VOLUME II (OF 2)***


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A HISTORY OF EPIDEMICS IN BRITAIN.

London: C. J. Clay and Sons,
Cambridge University Press Warehouse,
Ave Maria Lane.
and
H. K. Lewis,
136, Gower Street, W.C.

Cambridge: Deighton, Bell and Co.
Leipzig: F. A. Brockhaus.
New York: Macmillan and Co.


A HISTORY OF EPIDEMICS IN BRITAIN.

by

CHARLES CREIGHTON, M.A., M.D.,

Formerly Demonstrator of Anatomy in the University of Cambridge.

VOLUME II.

From the Extinction of Plague to the present time.







Cambridge:
At the University Press.
1894

[All Rights reserved.]

Cambridge:
Printed by C. J. Clay, M.A. and Sons,
At the University Press.




PREFACE.


This volume is the continuation of 'A History of Epidemics in Britain from
A.D. 664 to the Extinction of Plague' (which was published three years
ago), and is the completion of the history to the present time. The two
volumes may be referred to conveniently as the first and second of a
'History of Epidemics in Britain.' In adhering to the plan of a systematic
history instead of annals I have encountered more difficulties in the
second volume than in the first. In the earlier period the predominant
infection was Plague, which was not only of so uniform a type as to give
no trouble, in the nosological sense, but was often so dramatic in its
occasions and so enormous in its effects as to make a fitting historical
theme. With its disappearance after 1666, the field is seen after a time
to be occupied by a numerous brood of fevers, anginas and other
infections, which are not always easy to identify according to modern
definitions, and were recorded by writers of the time, for example
Wintringham, in so dry or abstract a manner and with so little of human
interest as to make but tedious reading in an almost obsolete phraseology.
Descriptions of the fevers of those times, under the various names of
_synochus_, _synocha_, nervous, putrid, miliary, remittent, comatose, and
the like, have been introduced into the chapter on Continued Fevers so as
to show their generic as well as their differential character; but a not
less important purpose of the chapter has been to illustrate the condition
of the working classes, the unwholesomeness of towns, London in
particular, the state of the gaols and of the navy, the seasons of dearth,
the times of war-prices or of depressed trade, and all other vicissitudes
of well-being, of which the amount of Typhus and Relapsing Fever has
always been a curiously correct index. It is in this chapter that the
epidemiology comes into closest contact with social and economic history.
In the special chapter for Ireland the association is so close, and so
uniform over a long period, that the history may seem at times to lose its
distinctively medical character.

As the two first chapters are pervaded by social and economic history, so
each of the others will be found to have one or more points of distinctive
interest besides the strictly professional. Smallpox is perhaps the most
suitable of all the subjects in this volume to be exhibited in a
continuous view, from the epidemics of it in London in the first Stuart
reigns to the statistics of last year. While it shares with Plague the
merit, from a historical point of view, of being always the same definite
item in the bills of mortality, it can be shown to have experienced, in
the course of two centuries and a half, changes in its incidence upon the
classes in the community, upon the several age-periods and upon town and
country, as well as a very marked change relatively to measles and
scarlatina among the infective scourges of infancy and childhood. For
certain reasons Smallpox has been the most favoured infectious disease,
having claimed an altogether disproportionate share of interest at one
time with Inoculation, at another time with Vaccination. The history of
the former practice, which is the precedent for, or source of, a whole new
ambitious scheme of prophylaxis in the infectious diseases of men and
brutes, has been given minutely. The latter practice, which is a radical
innovation inasmuch as it affects to prevent one disease by the
inoculation of another, has been assigned as much space in the chapter on
Smallpox as it seems to me to deserve. Measles and Whooping-cough are
historically interesting, in that they seem to have become relatively more
prominent among the infantile causes of death in proportion as the public
health has improved. Whooping-cough is now left to head the list of its
class by the shrinkage of the others. It is in the statistics of Measles
and Whooping-cough that the principle of population comes most into view.
The scientific interest of Scarlatina and Diphtheria is mainly that of
new, or at least very intermittent, species. Towards the middle of the
18th century there emerges an epidemic sickness new to that age, in which
were probably contained the two modern types of Scarlet Fever and
Diphtheria more or less clearly differentiated. The subsequent history of
each has been remarkable: for a whole generation Scarlatina could prove
itself a mild infection causing relatively few deaths, to become in the
generation next following the greatest scourge of childhood; for two whole
generations Diphtheria had disappeared from the observation of all but a
few medical men, to emerge suddenly in its modern form about the years
1856-59.

The history of Dysentery, as told by the younger Heberden, has been a
favourite instance of the steady decrease of a disease in London during
the 18th century. I have shown the error in this, and at the same time
have proved from the London bills of mortality of the 17th and 18th
centuries that Infantile Diarrhoea, which is now one of the most important
causes of death in some of the great manufacturing and shipping towns, was
formerly still more deadly to the infancy of the capital in a hot summer
or autumn. Asiatic Cholera brings us back, at the end of the history, to
the same great problem which the Black Death of the 14th century raised
near the beginning of it, namely, the importation of the seeds of
pestilence from some remote country, and their dependence for vitality or
effectiveness in the new soil upon certain favouring conditions, which
sanitary science has now happily in its power to withhold. I have left
Influenza to be mentioned last. Its place is indeed unique among epidemic
diseases; it is the oldest and most obdurate of all the problems in
epidemiology. The only piece of speculation in this volume will be found
in the five-and-twenty pages which follow the narrative of the various
historical Influenzas; it is purely tentative, exhibiting rather the
_disjecta membra_ of a theory than a compact and finished hypothesis. If
there is any new light thrown upon the subject, or new point of view
opened, it is in bringing forward in the same context the strangely
neglected history of Epidemic Agues.

Other subjects than those which occupy the nine chapters of this volume
might have been brought into a history of epidemics, such as Mumps,
Chickenpox and German Measles, Sibbens and Button Scurvy, together with
certain ordinary maladies which become epidemical at times, such as
Pneumonia, Erysipelas, Quinsy, Jaundice, Boils and some skin-diseases.
While none of these are without pathological interest, they do not lend
themselves readily to the plan of this book; they could hardly have been
included except in an appendix of _miscellanea curiosa_, and I have
preferred to leave them out altogether. It has been found necessary, also,
to discontinue the history of Yellow Fever in the West Indian and North
American colonies, which was begun in the former volume.

I have, unfortunately for my own labour, very few acknowledgements to make
of help from the writings of earlier workers in the same field. My chief
obligation is to the late Dr Murchison's historical introduction to his
'Continued Fevers of Great Britain.' I ought also to mention Dr Robert
Willan's summary of the throat-distempers of the 18th century, in his
'Cutaneous Diseases' of 1808, and the miscellaneous extracts relating to
Irish epidemics which are appended in a chronological table to Sir W. R.
Wilde's report as Census Commissioner for Ireland. For the more recent
history, much use has naturally been made of the medical reports compiled
for the public service, especially the statistical.

_September, 1894._




CONTENTS.


                                                                    PAGE

  CHAPTER I.

  TYPHUS AND OTHER CONTINUED FEVERS.

  The Epidemic Fever of 1661, according to Willis                      4

  Sydenham's epidemic Constitutions                                    9

  Typhus Fever perennial in London                                    13

  The Epidemic Constitutions following the Great Plague               17

  The Epidemic Fever of 1685-86                                       22

  Retrospect of the great Fever of 1623-25                            30

  The extinction of Plague in Britain                                 34

  Fevers to the end of the 17th Century                               43

  Fevers of the seven ill years in Scotland                           47

  The London Fever of 1709-10                                         54

  Prosperity of Britain, 1715-65                                      60

  The Epidemic Fevers of 1718-19                                      63

  The Epidemic Fevers of 1726-29: evidence of Relapsing Fever         66

  The Epidemic Fever of 1741-42                                       78

  Sanitary Condition of London under George II.                       84

  The Window-Tax                                                      88

  Gaol-Fever                                                          90

  Circumstances of severe and mild Typhus                             98

  Ship-Fever                                                         102

  Fever and Dysentery of Campaigns: War Typhus, 1742-63              107

  Ship-Fever in the Seven Years' War and American War                111

  The "Putrid Constitution" of Fevers in the middle third of the
  18th Century                                                       120

  Miliary Fever                                                      128

  Typhus Fever in London, 1770-1800                                  133

  Typhus in Liverpool, Newcastle and Chester in the last quarter
  of the 18th century                                                140

  Fever in the Northern Manufacturing Towns, 1770-1800               144

  Typhus in England and Scotland generally, in the end of the
  18th century                                                       151

  Fevers in the Dearth of 1799-1802                                  159

  Comparative immunity from Fevers during the War and high
  prices of 1803-15                                                  162

  The Distress and Epidemic Fever (Relapsing) following the Peace
  of 1815 and the fall of wages                                      167

  The Epidemic of 1817-19 in Scotland: Relapsing Fever               174

  The Relapsing Fever of 1827-28                                     181

  Typhoid or Enteric Fever in London, 1826                           183

  Return of Spotted Typhus after 1831: "Change of Type." Distress
  of the Working Class                                               188

  Enteric Fever mixed with the prevailing Typhus, 1831-42            198

  Relapsing Fever in Scotland, 1842-44                               203

  The "Irish Fever" of 1847 in England and Scotland                  205

  Subsequent Epidemics of Typhus and Relapsing Fevers                208

  Relative prevalence of Typhus and Enteric Fevers since 1869        211

  Circumstances of Enteric Fever                                     216


  CHAPTER II.

  FEVER AND DYSENTERY IN IRELAND.

  Dysentery and Fever at Londonderry and Dundalk, 1689               229

  A generation of Fevers in Cork                                     234

  Famine and Fevers in Ireland in 1718 and 1728                      236

  The Famine and Fever of 1740-41                                    240

  The Epidemic Fevers of 1799-1801                                   248

  The Growth of Population in Ireland                                250

  The Famine and Fevers of 1817-18                                   256

  Famine and Fever in the West of Ireland, 1821-22                   268

  Dysentery and Relapsing Fever, 1826-27                             271

  Perennial Distress and Fever                                       274

  The Great Famine and Epidemic Sicknesses of 1846-49                279

  Decrease of Typhus and Dysentery after 1849                        295


  CHAPTER III.

  INFLUENZAS AND EPIDEMIC AGUES.

  Retrospect of Influenzas and Epidemic Agues in the 16th and
  17th centuries                                                     306

  The Ague-Curers of the 17th Century                                315

  The Peruvian Bark Controversy                                      320

  The Influenza of 1675                                              326

  The Influenza of 1679                                              328

  The Epidemic Agues of 1678-80                                      329

  The Influenza of 1688                                              335

  The Influenza of 1693                                              337

  The Influenza of 1712                                              339

  Epidemic Agues and Influenzas, 1727-29                             341

  The Influenza of 1733                                              346

  The Influenza of 1737                                              348

  The Influenza of 1743                                              349

  Some Localized Influenzas and Horse-colds                          352

  The Influenza of 1762                                              356

  The Influenza of 1767                                              358

  The Influenza of 1775                                              359

  The Influenza of 1782                                              362

  The Epidemic Agues of 1780-85                                      366

  The Influenza of 1788                                              370

  The Influenza of 1803                                              374

  The Influenza of 1831                                              379

  The Influenza of 1833                                              380

  The Influenza of 1837                                              383

  The Influenza of 1847-48                                           389

  The Influenzas of 1889-94                                          393

  The Theory of Influenza                                            398

  Influenza at Sea                                                   425

  The Influenzas of Remote Islands                                   431


  CHAPTER IV.

  SMALLPOX.

  Retrospect of earlier epidemics                                    434

  Smallpox after the Restoration                                     437

  Sydenham's Practice in Smallpox                                    445

  Causes of Mild or Severe Smallpox                                  450

  Pockmarked Faces in the 17th Century                               453

  The Epidemiology continued to the end of the 17th century          456

  Smallpox in London in 1694: the death of the Queen                 458

  Circumstances of the great Epidemic in 1710                        461

  Inoculation brought into England                                   463

  The popular Origins of Inoculation                                 471

  Results of the first Inoculations; the Controversy in England      477

  Revival of Inoculation in 1740: a New Method                       489

  The Suttonian Inoculation                                          495

  Extent of Inoculation in Britain to the end of the 18th Century    504

  The Epidemiology continued from 1721                               517

  Smallpox in London in the middle of the 18th century               529

  The Epidemiology continued to the end of the 18th century          535

  The range of severity in Smallpox, and its circumstances           544

  Cowpox                                                             557

  Chronology of epidemics resumed from 1801                          567

  The Smallpox Epidemic of 1817-19                                   571

  Extent of Inoculation with Cowpox or Smallpox, 1801-1825           582

  The Smallpox Epidemic of 1825-26                                   593

  A generation of Smallpox in Glasgow                                597

  Smallpox in Ireland, 1830-40                                       601

  The Epidemic of 1837-40 in England                                 604

  Legislation for Smallpox after the Epidemic of 1837-40             606

  Other effects of the epidemic of 1837-40 on medical opinion        610

  The age-incidence of Smallpox in various periods of history        622


  CHAPTER V.

  MEASLES.

  Derivation and early uses of the name                              632

  Sydenham's description of Measles in London, 1670 and 1674         635

  Measles in the 18th century                                        641

  Increasing mortality from Measles at the end of the 18th century   647

  Measles in Glasgow in 1808 and 1811-12: Researches of Watt         652

  Measles in the Period of Statistics                                660


  CHAPTER VI.

  WHOOPING-COUGH.

  Earliest references to whooping-cough                              666

  Whooping-cough in Modern Times                                     671

  Whooping-cough as a Sequel of other Maladies                       674


  CHAPTER VII.

  SCARLATINA AND DIPHTHERIA.

  Nosological difficulties in the earlier history                    678

  The Throat-distemper of New England, 1735-36                       685

  Angina maligna in England from 1739                                691

  An epidemic of Throat-disease in Ireland, 1743                     693

  Malignant Sore-throat in Cornwall, 1748                            694

  Fothergill's Sore-throat with Ulcers, 1746-48                      696

  "Scarlet Fever" at St Albans, 1748                                 698

  Epidemics of Sore-throat with Scarlet rash in the period between
  Fothergill and Withering                                           699

  Scarlatina anginosa in its modern form, 1777-78                    708

  History of Scarlatina after the Epidemic of 1778                   713

  Scarlatina (1788) and Diphtheria (1793-94) described by the
  same observer                                                      715

  Scarlatinal Epidemics, 1796-1805                                   719

  Scarlatina since the beginning of Registration, 1837               726

  Reappearance of Diphtheria in 1856-59                              736

  Conditions favouring Diphtheria                                    744


  CHAPTER VIII.

  INFANTILE DIARRHOEA, CHOLERA NOSTRAS, AND DYSENTERY.

  Summer Diarrhoea of Infants in London, 17th century                748

  Summer Diarrhoea of Infants, 18th century                          754

  Modern Statistics of Infantile Diarrhoea                           758

  Causes of the high Death-rates from Infantile Diarrhoea            763

  Cholera Nostras                                                    768

  Dysentery in the 17th and 18th centuries                           774

  Dysentery in the 19th century                                      785


  CHAPTER IX.

  ASIATIC CHOLERA.

  Asiatic Cholera at Sunderland in October, 1831                     796

  Extension of Cholera to the Tyne, December, 1831                   802

  The Cholera of 1832 in Scotland                                    805

  The Cholera of 1832 in Ireland                                     816

  The Cholera of 1832 in England                                     820

  The Cholera of 1848-49 in Scotland                                 835

  The Cholera of 1849 Ireland                                        839

  The Cholera of 1849 in England                                     840

  The Cholera of 1853 at Newcastle and Gateshead                     849

  The Cholera of 1854 in England                                     851

  The Cholera of 1853-54 in Scotland and Ireland                     855

  The Cholera of 1865-66                                             856

  The Antecedents of Epidemic Cholera in India                       860

  Note on Cerebro-Spinal Fever                                       863




CHAPTER I.

TYPHUS AND OTHER CONTINUED FEVERS.


It was remarked by Dr James Lind, in 1761, that a judicious synopsis of
the writings on fevers, in a chronological sense, would be a valuable
book: it would bring to light, he was fain to expect, treasures of
knowledge; "and perhaps the influence of a favourite opinion, or of a
preconceived fancy, on the writings of some even of our best instructors,
such as Sydenham and Morton, would more clearly be perceived[1]." Lind
himself was the person to have delivered such a history and criticism. He
was near enough to the 17th century writers on fevers to have entered
correctly into their points of view; while so far as concerned the
detection of theoretical bias or preconceived fancies, he had shown
himself a master of the art in his famous satire upon the "scorbutic
constitution," a verbal or mythical construction which had been in great
vogue for a century and a half, and was still current, at the moment when
Lind destroyed it, in the writings of Boerhaave and Haller. A judicious
historical view of the English writings on fevers, such as this 18th
century critic desired to see, may now be thought superfluous. The
theories, the indications for treatment, the medical terms, have passed
away and become the mere objects of a learned curiosity. But the actual
history of the old fevers, of their kinds, their epidemic prevalence,
their incidence upon rich or poor, upon children or adults, their
fatality, their contagiousness, their connexion with the seasons and other
vicissitudes of the people--all this is something more than curious.

