and Vaccination_. London, 1889, for which see the Index under “test.”

[1085] Woodville tabulated 511 cases of applicants for inoculation at the hospital in whom cowpox matter was used, giving “the number of pustules” opposite the name of each; 90 had from a thousand to a hundred pustules, 215 had less than one hundred. William Woodville, M.D., _Reports of a Series of Inoculations for the Variolae Vaccinae or Cowpox; with remarks on this disease considered as a substitute for the Smallpox_. London, 1799. In a subsequent letter (_Med. Phys. Journ._ V., Dec. 1800), he thus explained the occurrence of smallpox among those recently inoculated with cowpox: “If a person who has been exposed to the contagion of smallpox for four or five days be then inoculated for this disease, the inoculation prevents the effects of the contagion, and the _inoculated_ smallpox is produced. But if the vaccine inoculation be employed in a case thus circumstanced, the smallpox is not prevented, although the tumour produced by the cowpox inoculation advance to maturation. It was not before the commencement of the present year [1800], that I ascertained that the cowpox had not the power of superseding the smallpox. For, though from the first trials that I made of the new inoculation it appeared that these diseases, as produced in the same subject from inoculation, did not interrupt the progress of each other; yet as the casual does not act in the same manner as the inoculated smallpox, and may be anticipated by the latter, I thought it still probable that the cowpock infection might have a similar effect. Numerous facts have, however, proved this opinion to be unfounded, and that the variolous effluvia, even after the vaccine inoculation has made a considerable progress, have in several instances occasioned an eruption resembling that of smallpox.”

[1086] _European Magazine_, XLIII. 137.

[1087] Bateman, u. s. 1819, Aug.-Nov. 1807: “In a court adjoining Shoe Lane, in the course of one month, twenty-eight persons had died of smallpox.” Autumn, 1812: “In one small court in Shoe Lane, seventeen have lately been cut off by this variolous plague.” Also in the summer of 1812, “perhaps universally through the metropolis.”

[1088] Extracted from the Annual Reports of the Dispensary.

[1089] Heysham to Joshua Milne, in the latter’s _Treatise on the Valuation of Annuities_. London, 1815. App. p. 755.

[1090] Cross, 1819, u. i. p. 2.

[1091] Most of these were brought to light by inquiries upon the alleged failures of cowpox to avert the epidemic. The serial numbers of the _Medical Observer_ contain frequent references to them.

[1092] Letter to Joshua Dixon, in _Memoirs_, III. 368.

[1093] Bateman, _Edin. Med. Surg. Journ._ VIII. 515.

[1094] C. Stuart, _ibid._ VIII. 380.

[1095] Rigby, _ibid._ X. 120.

[1096] Joshua Dixon, _The Literary Life of William Brownrigg, M.D._ Whitehaven, 1801, pp. 238-9.

[1097] Haygarth says: “With us in Chester, smallpox is seldom heard of except in the bills of mortality. _There_ its devastation appears dreadful indeed.” _Sketch of a Plan, &c._ 1793, p. 491.

[1098] Barker and Cheyne, _Account of the Fever, &c._ 2 vols. 1821. I. 92.

[1099] Francis Rogan, M.D., _Obs. on the Condition of the Middle and Lower Classes in the North of Ireland_. Lond. 1819, p. 17. He proceeds to say:--“The numerous cases, which came to my knowledge, of children in the neighbouring towns who had taken smallpox, after having been vaccinated by medical practitioners of high respectability, led me to pay particular attention to those whom I myself inoculated [with cowpox]; and, although they were numerous both in private practice and at the Dispensary, not one instance occurred among them.” It comes out however that he did not keep them long in sight; he saw them on the 7th day after vaccination, and again on the 11th; and as they were meanwhile almost daily exposed to contagion, without catching it, he concluded that his own cases never would do so.

[1100] W. L. Kidd. “A concise Account of the Typhus Fever at present prevalent in Ireland, as it presented itself to the Author in one of the towns in the North of that country.” _Edin. Med. and Surg. Journ._ XIV. (1817), 144. He goes on: “A great number of those attacked were _reported_ to have been formerly vaccinated. At Londonderry, in particular, great numbers who were _said_ to have undergone vaccination were the subjects of smallpox; and, whether justly or not, vaccination has in that part of the country lost much of its credit as a preservative against smallpox.”

[1101] Redhead (dated Ulverston, 3 July, 1816) in _Med. and Phys. Journ._ Jan. 1817, p. 3.

[1102] James Black, “On Anomalous Smallpox.” _Ed. Med. and Surg. Journ._ Jan. 1819, p. 39.

[1103] Henry Dewar, M.D., _Account of an Epidemic of Smallpox which occurred in Cupar in Fife in the Spring of 1817_. Lond. 1818.

[1104] P. Mudie, M.D. to Thomson, 18 Oct. 1818: “Many of the cases occurring after vaccination so much resembled smallpox that, if my mind had not been prejudiced against the possibility of such an occurrence, I should have pronounced the eruption to have been of a variolous nature”--which, of course, it was.

[1105] Thomson, _Account of the Varioloid Epidemic in Scotland, &c._ Edin. 1820.

[1106] In Thomson, u. s.

[1107] Thomas Bent, M.D., “Observations on an Epidemic Varioloid Disease lately witnessed in the County of Derby.” _Med. and Phys. Journal_, Dec. 1818, p. 457. One Jennerian, Dr Pew, of Sherborne, adopted an arrogant tone towards Bent (_Ibid._ April, 1819, and farther correspondence). Jenner employed Fosbroke, of Berkeley, son of his friend and neighbour the antiquary Fosbroke, to traverse the whole case of the epidemic of 1817-19, in a long paper in the _Medical Repository_ for June, 1819. The object of the paper appears to be to confuse the issues with a view to a verdict of _non liquet_. The _Edinburgh Review_ thought Thomson’s book on the epidemic of 1817-19 important enough for an article, which has been attributed to Jeffrey. The article pronounced vaccination to be a very great blessing to mankind, but not a complete protection. This was not enough for Jenner, who wrote of the article: “It will do incalculable mischief: I put it down at 100,000 deaths at least.”

[1108] John Green Cross, _A History of the Variolous Epidemic which occurred in Norwich in the year 1819_. Lond. 1820.

[1109] Cross, u. s. Appendix.

[1110] W. Shearman, M.D., “Cases illustrating the Nature of Variolous Contagion and the Modifying Influence of Vaccine Inoculation.” _Lond. Med. Repos._ Dec. 1822. Case of a mother, with good vaccine marks, attacked with smallpox, which became dry and horny about the fifth day; case of her child, in which the eruption ran the full course of pustules, but also a mild case.

[1111] _Lond. Med. and Phys. Journ._ May, 1818, p. 488: “By Mr Field’s report of Christ’s Hospital smallpox in a mild form has been frequent _post vaccinationem_.”

[1112] Thomas Stone, F.R.C.S. “Table of Deaths from Smallpox in Christ’s Hospital, 1750 to 1850, with remarks,” in Appendix to _Papers on the History and Practice of Vaccination: Parl. Papers_, 1857. In 1761 there were four deaths from smallpox. For ten years, 1775 to 1784, there were none. In some other years of the latter half of the 18th century there were one or two deaths from that cause. There must have been some special reason for the four deaths in 1761. According to Massey (_supra_, p. 545), the apothecary in the beginning of the 18th century, not one death happened in forty attacks, the ages from five to eighteen being the most favourable of all for smallpox to fall in. In the present century scarlatina has displaced smallpox as an infectious cause of death in that school as in others. The deaths from scarlatina at Christ’s Hospital during the six years 1851-56 were nine.

[1113] John Forbes, M.D., “Some Account of the Smallpox lately prevalent in Chichester and its Vicinity.” _Lond. Med. Repos._ Sept. 1822, p. 208.

[1114] H. W. Carter, M.D., in _Lond. Med. Repos._ Oct. 1824, p. 267: “The cases which came to light of smallpox after vaccination were unfortunately numerous; some, it must be confessed, were exceedingly severe; others were exaggerated.”

[1115] The vaccinations are given in Cleland’s _Rise and Progress of the City of Glasgow_. Glasgow, 1820. The smallpox deaths from 1813 to 1819 are given, on Cleland’s authority, in the _Edin. Med. and Surg. Journal_, XXVI. p. 177.

[1116] R. Watt, M.D., Appendix to _Treatise on Chincough_.

[1117] John Roberton, _Obs. on the Mortality, &c. of Children_. Lond. 1827, p. 59, _note_.

[1118] Gregory, _Report of the London Smallpox Hospital for the year 1825_. Cited in the _Med. and Phys. Journ._ Feb. 1826, p. 176.

[1119] Cross, u. s.

[1120] Carter, u. s.

[1121] T. Proudfoot, M.D., _Ed. Med. and Surg. Journ._ July, 1822.

[1122] C. Stuart, u. s.

[1123] Dr Stokes, of Chesterfield, _Med. and Phys. Journ._ v. 17.

[1124] Benjamin Moseley, M.D., _A Review of the Report of the Royal College of Physicians on Vaccination_. 1808, p. 11. Jenner writing to James Moore, 18 Nov. 1812 (in Baron, II. 383), enumerates his various grievances against Pearson, “and finally, finding all tricking useless, his insinuations that vaccination is good for nothing.”

[1125] The equality of the two methods in this respect comes out incidentally in two reports of the Whitehaven Dispensary. In the report for 1796, when smallpox matter was in use, it is said that “173 were inoculated, all of whom, soliciting little medical assistance, recovered.” In 1801, when cowpox matter had been substituted in every case, the same phrase is used: “We seldom find any medical assistance required in this disease.”

[1126] _The Beneficial Effects of Inoculation._ Oxford University Prize Poem. Oxford, 1807. It seems probable that this was the “Oxford copy of verses on the two Suttons” that Coleridge (_Biographia Literaria_ (1817), Pickering’s ed. II. 89) professed to quote from in the following passage; at least it would be remarkable if there had been printed another Oxford poem on the same subject and in the same manner: “As little difficulty do we find in excluding from the honours of unaffected warmth and elevation the madness prepense of pseudopoesy, or the startling hysteric of weakness over-exerting itself, which bursts on the unprepared reader in sundry odes and apostrophes to abstract terms. Such are the Odes to Jealousy, to Hope, to Oblivion, and the like, in Dodsley’s collection and the magazines of the day, which seldom fail to remind me of an Oxford copy of verses on the two Suttons, commencing with

‘Inoculation, heavenly maid! descend!’”

It appears that Coleridge himself contemplated a poem on Cowpox Inoculation, which was to have exemplified what poetry should be, just as the 18th century Oxford poem on Smallpox Inoculation exemplified what poetry should not be. It was clearly more than the difference ’twixt tweedle-dum and tweedle-dee. Writing to Dr Jenner on 27 Sept. 1811, from 7, Portland-place, Hammersmith, he said: “Dear Sir, I take the liberty of intruding on your time, first, to ask you where and in what publication I shall find the best and fullest history of the vaccine matter as the preventive of the smallpox. I mean the year in which the thought first suggested itself to you (and surely no honest heart would suspect me of the baseness of flattery if I had said, inspired into you by the All-preserver, as a counterpoise to the crushing weight of this unexampled war), and the progress of its realization to the present day. My motives are twofold: first and principally, the time is now come when the ‘Courier’ ... is open and prepared for a series of essays on this subject; and the only painful thought that will mingle with the pleasure with which I shall write them is, that it should be at this day, and in this the native country of the discoverer and the discovery, be even _expedient_ to write at all on the subject. My second motive is more selfish. I have planned a poem on this theme, which after long deliberation, I have convinced myself is capable in the highest degree of being poetically treated, according to our divine bard’s [Milton’s] own definition of poetry, as ‘_simple_, _sensuous_, (i.e. appealing to the senses by imagery, sweetness of sound, &c.) and _impassioned, &c._’” _The Life of Edward Jenner, M.D._ By John Baron, M.D. 2 vols. II. 175.

[1127] _Edin. Med. and Surg. Journ._ I. 507.

[1128] Jenner to James Moore, 26 Feb. 1810, in Baron, II. 367.

[1129] Walker to Lettsom, 1 Sept. 1813, in Pettigrew’s _Memoirs of Lettsom_. Lond. 1817, III. 350.

[1130] Dr Smith to Dr Monro, Dunse, 2 June, 1818, in Monro’s _Obs. on the different kinds of Smallpox_, 1818. There appears to have been some reluctance to face the facts. “Though I have seen,” says Smith, “a multitude of cases in which smallpox has in every possible shape taken place after vaccination, I feel myself placed in the painful situation [why painful?] of bringing forward many facts to which gentlemen of the first eminence in the profession will probably give little or no credit.”

[1131] _Lond. Med. Repository._ Sept. 1822.

[1132] J. J. Cribb, _Smallpox and Cowpox_. Cambridge, 1825.

[1133] _Ibid._ Letter of Rev. R. Marks, of Great Missenden, 6 May, 1824: “The summer I came here the smallpox was introduced, and as the weather was very hot, and the confluent sort was what appeared, the people began to die almost as fast as they took the plague. Great prejudice prevailed against vaccination, in consequence of the parish having some years ago been vaccinated by a gentleman who knew nothing of the matter, and contaminated the people with decomposed virus, when it was good for nothing but to make ulcers and produced very wretched arms, and left them all liable to smallpox, which they were all inoculated for the same year.” This clergyman subsequently vaccinated 500 cases, and the parish surgeon 300: “and here,” says the former, “I had the happiness of seeing the plague and destruction of a most horrid smallpox completely stopped.”

[1134] Robert Ferguson, M.D. _A Letter to Sir Henry Halford, proposing a method of Inoculating the Smallpox, which deprives it of all its Danger, but preserves all its Power of Preventing a Second Attack._ London, 1825.

[1135] John Roberton, _Observations on the Mortality and Physical Management of Children_. London, 1827, p. 59, _note_.

[1136] J. Dalton, “Smallpox as it prevailed at Bury St Edmunds in 1825.” _Lond. Med. and Phys. Journ._ May, 1827, p. 406.

[1137] Cribb, u. s.