Unfortunately for the historian of diseases, he has to look for the
realities amidst the "favourite opinions" or the "preconceived fancies" of
contemporary medical writers. Statements which at first sight appear to be
observations of matters of fact are found to be merely the necessary
truths or verbal constructions of some doctrine. One great doctrine of the
17th and 18th centuries was that of obstructions: in this doctrine, as
applied to fevers, obstructions of the mesentery were made of central
importance; the obstructions of the mesentery extended to its lymphatic
glands; so that we come at length, in a mere theoretical inference, to
something not unlike the real morbid anatomy of enteric fever. Another
great doctrine of the time, specially applied by Willis to fevers, was
that of fermentations and acrimonies. "This ferment," says a Lyons
disciple of Willis in 1682, "has its seat in the glandules of the velvet
coat of the stomach and intestines described by Monsieur Payer[2]." But
the Lyons physician is writing all the while of the fevers that have
always been common in the Dombes and Bresse, namely intermittents; the
tertian, double tertian, quotidian, quartan, or double quartan paroxysm
arises, he says, from the coagulation of the humours by the ferment which
has its seat in the glandules described by M. Payer, even as acids cause a
coagulation in milk, the paroxysm of ague continuing, "until this sharp
chyle be dissipated and driven out by the sweat or insensible
perspiration." The lymphatic follicles of the intestine known by the name
of Payer, or Peyer, were then the latest anatomical and physiological
novelty, and were chosen, on theoretical grounds, as the seat of
fermentation or febrile action in agues. On the ground of actual
observation they were found about a century and a half after to be the
seat of morbid action in typhoid fever.

While there are such pitfalls for the historian in identifying the several
species of fevers in former times, there are other difficulties of
interpretation which concern the varieties of a continued fever, or its
changes of type from generation to generation. Is change of type a reality
or a fiction? And, if a reality, did it depend at all upon the use or
abuse of a certain regimen or treatment, such as blooding and lowering, or
heating and corroborating? A pupil of Cullen, who wrote his thesis in
1782 upon the interesting topic of the change in fevers since the time of
Sydenham[3], inferred that the great physician of the Restoration could
not have had to treat the low, putrid or nervous fevers of the middle and
latter part of the 18th century, otherwise he would not have resorted so
regularly to blood-letting, a practice which was out of vogue in continued
fevers at the time when the thesis was written, as well as for a good many
years before and after. Fevers, it was argued, had undergone a radical
change since the time of Sydenham, in correspondence with many changes in
diet, beverages and creature comforts, such as the greatly increased use
of tea, coffee and tobacco, and of potatoes or other vegetables in the
diet, changes also in the proportion of urban to rural population, in the
use of carriages, and in many other things incident to the progressive
softening of manners. In due time the low, putrid, nervous type of typhus
fever, which is so much in evidence in the second half of the 18th
century, ceased to be recorded, an inflammatory type, or a fever of strong
reaction, taking its place; so that Bateman, of London, writing in 1818,
said: "The putrid pestilential fevers of the preceding age have been
succeeded by the milder forms of infectious fever which we now witness";
while Armstrong, Clutterbuck, and others, who had revived the practice of
blood-letting in fevers shortly before the epidemic of 1817-18, claimed
the comparatively slight fatality and short duration of the common fever
of the time as an effect of the treatment. After 1831, typhus again became
low, depressed, spotted, not admitting of the lancet; on which occasion
the doctrine of "change of type" was debated in the form that the older
generation of practitioners still remember.

Thus the task of the historian, whose first duty is to ascertain, if he
can, the actual matters of fact, or the realities, in their sequence or
chronological order, is made especially difficult, in the chapter on
continued fevers, by the contemporary influence of theoretical pathology
or "a preconceived fancy," by the ascription of modifying effects to
treatment, whether cooling or heating, lowering or supporting, and, most
of all, by the absence of that more exact method which distinguishes the
records of fever in our own time. Nor can it be said that the work of
historical research has been made easier in all respects, by the exact
discrimination and perfected diagnosis to which we are accustomed in
present-day fevers. In the years between 1840 and 1850, the three grand
types of fever then existing in Britain, namely, spotted typhus, enteric,
and relapsing fever, were at length so clearly distinguished, defined and
described that no one remained in doubt or confusion. Thereupon arose the
presumption that these had always been the forms of continued fever in
Britain, and that the same fevers, presumably in the same relative
proportions to each other, might have been left on record by the
physicians of former generations, if they had used the modern exactness
and minuteness in observing both clinical history and anatomical state,
which were seen at their best in Sir William Jenner. It would simplify
history, indeed it would make history superfluous, if that were really the
case. There are many reasons for believing that it was not the case. As
Sydenham looked forward to his successors having experiences that he never
had, so we may credit Sydenham with having really seen things which we
never see, not even those of us who saw the last epidemics of relapsing
fever and typhus. It is due to him, and to his contemporaries and nearest
successors, to reciprocate the spirit in which he concludes the general
chapter on epidemics prefatory to his annual constitutions from 1661 to
1676:

    "I am far from taking upon myself the credit of exhausting my subject
    in the present observations. It is highly probable that I may fail
    even in the full enumeration of the epidemics. Still less do I warrant
    that the diseases which during the years in question have succeeded
    each other in the sequence about to be exhibited shall remain the same
    in all future years. One thing most especially do I aim at. It is my
    wish to state how things have gone lately; how they have been in this
    country, and how they have been in this the city which we live in. The
    observations of some years form my ground-work. It is thus that I
    would add my mite, such as it is, towards the foundation of a work
    that, in my humble judgment, shall be beneficial to the human race.
    Posterity will complete it, since to them it shall be given to take
    the full view of the whole cycle of epidemics in their mutual
    sequences for years yet to come[4]."


The epidemic fever of 1661, according to Willis.

On the very threshold of the period at which the history is resumed in
this volume, we find a minute account by Willis of an epidemic in the year
1661, which at once raises the question whether a certain species of
infectious fever did really exist at that time which exists no longer, or
whether Willis described as "a fever of the brain and nervous stock" what
we now call enteric fever. Willis's fever corresponds in every respect to
the worm fever, the comatose fever, the remittent fever of children, the
acute fever with dumbness, the convulsive fever, which was often recorded
by the medical annalists and other systematic observers as late as the
beginning of the 19th century[5]. It ceased at length to be recorded or
described, and it has been supposed that it was really the infantile or
children's part of enteric fever, which had occurred in former times as
now[6]. The epidemic fever which Willis saw in the summer of 1661, after a
clear interval of two years from the great epidemics of agues, with
influenzas, in 1657-59, is called by him "a certain irregular and
unaccustomed fever[7]." It was not, however, new to him altogether; for he
had seen the same type, and kept notes of the cases, in a particular
household at Oxford in 1655, as well as on other occasions. It was an
epidemical fever "chiefly infestous to the brain and nervous stock." It
raged mostly among children and youths, and was wont to affect them with a
long and, as it were, a chronical sickness. When it attacked the old or
middle-aged, which was more rarely, it did sooner and more certainly kill.
It ran through whole families, not only in Oxford and the neighbouring
parts, "but in the countries at a great distance, as I heard from
physicians dwelling in other places." Among those other witnesses, we
shall call Sydenham; but meanwhile let us hear Willis, whose account is
the fullest and least warped by theory.

    Its approach was insidious and scarce perceived, with no immoderate
    heat or sharp thirst, but producing at length great debility and
    languishing, loss of appetite and loathing. Within eight days there
    were brain symptoms--heavy vertigo, tingling of the ears, often great
    tumult and perturbation of the brain. Instead of phrensy, there might
    be deep stupidity or insensibility; children lay sometimes a whole
    month without taking any notice of the bystanders, and with an
    involuntary flux of their excrements; or there might be frequent
    delirium, and constantly absurd and incongruous chimaeras in their
    sleep. But in men a fury, and often-times deadly phrensy, did succeed.
    If, however, neither stupidity nor great distraction did fall upon
    them, swimmings in the head, convulsive movements, with convulsions of
    the members and leaping up of the tendons did grievously infest them.
    In almost all, there were loose and stinking motions, now yellow, now
    thin and serous; vomiting was unusual; the urine deep red. The
    sufferers in this prolonged sickness wasted to a skeleton, with no
    great heat or evacuations to account for the wasting. Some, at the end
    of the disease, had a severe catarrh. In others, with little infection
    of the head, soon after the beginning of the fever a cruel cough and a
    stinking spittle, with a consumptive disposition, grew upon them, and
    seemed to throw them suddenly into a phthisis, from which, however,
    they recovered often beyond hope. In some there were swellings of the
    glands near the hinder part of the neck, which ripened and broke, and
    gave out a thin stinking ictor for a long time. "I have also seen
    watery pustules excited in other parts of the body, which passed into
    hollow ulcers, and hardly curable. Sometimes little spots and
    _petechiales_ appeared here and there." But none of the spots were
    broad and livid, nor were there many malignant spots.

    Willis then gives several cases clinically, in his usual manner. The
    first is of a strong and lively young man, who was sick above two
    months and seemed near death, but began to mend and took six weeks to
    recover, sweating every night or every other night of his convalescent
    period. The second case, aged twelve, was restored to health in a
    month. Numbers three and four were children of a nobleman, who both
    died, the convulsive type being strongly marked; one of the two was
    examined after death, and found to have several sections of the small
    intestine telescoped, but all the abdominal viscera free from
    disease[8], the lungs engorged, the vessels of the brain full, much
    water in the sub-arachnoid space, and more than half a pint in the
    lateral ventricles.

    In farther illustration of this type of fever, epidemic in 1661,
    Willis goes back to his notes of a sporadic outbreak of what he thinks
    was the same disease in a certain family at Oxford in the winter of
    1653-4[9]: "yea I remember that sometime past very many laboured with
    such a fever." In the family in question, five children took the fever
    one after another during a space of four months, two of the cases
    proving fatal; the domestics also took it, and some strangers who came
    in to help them, "the evil being propagated by contagion." The cases
    in the children are fully recorded[10], the following being some of
    the symptoms:

    In case 1, aged seven, the illness began at the end of December, 1653
    (or 1655): there were contractions of the wrist tendons, red spots
    like fleabites on his neck and other parts, drowsiness, and
    involuntary passage of the excrements. At the end of a fortnight, a
    flux set in and lasted for four days; next, after that, a whitish
    crust or scurf, as it were chalky, began to spread over the whole
    cavity of his mouth and throat, which being often in a day wiped away,
    presently broke forth anew. He mended a little, but had paralysis of
    his throat and pharynx, was reduced to a living skeleton, but at
    length got well.

    Case 2, a brother, aged nine, had frequent loose and highly putrid
    motions on the eleventh day; and next day, the flux having ceased, the
    most severe colic, so that he lay crying out day and night, his belly
    swollen and hard as a drum, until, on the 24th day, he died in an
    agony of convulsions.

    Case 3, a brother, aged 11, was taken with similar symptoms on the
    13th February, and died on the 13th day.

    Case 4, a sister, was taken ill in March, with less marked symptoms,
    and recovered slowly, having had no manifest crisis.

    Case 5, a boy of the same family, and the youngest, fell ill about the
    same time as No. 4, and after the like manner, "who yet, a looseness
    arising naturally of itself, for many days voiding choleric and
    greenish stuff, was easily cured."

    Then comes a general reference to the domestics and visitors, who fell
    sick of the same and all recovered.

The prolonged series of cases in the household of this "venerable man"
appears to have made a great impression upon Willis, as something new in
his experience, as well as in the experience of several other physicians
who gave their services. That it was malignant he considers proved "ex
contagio, pernicie, macularum pulicularum apparentia, multisque aliis
indiciis." He adds that he had seen the same disease sporadically at other
times; and again "I remember that formerly several laboured under such a
fever." Those cases were all previous to the general prevalence of the
fever which he identifies with them in the summer of 1661, under the name
of a "fever of the brain and spinal cord."

The signs given by Willis are as nearly as may be the signs of infantile
remittent fever, or worm fever, or febris synochus puerorum, or hectica
infantilis, or febris lenta infantum, or an acute fever with dumbness, of
which perhaps the first systematic account in this country was given by Dr
William Butter of Lower Grosvenor Street, in 1782[11]. It is, he says,
both a sporadical and an epidemical disease, "and when epidemical it is
also contagious." The age for it is from birth up to puberty; but "similar
symptoms are often observed in the disorders of adults." Morton, writing
in 1692-94, clearly points to the same fever under the name of worm fever
(febris verminosa). He adds it at the very end of his scheme of fevers, as
if in an appendix, having been unable to find a place for it in any of his
categories owing to its varying forms--hectic, acute, intermittent,
continued, [Greek: syneches], inflammatory, but for the most part
colliquative or [Greek: synochos], "and malignant according to the varying
degrees of the venomous miasm causing it[12]." Butter also recognizes its
varying types: it has many symptoms, but they seldom all occur in the same
case; there are three main varieties--the acute, lasting from eight to ten
days up to two or three weeks; the slow, lasting two or three months; and
the low, lasting a month or six weeks. The slow form, he says, is only
sporadic; the low is only epidemic, and is never seen but when the acute
is also epidemical; it is rare in comparison with the latter, and not
observed at all except in certain of the epidemical seasons. Waiving the
question whether the remittent fever of children, thus systematically
described, was not a composite group of maladies, of which enteric fever
of children was one, we can hardly doubt that Willis found a distinctive
uniform type in the epidemic of 1661, in Oxford as he saw it himself, in
other parts of England by report. It had symptoms which were not quite
clearly those of enteric fever: spots, like fleabites, on the neck and
other parts, swelling and suppuration of the glands in the hinder part of
the neck, effusion of fluid on the brain and in the lateral ventricles,
and the intestine free from disease[13].

Confirming Willis's account for Oxford, is the case of Roger North, when a
boy at Bury St Edmunds Free School in 1661, as related by himself in his
'Autobiography[14].' Being then "very young and small," after a year at
school he had "an acute fever, which endangered a consumption." Elsewhere
he attributes his bad memory with "confusion and disorder of thought," to
that "cruel fit of sickness I had when young, wherein, I am told, life was
despaired of, and it was thought part of me was dead; and I can recollect
that warm cloths were applied, which could be for no other reason, because
I had not gripes which commonly calls for that application." That "great
violence of nature," while it had impaired his mental faculties, had
sapped his bodily vigour somewhat also, of which he gives a singular
illustration.

This special prevalence of epidemic fevers in the summer and autumn of
1661 is noticed also by the London diarists.

Evelyn says that the autumn of 1661 was exceedingly sickly and wet[15].
Pepys has several entries of fever[16]. On 2 July, 1661: "Mr Saml. Crewe
died of the spotted fever." On 16 August: "At the [Navy] Office all the
morning, though little to do; because all our clerks are gone to the
burial of Tom Whitton, one of our Controller's clerks, a very ingenious
and a likely young man to live as any in the office. But it is such a
sickly time both in the city and country everywhere (of a sort of fever)
that never was heard of almost, unless it was in a plague-time. Among
others the famous Tom Fuller [of the 'Worthies of England'] is dead of it;
and Dr Nichols [Nicholas], Dean of St Paul's; and my Lord General Monk is
very dangerously ill." On 31 August: "The season very sickly everywhere of
strange and fatal fevers." On 15 January, 1662: "Hitherto summer weather,
both as to warmth and every other thing, just as if it were the middle of
May or June, which do threaten a plague (as all men think) to follow; for
so it was almost the last winter, and the whole year after hath been a
very sickly time to this day."

The great medical authority of the time is Sydenham. His accounts of the
seasons and reigning diseases of London extend from 1661 to 1686, so that
they begin with the year for which Willis described the epidemic fever
"chiefly infestous to the brain and nervous stock," popularly called the
new disease. But Sydenham did not describe the epidemic in the same
objective way that Willis did. He records a series of "epidemic
constitutions of the air," the particular constitution of each year being
named from the epidemic malady that seemed to him to dominate it most. It
was, perhaps, because it had to conform to Sydenham's "preconceived
fancy," as Lind said, that his account of the dominant type of fever in
1661 differs somewhat from that given by Willis.


Sydenham's epidemic Constitutions.

Sydenham adopted the epidemic constitutions from Hippocrates, as he did
much else in his method and practice. In the first and third books of the
'Epidemics,' Hippocrates describes three successive seasons and their
reigning diseases in the island of Thasos, as well as a fourth
plague-constitution which agrees exactly with the facts of the plague of
Athens as described by Thucydides. The Greek term translated
"constitution" is [Greek: katastasis], which means literally a settling,
appointing; ordaining, and in the epidemiological sense means the type of
reigning disease as settled by the season. The method of Hippocrates is
first to give an account of the weather--the winds, the rains, the
temperature and the like,--and then to describe the diseases of the
seasons[17]. Sydenham followed his model with remarkable closeness. The
great plague of London has almost the same place in his series of years
that the plague-constitution, the fourth in order, has in that of
Hippocrates. It looks, indeed, as if Sydenham had begun with the year
1661, more for the purpose of having several constitutions preceding that
of the plague than because he had any full observations of his own to
record previous to 1665. He is also much influenced by the example of
Hippocrates in giving prominence to the intermittent type of fevers. It
was remarked by one of our best 18th century epidemiologists, Rogers of
Cork, and with special reference to Sydenham's "intermittent
constitutions," that fevers proper to the climate of Thasos were not
likely to be identified in or near London excepted by a forced
construction.

_Sydenham's Constitutions._

  -----------------------------------------------------------------------
      |                         | Total |      | Fever |        |       |
      |       Constitutions     | deaths|Plague|  and  |Smallpox|Measles|
      |                         |   in  |      |Spotted|        |       |
      |                         | London|      | Fever |        |       |
  ----|-------------------------|-------|------|-------|--------|-------|
  1661|"Intermittent"           | 16,665|    20| 3,490 |  1,246 |  188  |
  1662|  constitution: with a   | 13,664|    12| 2,601 |    768 |   20  |
  1663|  continued fever        | 12,741|     9| 2,107 |    411 |   42  |
  1664|  throughout.            | 15,453|     5| 2,258 |  1,233 |  311  |
      |                         |       |      |       |        |       |
  1665|Constitution of plague   | 97,306|68,596| 5,257 |    655 |    7  |
  1666|  and pestilential fever.| 12,738| 1,998|   741 |     38 |    3  |
      |                         |       |      |       |        |       |
  1667|Constitution of smallpox,| 15,842|    35|   916 |  1,196 |   83  |
  1668|  with a continued       | 17,278|    14| 1,247 |  1,987 |  200  |
  1669|  "variolous" fever.     |}      |      |       |        |       |
      |                         |}19,432|     3| 1,499 |    951 |   15  |
  1669|Constitution of dysentery|}      |      |       |        |       |
  1670|  and cholera nostras,   | 20,198|     0| 1,729 |  1,465 |  295  |
  1671|  with a continued fever.| 15,729|     5| 1,343 |    696 |   17  |
  1672|  Measles in 1670.       | 18,230|     5| 1,615 |  1,116 |  118  |
      |                         |       |      |       |        |       |
  1673|Constitution of          | 17,504|     5| 1,804 |    853 |   15  |
  1674|  "comatose" fevers.     | 21,201|     3| 2,164 |  2,507 |  795  |
  1675|Influenza in 1675.       | 17,244|     1| 2,154 |    997 |    1  |
  1676|                         | 18,732|     2| 2,112 |    359 |   83  |
      |                         |       |      |       |        |       |
  1677|Not recorded.            | 19,067|     2| 1,749 |  1,678 |   87  |
      |                         |       |      |       |        |       |
  1678|Return of the            | 20,678|     5| 2,376 |  1,798 |   93  |
  1679|  "intermittent"         | 21,730|     2| 2,763 |  1,967 |  117  |
  1680|  constitution, absent   | 21,053|     0| 3,324 |    689 |   49  |
      |  since 1661-64.         |       |      |       |        |       |
      |                         |       |      |       |        |       |
  1681|"Depuratory" fevers,     | 23,951|     0| 3,174 |  2,982 |  121  |
  1682| or dregs of the         | 20,691|     0| 2,696 |  1,408 |   50  |
  1683| intermittents.          | 20,587|     0| 2,250 |  2,096 |   39  |
  1684|                         | 23,202|     0| 2,836 |  1,560 |    6  |
      |                         |       |      |       |        |       |
  1685|Constitution of a        | 23,222|     0| 3,832 |  2,496 |  197  |
  1686| "new" continued fever.  | 22,609|     0| 4,185 |  1,062 |   25  |

      --------
      |Griping
      | in the
      |  Guts
      |
      |-------
      | 1,061
      |   835
      |   866
      | 1,146
      |
      | 1,288
      |   676
      |
      | 2,108
      | 2,415
      |
      | 4,385
      |
      | 3,690
      | 2,537
      | 2,645
      |
      | 2,624
      | 1,777
      | 3,321
      | 2,083
      |
      | 2,602
      |
      | 3,150
      | 2,996
      | 3,271
      |
      |
      | 2,827
      | 2,631
      | 2,438
      | 2,981
      |
      | 2,203
      | 2,605

The foregoing is a Table of Sydenham's epidemic constitutions from 1661 to
1686, compiled from his various writings, with the corresponding
statistics from the London Bills of Mortality.

I give this Table both as a convenient outline and in deference to the
great name of Sydenham. But we should be much at fault in interpreting the
figures of the London Bills, or the history of epidemic diseases in the
country at large, if we had no other sources of information than his
writings. Only some of the figures in the Table concern us in this
chapter; plague has been finished in the previous volume, smallpox,
measles and "griping in the guts" are reserved each for a separate
chapter, as well as the influenzas and epidemic agues which formed the
chief part of the "strange" or "new" fevers. If this work had been the
Annals of Epidemics in Britain, it would have been at once proper and easy
to follow Sydenham's constitutions exactly, and to group under each year
the information collected from all sources about all epidemic maladies.
But as the work is a history, it proceeds, as other histories do, in
sections, observing the chronological order and the mutual relations of
epidemic types as far as possible; and in this section of it we have to
cull out and reduce to order the facts relating to fevers, beginning with
those of 1661.

Cases of fever, says Sydenham, began to be epidemic about the beginning of
July 1661, being mostly tertians of a bad type, and became so frequent day
by day that in August they were raging everywhere, and in many places made
a great slaughter of people, whole families being seized. This was not an
ordinary tertian intermittent; indeed no one but Sydenham calls it an
intermittent at all, and he qualifies the intermittence as follows:

    "Autumnal intermittents do not at once assume the genuine type, but in
    all respects so imitate continued fevers that unless you examine the
    two respectively with the closest scrutiny, they cannot be
    distinguished. But, when by degrees the impetus of the 'constitution'
    is repelled and its strength reined in, the fevers change into a
    regular type; and as autumn goes out, they openly confess themselves,
    by casting their slough (_larva abjecta_) to be the intermittents that
    they really were from the first, whether quartans or tertians. If we
    do not attend to this diligently" etc. And again, in a paragraph which
    does not occur in the earlier editions, he writes as follows in the
    context of the "Intermittent Fevers of the years 1661-1664:"

    "It is also to be noted that in the beginning of intermittent fevers,
    especially those that are epidemic in autumn, it is not altogether
    easy to distinguish the type correctly within the first few days of
    their accession, since they arise at first with continued fever
    superadded. Nor is it always easy, unless you are intent upon it, to
    detect anything else than a slight remission of the disease, which,
    however, declines by degrees into a perfect intermission, with its
    type (third-day or fourth-day) corresponding fitly to the season of
    the year."

The intermittent character of these fevers seems to have struck Sydenham
himself in a later work as forced and unreal. Writing in 1680, when the
same kind of fevers were prevalent, after the epidemic agues of 1678 and
1679, he calls them "depuratory," and says that "doubtless those
depuratory fevers which reigned in 1661-64 were as if the dregs of the
intermittents which raged sometime before during a series of years," i.e.
the agues of 1657-59[18].

Theory or names apart, Sydenham's account of the fatal epidemic fever of
the summer and autumn of 1661, comes to nearly the same as Willis's.
Without saying expressly, as Willis does, that the victims were mostly
children or young people, he speaks in one place of those of more mature
years lying much longer in the fever, even to three months, and he
specially mentions the same sequelae of the fever in children that Willis
mentions, and that Roger North remembered in his own case--namely that
they sometimes became hectic, with bellies distended and hard, and often
acquired a cough and other consumptive symptoms, "which clearly put one in
mind of rickets." He refers also to pain and swelling of the tonsils and
to difficulty of swallowing, which, if followed by hoarseness, hollow
eyes, and the _facies Hippocratica_, portended speedy death. Among the
numerous other _accidentia_ of the fever, was a certain kind of mania.
Among the symptoms were phrensy, and coma-vigil; diarrhoea occurred in
some owing, as he thought, to the omission of an emetic at the outset;
hiccup and bleeding at the nose were occasional.

But, although Sydenham must have had the same phenomena of fever before
him that Willis had, the epidemic being general, according to the
statements of both, one would hardly guess from his way of presenting the
facts, that the fever was what Willis took it to be--a slow nervous fever,
with convulsive and ataxic symptoms, specially affecting children and the
young. Both Willis and Sydenham recognised something new in it; the common
people called it, once more, the "new disease," and Pepys calls it a "sort
of fever," and "strange and fatal fevers."

As Sydenham maintains that the same epidemic constitution continued until
1664 (although the fever-deaths in London are much fewer in 1662-3-4 than
in the year 1661, which was the first of it), we may take in the same
connexion Pepys's account of the Queen's attack of fever in 1663. The
young princess Katharine of Portugal, married to Charles II. in 1662, had
the beginning of a fever at Whitehall about the middle of October, 1663;
Pepys enters on the 19th that her pulse beat twenty to eleven of the
king's, that her head was shaved, and pigeons put to her feet, that
extreme unction was given her (the priests so long about it that the
doctors were angry). On the 20th he hears that the queen's sickness is a
spotted fever, that she was as full of the spots as a leopard: "which is
very strange that it should be no more known, but perhaps it is not so."
On the 22nd the queen is worse, 23rd she slept, 24th she is in a good way
to recovery, Sir Francis Prujean's cordial having given her rest; on the
26th "the delirium in her head continues still; she talks idle, not by
fits, but always, which in some lasts a week after so high a fever, in
some more, and in some for ever." On the 27th she still raves and talks,
especially about her imagined children; on the 30th she continues
"light-headed, but in hopes to recover." On 7th December, she is pretty
well, and goes out of her chamber to her little chapel in the house; on
the 31st "the queen after a long and sore sickness is become well again."


Typhus fever perennial in London.

Sydenham says that a continued fever, the symptoms of which so far as he
gives them suggest typhus, was mixed with the masked intermittent, (or the
convulsive fever of children, as in Willis's account), in every one of the
years 1661-4; and that statement raises a question which may be dealt with
here once for all. Fever in the London bills is a steady item from year to
year, seldom falling below a thousand deaths and in the year 1741, during
a general epidemic of typhus, rising to 7500. The fevers were a composite
group, as we have seen, and shall see more clearly. But the bulk of them
perennially appears to have been typhus fever. Where the name of "spotted
fever" is given there can be little doubt. Every year the bills have a
small number of deaths from "spotted fever," and the number of them
always rises in the weekly bills in proportion to the increase of "fever"
in general, sometimes reaching twenty in the week when the other fevers
reach a hundred. It would be a mistake to suppose that only the fevers
called spotted were typhus, the other and larger part being something
else. The more reasonable supposition is that the name of spotted was
given by the searchers in cases where the spots, or vibices or petechiae
of typhus were especially notable. If a score, or a dozen or half-a-dozen
deaths in a week are set down to spotted fever, it probably means that a
large part of the remaining hundred, or seventy, or fifty cases of "fever"
not called spotted were really of the same kind, namely typhus. In the
plague itself, the "tokens," which were of the same haemorrhagic nature as
the larger or more defined spots of typhus, were exceedingly variable[19].
One of the synonyms of typhus (the common name in Germany) is spotted
typhus; but the spots were of at least two kinds, a dusky mottling of the
skin and more definite spots, sometimes large, sometimes like fleabites.

Assuming that the cases specially called "spotted" in the London Bills
were only a part of all that might have been called by the same name in
the wider acceptation of the term (as in Germany), it is a significant
fact that there are few of the weekly bills for a long series of years in
the 17th and 18th centuries without some of the former. Such a case as
that of Mr Samuel Crewe, brother of Lord Crewe, who died of the "spotted
fever" on 2 July, 1661, probably means that there were more cases of the
same kind in the poorer parts of the town, from which no account of the
reigning sicknesses ever came unless it were the number of deaths in the
bills. The conditions of endemic typhus were there long before we have
authentic accounts, towards the end of the 18th century, of that disease
being ever present in the homes of the lower classes. In the time of
Sydenham, and even in the time of Huxham two generations after, there was
no thought of the unwholesome domestic life graphically described by
Willan and others, as a cause of typhus--the overcrowding, the want of
ventilation, the foul bedding and the excremental effluvia.

If there had been any reason to suppose that the London of the
Restoration, or of the time of Queen Anne, or of the first Georges had
enjoyed better public health in its crowded liberties and out-parishes
than we know it to have done from the time when the authentic accounts of
Lettsom and other dispensary physicians begin, then one might err in
assuming the perennial existence of typhus fever and in assigning to that
cause the bulk of the deaths under the heading of "fevers" in the Parish
Clerks' bills. But the public health was undoubtedly worse in the earlier
period. A writer as late as the year 1819, who is calling for that reform
of the dwellings of the working classes in London which was soon after
carried out, namely the construction of regular streets instead of mazes
of courts and alleys, speaks of the "silent mortality" that went on in the
latter[20]. It was still more silent in earlier times, when the west end
of London knew nothing of what was passing in the east end[21].

In all matters of public health, after the somewhat romantic interest in
plague had ceased, the poorer parts of London were for long an unexplored
territory. Dr John Hunter, who had been an army physician and was
afterwards in practice in Mayfair, began about the year 1780 to visit the
homes of the poor in St Giles's or other parishes near him, and was
surprised to find in them a fever not unlike the hospital typhus of his
military experience. I quote at this stage only a sentence or two[22].

    "It may be observed, that though the fever in the confined habitations
    of the poor does not rise to the same degree of violence as in jails
    and hospitals, yet the destruction of the human species occasioned by
    it must be much greater, from its being so widely spread among a class
    of people whose number bears a large proportion to that of the whole
    inhabitants. There are but few of the sick, so far as I have been able
    to learn, that find their way into the great hospitals in London." I
    shall defer the subject of the dwellings of the working class in
    London until a later stage.

The "constitution" in Sydenham's series which succeeded the febrile one of
1661-64 was "pestilential fever." It began in the end of 1664, lasted into
the spring of 1665, and passed by an easy transition into the plague
proper. The bills for those months have very large weekly totals of deaths
from "fever," as well as a good many deaths from "spotted fever," before
they begin to have more than an occasional death from plague. It is this
particular form of typhus fever that Bateman had in mind when he wrote, in
1818, "We never see the pestilential fever of Sydenham and Huxham";
although Willan, who preceded him at the Carey Street dispensary,
described in 1799 a fever of so fatal a type that it gave rise to the
rumour that the plague was back in London. The term "pestilential" was
technically applied to a kind of fever a degree worse than the
"malignant."

Willis, the earliest of the Restoration authorities on fevers, had three
names in an ascending scale of severity--putrid, malignant and
pestilential. The putrid fevers were what we might call idiopathic,
engendered within the body in some way personal to the individual from
"putrefaction" or fermentation of the humours; all the intermittents were
included in that class, and the theory of their cure by bark was that the
drug corrected putridity. In the malignant and pestilential, an altogether
new element came in--the [Greek: to theion] of Hippocrates, the mysterious
something which we call infection; and of these two infectious fevers, the
malignant was milder than the pestilential[23].

Morton drew out the scale of fevers in an elaborate classification, of
which only the last section of continued contagious fevers concerns us at
present[24]:

            {                        {Fever mostly with sweats and
            {Simple Malignant Fever  {other signs of malignity, but
            {                        {without buboes, carbuncles, petechiae
            {                        {or miliary rash.
  Synochus  {
            {                        {Fever with petechiae, purple
            {Pestilential Fever      {spots, miliaria, morbillous rash
            {                        {on the chest.
            {
            {Plague                  {With buboes, carbuncles and
            {                        {black spots.