[1138] “Observation on Smallpox as it has occurred in London in 1825.” _Med. and Phys. Journ._ Feb. 1826, p. 117.

[1139] _Med. and Phys. Journ._ 1826, p. 122. “The general voice of the public satisfactorily showed that the upper ranks of society suffered during the past year from smallpox much less than the lower.”

[1140] Gregory, _Report on the Smallpox Hospital_, 4 Dec. 1825.

[1141] Farr, in the First Report of the Registrar-General (1839, p. 100), said: “It may be safely asserted that the parish clerks registered little more than half the deaths that occurred within the limits of the London bills of mortality.” Outside the limits of the bills there were large parishes, such as St Pancras, Marylebone, Kensington and Chelsea, which had large mortalities from smallpox in the first years of registration.

[1142] Tables in Murchison’s _Continued Fevers of Great Britain_.

[1143] _Med. Chir. Trans_, XXIV. 15. His other papers are: “Cursory Remarks on Smallpox as it occurs subsequent to Vaccination,” _ibid._ XII. 324; and “Notices of the Occurrences at the Smallpox Hospital during the year 1838,” _ibid._ XXII. 95. He contributed the treatise on Smallpox to Tweedie’s _Library of Medicine_, I. 1840, and indicated his final opinions (which are interesting) in his _Lectures on the Eruptive Fevers_, 1843.

[1144] Kenrick Watson, “Medical Topography of Stourport and Kidderminster.” _Trans. Prov. Med. and Surg. Assoc._ II. 195.

[1145] John Roberton, “On the Increasing Prevalence of Smallpox after Vaccination.” _Lond. Med. Gaz._ 9 Feb. 1839, p. 711. Roberton had been a warm supporter of the Jennerian method from as early a date as 1808, when he was resident in Edinburgh, and again in his book on _The Mortality of Children_, in 1827. The above cited paper is somewhat satirical, the disappointing facts of it being referred to the Island of Barataria. His conclusions are (p. 713): (1) “It is not fact, but conjecture, that the protective power of cowpox gradually ceases in the human system. (2) It is not fact, but conjecture, that a person successfully re-vaccinated is less liable to smallpox than he was before. (3) To affirm that, when re-vaccination fails in individuals, they are thereby proven to be secure from smallpox, is conjecture.”

[1146] Cowan, “On the Mortality of Children in Glasgow,” _Glas. Med. Journ._ V. (1831), p. 358, does not give Cleland’s figures, but says: “No bills of mortality except those for the Royalty in the _Glasgow Courier_ are in existence for the period from 1812 to 1821”; and again: “Finding that the suburbs were excluded, and the Calton being the burying-place in which the greatest number of children are interred, I thought it needless to insert any tabular view of the deaths by measles since the date of Dr Watt’s tables.” Watt could have made no tables if he had not gone direct to the sixteen MS. volumes of burial registers, including those of the Calton.

[1147] J. C. Steele, _Glas. Med. Journ._ N. S. I. 60: “From 1812 to 1835 it is much to be regretted that no record of the deaths from smallpox has been kept for even a limited period.”

[1148] _Glas. Med. Journ._ I. 105: “There exists at present among the poorer classes an increasing carelessness and aversion to vaccination, from a belief that it does not afford adequate protection from the varioloid disease.”

[1149] Andrew Buchanan, M.D. “Present Condition of the Poor in Glasgow.” _Glasg. Med. Journ._ III. (1830), 437.

[1150] Chalmers had been urging the repeal of the Corn Law since 1819. In a letter to Wilberforce, Glasgow, 15 Dec. 1819, he says: “From my extensive mingling with the people, I am quite confident in affirming the power of another expedient to be such that it would operate with all the quickness and effect of a charm in lulling their agitated spirits--I mean the repeal of the Corn Bill.” Hanna’s _Memoirs of Dr Chalmers_, 1850, II. 250.

[1151] J. Orgill, “Obs. on the Measles and Smallpox that prevailed epidemically in Stranraer, in the autumn of 1829.” _Glasg. Med. Journ._ IV. 351.

[1152] McDerment, _ibid._ IV. 201.

[1153] Howison, _ibid._ V. 256-7.

[1154] J. C. Steele, _Glasg. Med. Journ._ N. S. I. 59.

[1155] _Eleventh detailed Report of the Regr.-Genl. for Scotland_, 1865, p. xxxix. The Report says that vaccination was general during the above period, although there was no Vaccination Act for Scotland (until 1864). This was familiar knowledge in Scotland, so much so that the necessity for a compulsory law, on the English model, was not quite obvious in the medical circles of Edinburgh. See Christison’s address to the Social Science Association at Edinburgh in 1863 (p. 106). In my own recollection of Aberdeenshire, the vaccination of infants was as little neglected as their baptism; the law made no real difference.

[1156] “An Enquiry into the Mortality among the Poor in the City of Limerick.” _Journ. Statist. Soc._ Jan. 1841, III. 316.

[1157] _The Census of Ireland_, 1841. Parl. Papers, 1843. Report on the Tables of Deaths, by W. R. Wilde.

[1158] From the Second Report of the Registrar-General, Lond. 1840, p. 180.

[1159] 1840.

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

Liverpool 172 184 90 85 Bath 25 42 22 8 Exeter -- -- 1 1 Bristol 6 54 49 76 Clifton 11 28 22 42

[1160] Douglass to Colden, 1 May, 1722, in _Massach. Hist. Soc. Collect._ Series 4, vol. II. p. 169.

[1161] Philip Rose, M.D., _Essays on the Smallpox_. London, 1724, p. 76.

[1162] Rev. R. Houlton, App. to _A Sermon in Defence of Inoculation_, Chelmsford, 1767, p. 59: “For, had the indictment been found, he would have assuredly nonsuited his enemies, and have proved beyond a possibility of doubt that he never brought into Chelmsford a patient who was capable of infecting a bystander, notwithstanding such person would convey infection by inoculation. However paradoxical this may seem, it is truth, and would have been proved to a demonstration.”

[1163] Darwin, _Animals and Plants under Domestication_, II. 356: “From these facts we clearly see that the quantity of the peculiar formative matter which is contained within the spermatozoa and pollen-grains is an all-important element in the act of fertilization, not only for the full development of the seed, but for the vigour of the plant produced from such seed.”

[1164] J. C. Lettsom, M.D., _A Letter to Sir Robert Barker, F.R.S. and G. Stackpoole, Esq. upon General Inoculation_. London, 1778, p. 8.

[1165] W. Black, M.D., _Observations Medical and Political on the Smallpox, etc._ London, 1781, p. 103.

[1166] “But, in the cowpox, no pustules appear, nor does it seem possible for the contagious matter to produce the disease from effluvia, or by any other means than contact, and that probably not simply between the virus and the cuticle; so that a single individual in a family might at any time receive it without the risk of infecting the rest, or of spreading a distemper that fills a country with terror.”

[1167] _Parliamentary Papers_, 1807, 8th July.

[1168] Bateman, _Reports etc._ 1819, p. 102. The principle of the Common Law on which the judgment rested was, “Sic utere tuo ut alienum non laedas.”

[1169] Joseph Adams, _An Inquiry into the Laws of Epidemics, with Remarks on the Plans lately proposed for Exterminating the Smallpox_. London, 1809. The _Edin. Med. and Surg. Journal_ (VI. 231), in a long review of this essay, declared that Adams was inconsistent in reaffirming his old faith in cowpox and at the same time demanding liberty for the inoculators.

[1170] J. C. Steele, M.D., “Increase of Smallpox in Glasgow.” _Glas. Med. Journ._ N. S. I. 59. The Paris figures are cited from the _Annuaire pour l’an 1852-53_.

[1171] I do not, of course, answer for the correctness of Gregory’s statements.

[1172] _Lancet_, 12 Dec. 1838.

[1173] 409 of these in Sheffield.

[1174] There are two notable exceptions, marked †, Lancashire and Yorkshire; but, in regard to their higher mortality from smallpox in 1837-40, it should be kept in mind that they were the chief scenes of the great distress among the working class in those years, the same causes which produced an enormous mortality from typhus fever in adults having tended to increase the fatality of smallpox among the children.

[1175] In the first universal and very fatal epidemic of measles, that of 1808, a good many adults, who had not had measles before, were attacked. See the chapter on Measles.

[1176] The accounts by Fothergill, Wall and others, of the malignant sore-throat with scarlet rash about 1740 give prominence to cases in early manhood or womanhood.

[1177] _Supplement (Decennial) to the 45th Report of the Regr.-Genl._ 1885, p. cxii.

[1178] The figures for 1721 are cited above (p. 485) from Douglass and others. Those for 1752 are given in the _Gent. Magaz._ 1753, Sept., p. 413, as “collected from the Accounts of the Overseers in the Twelve several Wards,” and sent by the Rev. T. Prince.

[1179] _Supplementary Report of the Registrar-General_, 1883. The mean death rate per 1000 living, for the period 1838-82, has been 71·0 males, and 61·2 females under five years of age; but as late as 1878 the annual average was the mean of the period, namely 71·2 males and 61·1 females.

[1180] Lettsom (_Gent. Magaz._ 1804, Aug. p. 701), in a preface to Neild’s papers on the state of the prisons, estimated that 40,000 lives might be saved every year in England by preventing infectious fevers, “for in this metropolis my respectable friend Thomas Bernard, Esq., whose caution and accuracy no person will doubt, calculates the number of victims at 3000 each year [doubtless from the London Bills of Mortality].... If to this pleasing view we add the preservation of 48,000 victims to the smallpox, which may now be preferred by the cowpox, we have in our power to possess the sublime contemplation of forming a saving fund of human life of nearly 88,000 persons annually in this empire, by the exercise of reason, philanthropy and judicious policy.”

[1181] Duvillard, _Tableaux etc._ Paris, 1806.

[1182] _Essay on the Principle of Population._ Bk. IV. chap. 5.

[1183] Robert Watt, M.D. _Treatise on Chincough, with Inquiry into the Relative Mortality of the Diseases of Children in Glasgow._ Glasgow, 1813.

[1184] John Graunt, _Natural and Political Observations upon the Bills of Mortality_, London, 1662, says: “The original entries in the Hall books were as exact in the very first year [he probably means 1629, which is the first year of his own extracts from them, but the classification of deaths began in 1604] as to all particulars, as now; and the specifying of casualties and diseases was probably more.” The searchers, he explains, were in many cases able to report the opinions of the physicians, receiving the same from the friends of the deceased; while for certain causes of death, among which he includes smallpox, “their own senses are sufficient.”

[1185] _Cal. Coke MSS._ (Hist. MSS. Commis.) I. 21 June, 1628.

[1186] Sutherland Letters, in _Rep. Hist. MSS. Com._ V. 152.

[1187] _Cal. State Papers, Domestic. Charles II._ s. d. It appears from the _Pyretologia_ by Drage, of Hitchin (1665), that the natural history of measles must have been familiar, for he mentions that its incubation period was from fourteen to fifteen days: p. 20.

[1188] _Obs. Med._ 3rd ed. (1675), Bk. IV. chap. 5.

[1189] Sydenham, _Obs. Med._ 1675, V. 3. “Morbilli anni 1674.” It entered almost every household, as on the last occasion, attacking infants more especially. It had some points of difference from the measles of 1670. The rash was less uniformly on the fourth day, now sooner, now later; it would come on the arms or trunk before the face; nor was it followed by the branny powdering which was as obvious in the measles of 1670 as it was usual to see it after scarlatina. Along with these anomalies of the rash, the consecutive fever and peripneumonia were also more severe, and a more frequent cause of death. But in the principal characters of measles the disease of 1674 was the same as that of 1670, and called for no fresh description. Among Sydenham’s patients were the children of the Countess of Salisbury, who all took measles in turn, and all passed through the attack and its sequelae without danger, under a particular regimen which is detailed. It is of great interest to see how this season of anomalous measles looks in the weekly bills, as in the above table.

[1190] Richard Morton, M.D. _Pyretologia._ 2 vols. Lond. 1692-94, I. 427. He places it in the year 1672 and in the six months of autumn and winter; and in another place (II. 71), where he cites clinical cases, he again gives the year 1672 as that in which measles “epidemice Londini publice grassabantur.” He compares the epidemic to a _pestis mitior_, and says that the disease had never been epidemic again to the date of his writing (1692-94). It is tolerably clear that, in writing twenty years after, he had forgotten the year and even the season--not the only error in dates in his work. Sydenham’s account of the great measles epidemic of spring and summer, 1674, was published the year after, and is exactly borne out by the weekly bills of mortality. Morton’s obvious mistake of the date is the subject of a refutation four pages long by Thomas Dickson, M.D., F.R.S., physician to the London Hospital, in _Med. Obs. and Inquiries_, IV. (1771), p. 266.

[1191] Fothergill (_Gentleman’s Magazine_, Dec. 1751) says, in a criticism of the Bills of Mortality: “If the body is emaciated, which may happen even from an acute fever, ’tis enough for them to place it to the article of consumption.” And of course they would do so the more readily if the acute fever, say measles, were past, and its sequelae had been the cause of death. Referring to Kidderminster in 1756, Johnstone says: “Measles at this time went through our town and neighbourhood: vast numbers of children died tabid.” It is to be remarked that the fever column is augmented but little during the measles of 1674, a fact which shows that the inflammatory causes of death, such as capillary bronchitis and pneumonia (specially recorded by Sydenham for this epidemic), were more apt to be entered under “consumption” than under “fevers.”

[1192] See Watson’s account of smallpox following measles at the Foundling Hospital, _supra_, p. 550.

[1193] It may have been this high mortality that Dover had in mind when he wrote, in 1733: “I do not remember I ever heard of anyone’s dying of this disease [measles] till about twenty-five years since; but of late, by the help of Gascoin’s powder and bezoartic bolusses, together with blisters and a hot regimen, the blood is so highly inflamed and the fever encreased to that degree that it is become equally mortal with the smallpox.” _Physician’s Legacy_, 1733, p. 116.

[1194] Memorial to the House of Commons, _supra_, p. 84.

[1195] _Edin. Med. Essays and Obs._ V. 26.