The order in this Table was also the order in time: the fever of 1661,
which Willis calls malignant, remained as the constitution of the years
following until the end of 1664; then began the pestilential, which passed
definitely in the spring of 1665 into the plague proper. Willis, Sydenham
and Morton, differing as they did on many points of theory and treatment,
all alike taught the scale of malignity in fevers and plague, and all used
the language of "constitutions." The Great Plague of 1665 was, in their
view, the climax of a succession of febrile constitutions of the air,
being attended by much pestilential fever and followed by a fever which
Morton places in the milder class of [Greek: syneches].


The epidemic Constitutions following the Great Plague.

During the ten or twelve years following the Great Plague of London, the
epidemic maladies which Sydenham dwelt most upon as the reigning types
will appear on close scrutiny to have been on the whole proper to the
earlier years of life. This cannot be shown in the simple way of figures;
for the ages at death from the several maladies, although they were in the
books of the Parish Clerks, were not published.

There was some continued fever every year, which we may take to have been
chiefly the endemic typhus of a great city, and there were also deaths
among adults due to those reigning epidemics which fell most on the young.
In 1667 and 1668 the leading epidemic was smallpox, with a continued fever
towards the end of the period which Sydenham called "variolous," for no
other reason, apparently, than that it was part of a variolous
constitution. In the autumn of 1669, and in the three years following, the
epidemic mortality was peculiarly infantile, in the form of diarrhoea or
"griping in the guts," with some dysentery of adults, and some measles in
1670. From 1673 to 1676, the constitution was a comatose fever, which
chiefly affected children, with a sharp epidemic of measles in the first
half of 1674, attended by a very high mortality from all causes, and a
severe smallpox in the second half of 1674, attended by a much lower
mortality from all causes. There was also an influenza for a few weeks in
1675. In 1678 the "intermittent" constitution returned, having been absent
for thirteen years, and continued through 1779-80, until its "strength was
broken." In 1681 smallpox was unusually mortal, the deaths being more than
in any previous year. Most of these constitutions fall to be dealt with
fully in other chapters: but as we are here specially concerned with the
succession to the plague, it is to be noted how largely the epidemic
mortality in London fell upon the age of childhood for a number of years
after the Great Plague of 1665. It was observed both by English and
foreign writers that the next epidemic following the Black Death of
1348-49, namely, that of 1361 in England and of 1359-60 in some other
parts of Europe, fell mostly upon children and upon the upper classes of
adults. There is doubtless some particular application of the population
principle in the earlier instance as in the later, but not the same
application in both. The conditions at the beginning of the three hundred
years' reign of plague in Britain were different from those at the end of
it. The increased prevalence of smallpox in the generation before the last
great outburst of plague, and the infantile or puerile character of the
epidemic fever of 1661, as described by Willis, show that the incidence of
infectious mortality had already begun to shift towards the age of
childhood. It looks as if the conditions of population, intricate and
obscure as they must be confessed to be, were somehow determining what the
reigning infectious maladies, with their special age-incidence, should be.
Such a gradual change is the more probable for the reason that infectious
mortality came in due time to be mostly an affair of childhood. The
plague, which was the great infection of the later medieval and earlier
modern period, was peculiarly fatal to adult lives; on the other hand, the
mortality from infectious diseases in our own time falls in much the
larger ratio upon infants and children. It looks as if this change, now so
obvious, had begun before the end of plague in Britain, having become more
marked in the generation following its extinction. The direct successor of
plague, so far as concerns age-incidence and nosological affinity, was the
pestilential or malignant typhus, which came into great prominence in
1685-86, in circumstances that seemed to contemporaries to forebode a
return of the plague. But before we come to that, there remains a little
to be said of some other fevers, especially of the comatose fever of
1673-76, which was largely an affair of childhood.

Pepys says that he went on 3 May, 1668, to Old Street (St Luke's) to see
Admiral Sir Thomas Teddiman, "who is very ill in bed of a fever," and, in
a later entry, that he "did die by a thrush in his mouth" on the 12th of
May. Next year, 1669, Pepys and his wife went on tour through several
parts of Europe, and had hardly returned to their house in Seething Lane
when the lady fell ill of a fever; on 2nd November, it was "so severe as
to render her recovery desperate," and on 10th November she died, in her
29th year,--a surprising sequel, as her husband felt, to a "voyage so full
of health and content." These two years, for which we have a sample of the
London fevers, were marked in the Netherlands by epidemics of fevers which
are among the most extraordinary in the whole history. At Leyden in 1669
the fever reached such a height as to cut off 7000--a mortality which
would not have been surprising if the disease had been plague; but it was
not plague, it wanted the buboes, carbuncles &c., was longer in its
course, and, strangest of all, affected the upper classes far more
severely than the poor, so much so "that of seventy men administering the
public affairs, scarcely two were left[25]," while, according to Fanois,
who was the Leyden poor's doctor, the lower classes, "protected as it were
by having survived the simpler forms of fever," suffered from this
malignant epidemic far less than the rich[26]. The mortality is said to
have risen as high as three-fourths of the attacks. At Haarlem the burials
in a week rose to three or four hundred (which was a fair week's average
for London itself in an ordinary season), the epidemic lasting four months
and leaving hardly one family untouched. Among the symptoms were extreme
praecordial anxiety, weight at the pit of the stomach, constant nausea and
loathing, vomiting, in part bilious but chiefly "pituitous," thirst and
restless tossing. It was attended by an affection of the throat and
mouth--an angina with aphthae or thrush of the palate. The pools and other
sources of water for domestic use were unusually stagnant that summer in
Holland, and were commonly blamed for the epidemic; but Fanois points out
that at Haarlem and Emden, where similar fevers raged, "salubriores non
desunt aquae[27]."

After such an instance as the Leyden fever of 1669, nothing is incredible
in the records of fever subsequent to the extinction of plague. Turning to
Sydenham's account of the continued fever which occurred in London during
the same season, the latter half of 1669, as well as in the three years
following, we find that it was characterized rarely by diarrhoea or
sweats, commonly by pain in the head, by a moist white tongue which
afterwards became covered by a dense skin, and by a greater tendency than
Sydenham had ever seen to aphthae (the "thrush in the mouth" of Admiral
Teddiman in 1668) when death threatened--the same being a "deposition from
the blood of foul and acrid matter upon the mouth and throat." But London
in 1668 and 1669 suffered little from fevers in comparison to Leyden,
Haarlem and other Dutch towns, its high mortality in the summer and autumn
of 1669 being from infantile diarrhoea, cholera nostras and dysentery.

Sydenham's continued fever from 1673 to 1676 (he was absent from his
practice in 1677 owing to ill health) was a malady which affected adults
as well as children, but, it would appear, the latter especially. The only
characteristic case given is of a boy of nine who did not begin to mend
until the thirtieth day. Many recovered in a fortnight, while others were
not clear of the fever in a month. On account of the remarkable stupor
which almost always attended it, Sydenham called the fever of this
constitution a comatose fever. It began with sharp pains in the head and
back, pains in the limbs, heats and chills, etc. His account of the
comatose state is exactly like that given by Willis for the fever of
children in 1661--profound stupor, sometimes for a week long, so profound
in some as to pass into absolute aphonia (the "acute fever with dumbness"
of later writers), while others would talk a few words in their sleep, or
would seem to be angry or perturbed by something (the chimaeras mentioned
by Willis) and would then become tranquil again; when roused to take
physic or to drink they would open the eyes for a moment and then fall
back into stupor. When they began to mend, they would crave for absurd
things to eat or drink. During convalescence the head, through weakness,
could not be kept straight but would incline first to one side and then to
the other[28].

The years 1678-1680 witnessed remarkable epidemics of ague, such as had
occurred on several occasions before, the last in the years 1657-59. They
engross so much of Sydenham's writing, especially in connexion with the
Peruvian-bark controversy, that we hear little of any other fever until
the great epidemic of continued fever, or typhus, in 1685-6. But he does
mention briefly that the interval between the decline of the agues in 1680
and the beginning of the "new fever" of 1685, was occupied by "continued
depuratory" fevers--depuratory of the dregs of the preceding intermittent
constitution, and comparable in that respect to the fevers of 1661-64
which followed the agues of 1657-59[29].

Sydenham's term "depuratory" does not help us much; but we learn something
from Morton as to what fevers were prevalent, besides the epidemical
intermittents, in the years preceding the epidemic of 1685-86. Morton
classes them as continued [Greek: syneches] (_Synocha_), by which he means
something less malignant than _Synochus_. A fever which began in the
milder form would often degenerate into the more malignant, the cause
assigned, in the usual recriminatory manner of the time between rival
schools, being mistaken treatment. But sometimes the fever was malignant
from the outset, with purple spots, petechiae, morbillous efflorescence,
watery vesicles on the neck and breast, buboes, and anthraceous boils. All
these fevers, says Morton, whether they were spurious forms of synocha, or
malignant from the outset, were sporadic, "neque contagione, ut in
pestilentiali constitutione, sese propagabant[30]." This points to their
having been part of that strange aguish epidemic of which an account is
given in another chapter. In Short's abstracts of parish registers, the
year 1680 seems to have been the most unhealthy of the series in country
parishes, and that is borne out by one Lamport, or Lampard, an empiric who
practised in Hampshire: "I will tell you somewhat concerning a malignant
fever. In the year '80 or '81 there were great numbers of people died of
such fevers, many whereby were taken with vomitings, etc., yet I had the
good fortune to cure eighteen in the parish of Aldingbourn, not one dying,
in that great compass, of that disease[31]." The moral is that the empiric
recovered his cases, whereas the regular faculty lost theirs; which means
that the fevers were of various degrees, some aguish, some typhus, as in
the exactly similar circumstances a century after, 1780-85.

In the London Bills from 1681 to 1684, the deaths from fever were many,
with some from "spotted fever" nearly every week, while the annual
mortalities from all causes were high. It is the more remarkable,
therefore, that Sydenham should have discovered, in the beginning of 1685,
the outbreak of a new fever, different from any that had prevailed for
seven years before. The explanation seems to be that a malignant typhus
fever, such as might have been discovered in any year in the crowded
parishes where the working classes lived, broke out at the Court end of
the town, where Sydenham's practice lay.


The epidemic fever of 1685-86.

A letter of 12 March, 1685, says: "Sir R. Mason died this morning in his
lodging at Whitehall. A fever rages that proves very mortal, and gives
great apprehensions of a plague[32]." Sydenham also was reminded of the
circumstances preceding the Great Plague of London in 1665. In his first
account of the epidemic of fever in 1685[33], which began with a thaw in
February, he points out that the thaw in March, 1665, had been followed by
pestilential fever and thereafter by the plague proper. In a later
reference, when the epidemic of fever was in its second year (1686) he
says: "How long it may last I shall not guess; nor do I quite know whether
it may not be a certain more spirituous, subtle beginning, and as if
_primordium_, of the former depuratory fever (1661-64) which was followed
by the most terrible plague. There are some phenomena which so far incline
me to that belief[34]." However, no plague followed the malignant, if not
pestilential, fever of 1685-86. The reign of plague, as the event showed,
was over; the fever which had been on former occasions its portent and
satellite, came into the place of reigning disease. It is true that
Sydenham does not identify the fever of 1685-86 by name as pestilential
fever; on the contrary, he entitles his essay "De Novae Febris Ingressu."
But the novelty of type was partly in contrast to the fevers immediately
preceding, which admitted treatment by bark, and its principal difference
from the pestilential fever of former occasions seems to have been that it
was not followed by plague[35]. Its antecedents and circumstances were
very much those of plague itself. Its mortality was greatest in the old
plague-seasons of summer and autumn, it had slight relation to famine or
scarcity, or to other obvious cause of domestic typhus. Sydenham can find
no explanation of the new constitution but "some secret and recondite
change in the bowels of the earth pervading the whole atmosphere, or some
influence of the celestial bodies." He enlarges, however, on the character
of the seasons preceding, which would have affected the surface, if not
the bowels, of the earth, and the levels of the ground-water.

The winter of 1683-84 was one of intense frost; an ice-carnival was held
on the Thames during the whole of January. The long dry frost of winter
was followed by an excessively hot and dry summer, the drought being such
as Evelyn did not remember, and as "no man in England had known." For
eight or nine months there had not been above one or two considerable
showers, which came in storms. The winter of 1684-85 set in early, and
became "a long and cruel frost," more interrupted, however, than that of
the year before. The spring was again dry, and it was not until the end of
May 1685 that "we had plentiful rain after two years' excessive drought
and severe winters[36]."

The two years of excessive drought, with severe winters, had their effect
upon the public health, as will appear from Short's abstracts of parish
registers in town and country[37]; the years 1683-85 being conspicuous for
the excess of burials over baptisms:

_Country Parishes._

  Year   Registers   Registers with    Deaths in   Births in
         examined    excess of death     them        them

  1683      140            37             923         685
  1684      140            31             900         629
  1685      140            19             574         478
  1686      140            16             419         301
  1687      143            19             522         427
  1688      143            11             327         267

_Towns._

  1683       25             8            1398        1169
  1684       25             8            1243         865
  1685       25             4            1191         741
  1686       25             2             555         418
  1687       25             1             313         269
  1688       25             2             191         146

There is no clue to the forms of sickness that caused the excessive
mortality in country parishes and provincial towns. But in London it
appears from the Bills that the one great cause of the unusual excess of
deaths in 1684 was an enormous mortality from infantile diarrhoea, from
the end of July to the middle of September, during the weather which
Evelyn describes as excessively hot and dry with occasional storms of
rain.

It was in the second year of the long drought, February, 1685, that
Sydenham dated the beginning of his new febrile constitutions. The
mortality of 1685 was just twenty deaths more than in 1684 (23,222); but
fever (with spotted fever) and smallpox had each a thousand more out of
the total than in the year before. Sydenham says that the fever did not
spare children, which might be alleged of typhus at all times; but a fever
of the kind, even if it ran through the children of a household, seldom
cut off the very young, the mortality being in greatest part of adults and
adolescents. Excepting smallpox for the year 1685, infantile and
children's maladies were not prominent during the constitution of the "new
fever;" the usual items of high infantile mortality, such as convulsions
and "griping in the guts" or infantile diarrhoea, were moderate and even
low. Hence, although the weekly fever-deaths in the following Table may
not appear sufficient for the professional and other interest that they
excited, it is to be kept in mind that they had been mostly of adult
lives. It is probable also that a good many of them had been among the
well-to-do, and perhaps at first in the West End; for there is nothing in
the height of the weekly bills for all London to bear out the remark of
the letter of 12 March, already quoted, "A fever rages that proves very
mortal and gives apprehensions of a plague."

_Weekly Mortalities in London._

1685.

  Week                          Of spotted       Of      Of griping
  ending      Dead   Of fever      fever      smallpox   in the guts

  March  3     376       49          0           11          35
        10     458       73          2           30          31
        17     367       53          1           25          17
        24     441       63          3           33          27
        31     366       53          5           24          36
  April  7     421       47         10           28          30
        14     433       64          8           32          27
        21     473       66          6           47          45
        28     470       68          3           49          45
    May  5     385       50          6           35          39
        12     447       75          3           59          41
        19     437       79          4           58          43
        26     452       61          2           74          39
   June  2     469       65          8           65          36
         9     521       88         14           62          41
        16     499       91          9           66          34
        23     478       76         12           71          53
        30     526       82         13           84          45
   July  7     497       81          8           87          53
        14     478       82         11           78          51
        21     464       79         11           87          47
        28     488       62          6           68          54
   Aug.  4     493       82          5           86          51
        11     529      109         13           89          47
        18     580       74         13           99          71
        25     536       91          7           67          85
  Sept.  1     556       94         13           53         104
         8     539       82         10           81          77
        15     485       90          7           63          70
        22     459       90         10           37          51
        29     502      114          3           58          53
   Oct.  6     444      108         11           40          54
        13     445       89         13           61          38
        20     369       86          5           40          28
        27     379       73          7           29          45
   Nov.  3     443       96          8           55          43
        10     410       84          7           26          35
        17     432      103          8           35          39
        24     471      107          6           56          31
   Dec.  1     384       87          4           36          24
         8     452       98          8           49          24
        15     403       69          3           29          47
        22     438       99          2           34          27
        29     432       80          9           28          28

_Weekly Mortalities in London._

1686.

  Week                          Of spotted       Of      Of griping
  ending      Dead   Of fever      fever      smallpox   in the guts

   Jan.  5     394       80          5           28          29
        12     400       80          3           27          48
        19     396       67          5           36          32
        26     366       76          2           21          30
   Feb.  2     452       87          8           16          30
         9     416       78          5           37          30
        16     405       94          9           20          25
        23     419       74          7           16          40
  March  2     417       84          1           20          37
         9     455       95          6           18          30
        16     415       71         10           31          21
        23     453       78         11           22          46
        30     372       58          8           17          35
  April  6     392       80         11           13          27
        13     393       72          7           21          29
        20     420       61         10           26          37
        27     471       99          9           27          22
    May  4     429       78         21           28          46
        11     374       71          6           16          22
        18     395       69          5           17           3 (sic)
        25     395       66         11           24          36
   June  1     383       63          4           15          49
         8     404       66          6           26          38
        15     523       88          9           43          64
        22     503       99          9           25          73
        29     473       90         10           31          62
   July  6     430       71          6           18          62
        13     401       76          2           19          56
        20     464       87         14           24          74
        27     508       99          3           23          76
   Aug.  3     506       86          9           14          90
        10     493       74          7           14         104
        17     522       99          7           26         101
        24     536      115          5           18         104
        31     520       90          8           22          93
  Sept.  7     531       94          4           21         104
        14     498       84          6           18         110
        21     540      100          3           17         101
        28     443       90          5           13          67
   Oct.  5     425       81          4           13          60
        12     432       96          2            9          56
        19     391       73          1            9          33
        26     402       79          3           11          43
   Nov.  2     373       64          1           23          39
         9     456       85          1           19          31
        16     401       73          2            9          23
        23     359       61          4           10          54
        30     397       68          1            7          34
   Dec.  7     359       76          0            9          21
        14     438       60          0            8          46
        21     354       49          1            8          39
        28     356       53          2            9          32

Sydenham says that he regarded the new fever at first as nothing more than
the "bastard peripneumony" which he had described for previous seasons;
but he had soon cause to see that it wanted the violent cough, the racking
pain in the head during coughing, the giddiness caused by the slightest
movement, and the excessive dyspnoea of the latter (Huxham likewise
distinguished typhus from "bastard peripneumony"). The early symptoms of
the "new fever" were alternating chills and flushings, pain in the head
and limbs, a cough, which might go off soon, with pain in the neck and
throat. The fever was a continued one, with exacerbation towards evening;
it was apt to change into a phrensy, with tranquil or muttering delirium;
petechiae and livid blotches were brought out in some cases (Sydenham
thought they were caused by cordials and a heating regimen), and there
were occasional eruptions of miliary vesicles. The tongue might be moist
and white at the edges for a time, latterly brown and dry. Clammy sweats
were apt to break out, especially from the head. If the brain became the
organ most touched, the fever-heat declined, the pulse became irregular,
and jerking of the limbs came on before death.

Later writers, for example those who described the great epidemic fever of
1741, have identified the fever of 1685-86 with the contagious malignant
fever afterwards called typhus, and Murchison, in his brief retrospect of
typhus in Britain, has included it under that name. Sydenham mentions
petechiae and livid blotches in some cases, and the Bills give a good many
of the deaths in the worst weeks of the epidemic under the head of
"spotted fever." It is not at first easy to understand why Sydenham should
have written an essay specially upon it, in September, 1686, to claim it
as a new fever[38] and not rather as the old pestilential
fever--"populares meos admonens de subingressu novae cujusdam
Constitutionis, a qua pendet Febris nova species, a nuper grassantibus
multum abludens." It should be kept in mind that his motive was correct
treatment, and that the fashionable treatment of the day by Peruvian bark
was, in his judgment, unsuited to this fever, however much it may have
suited the epidemical intermittents of 1678-79 and the "depuratory" dregs
of them for several years after. Physicians, he says, had learned to drive
off by bark the fevers of the former constitution, from 1677 to the
beginning of 1685, even when the fever intermitted little and sometimes
when it intermitted not at all; and they saw an indication for bark in the
nocturnal exacerbations of the new fever. Sydenham found that even large
doses of bark did not free the patient from fever, and that restoration to
health under treatment with the bark was due "magis fortunato alicui morbi
eventu quam corticis viribus." He seeks to establish the indications for
another treatment by setting forth the symptoms minutely; and as the
question of bark in fevers was the great medical question of the time,
this may well have been Sydenham's motive for discovering in the epidemic
of 1685-6 a "new fever" although he does not say so in as many words. We
have a good instance of how the bark-craze was at this time influencing
the very highest circles of practice in the case of Lord Keeper Guildford,
in July, 1685, as related in another chapter.

It will be seen from the table of weekly deaths that the second of the two
hard winters was over before the fever began to attract notice. Sydenham
compares its beginning after the thaw in February, 1685, to the beginning
of the plague when the frost broke in March, 1665.

If it had been merely the typhus of a hard winter, of overcrowding
indoors, of work and wages stopped by the frost, and of want of fuel
(which things Evelyn mentions as matters of fact), it would have come
sooner than the spring of 1685. The Bills for years before have regularly
a good many deaths from fever, and always some from spotted fever; but
these may have come from parishes wholly beyond the range of Sydenham's
practice. The fever began definitely for him in February, 1685, and was at
its worst in the old plague-seasons of summer and autumn. If the seasons
had any relation at all to it, the epidemic was a late effect of the long
drought, an effect which was manifested most when the rain came, in the
summer of 1685 and throughout the mild winter and normal summer of
1685-86. It must have been for that reason that Sydenham traced the source
of it to "some secret and recondite change in the bowels of the earth,"
rather than to a change in the sensible qualities of the air. One must
ever bear in mind that the physicians of the Restoration gave no thought
to insanitary conditions of living; in that respect the later Stuart
period seems to have been behind the Elizabethan or even the medieval; we
cannot err in assuming, behind all Sydenham's speculative causes, a great
deal of unwholesomeness indoors. Sydenham's fullest reference to the
subterranean sources of poisonous miasmata occurs in his tractate on Gout:

    "Whether it be that the bowels of the earth, if one may so speak,
    undergo various changes, so that by the accession of vapours exhaled
    therefrom the air is disturbed, or that the whole atmosphere is
    infected by a change which some peculiar conjunction of certain of the
    heavenly bodies induces in it;--the matter so falls out that at this
    or that time the air is furnished with particles that are adverse to
    the economy of the human body, just as at another time it is
    impregnated with particles of a like kind that agree ill with the
    bodies of some species of brute animals. At these times, as often as
    by inspiration we draw into the naked blood miasmata of this kind,
    noxious and inimical to nature, and we fall into those epidemical
    diseases which they are apt to produce, Nature raises a fever,--her
    accustomed means of vindicating the blood from some hostile matter.
    And such diseases are commonly called _epidemical_; and they are short
    and sharp because they have thus a quick and violent movement[39]."

It was Sydenham's intimate friend Robert Boyle who worked out the
hypothesis of subterraneous miasmata as a cause of epidemic (and endemic)
diseases. An account of his theory will be found in the chapter on
Influenzas and Epidemic Agues. It may be said here that it needs only a
few changes, especially the substitution of organic for inorganic matters
in the soil, to bring it into line with the modern doctrine of miasmatic
infective disease as expounded by the Munich school.

It has not been usual to think of spotted fever, (or of influenzas), in
that connexion; but a telluric source of the epidemic constitution of
1685-86 was clearly Sydenham's view; and as the fever came in
circumstances like those of the last great plague, and was thought at the
time to be the forerunner of another great plague, its connexion with
recondite decompositions in the soil, dependent on the phenomenal drought
of two whole years before, cannot be set aside as a possibility, the less
so that the fever, although of the type of typhus, was not a fever of
cold, hunger, and domestic distress, but mainly of the warm, or mild, or
soft weather following the long drought, and of many well-to-do-people, as
in the great Netherlands fever of 1669. My view of it is that it was the
modified successor of plague, the _pestis mitior_, which used to precede
and accompany the plague, now become the dominant constitution. The
authentic figures of its mortality come from London; but Sydenham says
that its "effects were felt far more in other places"; although Short's
abstracts of parish registers, given above, do not indicate excessive
mortality throughout England.


Retrospect of the great Fever of 1623-25.

The most instructive instance of _pestis mitior_ in Britain is not the
pestilential fever which led up to the last plague (1665-6), but the great
epidemic of fever all over England and Scotland which reigned for two or
three years before the great outburst of plague in 1625. I go back to this
because it was not wholly or even mainly a famine fever (although it was
as general as one of the medieval famine-fevers), and because in that
respect it furnishes a close parallel to the fever of 1685-86, which I
regard as the successor of the plague. After this interlude in the
history, we shall proceed to consider the question of the final extinction
of plague.

    In Scotland the fever of 1622-23 was directly connected with famine,
    but in England it was not obviously so according to the records that
    remain. The dearth in Scotland began as early as the autumn of 1621:
    "Great skarsitie of cornes throw all the kingdome," the harvest having
    been spoiled by wet weather and unheard of river floods; however,
    abundance of foreign victual came in, and the scarcity was got
    over[40]. In England the same harvest of oats was abundant, and
    probably yielded the "foreign victual" which relieved the Scots; but
    the price of wheat rose greatly[41]. It was the year following, 1622,
    that really brought famine and famine-sickness to Scotland, as the
    second of two bad harvests had always done. On 21 July, 1622, a fast
    was proclaimed at Aberdeen for "the present plague of dearth and
    famine, and the continuance thereof threatened by tempests,
    inundations and weets likely to rot the fruit on the ground[42]."

    In an entry of the Chronicle of Perth, subsequent to July, 1622, it is
    said: "In this yeir about the harvest and efter, thair wes suche ane
    universall seikness in all the countrie as the ellyke hes not bene
    hard of. But speciallie in this burgh, that no familie in all the
    citie was frie of this visitation. Thair was also great mortalitie
    amonge the poore." From which it appears that the autumnal fever of
    1622 was among all classes in Scotland. The famine in Scotland became
    more acute in the spring and summer of 1623; the country swarmed with
    beggars, and in July, says Calderwood, the famine increased daily
    until "many, both in burgh and land, died of hunger." At Perth ten or
    twelve died every day from Midsummer to Michaelmas; the disease was
    not the plague, but a fever[43]. At Dumfries 492 died during the first
    ten months of 1623, perhaps a ninth part of the inhabitants, about one
    hundred of the deaths being specially marked as of "poor[44]." The
    "malignant spotted fever" which caused numerous deaths in 1623 in
    Wigton, Penrith and Kendal is clearly part of the famine-fever of
    Scotland extending to the Borders and crossing them. This is a
    famine-fever of the old medieval type, like that of 1196 which,
    according to William of Newburgh "crept about everywhere," always the
    same acute fever, putting an end to the miseries of the starving, but
    attacking also those who had food.

    The same spotted fever was all over England in 1623, but it did not,
    as in Scotland, come in the wake of famine. It is true that the
    English harvest of 1622 was a good deal spoiled; a letter of 25
    September says[45]: "Though the latter part of this summer proved so
    far seasonable, yet the harvest is scant, and corn at a great price by
    reason of the mildews and blasting generally over the whole realm,"
    rye being quoted a few weeks later at 7/- the bushel and wheat at
    10/-, although the average of wheat for the year, in Rogers's tables,
    is not more than 51/1_d._ per quarter, while the average of next year
    falls to 37/8_d._ These were not famine-prices in England, and there
    is no evidence of general sickness directly after the harvest of 1622,
    when corn was dearest. Also, although the autumn of 1623 was a time of
    "continual wet" in England[46], the price of wheat remained moderate,
    and even low as compared with the rather stiff price of the winter of
    1622-23. But it was not until the summer and autumn of 1623 that the
    spotted fever became epidemic in England. Short's abstracts of the
    registers of market towns show how sickly that year was:

        Year.    No. of     No. with    Buried   Baptised
                registers   excess of   in the    in the
                examined.   burials.    same.     same.

        1622      25           4          442       345
        1623      25          16         2254       439 (sic)
        1624      25           9          978       714
        1625      25           9          666       563

    In September, 1623, the corporation of Stamford made a collection "in
    this dangerous time of visitation," and sent L10 of it to Grantham,
    the rest to go "to London or some other town, as occasion offered." A
    London letter of 6 December, 1623, from Chamberlain to Carleton
    says[47]:--

    "Here is a contagious spotted or purple fever that reigns much, which,
    together with the smallpox, hath taken away many of good sort, as well
    as meaner people." He then gives the names of notables dead of it, and
    adds: "Yet many escape, as the dean of St Paul's [Dr Donne, who used
    the occasion to compile a manual of devotion] is like to do, though he
    were in great danger." One of the Coke family writes early in January,
    1624, from London[48]: "Having two sons at Cambridge, we sent for them
    to keep Christmas with us, and not many days after their coming my
    eldest son Joseph fell suddenly into the sickness of the time which
    they call the spotted fever, and which after two days' extremity took
    away his life." From another letter it appears that one of his
    symptoms was "not being able to sleep," the unmistakable vigil of
    typhus. Although there is no word of the epidemic continuing in
    Scotland in 1624, it was undoubtedly as prevalent in England in that
    year as the year before, and prevalent in country houses as well as
    in towns and cities. Thus, on 7 August, 1624, Chamberlain writes: "The
    [king's] progress is now so far off that we hear little thence, but
    only that there be many sick of the spotted ague, which took away the
    Duke of Lennox in a few days. He died at Kirby," a country house in
    Northamptonshire[49]. On 21 August he writes again: "This spotted
    fever is cousin-german to it [the plague] at least, and makes as quick
    riddance almost. The Lady Hatton hath two or three of her children
    sick of it at her brother Fanshaw's in Essex, and hath lost her
    younger daughter, that was buried at Westminster on Wednesday night by
    her father; a pretty gentlewoman, much lamented." A letter of 4
    September says there was excessive mortality in London, in great part
    among children (doubtless from the usual infantile trouble of a hot
    autumn, diarrhoea), while "most of the rest are carried away by this
    spotted fever, which reigns almost everywhere, in the country as ill
    as here." Sir Theodore Mayerne, the king's physician, confirms this,
    under date 20 August, 1624: the purple fever, he says, was "not so
    much contagious as common through a universal disposing cause,"
    seizing upon many in the same house, and destroying numbers, being
    most full of malignity[50]. It was clearly an inexplicable visitation.
    The summer was hot and dry, from which character of the season, says
    Chamberlain, "some have found out a far-fetched speculation, which yet
    runs current, and would ascribe it [the spotted fever] to the
    extraordinary quantity of cucumbers this year, which the gardeners, to
    hasten and bring forward, used to water out of the next ditches, which
    this dry time growing low, noisome and stinking, poisoned the fruit.
    But," adds Chamberlain, "that reason will reach no farther than this
    [London] town, whereas the mortality is spread far and near, and takes
    hold of whole households in many places." He then gives the names of
    several eminent persons dead of it, and speaks of others who were
    "still in the balance[51]." On 9 October, "the town continues sickly
    still," and Parliament had been put off, "in consideration of the
    danger," from 2 November, 1624, to 15 February, 1625. On Ash
    Wednesday, 1625, the Marquis of Hamilton died of the pestilent fever
    at Moor Park, Rickmansworth. Thus far there had been no plague; and if
    the spotted fever were cousin-german to the plague, as Chamberlain
    said, it was remarkable in this that it prevailed in the mansions of
    the rich in town and country and took off more victims among the upper
    classes than the plague itself even in its most terrific outbursts.
    However, a plague of the first rank followed in London and elsewhere
    in the summer and autumn of 1625.

    The cucumber-theory, above mentioned, shows how puzzled people must
    have been to account for the spotted fever, or "spotted ague" as it
    was also called, in 1624. Sir Theodore Mayerne did not think contagion
    from person to person could explain it, but referred it to "some
    universal disposing cause." It is conceivable that the famine-fever of
    1622 and 1623 in Scotland and the Marches may have spread by contagion
    into England in the latter year; but in 1624 there is nothing said of
    fever in Scotland or of scarcity as a primary cause in England.

    Besides the famine-fever of Scotland in 1622-23, there was another
    associated thing which should not be left out of account. Before the
    famine and fever had begun in that country, the notorious Hungarian
    fever was raging in the Palatinate, and continued to rage for four
    years. "Hungarian fever" had become the dreaded name for war-typhus of
    a peculiar malignity and diffusive power. It had been so often
    engendered since the 16th century in campaigns upon Hungarian soil as
    to have become known everywhere under the name of that country. Its
    infection spread, also, everywhere through Europe; thus it is said to
    have even reached England in 1566, and again in 1589, although it is
    not easy to find English evidence of it for either year. It was this
    type of fever which broke out in the Upper Palatinate, occupied by
    troops of the Catholic powers, in 1620, and continued through the
    years 1621, 1622 and 1623; as the title of one of the essays upon this
    outbreak somewhat fantastically declares, it spread "ex castris ad
    rastra, ex rastris ad rostra, ab his ad aras et focos[52]." Was the
    epidemic constitution of "spotted ague" in England in 1623 and 1624
    derived from the centre of famine-fever in Scotland, or from the
    centre of camp-fever in the Palatinate? In the last years of James I.
    communications were frequent with the latter country, and there was of
    course much intercourse with Scotland.