[1196] Pronounced by Sims to have been wholly scarlatina, and by Willan to have been in part that disease.

[1197] Monthly reports in the _Gentleman’s Magazine_, under the dates.

[1198] Heberden’s paper on measles in _Trans. Col. Phys._ III. (1785), pp. 389, 395.

[1199] W. Black, M.D., _Obs. Med. and Political on the Smallpox, &c._ London, 1781, p. 207: “Few escape measles in infancy or childhood, and as we find one-tenth fewer to die of measles than of smallpox, etc.... In their future consequences, measles, especially in cities, are not without hazard, and are not unfrequently followed by hecticks.”

[1200] Percival, in _Med. Obs. and Inquiries_, V. (1776), p. 282.

[1201] Omitting the year 1760.

[1202] Compiled from the tables in the _Gentleman’s Magazine_, 1742-57. All Saints parish contained more than half the population.

[1203] Pearce, writing from St Croix, West Indies, 12 Oct. 1782, to Lettsom (_Memoirs_, III. 429), says the measles had been “very rife and fatal” there.

[1204] MS. Apothecary’s Books at the Foundling Hospital.

[1205] R. Willan, M.D., _On Cutaneous Diseases_. Vol. I. 1808, p. 244.

[1206] Heysham, u. s., p. 538.

[1207] James Lucas, “On Measles.” _Lond. Med. Journ._ XI. 325, dated 22 Aug. 1790.

[1208] _Reports on the Diseases of London, 1796-1800._ Lond. 1801, pp. 2, 13, 18, 32, 229.

[1209] John Roberton, in _Med. and Phys. Journ._ XIX. 185. Measles seems to have been more usual than scarlatina in Scotland as well as in Ireland. In the accounts of the several parishes written for the _Statistical Account_, about 1791-99, measles is often mentioned (and would appear at that time to have been more usual in country districts than smallpox), while hardly anything is said of scarlatina under that name, and not much of sore-throat.

[1210] _Med. and Phys. Journ._ VII. (1802), p. 316.

[1211] “Observations on Measles.” By Mr Edlin, surgeon, Uxbridge. _Med. and Phys. Journ._ VIII. (July-Dec. 1802), p. 28. An earlier epidemic of anomalous eruptive fever (“dark coloured eruption of the neck and breast which spread at length over the whole body”) was described for Uxbridge and its vicinity in the summer and autumn of 1799, in an essay reviewed in _British Critic_, XV. 435.

[1212] T. Bateman, M.D., _Report on the Diseases of London, 1804-16_. Lond. 1819, p. 90-91.

[1213] Samuel Fothergill, M.D., and others, in _Med. and Phys. Journ._ XVIII. (Dec. 1807), pp. 569, 572; XIX. 91, 185.

[1214] “The Epidemic Measles of 1808.” By Dr Ferguson. _Med. and Phys. Journ._ XXI. 359.

[1215] John Roberton, _Med. and Phys. Journ._ XIX. 182, 272, 278, 471.

[1216] Roberton, _loc. cit._ XIX. 471.

[1217] In the earlier period, according to Grainger, Lind and others, numerous cases of measles sometimes occurred on board ships of war.

[1218] Published as an Appendix to his _Treatise on the History, Nature and Treatment of Chincough_. Glasgow, 1813. Reprinted by John Thomson, Glasgow, 1888. Dr Watt is best known by his _Bibliotheca Britannica_ (Edinburgh, 1819. 4 vols. 4to.), a wonderfully complete bibliography under the dual arrangement of subjects and authors, which is still indispensable for research in every branch of knowledge. Perhaps the many who use it are not all aware that it was the labour of a physician in Glasgow (originally a surgeon at Paisley), who died (in 1819) at the age of forty-five, having reached such professional distinction in his own city as to be elected President of the Faculty of Physicians and Surgeons.

[1219] _De Febribus_, 1659. Cap. XV.

[1220] _Sketch of a Plan to exterminate the Casual Smallpox, &c._ London, 1793, p. 152.

[1221] It was believed that smallpox left ill effects in some constitutions. William III. is said to have had the dregs of smallpox in his lungs. Roberton (u. s.) cites Saunders as teaching that smallpox caused scrofula, and he is himself doubtful whether an attack of it ever improved the constitution. Dr Moses Younghusband, of New Lebanon Springs, _Med. Phys. Journ._ XI. (1804), 317, wrote: “I see no more of the glandular suppurations formerly so frequent and unavoidable” after smallpox.

[1222] Johnstone, _Malignant Epidemic Fever of 1756_, London, 1757, says of Kidderminster during a season of high mortality from fever and other diseases: “The measles at this time went through our town and neighbourhood. The children commonly got over the usual course of this distemper; but vast numbers died tabid of its consequences. The chincough succeeded the measles.”

[1223] The _Edin. Med. and Surg. Journ._ XXVI. 177, cites from Cleland, with a reference which I have not succeeded in verifying, the following Glasgow figures for the period 1813-19: all deaths 22,060, smallpox 236 (1·07 per cent.), measles 614 (3·69 per cent.). But see Cowan, _Glas. Med. Journ._ V. 358, _supra_, p. 597.

[1224] Cowan, _Journ. Statist. Soc._ III.

[1225] Griffin, _ibid._ III.

[1226] Macmichael, in an essay on scarlatina and other contagions, 1822, says: “Parents considering the measles as a disease almost inevitable have wisely chosen to expose their children to the contagion at such auspicious times [summer season]; so that the disorder may be once well over, and all further anxiety at an end.” p. 30.

[1227] P. Macgregor, _Med. Chir. Trans._ V. 436, obtained from Henry, of Manchester, the burials from measles at the Collegiate Church and St John’s Church for two years, 1812-13, which when compared with those abstracted by Percival from the former register for twenty years, 1754-74, showed a higher ratio of measles to the burials from all causes.

[1228] Cross, u. s.

[1229] Delagarde, _Med. Chir. Trans._ XIII. 163.

[1230] A. Campbell Monro, M.D., “Measles: an Epidemiological Study.” Chiefly from the Jarrow statistics. _Trans. Epid. Soc._ N. S. X. (1890-91), p. 94. The author connects the recent increase with the greater concourse of children to infant and elementary schools under the Education Act.

[1231] _Rep. Reg.-Genl._ LIV. p. xviii, and LV. p. xi. The explanation given is as follows: “When a county or other area has been visited by a severe epidemic [of measles] there is for several succeeding years scarcely sufficient material, in the shape of unprotected children, for another considerable outbreak, unless it be in very populous areas such as London or Liverpool; and in such places the disease is endemic.”

[1232] Buchan and Mitchell, _Journ. Scot. Meteor. Soc._ July, 1874, p. 194.

[1233] Ogle, in the 47th Report of the Registrar-General (for 1884), p. xv.

[1234] Cited by Hirsch, _Geogr. and Histor. Pathology_. Eng. transl. III. 28.

[1235] _Harl. MSS._ No. 2378. Moulton’s _This is the Myrour or Glasse of Health_, circa 1540, is in the main a printed reproduction of this manuscript prescription-book. The same receipt which is “for ye kink” in the one, is “for the chyncough” in the other (formula LXXIX.).

[1236] “Sycknesses happenynge to children:--When they be new borne, there do happen to them sores of the mouth called aphte, vometyng, coughes, watchinge, fearefulness, inflamations of the nauelle, moysture of the eares. When they brede tethe, ytchinge of the gummes, fevers, crampes and laskes. When they waxe elder, than be they greved with kernelles, opennesse of the mould of the head, shortnesse of wynde, the stone of the bladder, wormes of the bealy, waters, swellynges under the chynne, and in Englande commonly purpyles, measels and small pockes.”

[1237] _Obs. Med._ 3rd ed. Bk. IV. chap. V. § 8; _Epist. Respons._ I. § 42.

[1238] Mary Barker at Hambleton, to Abel Barker at the Dog and Ball in Fleet Street. _Hist. MSS. Commis._ V. 398.

[1239] _Tractatus de morbis acutis infantum._ Lond. 1689. Englished by W. Cockburn, M.D. London, 1693, pp. 38, 78, 87.

[1240] _Gent. Magaz._ 1751, pp. 195, 578.

[1241] _Treatise on Chincough._ Glasgow, 1813.

[1242] Vierordt, _Physiologie des Kindesalters_, Tübingen, 1877, p. 82, without adducing evidence that the larynx is congenitally different in the two sexes (a matter of very nice measurements which even Beneke does not appear to have attempted), says that the development of the posterior glottidean space has advanced before puberty much more in boys than in girls. Stark, a former Superintendent of Statistics for Scotland (_Rep. Reg. Gen. Scot. for 1856_, p. xxxviii), has raised the question thus: “The causes of this greater liability of the female sex to death while suffering from whooping-cough are worthy of being investigated. So far as one’s own limited experience goes, it would appear to be produced by the greater tendency which the female sex exhibits to have fits or convulsions when attacked by a paroxysm or fit of coughing in that disease.”

[1243] _Changes in the Air, &c. ... in Barbadoes._ Lond. 1760.

[1244] In the Irish Decennial Summary for 1871-80 (_Suppl. to 17th Report of Reg.-Gen. Ireland_, 1884) it is said: “A general relation has been noticed by many observers between the prevalence of whooping-cough and measles, and there is no doubt that in many localities an epidemic of measles is frequently accompanied by or followed by a prevalence of whooping-cough. A comparison of the figures in Table XV. does not point to any very close relationship. Whooping-cough was a much more fatal disease than measles, but it is more than probable that measles was equally prevalent.”

[1245] _Illustrations of Unconscious Memory in Disease._ London, 1886 [1885]. Chapter VI. pp. 64-83.

[1246] _Med. Times and Gaz._ 1885, II. p. 6.

[1247] Preface to 3rd ed. of _Obs. Med._, Greenhill’s ed. p. 16.

[1248] _Sydenhami Opera_, ed. Greenhill, 1844, p. 243.

[1249] Maton, _Med. Trans. Col. Phys._ V., having seen an extensive epidemic attended by a red rash in one of the great public schools, was disposed to erect it into a new type of roseola, owing to its mildness, while he admitted that it was the same as Sydenham’s scarlatina simplex. Macmichael (_New View of the Infection of Scarlet Fever_, 1822, p. 78) thought that this was “rather a proof of extreme refinement,” and that there was no need to give it a new designation. Gee, _Brit. Med. Journ._, 1883, II. 236, cites this “refinement” of Maton’s as one of the noteworthy things in the history of the diseases of children in this country.

[1250] Sir Robert Sibbald, M.D., _Scotia Illustrata, sive Prodromus Historiae Naturalis_. Edin. 1684. Lib. II. cap. 5, p. 55.

[1251] Richard Morton, M.D. _Pyretologia._ 2 vols. London, 1692-94, II. 69.

[1252] Engl. transl. 1737, p. 80. The reference by Dover (_Ancient Physician’s Legacy_, 1732, p. 117), is almost in the words of Sydenham, his master: “This is a fever of a milder kind than the measles [of which latter he did not remember anyone’s dying till about twenty-five years since], and does not want the assistance of a doctor. The skin seems to be universally inflamed, but the inflammation goes off in forty-eight hours.”

[1253] _Edin. Med. Essays and Obs._ III. 26.

[1254] _Obs. de aere et morb. epid._

[1255] H. Warren, M.D., _On the Malignant Fever in Barbados_. London, 1740, p. 73.

[1256] Le Cat, in _Phil. Trans._ XLIX. 49: In 1736 and 1737, a prevalence of gangrenous sore-throats which chiefly attacked children. They reappeared in 1748 in young persons of the first distinction, not only at Rouen, but also at St Cyr, near Versailles, and at Paris.

[1257] Webster, _Brief History of Epidemick and Pestilential Diseases_. Hartford, 1799, II. 253: “Away, then, with crowded cities--the thirty feet lots and alleys, the artificial reservoirs of filth, the hot-beds of atmospheric poison! Such are our cities--they are great prisons, built with immense labour to breed infection and hurrying mankind prematurely to the grave.”

[1258] W. Douglass, M.D., _The Practical History of a New Epidemical Eruptive Miliary Fever, with an Angina Ulcusculosa, which prevailed in New England in the years 1735 and 1736_. Boston, N.E. 1736. This rare essay was reprinted in the _New England Journ. of Med. and Surg._ XIV. 1 (Jan. 1825).

[1259] In Belknap’s _History of New Hampshire_. Boston, 1791.

[1260] _Gent. Magaz._ Feb. 1752, p. 73.

[1261] The account by Kearsley, of Philadelphia, written about 1769 (_Gent. Magaz._ XXXIX. 251), refers to a great epidemic of throat-disease in New England in the spring, summer and autumn of 1746; but the date is almost certainly a mistake for 1736, as no such epidemic is known on contemporary authority.

[1262] Cadwallader Colden, M.D. “Letter to Dr Fothergill on the Throat Distemper,” dated New York, 1 Oct. 1753, in _Med. Obs. and Inquiries_, I. 211.

[1263] Belknap, III. 421.

[1264] Samuel Bard, M.D. “An Inquiry into the Nature, Cause and Cure of the Angina Suffocativa, or Sore throat Distemper, as it is commonly called by the inhabitants of this city and colony.” _Trans. Amer. Philos. Soc._ I. (1769-1771). Philad. 1771, p. 322. What purports to be a translation of this, is given in Reutte’s _Recueil d’Obs. sur le Croup_ (Paris, 1810), the name of “croup” being introduced into the title, and some strange liberties taken with the text.