The spotted fever or spotted ague of 1623-24, the plague of 1625, and the
country agues of the same autumn make really a more instructive series of
epidemic constitutions than any that fell under Sydenham's observation, so
instructive, indeed, that it has seemed worth while to revert to it for
the sake of illustrating the doctrine of epidemics then in vogue. That
doctrine made little of contagion from person to person; yet the idea of
contagion was familiar, and had been so since medieval times. If we might
assume contagion to explain such cases as those that occurred in the
houses of squires and nobles, we might find a source of it either in the
famine-fever of Scotland or in the war-fever of the Palatinate. But the
teaching of the time was that it was in the air; and if the infective
principle had been generated either in Scotland or on the upper Rhine it
had diffused itself in some inscrutable way. The doctrine of epidemic
constitutions seems strange to us; but some of the facts that it was meant
to embrace are also strange to us. Were it not for an occasional reminder
from influenza, we should hardly believe that any fevers could have
travelled as the Hungarian fevers, the spotted fevers or "spotted agues"
of former times are said to have done.

On the other hand, we have now a scientific doctrine of the effects of
great fluctuations of the ground-water upon the production of telluric
miasmata, which may be used to rationalize the theory of emanations
adopted by Sydenham and Boyle. From this modern point of view the
remarkable droughts preceding the pestilential fevers and plagues of
1624-25 and 1665, and preceding the fever of 1685-86, which is the one
that immediately concerns us, may be not without significance.

The London fever of 1685-86 having been suspected at the time to be the
forerunner of a plague, as other such fevers in the earlier part of the
century had been, and no plague having ensued, the question arises most
naturally at this stage, why the plague should have never come back in
London or elsewhere in Britain after the great outbreak of 1665-66.


The extinction of Plague in Britain.

Plague had been the grand infective disease of Britain from the year of
the Black Death, 1348-9, for more than three centuries, down to 1666. The
last of plague in Scotland was in 1647-8, in the west and north-west of
England about 1650 (in Wales probably in 1636-8), in Ireland in 1650, and
in all other parts of the kingdom including London in 1666, the absolute
last of its provincial prevalence having been at Peterborough in the first
months of 1667[53], while two or three occasional deaths continued to
occur annually in London down to 1679. False reports of plague,
contradicted by public advertisement, were circulated for Bath in
1675[54], and for Newcastle in 1710[55]; while in London as late as 1799,
during a bad time of typhus fever, the occurrence of plague was
alleged[56].

It is not easy to say why the plague should have died out. It had been
continuous in England from 1348, at first in general epidemics, all over
the country in certain years, thereafter mostly in the towns, either in
great explosions at long intervals or at a moderate level for years
together. The final outburst in 1665, which was one of the most severe in
its whole history, had followed an unusually long period of freedom from
plague in London, and was followed, as it were, by a still longer period
of freedom until at last it could be said that the plague was extinct. In
some large towns it had been extinct, as the event showed, at a much
earlier date; thus at York the last known epidemic was in 1604, and it can
hardly be doubted that many other towns in England, Scotland and Ireland
would have closed their records of plague earlier than they did had not
the sieges and military occupations of the Civil Wars given especial
occasion for the seeds of the infection to spring into life. Plague seemed
to be dying out all over England and Scotland (in Ireland it is little
heard of except in connexion with the Elizabethan and Cromwellian
conquests) for some time before its final grand explosion in London in
1665.

In seeking for the causes of its decline and extinction we must keep
prominently in view the fact that the virus was brought into the country
from abroad as the Black Death of 1348-9. But for that importation it is
conceivable that there would have been no signal history of plague in
Britain. Its original prevalence was on a great scale, and there were
several other widespread epidemics throughout the rest of the 14th
century. In the first volume of this history I have collected evidence
that plague was endemic or steady for long periods of the 15th and 16th
centuries in London, with greater outbursts at intervals, and that in the
17th century it came chiefly in great explosions. Something must have
served to keep the virus in the country, and more especially in the towns,
until at length it was exhausted. An exotic infection, or one that had not
arisen from indigenous conditions, and would probably never have so
arisen, does not remain indefinitely in the country to which it is
imported. Thus Asiatic cholera, imported into Europe on six, or perhaps
five, occasions in the 19th century, has never become domesticated; and
yellow fever had a career in the southern provinces of Spain during some
twenty years only. Plague did become domesticated for about three
centuries in England, and for longer in some other countries of Europe;
but it died out at length, and it would almost certainly have died out
sooner had it not found in all European countries some conditions not
altogether unsuited to it. What were the favouring conditions?

If, as I believe, the virus of plague had its habitat in the soil, from
which it rose in emanations, and if it depended therein, both remotely for
its origin in some distant country, as well as immediately for its
continuance in all countries, upon the decomposition of human bodies, then
it is easy to understand that the immense mortalities caused by each
epidemic would preserve the seeds of the disease, or the crude matters of
the disease, in the soil. Buried plague-bodies would be the most obvious
sources of future plagues. But if the theory given of the Black Death be
correct, bodies dead of famine or famine-fever would also favour in an
especial way the continuance of the plague-virus in certain spots of
ground, although they would probably never have originated it in this
country. Moreover, the products of ordinary cadaveric decomposition would
be so much pabulum or nutriment for the continuance of the virus. But all
those things being constant, the continuance of plague would largely
depend upon the manner in which the dead, after plague, or after famine
and fever, or in general, were disposed of. The soil of all England in
1348-9 was filled with multitudes of the dead laid in trenches, and there
were several general revivals of plague in the fifty or sixty years
following. In London there were plague-pits opened in the suburbs in many
great epidemics during three centuries. Even when there was no epidemic
the dead were laid in the ground in such a manner that their resolution
was speedy, and the diffusion of the products unchecked. But it is
undoubted that greater care in the disposal of the dead did at length come
into vogue. Thus, in the Black Book of the Corporation of Tewkesbury there
is an entry under the year 1603, that all those dead of plague, "to avoid
the perill, were buried in coffins of bourde," the disease having carried
off no fewer than 560 the year before (1602) and being then in its second
season.[57]. The reason given is "to avoid the peril," and it is beyond
question that burial in a coffin did in fact delay decomposition (unless
in peculiar circumstances which need not be particularized), and kept the
cadaveric products from passing quickly and freely into the pores of the
ground. Again, if the burial were in such coffins as the Chinese commonly
use, the decomposition would proceed almost as slowly as if the body had
been embalmed, and with as little risk of befouling the soil. For a long
time in England such burials were the privilege only of the rich; but as
wealth increased by commerce they became the privilege of all classes; and
in the last great plague of London, as I said in my former volume, "even
at the worst time coffins would seem to have been got for most." Defoe's
account of the burials in heaps in plague-pits is so exactly like that of
Dekker for the plague of 1603, and of other contemporaries for the plague
of 1625, that one may reasonably suspect him to have used these earlier
accounts as his authority for the practice in 1665, which he had no
direct knowledge of. However, I do not contend that there were no such
burials in 1665; just as one learns from Dekker that the coffin-makers in
1603 were busily employed and grew rich, although he also describes how a
husband "saw his wife and his deadly enemy whom he hated" launched into
the pit "within a pair of sheets." In ordinary times, as we learn from the
tables of burial-dues, there were poorer interments without coffins as
late as 1628, according to a document printed by Spelman, the name of the
parish being withheld, and even as late as 1672 in the parish of St
Giles's, Cripplegate. Spelman's object in writing in 1641 was to protest
against the mercenary practices of the clergy in the matter of burial,
recalling the numerous canons of the medieval Church directed against all
such forms of simony; and incidentally he mentions that it was testified
before the Commissioners that a certain parson "had made forty pound of
one grave in ten yeeres, by ten pounds at a time"[58]--a "tenancy of the
soil" short enough to satisfy even the so-called Church of England Burial
Reform Association. The use of coffins in the burial of the very poorest
is now so universal that we hardly realize how gradually it was
introduced. I am unable to say when burial in a sheet or cerecloth ceased;
but it became less and less the rule for the poorer classes throughout the
17th century. In 1666 was passed the Act for burial in woollen, which was
re-enacted more strictly in 1678[59]. The motive of it was to encourage
the native woollen manufactures, or to prevent the money of the country
from being expended on foreign-made linen; and its clauses ordained that
woollen should be substituted for linen in the lining of the coffin and in
the shrouding of the corpse, but that no penalty should be exacted for
burying in linen any that shall die of the plague. Whether it prohibited
in effect the use of linen cerecloths to enshroud corpses where no coffin
was used does not appear clearly from the terms of the Act; but, as the
intention was to discourage the use of linen, and to bring in the use of
woollen, for all purposes of burial, it is probable that it served to put
an end to coffinless burials altogether, wherever it was enforced,
inasmuch as the prescribed material was wholly unsuited for the purpose of
a cerecloth.

The history of the London plague-pit between Soho and the present Regent
Street shows that, after the last great plague of 1665-66, more caution
was used against infection from the buried plague-bodies. Macaulay says it
was popularly believed that the earth was deeply tainted with infection,
and could not be disturbed without imminent risk to human life; and he
asserts that no foundations were laid in the pest-field till two
generations had passed and till the spot had long been surrounded with
buildings, the space being left blank in maps of London as late as the end
of George I.'s reign[60].

After 1666 the old churchyards were not less crowded than before, but more
crowded, perhaps because coffined corpses occupied more space and decayed
more slowly. On 17 October, 1672, Evelyn paid a visit to Norwich: "I
observed that most of the churchyards (tho' some of them large enough)
were filled up with earth, or rather the congestion of dead bodys one upon
another, for want of earth, even to the very top of the walls, and some
above the walls, so as the churches seemed to be built in pitts." The same
day he had visited Sir Thomas Browne, the author of the famous essay on
urn burial or cremation, (suggested to him by the digging up of forty or
fifty funeral urns in a field at Old Walsingham). The essay is full of
curious learning and equally curious moralizing. But Sir Thomas, though a
physician, has not a word to say on so proximate a topic as the state of
the Norwich churchyards, which came under his eyes and perhaps under his
nose every day of his life[61].

The practice of burying in coffins, which came at length within the means
of all classes, may seem too paltry a cause to assign, even in part, for
so remarkable an effect as the absolute disappearance of plague after a
duration of more than three centuries. My view of the matter is that the
virus would have died out of itself had it not been continually augmented,
or fed by its appropriate pabulum, and that the gradual change in the mode
of interment helped to check such augmentation or feeding.

But the more elaborate interment of the dead was itself an index of the
greater spending power of the community, and it may be said that it was
the better condition of the people, and not this one particular thing in
it, which put an end to the periodical recurrences of plague. In all but
its earliest outbursts in the fourteenth, and perhaps the fifteenth
century, plague had been peculiarly an infection of the poor, being known
as "the poor's plague." Perhaps the chief reason why the richer classes
usually escaped it was that they fled from the plague-tainted place,
leaving the poorer classes unable to stir from their homes, exposed to the
infectious air, and all the more exposed that their habitual employments
and wages would cease, their sustenance become precarious, their condition
lowered, and their manners reckless. Again, it was not unusual for the
plague to break out in a season of famine or scarcity, during which the
ordinary risks of the labouring class would be aggravated. Famines ceased
(except in Ireland, where there had been comparatively little plague), and
scarcities became less common. The sieges and occupations of the Civil
Wars in the middle of the 17th century, which undoubtedly were the
occasion of the last outbursts of plague in many of the towns, were a
brief experience, followed by unbroken tranquillity. Whatever things were
tending to the removal of plague in all its old seats had free course
thereafter.

On the other hand, one may make too much of the increase of well-being
among the labouring class which coincided with the cessation of plague. As
a check upon population plague worked in a very remarkable way. In London,
as well as in towns like Newcastle and Chester, plague towards the end of
its reign arose perhaps once in a generation and made a clean sweep of a
fifth or a fourth part of the inhabitants, including hardly any of the
well-to-do. It destroyed, of course, many bread-winners and many that were
not absolutely sunk in poverty; but its broad effect was to cut off the
margin of poverty as if by a periodical process of pruning. The Lord Mayor
of London wrote to the Privy Council at the end of the great plague of
1625: "The great mortality, although it had taken many poor people away,
yet had made more poverty by decay of tradesmen"--a decay of trade which
they might reasonably expect to recover from before long. No such ruthless
shears was ever applied at intervals to the growing fringe of poverty in
after times. The poor were a more permanent residue, pressing more upon
each other; but they did not press more upon the rich, except through the
poor rate; on the contrary, the separation of classes became more marked.

Perhaps I ought to give an illustration of this, so as not to leave so
radical a change in the vague and disputable form of a generality. I shall
take the instance of Chester; its circuit of walls, remaining from the
Roman conquest, is something fixed for the imagination to rest upon amidst
changes within and without them.

    Passing over its medieval and its not infrequent Tudor experiences of
    epidemic sickness, let us come to the beginning of the 17th century.
    In two or three successive seasons from 1602 to 1605 it lost 1,313
    persons by plague, as well as about 250 from other causes. The
    population was then mostly within the walls, and probably did not
    exceed 5000. There was a shipping quarter on the west side, with
    egress by the Water-gate to the landing-places on the Dee; a millers'
    quarter, with corn-market and hostelries, on the south, connecting by
    the South gate and bridge with a hamlet across the river along the
    road to Wales; a Liberty or Freedom of the city outside the walls on
    the east, along the road to Warrington and Manchester, with a Bar, a
    short distance out, as in London, to mark the limit of the mayor's
    jurisdiction; and on the north side, within the walls, the
    cattle-market and shambles, with the market for country produce, and a
    few straggling houses without the gate on the road leading to
    Liverpool. Chester was a characteristic county town, with its
    cathedral clergy, its garrison, its resident nobility and gentry, its
    professional classes, its tradesmen, market people and populace, with
    the addition of a shipping trade to Ireland and afterwards to foreign
    and colonial ports. Plague continuing from 1602 to 1605 cut off a
    fourth or a fifth of its population, and these the poorest. The gaps
    in the population would gradually have filled up, and the fringe of
    poverty grown again[62].

    The plague came again in 1647, and cut off 2053 in the short space of
    twenty-three weeks from 22 June to 30 November. The bills of it are
    extant[63], and show on what parishes the plague fell most. All the
    parishes were originally within the walls but one, St John's, the
    ancient collegiate church of Mercia, built upon a rocky knoll in the
    south-east angle made by the walls with the river. The other nine
    parish churches and their graveyards were within the walls; but the
    parishes of three of them extended beyond the gates, just as the three
    parishes dedicated to St Botolph at the gates of London did. These
    three were St Oswald's, which included the Liberty on the east side,
    Trinity, which included the shipping quarter on the west as well as
    the houses along the Liverpool road on the north, and St Mary's, which
    included the millers' suburb across the Dee on the south. Hollar's
    map, made a few years after the plague of 1647, shows very few houses
    beyond the walls, except in the ancient Liberty on the east. But it
    will appear from the following table that the parishes which had
    extended beyond the walls must either have been very crowded close up
    to the walls (as the Gate parishes were always apt to be), or there
    must have actually been a greater population outside the gates than
    the contemporary map shows:

    _Burials from Plague in the several Parishes of Chester in 23 weeks,
    June 22-Nov. 30, 1647._

    _5 parishes wholly within the walls._

                     Total.   First   Worst (7th)
                              week.      week.

        St Peter       75        0        14
        St Bridget     85        7         9
        St Martin     173        9        23
        St Michael    133       26         9
        St Olave       59        3         5

    _3 parishes extending beyond the walls._

        St Oswald     396       11        37
        St Mary       314        5        20
        Trinity       232        1        32

    _1 parish wholly without the walls._

        St John       358        2        26
        Pesthouse     228        0        34
                     ----       --       ---
                     2053       64       209

    This was the last plague of Chester, but for a small outbreak in 1654.
    The next vital statistics that we get for the city are more than a
    century after, in 1774[64]. The population of 14,713 was then divided
    into two almost distinct parts, separated by the wall. The old city
    was being rebuilt, all but some ancient blocks of buildings held in
    the dead hand of the cathedral chapter; it was becoming a model 18th
    century place of residence for a wealthy and refined class, who were
    remarkably healthy and not very prolific, the parishes wholly within
    the walls having 3502 inhabitants. The poorer class had gone to live
    mostly outside the walls in new and mean suburbs, the three parishes
    at the Gates and extending now far beyond the walls, together with the
    original extramural parish of St John's, having a population of
    11,211. There was no town in Britain where the separation of the rich
    from the poor was more complete; there was hardly another town of the
    size where the health of the rich was better; and although the health
    of the populace was not so bad as in the manufacturing towns of
    Lancashire and Cumberland, close at hand, yet it is hardly possible to
    find so great a contrast as that between the clean and wholesome
    residential quarter within the walls and the mean fever-stricken
    suburbs as described by Haygarth in 1774:

    "The inhabitants of the suburbs," he says, "are generally of the
    lowest rank; they want most of the conveniences and comforts of life;
    their houses are small, close, crowded and dirty; their diet affords
    very bad nourishment, and their cloaths are seldom changed or
    washed.... These miserable wretches, even when they go abroad, carry a
    poisonous atmosphere round their bodies that is distinguished by a
    noisome and offensive smell, which is peculiarly disgustful even to
    the healthy and vigorous, exciting sickness and a sense of general
    debility. It cannot therefore be wondered that diseases should be
    produced where such poison is inspired with every breath."

The case of Chester shows by broader contrasts than anywhere else the
change from the public health of plague-times to that of more modern
times. But it can hardly be said to show the populace better off than
before; it shows them changed into a proletariat, and separated from the
richer classes by walls several feet thick. Such, at least, was the result
after four generations of immunity from plague, a result which indicates,
as I have said, that we may easily make too much of the improved
well-being of the poorer classes as a cause of the cessation of plague.

An easy explanation of plague ceasing in London has long been current, and
just because it is an easy explanation it will probably hold the field for
many years to come. It is that the fire of 1666 burnt out the seeds of
plague. Defoe, writing in 1723, ascribed this opinion to certain "quacking
philosophers," but he would hardly have said so if he could have foreseen
the respectable authority for it in after times. The plague had ceased in
most of its provincial centres after the Civil Wars, and in some of them,
such as York, from as early a date as 1604. It ceased in all the principal
cities of Western Europe within a few years of its cessation in London. In
London itself it ceased after 1666, not only in the City which was the
part burned down in September of that year, but in St Giles's, where the
Great Plague began, in Cripplegate, Whitechapel and Stepney, where it was
always worst, in Southwark, Bermondsey and Newington, in Lambeth and
Westminster. Nor can it be said that the City was the source from which
the infection used to spread to the Liberties and out-parishes. All the
later plagues of London, perhaps even that of 1563, began in the Liberties
or out-parishes and at length invaded the City. The part of London that
was rebuilt after 1666 contained many finer dwelling-houses than before,
built of stone, with substantial carpentry, and elegantly finished in fine
and rare woods. The fronts of the new houses did not overhang so as to
obstruct the ventilation of the streets and lanes; but the streets, lanes,
alleys and courts were somewhat closely reproduced on the old foundations.
A side walk in some streets was secured for foot-passengers by means of
massive posts, which, with the projecting signs of houses and shops, were
at length removed in 1766. The improvements in the City after the fire
were mostly in the houses of the richer citizens. The City was the place
of residence of the rich, with perhaps as many poorer purlieus in close
proximity as the residential districts of London now have. But four-fifths
of London at the time of the fire were beyond the walls of the City. It is
in these extramural regions that the interest mostly lies for epidemical
diseases. They remain, says Defoe in 1723, "still in the same condition
they were in before." Unfortunately we know little of their condition,
whether in the 17th century or in the 18th. But there must have been
something in it most unfavourable to health; for we find from the Bills of
Mortality that the cessation of plague made hardly any difference to the
annual average of deaths, the increase of population being allowed for.
This fact makes the disappearance of plague all the more remarkable.


Fevers to the end of the 17th century.

The epidemical seasons of 1685-86 were the last that Sydenham recorded; he
was shortly after laid aside from active work by gout, and died in 1689.
Morton, who made notes of fevers and smallpox until 1694, is more a
clinical observer than a student of "epidemic constitutions"; and although
his writings are of value to the epidemiologist, he does not help us to
understand the circumstances in which epidemic diseases prevailed more at
one time than another. To the end of the century there is no other medical
source of information, and little besides generalities to be collected
from any source. It is known that the years from 1693 to 1699 were years
of scarcity all over the kingdom, that the fever-deaths in London reached
the high figure of 5036 in 1694, and that there was a high mortality in
many country parishes and market towns during the scarcity. But there are
few particular illustrations of the type of epidemic sickness. There is,
therefore, little left to do but to give the figures, and to add some
remarks.

_Fever Deaths in the London Bills, 1687-1700._

                    Spotted   Deaths
           Fever     fever   from all
  Year     deaths    deaths   causes

  1687      2847      144     21460
  1688      3196      139     22921
  1689      3313      129     23502
  1690      3350      203     21461
  1691      3490      193     22691
  1692      3205      161     20874
  1693      3211      199     20959
  1694      5036      423     24109
  1695      3019      105     19047
  1696      2775      102     18638
  1697      3111      137     20292
  1698      3343      274     20183
  1699      3505      306     20795
  1700      3675      189     19443

_Tables from Short's Abstracts of Parish Registers._

          Registers    Registers with     Deaths     Births
  Year    examined     excess of death   in them    in them

  _Country Parishes._

  1689       144             27            828        692
  1690       146             17            532        324
  1691       147             16            336        180
  1692       147             10            207        146
  1693       146             27            650        426
  1694       148             18            465        348
  1695       149             23            649        492
  1696       150             19            503        344
  1697       150             21            559        409
  1698       152             12            397        289
  1699       151             20            433        318
  1700       160             29            890        739

  _Market Towns._

  1689        25             12           1965       1415
  1693        25              5            417        338
  1694        25              6           1307        681
  1695        25              3            309        246
  1696        26              4           1020        708
  1697        26              2            109         80
  1698        26              4            575        423
  1699        26              7           1181        867
  1700        27              4            726        587

In the London figures the year 1694 stands out conspicuous by its deaths
from all causes, and by its high total of fevers. The fever-deaths began
to rise from their steady weekly level a little before Christmas, 1693,
and remained high all through the year 1694, with a good many deaths from
"spotted fever" in the worst weeks. Among the victims in London in
February was Sir William Phipps, Governor of New England: his illness
appeared at first to be a cold, which obliged him to keep his chamber; but
it proved "a sort of malignant fever, whereof many about this time died in
the city[65]." Pepys, writing to Evelyn on 10 August, 1694, calls it "the
fever of the season," three being down with it at his house, but well
advanced in their recovery. In that week and in the week following, the
deaths in London from all causes touched the highest points of the year,
the deaths from fever and spotted fever being a full quarter of them.
Fever at its worst in London never made more than a quarter of the annual
deaths from all causes; so that, if we take it to have been the successor
of the plague, it operated in a very different way--with a greatly
lessened fatality of all that were attacked, with only a reminder of the
old special incidence upon the summer and autumn seasons, but with a
steadiness from year to year, and throughout each year, that made the
fever-deaths of a generation little short of one of those enormous totals
of plague-deaths that were rapidly piled up during a few months, perhaps
once or twice in a generation.

The following table from the London weekly Bills shows the progress of the
fever from the end of April, 1694, with the number of deaths specially
assigned to "spotted fever":--

_London: Weekly Mortalities from fever and all causes, epidemic of 1694._

  Week              Spotted   All
  ending     Fever   fever   deaths

  April 24     90      15    427
  May    1     77      10    369
         8     89       9    413
        15     80       5    395
        22    101       3    428
        29     72       8    430
  June   5    112      12    469
        12    113      12    434
        19    113      11    430
        26     99      14    396
  July   3     94      11    423
        17     86      10    445
        24    115      13    507
        31     84      13    484
  Aug.   7     99      10    462
        14    110      20    530
        21    135      19    583
        28    111      20    510
  Sept.  5    115      16    505
        12    112      12    462
        18     98       9    504
        25    106       4    490
  Oct.   2    124       8    533
         9    125      10    553
        16    114       9    552
        23    104       3    511
        30    118       3    528
  Nov.   6     70       3    439
        10     89       7    453
        13    106       2    471
        20    117      13    538
        27     79       6    456
  Dec.   4     87       6    475
        11     87       3    407
        18     78       4    445
        25     66       3    394

The year 1694, to which the epidemic of malignant fever (as well as
malignant smallpox) belongs, was one of the series of "seven ill years" at
the end of the 17th century (1693-99). They were long noted, says Thorold
Rogers, "for the distress of the people and for the exalted profits of the
farmer." The price of wheat in the autumn and winter of 1693 was the
highest since the famine of 1661. In 1697-8 corn was again dear and much
of it was spoilt. At Norwich in 1698 wheat was sold at 44_s._ a comb.

Harvests spoiled by wet weather or unseasonable cold appear to have been
the most general cause of the high prices of food. In London there was no
unusual sickness except in 1694; indeed the other years to the end of the
century show a somewhat low mortality, the year 1696, which Macaulay
marks as a time of severe distress among the common people owing to the
calling in of the debased coinage[66], had the smallest number of deaths
from all causes (18,638) since many years before, and for a century after
allowing for the increase of population. But the deaths from "fever" were
some three thousand every year, and the births, so far as registered,
were, as usual, far below the deaths.

It was in the country at large that the effects of the "seven ill years"
were chiefly felt. According to Short's abstracts of parish registers,
there was unusual mortality at the beginning of the period and at the end
of it; in his Chronology he mentions spotted fever, bloody flux and agues
in 1693 (besides an influenza or universal slight fever recorded by
Molyneux of Dublin), and again in 1697 and 1698 "purples, quinsies,
Hungarian and spotted fever, universal pestilential spotted fever," from
famine and bad food.

When we look for the evidence of this in England we shall have difficulty
in finding it. Short's own abstracts give almost no colour to it; but
there are other figures from the parish registers, scattered through the
county histories and statistical works, which prove that the seven ill
years must have checked population. Thus at Sheffield in the ten years
1691-1700 there was the greatest excess of burials over baptisms in the
whole history of the town from 1561--namely, 2856 burials to 2221 baptisms
(688 marriages). At Minehead, Somerset, a parish of some 1200 people
occupied in weaving, the deaths and births were as follows in four years
of the decennium:

        Baptised. Buried.

  1691     57      75
  1694     34      55
  1695     47      48
  1697     35      65

A glimpse of spotted or pestilential fever in Bristol during the years of
distress at the end of the 17th century comes from Dr Dover, a man of no
academical repute, but at all events an articulate voice. Passing from an
account of the spotted pestilential fever at Guayaquil, "when I took it by
storm," he goes on[67]:

    "About thirty-seven years since [written in 1732], this fever raged
    much in Bristol, so that I visited from twenty-five to thirty patients
    a day for a considerable time, besides their poor children taken into
    their workhouse, where I engaged myself, for the encouragement of so
    good and charitable an undertaking, to find them physick and give them
    advice at my own expense and trouble for the two first years. All
    these poor children in general had this fever, yet no more than one of
    them died of it of the whole number, which was near two hundred."

--an experience of typhus in children which was strictly according to
rule. This had clearly been the occasion of a memorial addressed to the
Mayor and Aldermen of Bristol, in 1696, praying that a capacious workhouse
should be erected for children and the aged, which "will prevent children
from being smothered or starved by the neglect of the parish officers and
poverty of their parents, which is now a great loss to the nation[68]."

The year 1698 was the climax of the seven ill years. The spring was the
most backward for forty-seven years, the first wheat in the ear being seen
near London on 16th June. For four months to the end of August the days
were almost all rainy, except from the 18th to the 26th July. Whole fields
of corn were spoilt. In Kent there was barley standing uncut on 29th
September, and some lay in the swathe until December. Much of the corn in
the north of England was not got in until Christmas, and in Scotland they
were reaping the green empty corn in January[69].


Fevers of the seven ill years in Scotland.

It is from Scotland that we hear most of the effects of the seven ill
years in the way of famine and fever. Scotland was then in a backward
state compared with England; and its northern climate, making the harvest
always a few weeks later than in England, told especially against it in
the ill years. Fynes Morryson, in the beginning of the 17th century,
contrasts the Scotch manner of life unfavourably with the English, and Sir
Robert Sibbald's account towards the end of that century is little better.
Morryson says, "the excesse of drinking was then farre greater in generall
among the Scots than the English." Sibbald remarks[70] on the drinking
habits of the Scots common people: their potations of ale or spirits on
an empty stomach, especially in the morning, relaxed the fibres and
induced "erratic fevers of a bad type, bastard pleurisies, ... dropsies,
stupors, lethargies and apoplexies." Morryson says: "Their bedsteads were
then like cubbards in the wall, with doores to be opened and shut at
pleasure, so as we climbed up to our beds. They used but one sheete, open
at the sides and top, but close at the feete, and so doubled[71]." Sibbald
says the peasantry had poor food and hard work, and were subject to many
diseases--"heartburn, sleeplessness, ravings, hypochondriac affections,
mania, dysentery, scrophula, cancer, and a dire troop of diseases which
everywhere now invades the husbandmen that were formerly free from
diseases." _Causa a victu est._ Therefore consumption was common enough.
He has much to say of fevers,--of intermittents, especially in spring and
autumn, catarrhal fevers, nervous fevers, comatose fevers, with delirium,
spasms and the like symptoms, malignant, spotted, pestilential, hectic,
&c. The continued fevers ranged in duration from fifteen to thirty-one
days, recovery being ushered in with sweats, alvine flux and salivation.
Purple fevers had sometimes livid or black spots mixed with the purple
(mottling); in a case given, there were suppurations which appear to have
been bubonic. There had been no plague in Scotland since 1647-48; but
fevers, unless Sibbald has given undue prominence to them, would appear to
have filled its place among the adults.

Another writer of this period, from whom some information is got as to
fevers, was Dr Andrew Brown of Edinburgh. He is mainly a controversialist,
and is on the whole of little use save for the history of the treatment of
fevers. He came to London on a visit in 1687, attracted by the fame of
Sydenham's method of curing fevers by antimonial emetics and by purgation:
"Returning home as much overjoyed as I had gotten a treasure, I presently
set myself to that practice"--of which he gave an account in his
'Vindicatory Schedule concerning the New Cure of Fever[72].' Continual
fever, he says, takes up, with its pendicles, the half of all the diseases
that men are afflicted with; and some part of what he calls continual
fever must have been spotted: "As concerning the eruption of spots in
fevers, these altogether resemble the marks made by stroaks on the skin,
and these marks are also made by the stagnation and coagulation of the
blood in the small channels [according to the doctrine of
obstructions].... They tinge the skin with blewness or redness."

The bitter controversy as to the treatment of fevers led Brown into
another writing in 1699[73].

    "The fevers that reign at this time [it was towards the end of the
    seven ill years] are for the most part quick and peracute, and cut off
    in a few days persons of impure bodies. And as I have used this method
    by vomiting and purging in many, and most successfully at this time,
    so I have had lately considerable experience thereof in my own family:
    wherein four of my children and ten servants had the fever, and
    blessed be God, are all recovered, by repeated vomiting with
    antimonial vomits and frequent purgings, except two servants, the one
    having gotten a great stress at work, who bragging of his strength did
    contend with his neighbour at the mowing of hay, and presently
    sickened and died the sixth day, and whom I saw not till the day
    before he died, and found him in such a condition that I could not
    give him either vomit or purge: and the other was his neighbour who
    strove with him, being a man of most impure and emaciate body, who had
    endured want and stress before he came to my service, and who got not
    all was necessary because he had not the occasion of due attendance,
    all my servants being sick at the time[74]."

This account of the experience which Dr Andrew Brown had lately had among
his children and domestics in or near Edinburgh was written in 1699, and
may be taken as relating to part of the wide-spread sickliness of the
seven ill years in Scotland. Fletcher of Saltoun gives us a general view
of the deplorable state of Scotland at the end of the 17th century, which
was intensified by the succession of bad harvests[75]. The rents of
cultivated farms were paid, not in money, but in corn, which gave occasion
to many inequalities, to the traditional fraudulent practices of millers
and to usury. The pasture lands for sheep and black cattle had no shelters
from the weather, and no winter provision of hay or straw (roots were
unheard of until long after), "so that the beasts are in a dying
condition." The country swarmed with vagrants (a hundred thousand, he
estimates, in ordinary times, but doubled in the dear years), who lived
and multiplied in incest, rioted in swarms in the nearest hills in times
of plenty, and in times of distress fell upon farmhouses in gangs of
forty or more, demanding food. Besides these there were a great many poor
families very meanly provided for by the Church boxes, who lived wholly
upon bad food and fell into various diseases. He had been credibly
informed that some families in the years of mere scarcity preceding the
climax of 1698-99 had eaten grains, for want of bread. "In the worst time,
from unwholesome food diseases are so multiplied among poor people that,
if some course be not taken, the famine may very probably be followed by a
plague[76]."