[1265] The impression made upon modern historians by these American accounts of the throat-distemper has not always been the same. Hecker finds in the malady described by Douglass the form of _Frieselbräune_, or miliary diphtheria, a somewhat rare and sporadic malady; in the account by Bard, he finds _häutige Brandbräune_, or membranous angina maligna; while he finds in an account by Chalmers for Charleston, S. Carolina, in 1770, a third variety, _Friesel-Scharlachbräune_, or miliary scarlet angina. Again, Jaffe finds in the account by Bard “many analogies with the diphtheria of our own day.” Hirsch identifies the throat-distemper of Douglass and Colden as “exquisite scarlet fever” and the disease described by Bard as diphtheria. Häser identifies the epidemic described by Douglass as diphtheria. Bard himself did not doubt that the disease which he saw in New York previous to 1771 was the same that Douglass saw at Boston in 1735-36. Hecker, _Geschichte der neueren Heilkunde_. Bk. I. chap. 8. Max Jaffe, “Die Diphtherie in epidemiol. u. nosol. Beziehung, &c.” Original paper in _Schmidt’s Jahrbücher_, CXIII. (1862), p. 97. Hirsch, 1st ed. of _Handb. der histor. geogr. Pathol._ I. 237, note 6; II. 125, note 4; and 2nd ed. III. 80. Eng. transl. Häser, _Geschichte, &c._ III. 471.

[1266] _Gent. Magaz._ IX. Nov. 1739, p. 606:--Died, “Nov. 27, the eldest and youngest son of Henry Pelham, Esq. of sore throats.”

[1267] John Chandler, F.R.S., _A Treatise of the Disease called a Cold. Also a Short Description of the Genuine nature and seat of the Putrid Sore-Throat._ London, 1761, p. 55.

[1268] Munk, _Roll of the College of Physicians_. Fothergill cites Spanish and other foreign writers on garrotillo in the historical introduction to his essay on the Sore-Throat (1748), without mentioning the fact that Letherland had been before him in that field.

[1269] John Rutty, M.D., _Chronological History of the Weather and Seasons, and prevailing Diseases in Dublin, during forty years_. London, 1770, p. 108.

[1270] John Starr, M.D., “Account of the Morbus Strangulatorius.” _Phil. Trans._ XLVI. 435, dated Liskeard, Jan. 10, 1749/50.

[1271] John Fothergill, M.D., _An Account of the Sore Throat attended with Ulcers; a Disease which hath of late years appeared in this City and the parts adjacent_. London, 1748.

[1272] Sir Thomas Watson (_Lectures_, II. 817), who mentions excoriations of the anus, carried Fothergill’s idea of an absorption of the acrid matter to an extreme length in explaining the irritation of the alimentary canal in scarlet fever.

[1273] Letter to Rutty, _Chronol. Hist._ 1770, p. 117.

[1274] _Gent. Magaz._ Oct. 1751, and July, 1755, p. 343.

[1275] Nathaniel Cotton, M.D. _Observations on a particular kind of Scarlet Fever that lately prevailed in and about St Albans._ In a Letter to Dr Mead. London, 1749 (12th February). The copy in the British Museum library has a written note signed R. W. (Robert Willan, M.D.): “The only just and correct account; but was not noticed during the author’s lifetime, and it has since been consigned to oblivion.” In his work _On Cutaneous Diseases_ (1808), Willan sarcastically contrasts the means by which Fothergill gained fame while Cotton escaped notice; of the latter he says: “But, as he gave an old appellation to a disease certainly not new, his work attracted little attention, and procured him no emolument.”

[1276] John Huxham, M.D., _A Dissertation on the Malignant Ulcerous Sore-Throat_. London, 1757.

[1277] _Supra_, p. 125.

[1278] John Wall, M.D. “Bark in the Ulcerated Sore Throat.” _Gent. Magaz._ 1751, Nov. p. 497. Dated Worcester, 15 Oct. 1751.

[1279] Nash, _History of Worcestershire_, II. 39.

[1280] James Johnstone, M.D., _Malignant Epidemic Fever of 1756_. London, 1758.

[1281] To those who explicitly distinguished the sore-throat or angina maligna from scarlatina may be added Dr Richard Russell: “In hoc quidem morbi statu mitissimo, si ad quartum vel quintum usque diem eruptiones in cute superstites sint, paulatim recedant, et desquamationes furfuraceae, perinde ut in febre scarlatina, post se reliquant, ibi crisis integra et perfectissima est.” _Œconomia Naturae in Morbis Acutis et Chronicis Glandularum._ Lond. 1755, p. 105 seq.

[1282] _Letters of Horace Walpole_, ed. Cunningham, III. 280, letter to Mann, 20 Jan. 1760.

[1283] Charles Bisset, _Essay on the Medical Constitution of Great Britain, with obs. on the weather and diseases in 1758-60_. London, 1762.

[1284] Hecker (u. s.) identified Bisset’s epidemic disease in Cleveland with Douglass’s in New England. Merely because they used the term “miliary,” he erects their epidemics into an imaginary class of _angina miliaris_ which was not scarlatina.

[1285] Short to Rutty, Rotherham, 26 March, 1760, in Rutty’s _Chronol. Hist. of Weather, &c. and Diseases in Dublin_. London, 1770, p. 117.

[1286] Sir David Hamilton, _Tractatus Duplex, &c._ London, 1710 (Engl. transl. 1737, p. 84), says that, in 1704, several in the “miliary fever” had “a pain in the jaws resembling that of the squinsy,” which killed many suddenly. At the other end of the century, Willan (_Cutaneous Diseases_, 1808, p. 333), said of fever in 1786: “The title ‘angina maligna’ would have applied with equal, if not with more propriety, to the sore-throat connected with a different species of contagion, namely, that of the typhus or malignant fever originating in the habitations of the poor where no attention is paid to cleanliness or ventilation.”

[1287] Francis Penrose, _A Dissertation on the Inflammatory, Gangrenous and Putrid Sore-Throat. Also on the Putrid Fever._ Oxford, 1766.

[1288] _Some Thoughts on the Anomalous Malignant Measles lately peculiarly prevalent in the Western Parts of England._ London, 1760. And to be sold at Bath and Exeter.

[1289] William Watson, M.D. “An Account of the Putrid Measles as they were observed at London in the years 1763 and 1768.” _Med. Obs. and Inquiries_, IV. (1771), p. 132.

[1290] James Clarke, M.D. “Medical Report for Nottingham from March, 1807, to March, 1808.” _Edin. Med. Surg. Journ._ IV. 425.

[1291] These changes of the name from week to week represent probably the independent judgment of the apothecary more than the modified opinions of Watson the physician. The views which the latter expressed in his paper of 1771, are clearly reechoed in the following anonymous paragraph in the _Gent. Magaz._ XLII. (1772), Nov. p. 541: “The measles have lately been very rife and fatal in this metropolis. They are of a very different kind from those described by the great Doctor Sydenham, being of a malignant putrid nature, such as visited London in 1763 and 1768, where bleeding seemed of so little service, but small doses of emetic tartar, cordial medicines and blisters, were very efficacious. The above disorder was epidemic at Plymouth and parts adjacent in the years 1745 and 1750, and so long since as the year 1762 [1672] was described by Dr Morton, who says it raged so severely during the autumn of that year that it appeared like a gentle kind of plague, sparing neither sex nor age, and that 300 died weekly of it.”

[1292] W. Grant, M.D., _Account of a Fever and Sore Throat in London, September, 1776_. London, 1777.

[1293] W. Fordyce, M.D., _A new Inquiry into the Causes, Symptoms and Cure of Putrid and Inflammatory Fevers; with an Appendix on the Hectic Fever, and on the Ulcerated and Malignant Sore Throat_. London, 1773. The appendix on Sore-throat is pp. 209-222.

[1294] _Gent. Magaz._ XLII. (1772), June, p. 258.

[1295] G. Levison, M.D., _An Account of the Epidemical Sore-Throat_. 2nd ed. corrected. London, 1778 (1st ed. 1778).

[1296] It might have been the third, as Grant (u. s.) says there was fever with sore-throat in London in September, 1776.

[1297] “Angina and Scarlet Fever of 1778.” _Mem. Med. Soc._ III. 355.

[1298] James Johnstone, junr. M.D., _A Treatise on the Malignant Angina or Putrid and Ulcerous Sore-Throat, &c._ Worcester, 1779.

[1299] Robert Saunders, _Observations on the Sore-Throat and Fever in the North of Scotland in 1777_. London, 1778.

[1300] William Withering, M.D., _Account of the Scarlet Fever and Sore-Throat, particularly as it appeared at Birmingham in 1778_. London, 1779; preface dated 1st January.

[1301] Withering was perhaps too desirous to be thought the first in England to have described scarlatina anginosa. “The scarlet fever in its simple state,” he says, “is not a very uncommon disease in England, but its combination with a sore-throat, as described above, the violence of its attack, and the train of fatal symptoms that follow, are circumstances hitherto unnoticed by English writers.” It is probable from this that he had not seen Levison’s essay, with preface dated 11 May, 1778, his own being dated 1 January, 1779; but Cotton’s essay of 1749 actually bore the name of scarlet fever on its title-page, and described the throat-affection, glandular swellings, and the like quite correctly.

The name of the elder Heberden is frequently brought into the history of the identification of scarlatina, with a reference to his _Commentaries on Diseases_, which were not published until 1802, some time after his death at a very advanced age. The following are among his remarks: “In the fever which has just been described there is always some degree of redness in the skin, and the throat is not without an uneasy sensation. Where it happens that the throat is full of little ulcers attended with considerable pain, there the disease, though the skin be ever so red, is not denominated from the colour, but from the soreness of the throat, and obtains the name of _malignant sore-throat_; and many suppose that the two disorders differ in nature as well as in name,” p. 23. “The enfeebled and disordered state of all the functions of the body evidently points out such a malignity of the fever as cannot be owing to the affection of the uvula or tonsils, which in other distempers we often see ulcerated and eaten away, without any danger of the patient’s life. These sores, therefore, like pestilential buboes, point out the nature of the disorder; but the danger arises, not from them, but from the fever,” p. 25.

In 1790 an elaborate attempt was made by William Lee Perkins, M.D. (dating from Hampton Court, 1 March) to distinguish between cynanche maligna and scarlatina anginosa, in _An Essay for a Nosological and Comparative View of the Cynanche Maligna or Putrid Sore-Throat, and the Scarlatina Anginosa_. London, 1790. He proceeds by the nosological method of Sauvages and Cullen, erecting genera, species and varieties. The result is not clear after all; for on p. 43 (note) we read that _scarlatina_ is frequently accompanied with inflammatory and ulcerous appearances in the fauces or throat, and that _angina maligna_ or ulcerated sore-throat is often attended with red efflorescence on the skin; this had led to their being regarded as one and the same, and treated by the same method of cure.

[1302] J. Parker, _A Treatise on the Putrid Constitution of 1777 and the preceding years, and the Pestilential one of 1778_. London, 1779 (of inferior value beside Withering’s).

[1303] Heysham, in Hutchinson’s _Hist. of Cumberland_, u. s.

[1304] John Clark, M.D., _Obs. on Fevers, and on the Scarlet Fever with Ulcerated Sore-Throat at Newcastle in 1778_. Lond. 1780; _Account of the Newcastle Dispensary from its commencement in 1777 to Michaelmas, 1789_. Newcastle, 1789 (also by Clark).

[1305] James Sims, M.D. “Scarlatina Anginosa as it appeared in London in 1786.” _Mem. Med. Soc. Lond._ I. 388. Willan, however, says that measles was the epidemic in the winter and spring of 1785-86; while the epidemic at the Foundling Hospital was “measles” in March and April, 1786, “fever” in June and July, and “scarlet fever” in 1787.

[1306] _On Cutaneous Diseases._ Vol. I. London, 1808, pp. 262, 277, 345.

[1307] I Have Not Succeeded in Finding the Apothecary’s Book for the Years 1776-82, Within Which the Great London Epidemic of 1777-78 Fell; But Willan, Who May Have Had the Complete Set of Books Before Him, Says (_op. cit._ 1808, P. 245) “the Denomination ‘scarlet Fever and Sore-throat’ First Occurs in the Weekly Report, 1st September, 1787.” I am Indebted To the Courtesy of Mr Swift, M.R.C.S. for A Sight of the Books.

[1308] J. Barker, _Epidemicks, Or General Observations on the Air and Diseases From The Year 1740 To 1777 Inclusive, and Particular Ones From That Time To the Beginning Of 1795_. Birmingham (no Date).

[1309] _Lond. Med. Journ._ XI. 374.

[1310] H. Rumsey, “Epidemic Sore-Throat at Chesham in 1788.” _Lond. Med. Journal_, X. 7, dated 14 Dec. 1788.

[1311] H. Rumsey, “An Account of the Croup as it appeared in the Town and Neighbourhood of Chesham, in Buckinghamshire, in the years 1793 and 1794.” _Trans. of a Soc. for Improving Med. and Chirurg. Knowledge_, II. (1800), 25. Read 1 July, 1794.

[1312] “Several children brought up portions of a film, or membrane of a whitish colour, resembling the coagulated matter which was found in the trachea of those children whose bodies were opened. This was thrown off by violent coughing or retching; and the efforts made to dislodge it were often so distressing that the child appeared almost in a state of strangulation.”

[1313] Sinclair’s _Statist. Account of Scotland_, IX. 190.

[1314] _Ibid._ II. 412.

[1315] _Ibid._ IX. 461.

[1316] Livingston to Lettsom, Aberdeen, 13 May, 1790, in _Memoirs of Dr Lettsom_, III.

[1317] R. Willan, M.D., _Reports on the Diseases in London, 1796-1800_. Lond. 1801, p. 2.

[1318] “Cursory Remarks on the Appearance of the Angina Scarlatina in the Spring of 1793.” _Mem. Med. Soc. Lond._ IV. (1795), p. 280.

[1319] W. Rowley, M.D., _An Essay on the Malignant ulcerated Sore-Throat, containing reflections on its causes and fatal effects in 1787, etc._, London, 1788; _The Causes of the Great Numbers of Deaths ... in Putrid Scarlet Fevers and Ulcerated Sore-Throats explained, etc._, London, 1793. Based on the practice of the St Marylebone Infirmary.

[1320] James Sims, M.D. “Sketch of a Description of a Species of Scarlatina Anginosa which occurred in the Autumn of 1798.” _Mem. Med. Soc. Lond._ V. (1799), p. 415.

[1321] This is the source of Noah Webster’s information for London; he adds that the “cat distemper” appeared in Philadelphia in June, and was very fatal in New York and over the Northern States.

[1322] E. Peart, M.D., _Practical Information on the Malignant Scarlet Fever and Sore-Throat_. London, 1802. See also _Med. and Phys. Journ._ IX. 16, report for Dec. 1802: “so very general that few of those who have continued in the same house have entirely escaped it”; and the reports, _ibid._ X. 76, 276.

[1323] Clark, u. s. Monteith, _Report of the Newcastle Dispensary from its Foundation_, 1878.

[1324] Polwhele’s _Cornwall_. Part VII. _Diseases_, p. 59.

[1325] F. Skirmshire, _Med. Phys. Journ._ VI. 424.

[1326] R. Freeman, _ibid._ IX. 157.

[1327] H. Gilbert, _ibid._ IX. 249.

[1328] Goodwin, _ibid._ IX. 509.

[1329] Braithwaite, _ibid._ XI.

[1330] Willan, _Cutan. Dis._ 1808, p. 379, particulars from Dr Binns, with full discussion of the methods of treatment. Willan was told by Dr Stanger that there were 71 cases in the Foundling Hospital from June to October, 1804, with 4 deaths.

[1331] W. Blackburne, M.D., _Facts and Observations concerning the Prevention and Cure of Scarlet Fever, &c._ London, 1803.

[1332] James Hamilton, M.D., _Obs. on the Utility, &c. of Purgative Medicines_. 4th ed. Edin. 1811. App. III. p. 66 (three boys in Heriot’s Hospital died of dropsy). Autenrieth, _Account of the State of Medicine in Great Britain_. Extracts translated by Graves, u. i.

[1333] Ferriar, _Med. Hist. and Reflect_. III. 128.

[1334] R. J. Graves, M.D., _A System of Clinical Medicine_. Dublin, 1843, p. 493.

[1335] T. Bateman, M.D., _Reports on the Diseases of London, and the State of the Weather, from 1804 to 1816_. London, 1819.

[1336] Clarke, _Ed. Med. and Surg. Journ._ XXX.

[1337] Goodwin, of Earlsoham, _Med. and Phys. Journ._ XXIV. 465.

[1338] Samuel Fothergill, M.D. _Med. and Phys. Journ._ XXXII. 481.

[1339] N. Bruce, _Med. Chir. Trans._ IX. 273.

[1340] Heysham to Joshua Milne, in the latter’s _Treatise on the Valuation of Annuities_. Lond. 1815. App. p. 755.

[1341] Currie, _Med. Reports_, 1805, II. 458; Armstrong, _Pract. Illustr. of the Scarlet Fever, Measles, &c._ Lond. 1818; Lodge, of Preston, in _Med. and Phys. Journ._ XXXIII. (1815), p. 358.

[1342] W. Macmichael, M.D., _A New View of the Infection of Scarlet Fever, &c._ London, 1822, pp. 30, 59, 78, 81-2. The title of another essay appears to reflect the same ideas, _Caution to the Public, or hints upon the nature of Scarlet Fever, designed to show that this disease arises from a peculiar and absolute virus, and is specifically infectious in its mildest as well as in its most malignant form_. By William Cooke, London, 1831.

[1343] Kreysig, “Ueber das Scharlachfieber,” _Hecker’s Annalen_, IV. 273, 401, 1826, says that scarlatina had been “not only almost uninterrupted in all Europe since twenty-six or twenty-seven years [1799 or 1800], but also frightfully fatal.” The period in which this was written appears to have been one of fatal scarlatina in some parts of Germany; so also the years 1817-19, and the years 1799-1805 (as in Great Britain and Ireland). But the sweeping assertion as to frightful scarlatina mortality in all Europe without interruption since 1799 is clearly a flight of rhetoric, and is as nearly as possible the reverse of the truth so far as concerns Britain and Ireland.

[1344] Blackmore, _Lond. Med. Gaz._ VI. 114.

[1345] Sandwith, _Edin. Med. and Surg. Journ._ XL. 249.

[1346] Aulsebrook, _Lancet_, 12 Nov. 1831, p. 217: cases of very malignant suddenly fatal scarlatina in infants and young persons up to the age of twenty-two. In the house of a canal boatman a son and two daughters, from 21 to 13 years, died in the course of two days after a very sudden and brief illness.

[1347] Rumsey, _Trans. Prov. Med. Assoc._ III. 194.

[1348] Hamilton, _Edin. Med. Surg. Journ._ XXXIX. 140.

[1349] Cowan, _Journ. Statist. Soc._ III.

[1350] Sidey, Stark and others in _Edin. Med. and Surg. Journ._ 1835-36. H. Kennedy, M.D., _Account of the Epidemic of Scarlatina in Dublin from 1834 to 1842_. Dublin, 1843.

[1351] The principal epidemics of scarlatina which have been inquired into by inspectors of the medical department since 1870 have been the following:

In 1870, Camborne, Wing. 1873, Fleetwood-on-Wyre. 1874, Hetton (Durham). 1877, Massingham, Portsmouth. 1879, Pontypool, Easington (Durham), Fallowfield (near Manchester), Yeadon. 1880, Bedlington (near Morpeth), Stourbridge, Swindon, Castleford, Llanelly, Huntingdon, Barkingside (Orphans’ Home near Romford). 1881, Durham, Halifax, Thame. 1882, Bedwelty (Tredegar and Aberystruth), Potton. 1883, Sutton in Ashfield, Thorne, Donington and Moulton (Spalding). 1885, Sandal (near Wakefield). 1886, Atherton, Hayfield, Hindley, Wombwell. 1889, Spennymoor (Durham), Macclesfield, Faringdon, Brixham.

[1352] William Ogle, M.D., in the _49th Report of the Registrar-General_ (_for 1886_), p. xiv.

[1353] See a paper, with Tables, on “Age, Sex and Season in relation to Scarlet Fever,” by Arthur Whitelegge, M.D. in _Trans. Epidemid. Soc._ N. S. VII. p. 153, for Nottingham and some other towns. A paper by Dr Ballard, “On the Prevalence and Fatality of Scarlatina as influenced by Sex, Age and Season,” which was written twenty years before but left unpublished, follows Whitelegge’s in the _Trans. Epidem. Soc._ N. S. VII. (1887-8).

[1354] A table of figures showing this will be found in Dr B. A. Whitelegge’s second lecture on “Changes of Type in Epidemic Diseases.” _Brit. Med. Journ._ 4 March, 1893.

[1355] Longstaff, _Trans. Epid. Soc._ N. S. IV. (1880), 421, and _Studies in Statistics_. London, 1891, p. 310. D. A. Gresswell, _Contribution to the Natural History of Scarlatina_. Oxford, 1890, p. 193.

[1356] _Journ. Scot. Meteorol. Soc._ July, 1874, p. 195.

[1357] _Cutaneous Diseases._ Vol. I. 1808, p. 254.

[1358] An unfortunate event that came under the writer’s notice some years ago may be illustrative of this. Two women with cancer of the breast were operated on, the one after the other, in the same operating theatre. Their beds were in the same hospital ward, but separated by the whole length of the ward. A few days after the operations, one of the women developed erysipelas, which was most extensive on the back; very soon after the other woman got the disease in a precisely similar way; they both died of it. As it seemed improbable that No. 1 had been infected in the ward, or that No. 2 had been infected from No. 1, (some dozen surgical cases between them escaping,) the suggestion arises of a common source of both infections in the operating theatre. The operating table was covered by a woollen cloth, of red colour so as not to show blood stains; it must have contained a good deal of putrid invisible blood from former operations.

[1359] The first instance showing this came from a dairy at Hendon. See James Cameron, M.D. _Trans. Epid. Soc._ V. (1885-6), p. 104; and _ibid._ VIII. 40. One of the latest and most fully investigated came from a dairy near Glasgow, J. B. Russell, M.D., LL.D., and A. K. Chalmers, M.D. _Glas. Med. Journ._ Jan. 1893, p. 1. An outbreak at Wimbledon and Merton is described, _Rep. Med. Off. Loc. Gov. Bd._ for 1886, p. 327. See also _ibid._ for 1882, p. 63. The scarlatina caused by cream (with strawberries) is traced, _ibid._ for 1875, p. 72. A very clear case of scarlatinal epidemic due to contaminated milk occurred at Blackheath, both among children and adults, in April, 1894.

[1360] E. M. Crookshank, _Path. Trans._ XXXIX. 382, in an extensive prevalence of cowpox on a dairy farm near Cricklade. No scarlatina could be traced in the neighbourhood.

[1361] Alfred Carpenter, M.D. _Lancet_, 28 Jan. and 4 Feb. 1871.

[1362] Wall, _Gent. Magaz._ 1751, p. 71, 501. He quotes Severinus to the effect that the great epidemic of _garrotillo_ in the province of Naples in 1618 was preceded by a murrain.

[1363] Prince A. Morrow, “Drug Eruptions,” edited for the New Sydenham Society by T. Colcott Fox, in _Selected Monographs on Dermatology_. London, 1893.

[1364] Hirsch, III. 87.

[1365] Cullen, _First Lines of the Practice of Physic_, Part I., Book II. chap. 5, § 2, and Book III. chap. 4.

[1366] _On Cutaneous Diseases_, vol. I., London, 1808, pp. 319, 326, 333. He included also the _garrotillo_ of Spain and the throat-plague of Naples (1618) among the “varieties of scarlatina,” inasmuch as they had not unfrequently a rash which was of the erysipelatous kind. Hirsch (u. s.) and Max Jaffe (“Die Diphtherie in epidemiologischer und nosologischer Beziehung vornehmlich nach Französischen und Englischen Autoren zusammengestellt,” Originalabhandlung in _Schmidt’s Jahrbücher_, CXIII., 1862, pp. 97-120) do not seem to doubt the diphtheritic nature of the _garrotillos_ of Spain and Italy in the 16th and 17th centuries, but they agree with Willan in classing most of the 18th century throat-distempers of English and American writers as scarlatinal, reserving as diphtheritic, or as more nearly allied to diphtheria, Starr’s “morbus strangulatorius” of Cornwall, some cases of infants recorded by Denman (_supra_, p. 714), Rumsey’s cases of “croup” (_supra_, p. 716), and the epidemic described by Bard, of New York (_supra_, p. 690). These matters of identification appear to be like matters of taste, for which the best rule is _non disputandum_. I have already pointed out that Bard himself did not hesitate to identify the epidemic throat-disease of his time with that which Douglass had described in New England thirty years before.

[1367] P. Bretonneau, _Des inflammations spéciales du tissu muqueux et en

## particulier de la Diphthérite_, Paris, 1826, with supplement in 1827.

[1368] Id. _Arch. gén. de méd._, Jan., 1855.

[1369] Mackenzie, _Ed. Med. and Surg. Journ._, April, 1825, p. 294, and _Med. Chir. Rev._, 1827, p. 289, for Glasgow in 1819. The disease which Mackenzie called croup, was generally known in Glasgow at that time as “croupy sore throat.” It was very fatal, attacking several children in the same family, was reckoned contagious, was not a modification of scarlatina, was very different from idiopathic croup as it began on the tonsils and descended to the larynx and trachea, and, lastly, was sometimes marked by gangrenous foetor.

Robertson, _Edin. Med. and Surg. Journ._ (1826) XXV. 279, for Kelso in 1825.

Bewley, _Dub. Journ. of Med. Sci._ VIII. 401, for Dublin in 1835-36. An outbreak observed by Brown, at Haverfordwest, in 1849-50, involving some 200 cases and 40 deaths, was identified in 1858 with diphtheria (_Med. Times and Gaz._, May, 1858, p. 566, see also _Med. Chir. Trans._ XL. 49). Outbreaks more vaguely recalled in 1858 as diphtheria occurred at Ashford in 1817, and at Leatherhead (30 deaths in the workhouse) at an uncertain date (_2nd Rep._ (1859) _Med. Offices Privy Council_, pp. 244, 320). F. Ryland, _Diseases and Injuries of the Larynx and Trachea_, London, 1837, pp. 161-175, described a similar disease as a complication of measles at Birmingham in 1835.

[1370] _Med. Times and Gazette_, _Lancet_, _British Med. Journal_, _&c._ for 1858 and 1859. See references in Hirsch, III. 89.

[1371] _Second Report_ (for 1859) _by the Medical Officer of the Privy Council_, London, 1860, p. 161 _seq._ Dr Greenhow published an essay on Diphtheria in 1860. Lectures important for the nosological definition were published by Sir William Jenner in 1861 (reprinted in 1893). Other essays called forth by the epidemic were by W. F. Wade (1858), Ernest Hart (1859), Edward Copeman (Norwich, 1859). Christison, J. W. Begbie and others wrote upon it in Scotland.

[1372] Mr Jones, of Fletching, Sussex, wrote that scores of cases (probably at least 50 or 60) have had more or less eruption. In one case it was general and bright.... It was like scarlatina ... but the whole surface was covered with minute miliary vesicles of clear fluid, ‘one mass of small vesications.’ There was a great deal of itching and no subsequent dropsy. In other cases the eruption was partial. _Rep. Med. Off. Privy Council_, II. (1859), p. 284.

[1373] Starr’s description for 1748 is referred to _supra_, p. 695. Sanderson, _Report_, u. s. p. 263, says of the disease in 1858: “At Launceston the diphtheritic pellicle was tough, leathery, and highly elastic; and on the mucous surface of the fauces and pharynx it attained so great thickness (from one-tenth to one-eighth of an inch) that it was compared by several practitioners to the coriaceous lichens which grow on rotten bark. In the other districts this was never observed.”

[1374] G. B. Longstaff, M.D., “The Geographical Distribution of Diphtheria in England and Wales,” in _Supplement to the 17th Annual Report of Loc. Gov. Board_, 1887-8, p. 135. See also Downes, _Trans. Epid. Soc._ N. S. VII. 193. Farr, _Rep. Reg. Genl._ for 1874, p. 219, gave the following illustration: “It is remarkable that of diphtheria, out of the same number born, more die in the healthy districts of England than in Liverpool; the proportions are 1029 in the healthy districts and 442 in Liverpool of 100,000 born. The deaths from scarlet fever are 2140 in the healthy districts to 3830 in Liverpool.”

[1375] _8th Detailed Report of the Reg. Gen. Scot._, p. xxxix.

[1376] R. T. Thorne, M.B., _Diphtheria: its Natural History and Prevention_. Milroy Lectures for 1891. London, 1891.

[1377] Farr, _Rep. Reg.-Genl._ XXIV. (1861), p. 217.

[1378] Longstaff, u. s.

[1379] G. Budd, M.D., “Obs. on Typhoid or Intestinal Fever.” _Brit. Med Journ._, 9 Nov. 1861, p. 485.

[1380] _Supra_, pp. 210, 213.

[1381] Matthew A. Adams, cited by Thorne, u. s. with diagram.

[1382] M. W. Taylor, M.D., “Diphtheria in connection with Damp and Mould Fungi.” _Trans. Epic. Soc._ N. S. VI. (1886-7), p. 104. Thorne, u. s. gives instances in which diphtheria seemed to choose out wet and impervious soils.

[1383] L. Traube, _Gesammelte Beiträge, &c._, Berlin, 1871, II. 11.

[1384] Thorne, u. s. has collected and analysed very fully the instances of diphtherial epidemics traced to cows’ milk. It is commonly assumed that the epidemics are either wholly diphtherial or wholly scarlatinal, but not a mixture of the two diseases.

[1385] W. N. Thursfield, _Lancet_, 3 Aug. 1878, p. 180, has contended for some such correlation between diphtheria and enteric fever in their respective preferences, at that time, for rural and urban districts.

[1386] William Heberden, M.D. junior. _Observations on the Increase and Decrease of Diseases, particularly the Plague._ Lond. 1801.

[1387] Among the numerous medical writers who have used it are Macmichael, Watson and Chevers. Among historians Lecky (I. 573) has thought it worthy of mention among the progressive improvements of the 18th century.

[1388] Heberden (l. c. p. 42) accounted for the enormous increase of the article “convulsions” in the Bills by the inclusion under that term of most of the deaths originally entered under “chrisomes and infants,” which were infants under one month. But the latter had been mostly transferred at an early period while convulsions was still a small total; and even at the worst period of the public health in London, about 1730-40, they would not have accounted for a sixth part of the deaths under convulsions. The probability of the deaths from “griping in the guts” having been transferred to “convulsions” was pointed out in a review of Heberden’s essay in the _British Critic_ on its appearance, without reasons given such as I adduce in the sequel.

[1389] _Observ. Med._ IV. cap. 7, § 2.

[1390] _Ibid._ III. cap. 2, § 54.

[1391] _Pathol. Cerebri._ Pordage’s Transl. p. 25.

[1392] Walter Harris, M.D., _Tractatus de Morbis Acutis Infantum_. Lond. 1689. Engl. Transl. by Cockburn, 1693, p. 39.

[1393] _Obs. Med._ IV. cap. 2, § 7: “haud aliter ac si in aëre peculiaris mensis hujus [Augusti] lateat reconditum ac peculiare quiddam, quod specificam hujus modi alterationem, soli huic morbo adaptatam, vel cruori vel ventriculi fermento valeat imprimere.”

[1394] See the reference to Simpson’s essay, _supra_, p. 333.

[1395] W. Fordyce, M.D. _A new inquiry into the Causes, Symptoms and Cure of Putrid and Inflammatory Fevers: with an Appendix on the Hectic Fever and on the Ulcerated and Malignant Sore Throat._ London, 1773, p. 207.

[1396] See the Representation of the College of Physicians on Drink in 1726, cited at p. 84.

[1397] Joseph Clarke, M.D. “Nine-day Fits in the Lying-in Hospital of Dublin.” _Trans. Royal Irish Academy_ (in _Med. Facts and Obs._ III. 1792).

[1398] Moss, u. s. He makes out that the infants of the poorer class were much neglected by their drunken parents.

[1399] John Ferriar, M.D., _Medical Histories and Reflections_. 2 vols. Lond. 1810. II. 213 seq. “On the Prevention of Fevers in Great Towns.”

[1400] Watt, u. s., says that “bowel-hive” at Glasgow included, along with teething, “a promiscuous mass which may be considered nearly in the same light as the great number of deaths in the London bills of mortality ranked under the terms convulsions, gripes of the guts, &c.... If the patient dies in a state of convulsions, this, we are told, is owing to the hives having gone in about the heart, or their having seized the bowels.”

[1401] Hirsch, _Geographical and Historical Pathology_, Engl. Transl. III. 376.

[1402] Supplement to the 45th Annual Report of the Registrar-General. London, 1885, p. xiii. Ballard, following the method of Pfeiffer (1871) for Asiatic cholera, has shown that the correspondence is closest with the temperature of the ground four feet deep.

[1403] Ballard, _Report to the Local Government Board upon the Causation of Summer Diarrhoea_, 1889, p. 32.

[1404] Willis mentions an instance (_Pathol. Cerebri_, Pordage’s transl. p. 25) which can hardly mean anything but congenital feebleness as a cause of infantile convulsions. A neighbour of his (in St Martin’s Lane) had lost all his children by convulsions within the space of three months. Another child was born, and Willis was sent for to advise what regimen should be followed so as to save it from the same fate.

[1405] This is clearly seen in comparing ages at death in Liverpool, and in Preston or Salford. Again in the ten years 1871-80, there were 4530 deaths from diarrhoea in the group of shipping towns, Yarmouth, Hull (with Sculcoates), Goole and Hartlepool, of which 70 per cent. were under one year, 19 per cent. from one to five, and 11 per cent. above five, chiefly in old age. In the group of Leicester, Worcester, Northampton and Coventry in the same period, there were 5001 deaths, of which 74 per cent. were under one year, 17 per cent. from one to five, and 9 per cent. above five, chiefly in old age.

[1406] Ballard, _Report, &c._ u. s. says that “occupation of females from home,” which had been often assigned by medical officers of health and others as a fruitful cause of infantile fatal diarrhoea, “resolves itself mainly into the question of maternal neglect, with the substitution more or less of artificial feeding for feeding at the breast.” Tatham, _Brit. Med. Journ._ 1892, II. 277, is of opinion that the rate of infant mortality was considerably increased by the practice, which obtained in most manufacturing towns, of allowing women to return to work within a week or ten days after their confinement, so that the duties of the mother were necessarily delegated. The paper by Dr G. Reid, _ibid._ p. 275, which called forth that and similar opinions as to the kind of maternal neglect that favoured the mortality by infantile diarrhoea, bore the title, “Legal restraint upon the employment of women in factories before and after childbirth”; but the emphasis falls almost wholly upon restraint of the mother’s industrial occupation after the child is born.

[1407] L. c. pp. 43-45.

[1408] Ballard, u. s. Table VI.

[1409] See former volume, p. 412.

[1410] _The Triall of Tabacco, &c._ by E. G. [Edmund Gardiner], Gent. and Practicioner in Physicke. London, 1610, fol. II.

[1411] _Obs. Med._ IV. cap. 2.

[1412] _Ibid._ IV. cap. 7.

[1413] Dr Andrew Wilson, a pupil of the Edinburgh School in the great period of the first Monro, Whytt and Rutherford, used his Newcastle experiences in 1758 and following years as the basis of two excellent essays, one on Dysentery (1761) and the other upon Autumnal Disorders of the Bowels (1765). In the latter he includes both cholera nostras and bilious colic, (as well as dry colic) as Sydenham had done, and makes the following distinction between the two forms, which “are very nearly allied in their nature”:--“The vomiting of bile in the cholera is not so early as it is in the other; neither is it so constant, nor in so large quantities. Though a purging generally attends the bilious colic, yet it does not correspond so regularly as it does in the cholera, in which there generally is a call to stool soon after every paroxysm of vomiting.... The bilious colic is not generally so quickly hazardous as the cholera is. The intervals between the sick fits are often longer, and when it is attended with danger, it does not become so so suddenly as the cholera does.” Bilious colic was not so strictly an autumnal complaint as cholera. It was not so soon relieved by medicines. It resembled cholera in the remarkable character of exciting cramps in other muscles than the abdominal.

[1414] _Pharmaceutice rationalis._

[1415] Appendix to _Essay on Smallpox_, 1740.

[1416] _Gent. Magaz._, Sept. 1751, p. 398.

[1417] _Two Papers on Fever and Infection_, 1763, p. 35.

[1418] _Med. Hist. and Reflect._ II. 220.

[1419] _Ed. Med. Surg. Journ._, 1807.

[1420] Charles Turner Thackrah, _Cholera, its character and treatment, with remarks on the identity of the Indian and English_. Leeds, 1832, p. 24.

[1421] W. Horsley, _Med. Phys. Journ._ 24 March, 1832, p. 270.

[1422] _Geogr. and Histor. Path._ Engl. transl. III. 315.

[1423] It is probable that the association of surfeit with bowel-complaint in general and at length with dysentery in particular came from the popular belief that these maladies of the autumnal season were due to repletion with fruit. That was the popular belief from an early period, which nearly all the medical writers on autumnal diarrhoea and dysentery took occasion to combat as either inadequate or erroneous.

[1424] See Vol. 1. of this History, p. 626. The following is in a letter from Charles Bertie to Viscountess Campden, London, 22 Nov. 1681: “I have safely received your choice present of four bottles, three of Plague and the other of Surfeit water, which I shall preserve against the occasion, being confident that better are not made with hands.” _Cal. Belvoir MSS._ (Hist. MSS. Com.) II. 60.

[1425] _Obs. Med._ IV. cap. 3.

[1426] _Pharmaceutice Rationalis_, lib. III. cap. 3.

[1427] _Supra_, p. 103.

[1428] Andrew Fletcher, _Two Discourses, &c._ No. 2. p. 2, 1698.

[1429] John Jones, M.D., _De Morbis Hibernorum specialim vero de Dysenteria Hibernica. Accesserunt nonnulla de Dysenteria Epidemica_. Inaug. Diss. Trin. Col. Dub. Londini, 1698, p. 12.

[1430] _Edin. Med. Essays and Obs._ I. (1733) 37, II. 30, IV. V.

[1431] James Stephen, surgeon to Gen. Whetham’s regiment, in Pringle’s collection of accounts of the “Success of the vitrum Antimonii ceratum.” _Ibid._ V. pt. 2, p. 179, 4th ed.

[1432] Professor T. Simpson, of St Andrews, Andrew Brown, of Dalkeith, John Paisley and John Gordon, of Glasgow. _Ibid._

[1433] _Gent. Magaz._, 1741, p. 705.

[1434] The “epidemic constitution” of 1743 was so markedly dysenteric after the influenza in the spring that Huxham regarded the dysentery as a sequela of the influenza.

[1435] Mark Akenside, M.D., _De Dysenteria Commentarius_, London, 1764.

[1436] George Baker, M.D., _De Catarrho et de Dysenteria Londinensi Epidemicis utrisque An._ MDCCLXII. _Libellus_, Lond., 1764.

[1437] William Watson, M.D., in _Phil. Trans._ LII. pt. 2 (1762), p. 647.

[1438] Pringle also, who was well acquainted with the dysentery of campaigns, speaks of the London epidemic as an exceptional occurrence, and as having caused few deaths.

[1439] _Med. Obs. and Inquiries_, IV. (1771), p. 153.

[1440] MS. Infirmary Book of the Foundling Hospital.

[1441] _An Essay on the Autumnal Dysentery._ By a physician (Andrew Wilson, M.D.), Lond., 1761 (Preface dated Newcastle, 25 March, 1760), pp. 1, 23.

[1442] _Trans. K. and Q. Col. Phys._ V. (1828), p. 221.

[1443] _Obs. on the History and Treatment of Dysentery and its Combinations, etc._, 2nd ed., Dublin, 1847.

[1444] _Alexandri Tralliani Medici libri duodecim._ Basil, 1556, Lib. VIII. pp. 423, 432.

[1445] Akenside, _l. c._ “Ut dysenteriam jam pro rheumatismo intestinorum habeam, et similem utriusque morbi causam et materiem esse contendimus.”

[1446] Hirsch, III. 333 (Eng. transl.): “As to the influence of an extreme diurnal range of the thermometer (cold nights after very hot days) there is almost complete agreement among the observers in those parts [tropical and subtropical] of the world.”

[1447] I have enunciated this view of the pathology of acute rheumatism more fully in the Article “Pathology” in the _Encyclopaedia Britannica_.

[1448] _Lond. Med. Journal._ Editorial note, II. 211. The parish register of Finchley shows double the average mortality in 1780, and indicates dysentery as a fatal malady. Lysons, _Environs of London_.

[1449] Moss, u. s.

[1450] Francis Geach, F.R.S., _Some Observations on the present Epidemic Dysentery_, 1781.

[1451] Dennis Ryan, M.D., “Remittent Fever of the West Indies.” _Lond. Med. Journ._ II. 253, iii. 63.

[1452] Dr Livingston to Dr Lettsom, Aberdeen, 29 June, 1789, in _Memoirs of Lettsom_, III.

[1453] Willan, _Report on the Diseases etc._, p. 42. The nearest approach to a fatality in dysentery, he says, happened in the case of a lady residing in Spa Fields, at whose window a brown owl, attracted by the solitary light, came flapping and hooting at midnight, to the great aggravation of the patient’s symptoms.

[1454] Bateman, u. s.

[1455] _Glasg. Med. Journ._ IV. (1831), pp. 5, 229.

[1456] Cheyne, _Dubl. Hosp. Reports_, III. (1822), p. 3. At Limerick, from June to September, 1821, there were 47 cases among the men of the 79th regiment.

[1457] Clarke, _Edin. Med. and Surg. Journ._ IV. 423.

[1458] A. C. Hutchinson, _Statement of the extraordinary sickness at the Penitentiary at Milbank_, Lond. 1823; P. M. Latham, M.D., _Account of the Disease lately prevalent at the General Penitentiary_. Lond. 1825.

[1459] James Wilson, _Glasgow Med. Journ._ I. (1828), p. 40.

[1460] James Wilson, _Glasgow Med. Journ._ I. 39; James Brown, _ibid._; Macfarlane, I. 99; Paterson, I. 438; Editors, IV. 1; Hume (Hamilton), IV. 14, and 229; McDerment (Ayr), IV. 19; Macnab (Callander), IV. 241.

[1461] Christison, “Notice on the Dysentery which has lately prevailed in the Edinburgh Infirmary.” _Edin. Med. Surg. Journ._ XXXI. (Jan. 1829), p. 216, and in _Life of Sir Robert Christison_, “Autobiography,” I. 376.

[1462] W. H. Gilby, M.D., “On the Dysentery which occurred in the Wakefield Lunatic Asylum in the years 1826, 1827, 1828 and 1829.” _North of Eng. Med. and Surg. Journ._ I. (1830-31), 91.

[1463] Hume, “Case of the Edinburgh New Town Epidemic.” _Glasgow Med. Journ._ IV. 229.

[1464] _Ibid._ IV. 7. The following is Buchanan’s reference to it: “The only epidemic fever belonging to the family of diseases we are here considering that occurred in Scotland during the _dysenteric_ years was that of the New Town of Edinburgh, in 1828, of which we have already spoken. As our knowledge of this fever is not derived from any source on which we can certainly rely, it is possible that we may have formed an erroneous opinion respecting it; but from all we have heard of its symptoms and mode of distribution, we are disposed to consider it as totally different in nature from the common fever of this country. The latter circumstance alone, the mode of distribution of the disease, is, we think, perfectly sufficient to demonstrate our proposition. Instead of occupying the Cowgate, the Grassmarket, and the High Street, the usual haunts of typhus, this fever had its head-quarters in Heriot Row and Great King Street; and, according to our information, it extended from the last mentioned street in the direction of the Water of Leith, and from Leith, along the shore, to Musselburgh. We do not vouch for the accuracy of these minute details, but we believe the important fact to be beyond doubt that this fever prevailed chiefly, not in the districts where typhus is invariably to be met with, but in the most fashionable parts of the New Town.”

[1465] James Black, M.D., _Edin. Med. Surg. Journ._ XLV. (1836), p. 63. “As the epidemic was ushered in and was accompanied during the half of its course with cholera, fever of a typhous character followed close in its train among the working and lower classes, and continued more or less during the first months of winter, after dysentery had totally disappeared.” The latter had not been seen again down to 1835.

[1466] J. Smith, _ibid._ XLII. (1833), p. 342.

[1467] Cleland, _Trans. Glasg. and Clydesd. Statist. Soc._ I. 1837.

[1468] Arrott, _Edin. Med. Surg. Journ._, Jan. 1839, p. 121.

[1469] Farr, in _First Report of the Registrar-General_, 1837-8, p. 103.

[1470] Baly, _Pathology and Treatment of Dysentery_. London, 1847.

[1471] Moyle, _Lond. Med. Gaz._ N. S. VII. Dec. 29, 1848, p. 1093.

[1472] Christison, “On a local Epidemic of Dysentery.” _Month. Journ. Med. Sc._ XVII. (Dec. 1853), 508.

[1473] T. S. Clouston, _Med. Times and Gaz._ 1865, I. 567.

[1474] W. H. Duncan, M.D., “On the recent Introduction of Fever into Liverpool by the crew of an Egyptian frigate.” _Trans. Epidemiol. Soc._ vol. 1. pt. 2. p. 246. (1 July, 1861).

[1475] James Boyle, surgeon to H. M. S. ‘Minden,’ _Epidemic Cholera of India_, London, 1821; W. B. Carter, _Cholera Indica vel Spasmodica_, Thesis, Glasgow, 1822; Thomas Brown, of Musselburgh, _On Cholera, more especially as it has appeared in British India_, Edin. 1824; Whitelaw Ainslie, M.D., _The Cholera Morbus of India_, Letter to the Court of Governors, H. E. I. C., Edin. 1825; A. T. Christie, M.D. (of Madras), _Obs. on the Nature and Treatment of Cholera_, Edin. 1828; Charles Searle (of Madras), _Cholera, its Nature, Cause and Treatment_, London, 1830 (dated 1st May, instigated, not by the Orenburg epidemic, but by the deaths of Sir Thomas Monro and others from cholera in Madras).

[1476] See extract in _Glas. Med. Journ._, Feb. 1831, p. 105, from _Scottish Mission. and Philan. Reg._

[1477] George Hamilton Bell, _Treatise on Cholera Asphyxia or Epidemic Cholera as it appeared in Asia and more recently in Europe_, Edin. 1831; Reginald Orton, _An Essay on the Epidemic Cholera of India_, 2nd. ed. with a supplement, London, 1831 (August); 1st ed. Madras, 1820; H. Young, M.D. (of the Bengal Service), _Remarks on the Cholera Morbus_, 2nd ed. 1831; Alex. Smith, M.D. (Calcutta), _Description of the Spasmodic Cholera_ (substance of an old report to the Army Medical Board); W. Macmichael, M.D., _Is the Cholera Spasmodica of India a Contagious Disease?_ London, 1831 (Sept.); T. J. Pettigrew, _Obs. on Cholera, comprising a description of the Epidemic Cholera of India_, London, 1831 (13 Nov.); John Austin, _Cholera Morbus, Indian and Russian Cholera_, London, 1831 (July); John Goss, late H. E. I. C. S., _Practical Remarks on the Disease called Cholera_, London, 1831 (Nov.); Whitelaw Ainslie, _Letters on the Cholera_, London, 1832 (from Edinburgh, Dec. 1831); Henry Penneck, M.D., _Nature and Treatment of the Indian Pestilence commonly called Cholera_, London, 1831 (Penzance, 24 Nov.); A. P. Wilson Philip, _Nature of Malignant Cholera_, London, 1832; _Official Reports made to Government by Drs Russell and Barry on Cholera Spasmodica observed during the Mission to Russia in 1831_, London, 1832; John V. Thompson, Dep. Insp. Gen. of Hosps. _The Pestilential Cholera unmasked_, Cork, 1832 (January).

[1478] _Op. cit._ p. 469.

[1479] _Lond. Med. Gaz._ 1831.

[1480] James Hall, “Narrative of an Epidemic English Cholera that appeared on board ships of war lying in ordinary in the River Medway during the Summer and Autumn of 1831.” _Edin. Med. Surg. Journ._, Feb. 1832, p. 295.

[1481] John Marshall, M.D., _Obs. on Cholera as it appeared at Port Glasgow in July and August, 1831. Illustrated by numerous cases._ 1831.

[1482] William Dixon, _Lond. Med. Gaz._ 4 Feb. 1832, IX. 668.

[1483] Dixon, u. s.

[1484] Kell, p. 22.

[1485] Kell, Dixon, and others; the statements about Henry’s case are contradictory.

[1486] Clanny, p. 19.

[1487] A table of the daily course of the cholera at Sunderland, which I must omit for want of space, is given in the essay by Haslewood and Morbey, _History and Medical Treatment of Cholera as it appeared in Sunderland in 1831_, London, 1832, p. 151.

[1488] Kell, however, suspected that there were many malignant cases in Monk Wearmouth after the 31st of October, which were not reported. l. c. p. 73.

[1489] Clanny says (p. 42), “At first our epidemic appeared only in certain streets or lanes, namely, the Fish Landing, Long Bank, Silver Street, High Street, Burleigh Street, Mill Hill, Sailors’ Alley, Love Lane, Wood Street, Warren Street; as also in several lanes in Bishopwearmouth, the New Town, Ayre’s Quay, and on the north side of the river in Monkwearmouth, in several of the byelanes near the river.... Generally speaking the disease fixed its residence in such places as medical men could have pointed out _à priori_.”

[1490] Besides the essay of Haslewood and Morbey, and the paper by Dixon, _supra_, the following were written on the Sunderland cholera: W. Ainsworth, _Obs. on the Pestilential Cholera at Sunderland_, London, 1832; John Butler Kell, surgeon to the 82nd Regt., _Cholera at Sunderland in 1831_, Edin. 1834; W. Reid Clanny, M.D., (chairman of the Local Board of Health), _Hyperanthraxis, or the Cholera of Sunderland_, Lond. 1832; Emile Dubuc, _Rapport sur le Cholera Morbus à Sunderland, Newcastle, etc._ Rouen, 1832.

[1491] Ainsworth, p. 164, u. s., says: “Dennis Mc Gwin, who took the disease to North Shields, came from Sunderland. The first case in South Shields was a boy from Gateshead. A pedler woman took it to Houghton, a traveller to Morpeth, and I have no doubt its arrival could similarly be traced to Durham, Haddington and Tranent, all towns on the same high road. A wanderer also perished of the disease at Doncaster; but luckily there were no other cases.”

[1492] T. M. Greenhow, M.D., _Cholera as it has recently appeared in the Towns of Newcastle and Gateshead, including Cases_, London, 1832; Thomas Mollison, M.D., _Remarks on the epidemic Disease called Cholera, as it occurred in Newcastle_, Edin. 1832. (He arrived at Newcastle from Edinburgh on the 21st Dec. and remained eleven days.)

[1493] In Greenhow, u. s.

[1494] Craigie, _Edin. Med. Surg. Journ._ XXXVII. 337.

[1495] John Douglas, M.D., “History of the Epidemic Cholera of Hawick,” in _Cholera Gazette_, no. 6, April 7, p. 234.

[1496] Chiefly from the paper by Professor George Watt, _Glas. Med. Journ._ v. 298, 384; see also Bryce, _ibid._ 262.

[1497] W. Auchincloss, M.D., “Report of the Epidemic Cholera as it appeared in the Town’s Hospital of Glasgow in February and March, 1832,” _Glas. Med. Journ._ v. 113.

[1498] James Cleland, LL.D., and James Corkindale, M.D., _Edin. Med. Surg. Journ._ XXXIX. 503.

[1499] J. Adair Lawrie, M.D., “Report of the Albion Street Cholera Hospital.” _Glas. Med. Journ._ V. 309, 416.

[1500] _Month. Journ. Med. Sc._ March, 1850, p. 302.

[1501] Wood, _Glas. Med. Journ._ VI. 1833.

[1502] Grieve, _Month. Journ. Med. Sc._ IX. 1849, p. 777.

[1503] Scott, _Edin. Med. and Surg. Journ._ XXXIX. 276. For a whole month it was confined to one suburb. All the earlier cases were without exception fatal. There were 130 cases and 65 deaths.

[1504] It is probably to Portmahomak or Inver that Howison refers in the following (_Lancet_, 10 Nov. 1832, p. 203): Cholera broke out in a small village several miles from Tain, and in a few days it carried off 41 out of a population of 120 to 140. Coffins could not be made fast enough. Many were buried in sailcloth. The people fled from their houses to the fields.

[1505] Hugh Miller, _My Schools and Schoolmasters_, Chap. XXII.

[1506] The good account by Paterson, “Observations on Cholera as it appeared at Collieston and Footdee,” _Edin. Med. and Surg. Journ._ XLIX. (1838), p. 408, shows how much panic a mortality of nine stood for.

[1507] Sir J. Y. Simpson gave to Dr Graves of Dublin a list of some places in Scotland where cholera had appeared, which contains the additional names of Helmsdale (23 July), Fort William (24 Sept.), Fort George (7 May), Islay (23 Oct.), Portpatrick (7 Aug.), Crieff (2 Oct.), and Kelso (29 Oct.).

[1508] _Dubl. Journ. Med. Sc._ III. 74.

[1509] _Times_, 1 July, 1832.

[1510] Simon McCoy, “Notes on Malignant Cholera as it appeared in Dublin,” _Dub. Journ. Med. Sc._ II. 357, and III. 1.

[1511] Compare Grimshaw’s observations on the admissions for fever to the Cork Street Hospital in the summer of 1864, _supra_, p. 298.

[1512] Wilde, _Census of Ireland 1841_. Table of Deaths, p. xxi.

[1513] _Gent. Magaz._ 1832, June, p. 555; _Annual Register_, 1832, Chronicle (June), p. 71.

[1514] Graves, _Dubl. Quart. Journ. Med. Sc._ Feb. 1849, p. 31, from information by Dr Little of Sligo.

[1515] W. Howison, M.D., of Edinburgh, _Lancet_, 10 Nov. 1832, p. 203. He was at Londonderry in August, and had probably heard the reports of the Sligo cholera there.

[1516] John Colvan, M.D., _Dubl. Journ. Med. Sc._ IV. 186. These five deaths in Armagh County in 1833 do not appear in the table.

[1517] Graves, u. s. 1849, VII. 246.

[1518] Roupell, _Croomian Lectures on Cholera_, Lond. 1833, p. 33, gives the suspicious case of a man named Webster, who sailed from Sunderland on 20 Jan. and arrived in the Thames about the 30th. “The vessel immediately obtained _pratique_; but a few days after, this man was seized with extreme pain in the epigastrium” &c. and died suddenly after symptoms in part those of cholera. Postmortem, 20 oz. of blood were found in the peritoneum, and some blood in the lower part of the bowel.

[1519] The populous parishes of the Black Country around Wolverhampton came under notice in another way in 1832 as a crucial instance in the redistribution of seats by the Reform Act.

[1520] T. Ogier Ward, “Cholera in Wolverhampton in Aug.-Oct. 1832,” _Trans. Prov. Med. and Surg. Assoc._ II. 368.

[1521] Rev. W. Leigh, _An authentic narrative of the awful visitation of Bilston by Cholera in Aug.-Sept. 1832_. Wolverhampton, 1833.

[1522] Rev. C. Girdlestone, _Seven Sermons preached during the prevalence of the Cholera in the parish of Sedgley, with a narrative of that visitation_. London, 1833.

[1523] T. Ogier Ward, u. s., p. 376.

[1524] James Collins, M.D., _Lond. Med. Gaz._ 30 June, 1832, p. 412; and report by Thompson, surgeon of the ‘Brutus,’ in the _Cholera Gazette_, s. d.

[1525] Henry Gaulter, M.D., _The Origin and Progress of the Malignant Cholera in Manchester_. London, 1833, p. 113.

[1526] The first case was of a coach-painter, who had had frequent attacks of painter’s colic. Opposite his house was a large stable dunghill in a very foetid state. On the evening of the 16th May he had eaten a heavy supper of lambs’ fry, and had been ill thereafter, the symptoms becoming those of Asiatic cholera on the night of the 18th, death ensuing at 2 p.m. 20th.

[1527] In the hamlet adjoining a cotton-mill at Hinds, near Bury, consisting of thirty cottages in a row between the mill lade and the canal, wretchedly built, without chimneys, with windows that would not open, the inmates sleeping four or five in a bed, there were 32 cases of cholera with 7 deaths, but none of these were in persons who worked in the mill. Gaulter, u. s. citing Goodlad. He cites also Flint, of Stockport, for the rarity of attacks among the mill workers in that town. See also Samuel Gaskell, “Malignant Cholera in Manchester,” _Edin. Med. and Surg. Journ._ XL. 52. The microbic theory, or, as it was then called by Sir Henry Holland and others, the “hypothesis of insect life,” was happily thought of by a working cotton-spinner in Manchester to explain the immunity of the mill-workers in 1832. Gaulter (u. s. p. 120) gives in correct English what would probably have been said in the vernacular as follows: “I’ve been thinkin’, Maister,” said a spinner to Mr Sowden, millowner, “as how th’ cholery comes o’ hinsecks that smo’ as we corn’d see ’em, an’ they corn’d live i’ factories for th’ ’eät and th’ ile. Me an’ my mates wor speakin’ o’t last neet, an’ we o’ on us thowt th’ saäm thing.” Hahnemann, cited by the _Times_, 17 July, 1831, believed that the cholera insect escaped from the eye, and fastened upon the hair, skin, clothes, &c. of other persons. The common microscopic objects uniformly found in the choleraic discharges by later observers have been vibrios, of which half-a-dozen, or perhaps a dozen, varieties have been distinguished. One of these was somewhat audaciously named the “cholera germ” or “comma bacillus of cholera” by Dr R. Koch, who went to Calcutta in 1884. All vibrios, which have a corkscrew form when in motion, are apt to assume the comma form when at rest.

[1528] _Times_, Sept. 5, 1832.

[1529] John Addington Symonds, “Progress and Causes of Cholera in Bristol, 1832.” _Trans. Prov. Med. Surg. Assoc._ III. 170.

[1530] Some cases were detailed by Edward Blackman, M.D., _Lond. Med. Gaz._ 1832, pp. 473, 546.

[1531] Thomas Shapter, M.D., _The History of the Cholera in Exeter in 1832_. London, 1849, pp. 297.

[1532] Besides the papers or books already cited, accounts were published for the following places: Warrington, by Mr Glazebrook, secretary to the Local Board of Health; Oxford, by Rev. V. Thomas; Hull, by James Alderson, M.D.; Kendal, by Thomas Proudfoot, M.D. (_Edin. Med. and Surg. J._ XXXIX. 85); various places by J. Y. Simpson, M.D. (_ibid._ XLIX. 358); Tynemouth, by E. H. Greenhow, M.D. (_Trans. Epid. Soc._ 1861); London, by Halma-Grand (_Relation_ etc. Paris, 1832), and by Gaselee and Tweedie (Lond. 1832). There are also various minor notices: for Whittlesea (_Lond. Med. Gaz._ I. 1832, p. 448), Hutton, Yorkshire (_ibid._ II. 1832, p. 316), York (_Lancet_, 13 Oct. 1832, p. 72), Cheltenham, showing how it was kept free (_ibid._ Nov. 10, p. 210), St Heliers, Jersey (_Lond. Med. Surg. J._ II. 359), Derby (_ibid._ 11. 383).

[1533] The daily mortality in Paris at the beginning of the epidemic was as follows (_Annual Register_, 1832, p. 318):

Days Cholera deaths

March 27-31 98 April 1 79 2 168 3 212 4 242 5 351 6 416 7 582 8 769 9 861 10 848 11 769 12 768 13 816 14 692 15 567 16 572

To the 16th of April the deaths were about 8700; before the end of the month the total was nearly doubled. As the whole cholera mortality of Paris in 1832 was about 19,000, April must have had much the greater part of it.

[1534] Proudfoot, _Edin. Med. and Surg. Journ._ XXXIX. 99.

[1535] Graves, who was a strong contagionist (l. c. 1848-49), cites the instances of nuns, nurses and porters at Tuam, and of medical men at Sligo.

[1536] G. D. Dermott, lecturer in Anatomy and Surgery, _Lond. Med. and Surg. Journ._ 1832, p. 274.

[1537] John Parkin, surgeon H.E.I.C.S., “Cause, Nature and Treatment of Cholera.” _Lond. Med. and Surg. Journ._ 1 Sept. 1832.

[1538] Graves, _Clinical Medicine_, 1843, p. 700: “I could bring forward the names of many medical men in Dublin whose lives, I am happy to say, were saved by the use of this remedy.”

[1539] Paterson, u. s. for the fishing village of Collieston, Aberdeenshire: “In most instances where the lancet was used at the proper period little else was required. The patient, although in an apparently hopeless state at the time of my visit, was in these instances not unfrequently in the course of twenty-four hours out of danger.”

[1540] A correspondent of the _Lond. Med. Gaz._ Sept. 1832, p. 731, dating from Warrington, proved by a statistical arrangement of 103 cases of cholera, that the saline treatment was nearly certain recovery, that the same combined with blood-letting was certain recovery, that blood-letting alone was certain death, and that opium with stimulants, and Morison’s pill, were each uniformly followed by a fatal result.

Cases Deaths Percentage of recoveries

Aged, neglected or seen too late 30 30 0 Obstinately refused medicine 4 4 0 Treated by opium and stimulants 23 23 0 " by Morison’s pill 3 3 0 " by blood-letting 13 13 0 " by blood-letting and salines 7 0 100 " by salines alone 23 2 92·3 --- -- --- 103 75 27 per cent.

[1541] _Quarterly Review_, CXVIII. 256.

[1542] Reported by Brewster to J. Y. Simpson, _Edin. Med. Surg. Journ._ XLIX. (1838), p. 368.

[1543] _Glas. Med. Journ._ VI. (1833), p. 366. Stark says, perhaps for Edinburgh, that cholera recurred in the end of 1833 and beginning of 1834, with a high degree of fatality.

[1544] Edmond Sharkey, M.B., _Dubl. J. Med. Sc._ XVI. 13. Of 28 houses or cabins (nearly all in three hamlets) which together had 76 cases, 16 cabins had each two cases, 8 had each three, 1 had four, 2 had each five, and 1 had six. The type of sickness was the same as in 1832-33.

[1545] R. Green, M.D., _Lancet_, 14 April, 1838, p. 83: true Asiatic cholera began at Youghal in the second week of December, 1837, and lasted two months, about 200 having been attacked: “two of my relatives, Miss A. ---- and Mrs K. ----, died in December of cholera, one in fourteen hours, the other in ten hours.”

[1546] Deaths from Cholera in the Coventry House of Industry:

1838.

Jan. Jan. Jan. Jan. Jan. Feb. Total 7-11 12-16 17-21 22-26 27-31 1-5

7 4 15 20 7 2 55

Twenty-seven were males and twenty-eight females. The ages were as follow:

under 1-5 5-10 10-20 20-40 40-60 60-80 80-90 Total one

1 6 4 4 3 8 20 9 55

--_Second Report of the Registrar-General_, p. 98.

[1547] Stark, _Ed. Med. and Surg. Journ._ LXXI. (1849), p. 388; W. Robertson, _Month. Journ. Med. Sc._ IX. (1849). The other outbreaks reported in that part of Scotland (_ibid._) were slight--at Dalkeith, Haddington, Borrowstowness.

[1548] Easton, _Glas. Med. Journ._ V. 444.

[1549] Sutherland, _Report of the Board of Health_.

[1550] Sutherland, _Report_, u. s.; Grieve, _Month. J. Med. Sc._ IX. 777. Barker, _ibid._ 940 (gives good account of the stormy weather).

[1551] _Month. Journ. Med. Sc._ IX. 783, 857, 1011, X. 403.

[1552] _Ibid._ IX. 1009.

[1553] Sutherland, _Report_, u. s. The year 1847, in which there was no cholera, had been much more fatal in the chief towns of Scotland, than either 1848 or 1849, owing to the great prevalence of typhus (Stark):

_Deaths from all causes._

1846 1847 1848 1849

Edinburgh 4594 6706 5475 4807 Glasgow 10854 18071 12475 12231 Dundee 1531 2520 2146 2312 Paisley 1429 2068 1552 1712 Leith 801 955 1212 1066 Greenock 1087 2214 1289 2344 Aberdeen 1315 1466 2366

[1554] H. MacCormac to Graves, _Dub. Journ. Med. Sc._ N. S. VII. 245.

[1555] Most of the information on the cholera of 1849 in England comes from two sources: (1) the _Report of the General Board of Health on the Epidemic Cholera of 1848 and 1849_ (Parl. papers, 1850), containing the detailed reports of Mr R. D. Grainger for London, and of Dr John Sutherland for various other towns; and (2) the _Quarterly Reports of the Registrar-General for the year 1849_. See also note 3, p. 846.

[1556] Sutherland, _Report_, u. s. p. 121. At Sheffield (_ibid._ p. 108) a sudden outbreak of diarrhoea occurred on 26 August over the whole town; 5319 cases of it were known, with only 76 cases of cholera and 46 deaths.

[1557] Henry Cooper, “On the Cholera Mortality in Hull during the epidemic of 1849,” _Journ. Statist. Soc._ XVI. 347. The total is higher than that in the Table.

[1558] Sutherland, _Report_, u. s., with map.

[1559] For Bristol, Sutherland (p. 126) cites Goldney: “In a certain lodging-house there were 35 attacks and 33 deaths during the epidemic of 1832.... Out of the same house in 1849, 64 people were turned, of whom 49 were sent to the House of Refuge.” Not one case of cholera occurred among these, but many attacks of diarrhoea, which was general all through the epidemic, especially along the Frome.

[1560] The epidemic in the small Devonshire fishing village of Noss Mayo near Plympton St Mary, was very fully investigated by A. C. Maclaren, _Journ. Statist. Soc._ XIII. (1850), p. 103. The Oxford epidemic (75 deaths) was described by Greenhill and Allen in the _Ashmolean Society Reports_. For Tynemouth, see Greenhow, _Trans. Epid. Soc._ The volume by Baly and Gull, _Reports on Epidemic Cholera drawn up at the desire of the Cholera Committee Roy. Col. Phys._ London, 1854, is in great part a review of the epidemic of 1849, in the form of a general discussion of the whole problem of Asiatic cholera. A subcommittee of the College also published a _Report on the nature of the microscopic bodies found in the intestinal discharges of Cholera_, London, 1849.

[1561] Farr, “Influence of elevation on the mortality of Cholera.” _Journ. Statist. Soc._ XV. (1852), p. 155, and in the Reports of the Registrar-General.

[1562] C. Barham, M.B., “Tavistock Parish Register,” _Journ. Statist. Soc._ IV. 37.

[1563] Middleton, “Sanitary Statistics of Salisbury,” _ibid._ XXVII. (1864), p. 541.

[1564] _Report of the Commissioners appointed to inquire into the late outbreak of Cholera in Newcastle, Gateshead and Tynemouth._ Parl. papers, 1854, pp. xl and 580.

[1565] The most elaborate and minute account of an epidemic on this occasion was that for Oxford, _Memoir on the Cholera at Oxford in the year 1854_. By H. W. Acland, M.D., in which all the points in the problem of cholera are illustrated from the easily surveyed local circumstances.

[1566] The registration district of Bideford had 46 deaths in 1854, the only large total in the West country. Kingsley’s graphic picture of the cholera of 1854 in _Two Years Ago_ may have corresponded to these naked figures in the registration tables; but no place in Cornwall, in which county the scene appears to be laid, could have furnished so considerable an epidemic as the novelist describes, a few places in it having had each some half-dozen deaths.

[1567] More than half in the end of 1853.

[1568] Nearly all in the end of 1853.

[1569] It was reported on by three commissioners, Dr Donald Fraser and Messrs Thomas Hughes and J. M. Ludlow, in the _Report of the Committee for Scientific Inquiries, Cholera Epidemic of 1854_. Appendix.

[1570] John Snow, M.D., _On the mode of communication of Cholera_. London, 1849, 2nd ed. 1855.

[1571] _General Board of Health, Report on Scientific Inquiries_, 1854, p. 52.

[1572] J. W. Begbie, _Ed. Med. and Surg. Journ._ April, 1855, p. 250.

[1573] _Glas. Med. Journ._ N. S. II. 127; III. 116, 500; John Crawford, M.D., “Report of Cases in the Cholera Hosp.” _ibid._ III. 48.

[1574] W. Alexander, M.D., _Edin. Med. Journ._ II. 86. The _Edin. Med. Journ._ I. July, 1855, p. 81, contains a few lines of abstract of a paper by W. T. Gairdner on the diffusion of cholera in the remote districts of Scotland. Information on the subject is invited, but it does not appear that any full account of the cholera of 1854 in Scotland was published. It is known to have been in Aberdeen.

[1575] _Census of Ireland 1861_, Part III. vol. 2, p. 23.

[1576] Compiled from Grainger’s report for 1849, the Registrar-General’s Reports for 1854 and 1866, a table in _Lancet_, I. 1867, p. 125, and, for 1866, a table by Radcliffe, in _Rep. Med. Off. Priv. Council for 1866_, p. 339.

[1577] Radcliffe, _Rep. Med. Off. Privy Council for 1866_, p. 294.

[1578] Scoutetten, _Histoire médicale et topographique du Cholera Morbus_, Metz, 1831; and _Histoire chronologique du Cholera_, Paris, 1870. David Craigie, M.D., “Remarks on the History and Etiology of Cholera,” _Edin. Med. and Surg. Journ._ XXXIX. (1833), 332. John Macpherson, M.D., _Annals of Cholera_, London, 1872 and 1884. N. C. Macnamara, _A History of Asiatic Cholera_, London, 1876.

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Transcriber's note:

Footnote 427 appears on page 233 of the text, but there is no corresponding marker on the page.

Footnote marker 562 appears on page 312 of the text, but there is no corresponding footnote on the page.