We owe some details of these calamities in Scotland to Patrick Walker, the
Covenanter, who records them to show how the prophecies of Divine
vengeance on the land, uttered during the Stuart persecutions by Cargill
and Peden, had been in due time fulfilled[77]:

    "In the year 1694, in the month of August, that crop got such a stroke
    in one night by east mist or fog standing like mountains (and where it
    remained longest and thickest the badder were the effects, which all
    our old men, that had seen frost, blasting and mildewing, had never
    seen the like) that it got little more good of the ground. In November
    that winter many were smitten with wasting sore fluxes and strange
    fevers (which carried many off the stage) of such a nature and manner
    that all our old physicians had never seen the like and could make no
    help; for all things that used to be proper remedies proved
    destructive. And this was not to be imputed to bad unwholesome
    victual; for severals who had plenty of old victual did send to
    Glasgow for Irish meal, and yet were smitten with fluxes and fevers in
    a more violent and infectious nature and manner than the poorest in
    the land, whose names and places where they dwelt I could instance.

    "These unheard-of manifold judgments continued seven years, not always
    alike, but the seasons, summer and winter, so cold and barren, and the
    wonted heat of the sun so much withholden, that it was discernible
    upon the cattle, flying fowls and insects decaying, that seldom a fly
    or gleg was to be seen. Our harvests not in the ordinary months, many
    shearing in November and December, yea some in January and February;
    the names of the places I can instruct. Many contracting their deaths,
    and losing the use of their feet and hands, shearing and working
    amongst it in frost and snow; and after all some of it standing still,
    and rotting upon the ground, and much of it for little use either to
    man or beast, and which had no taste or colour of meal. Meal became so
    scarce that it was at two shillings a peck, and many could not get it.

    "Through the long continuance of these manifold judgments deaths and
    burials were so many and common that the living were wearied with
    burying of the dead. I have seen corpses drawn in sleds. Many got
    neither coffins nor winding-sheet.

    "I was one of four who carried the corpse of a young woman a mile of
    way; and when we came to the grave, an honest poor man came and said,
    'You must go and help me to bury my son, he is lien dead this two
    days; otherwise I will be obliged to bury him in my own yard.' We
    went, and there were eight of us had two miles to carry the corpse of
    that young man, many neighbours looking on us, but none to help us. I
    was credibly informed, that in the North, two sisters on a Monday's
    morning were found carrying the corpse of their brother on a barrow
    with bearing-ropes, resting themselves many times, and none offering
    to help them.

    "I have seen some walking about at sunsetting, and next day at six
    o'clock in the summer morning found dead in their houses, without
    making any stir at their death, their head lying upon their hand, with
    as great a smell as if they had been four days dead; the mice or rats
    having eaten a great part of their hands and arms.

    "The nearer and sorer these plagues seized, the sadder were their
    effects, that took away all natural and relative affections, so that
    husbands had no sympathy with their wives, nor wives with their
    husbands, parents with their children, nor children with their
    parents. These and other things have made me to doubt if ever any of
    Adam's race were in a more deplorable condition, their bodies and
    spirits more low, than many were in these years."

    In the parish of West Calder, 300 out of 900 "examinable" persons
    wasted away.

    Some facts and traditions of the Seven Ill Years were recorded nearly
    a century after in the Statistical Account of Scotland. From the Kirk
    Session records of the parish of Fordyce, Banffshire, it did not
    appear "that any public measures were pursued for the supply of the
    poor, nor anything uncommon done by the Session except towards the
    end. The common distribution of the collections of the church amounted
    only to about 1_s._ 2_d._ or 1_s._ 4_d._ weekly." The Kirk Session
    records bore witness to the numerous cases of immorality in the years
    before the famine that had been dealt with ecclesiastically, and to
    the entire and speedy cessation of such cases thereafter[78].

    The account for the parish of Keithhall and Kinkell, Aberdeenshire,
    says that "many died of want, in particular ten Highlanders in a
    neighbouring parish, that of Kemnay; so that the Session got a bier
    made to carry them to the grave, not being able to afford coffins for
    such a number[79]." In the upland parish of Montquhitter, in the same
    county, the dear years reduced the population by one half or more.
    Until 1709 many farms were waste. Of sixteen families that resided on
    the estate of Lettertie, thirteen were extinguished. The account of
    this parish contains several stories of the distress, with the names
    of individuals[80]. It is clear, however, that all the parishes of
    Scotland were not equally distressed. The county of Moray and "some of
    the best land along the east coast of Buchan and Formartine
    [Aberdeenshire] abounded with seed and bread;" but transport to the
    upland parishes was difficult[81].

We may take it that these experiences in the reign of William III. were
peculiar to Scotland; even Ireland, which had troubles enough of the same
kind in the 18th and 19th centuries, was at that time resorted to as a
place of refuge by the distressed Scots. Among the special and temporary
causes in Scotland were antiquated agricultural usage, an almost
incredible proportion of the people in a state of lawless vagrancy, such
as Henry VIII. and Elizabeth had to deal with a century and a half before,
a low state of morals, both commercial and private, a tyrannical
disposition of the employers, a sullen attitude of the labourers, and a
total decay of the spirit of charity. An ancient elder of the parish of
Fordyce, who kept some traditions of the dear years, remarked to the
minister: "If the same precautions had been taken at that time which he
had seen taken more lately in times of scarcity, the famine would not have
done so much hurt, nor would so many have perished."

The evil of vagrancy, for which Fletcher of Saltoun saw no remedy but a
state of slavery not unlike that which Protector Somerset had actually
made the law of England for a couple of years, 1547-49, in somewhat
similar circumstances, gradually cured itself without a resort to the
practices of antiquity or of barbarism.

The union with England in 1707, by removing the customs duties and opening
the Colonial trade to Scots shipping (they had a share in the East India
trade already) gave a remarkable impulse to the manufacture of linen and
to commerce. Such was the demand for Scots linen that, it seemed to De
Foe, "the poor could want no employment"; and it may certainly be taken as
a fact that the establishment on a free basis of industries and foreign
markets gave Scotland relief from the pauperism and vagrancy, like those
of Ireland in the 18th and 19th centuries, that threatened for a time, and
especially in the Seven Ill Years, to <DW44> the developement of the
nation.

       *       *       *       *       *

For several years after the period of scarcity or famine from 1693 to
1699, the history of fever in Britain presents little for special remark.

A book of the time was Dr George Cheyne's _New Theory of Continual Fever_,
London, 1701. His theory is that of Bellini and Borelli, which accounted
for everything in fevers on mechanical principles, and ignored the
infective element in them. Cheyne does not even describe what the fevers
were; but in showing how the theory applies, he mentions incidentally the
symptoms--quick pulse, pain in the head, burning heat, want of sleep,
raving, clear or flame- urine, and morbid strength. Equally
theoretical is the handling of the subject by Pitcairn. Freind, in his
essays on fevers[82], is mainly occupied with controversial matters of
treatment, except in connexion with Lord Peterborough's expedition to
Spain in 1705, as we shall see in a section on sickness of camps and
fleets.

In the absence of clinical details from the medical profession, the
following from letters of the time will serve a purpose:

On 18 September, 1700, Thomas Bennett writes to Thomas Coke from Paris
giving an account of the fever of Coke's brother: His fever is very
violent upon him, and he has a hickup and twitchings in his face; he is
especially ill in the night, and has now and then violent sweats. He raved
for eight days together and in all that time did not get an hour's sleep.
He was attended by Dr Helvetius and other physicians. Lady Eastes, her
son, and most of her servants are sick, but they are all on the mending
hand; her steward is dead of a high fever, having been sick but five
days[83]. These are Paris fevers, the symptoms suggesting typhus,
especially the prolonged vigil in one of the cases. It is to be remarked
that they occurred among the upper classes; and it appears that the
universal fevers "of a bad type" in France in 1712 did not spare noble
houses nor even the palace of Louis the Great[84].

The following from the London Bills will show the prevalence of fever from
year to year[85].

         Dead of      Dead of         Dead of
  Year    Fever    Spotted Fever    all diseases

  1701     2902          68            20,471
  1702     2682          53            19,481
  1703     3162          74            20,720
  1704     3243          61            22,684
  1705     3290          41            22,097
  1706     2662          54            19,847
  1707     2947          42            21,600
  1708     2738          62            21,291
  1709     3140         118            21,800
  1710     4397         343            24,620
  1711     3461         142            19,833
  1712     3131          96            21,198
  1713     3039         102            21,057
  1714     4631         150            26,569
  1715     3588         161            22,232
  1716     3078         100            24,436
  1717     2940         137            23,446
  1718     3475         132            26,523
  1719     3803         124            28,347
  1720     3910          66            25,454


The London fever of 1709-10.

The "seven ill years" were followed by the fine summer and abundant
harvest (although hardly more than half the breadth was sown) of 1699.
Scarcity was not a cause of excessive sickness again until 1709-10;
although the harvest of 1703 was unfavourable. The price of wheat in 1702
was 25_s._ 6_d._ per quarter, and continued low for a number of years,
notwithstanding the war with France. In Marlborough's wars there were no
war-prices for farmers, as in the corresponding circumstances a century
after; on the contrary, corn and produce of all kinds were so cheap that
farmers had difficulty in paying their rents. The bounty of five shillings
per quarter on exported wheat had given a great impulse to corn-growing,
so that the acreage of wheat sown was much more than the country in an
ordinary year required, partly, no doubt, because the bread of the poorer
classes was largely made from the coarser cereals. The period of abundance
was broken by the excessively severe winter of 1708-9, one of three
memorable winters in the 18th century. The frost lasted all over Europe
from October to March, and was followed by a greatly deficient crop in
1709. The following shows the rise of the price of the quarter of wheat in
England:

                       _s._  _d._
  1708    Lady-day      27    3
   "      Michaelmas    46    3
  1709    Lady-day      57    6
   "      Michaelmas    81    9
  1710    Lady-day      81    9

The export of corn was prohibited in 1709 and again in 1710.

An epidemic of fever began in London in the autumn of 1709 and continued
throughout 1710, in which year the fever-deaths reached the highest total
since 1694. But it was not altogether a fever of starvation or distress
among the poor, and perhaps not mainly so. There is always the dual
question in connexion with fever following bad seasons and high prices:
how much of it was due to the scarcity, and how much to those states of
soil and atmosphere upon which the failure of the crop itself depended. An
authentic case of the malignant fever which began to rage in London in the
autumn of 1709 will both serve to show the remarkable type of at least a
portion, if not the whole of the epidemic, and to prove its incidence upon
the houses of the rich.

    The case is recorded by Sir David Hamilton[86]:

    "About the 5th of October, 1709, the son of that worthy gentleman,
    William Morison, esquire, was seized with a fever; at which time, and
    for some weeks before, a malignant fever raged in London." He had a
    quick and weak pulse, great difficulty or hindrance of speech, and a
    stupidity; "whereto were added tremors, and startings of the tendons,
    a dry and blackish tongue, a high- but transparent urine and
    coming away for the most part involuntarily, and a hot and dry skin."
    Dr Grew was called in, and prescribed alexipharmac remedies (cordials,
    sudorifics, etc.) "A few days after the patient's skin was stained or
    marked with red and purple spots, and especially upon his breast, legs
    and thighs. These symptoms, although a little milder now and then,
    prevailed for fourteen days; after that the spots vanished, and the
    convulsive motions so increased that the young gentleman seemed ready
    to sink under them for several days together." He was treated with the
    application of blisters, and with doses of bark. His strength and
    flesh were so wasted that the hip whereon he lay was seized with a
    gangrene. For ten or twelve days before his death, "he breathed and
    perspired so offensive a smell that they were obliged to smoke his
    chamber with perfumes; and even myself, whilst I inclined my body a
    little too near him, was, by receiving his breath into my mouth,
    seized all on a sudden with such a sickness and faintness that I was
    obliged to take the air in the open fields, and returning thence to
    drink plentifully of _mountain_ wine at dinner." The examination after
    death was made by the celebrated anatomist Dr Douglas. There was still
    a heap of brown- spots visible on the breast; "there was
    nothing contained in the more conspicuous vessels of the abdomen but
    grumes or clots of blackish blood, without any serum in the
    interstices." Hamilton adds: "We too seldom dissect the bodies of
    those dying in fevers."

The tremors, offensive sweats and offensive breath are distinctive of a
form of typhus that became common towards the middle of the century, and
was called putrid fever (not in the sense of Willis) or miliary fever from
the watery vesicles of the skin that often attended it. But although
Hamilton was writing on miliary fever (of the factitious variety) this
case is not given as an example, but is appended to his sixteen cases of
the latter, as an example of "a deadly fever with loss of speech from the
beginning." Among earlier cases, those belonging to the epidemic of 1661
as described by Willis correspond closely with this case, which we may
take as representing part of the malignant fever that then raged in
London. We have an anatomical record from each; but in neither was there
sloughing of the lymph-follicles of the intestine, or of the mesenteric
glands, as in the enteric fever of our own time; while in both there were
red or purple spots on the breast or neck, and on the limbs. The "loss of
speech from the beginning" suggests Sydenham's "absolute aphonia" in the
comatose fever of 1673-76, which resembled in other respects Willis's
fever of the brain and nervous stock (mostly of children) in 1661. One of
the synonyms of "infantile remittent" was "an acute fever with
dumbness[87]." This seems to have been a common type of fever in the
latter part of the 17th century and early part of the 18th. Some likeness
to enteric fever may be found in it, but there is no warrant for
identifying it with that fever. Its main features may be said to have been
its incidence upon the earlier years of life, but not to the exclusion of
adult cases, its remarkable ataxic symptoms, which led Willis to refer it
to "the brain and nervous stock" (spinal cord), its comatose character,
its spots, occasional miliary eruption, ill-smelling sweats and other
foetid evacuations, its protracted course, and its hectic sequelae.

The weekly bills of mortality in London bear little evidence of unusual
prevalence of fever in 1709, except in the weeks ending 13 and 20
September, when the fever-deaths were 96 and 75 (including "spotted
fever"). But the unusual entry of "malignant fever" appears in three
weekly bills, 19 July, 9 August and 23 August, one death being referred to
it on each occasion. It was in the summer and autumn of 1710 that the
fever reached a height in London, being attended with a very fatal
smallpox. An essay on the London epidemic of 1710[88] is interesting
chiefly for recording a probable case of relapsing fever, a form which was
almost certainly part of the great febrile epidemic in London in 1727-29.

    Mrs Simon, aged 20, had a burning fever, stifling of her breath,
    frequent vomiting and looseness, foul tongue, loss of sleep,
    restlessness, intermitting, low and irregular pulse. This terrible
    fever disappeared on the fourth day, and she thought herself
    recovered. But on the seventh day from her being taken ill the fever
    returned, she was light-headed, did not know her relatives, and was
    fevered in the highest degree. It looked like a malignant fever, but
    there were no spots.

The following table shows the very high mortality from fever (as well as
from smallpox) in the epidemic to which the above case belonged.

_London: Weekly deaths from fever, smallpox and all causes._

1710.

  Week       Dead of       Dead of       Dead of       Dead of
  ending      fever     spotted fever    smallpox    all diseases

    May  2     103       [illegible]        99           571
         9      90             6            60           517
        16      84             7            71           502
        23      93            15            71           503
        30     106            11            83           550
   June  6      93             2            98           508
        13      79             8            84           509
        20     106            12            99           574
        27     105            15            86           503
   July  4     106             7            99           482
        11     107            13            97           467
        18     126            16            89           509
        25     109            13           105           562
   Aug.  1      91            12            79           444
         8      92            11            72           463
        15      98            10            58           459
        22     105            10            63           463
        29     111            16            71           495
  Sept.  5      76             4            63           414
        12[89] 107            12            57           520
        19     115             9            83           548
        26      81            11            46           456
   Oct.  3      98             9            45           469
        10      79            10            49           480
        17      90             5            41           477
        24     107             5            45           470
        31     106            14            51           421
   Nov.  7      71             6            55           425
        14      92             2            41           390
        21      70             4            25           345

Throughout England, in country parishes and in towns, the first ten years
of the 18th century were on the whole a period of good public health. In
Short's abstracts of the parish registers to show the excess of deaths
over the births, those years are as little conspicuous as any in the long
series. It was a time when there was a great lull in smallpox, and
probably also in fevers. The figures for Sheffield may serve as an
example[90]. It will be seen from the Table that the burials exceeded the
baptisms in every decade from the Restoration to the end of the century;
after that for twenty years the baptisms exceeded the burials, the
marriages having increased greatly.

_Vital Statistics of Sheffield._

  Ten-year
  periods        Marriages     Baptisms     Burials

  1661-70           585          2086         2266
  1671-80           537          2240         2387
  1681-90           540          2595         2856
  1691-1700         688          2221         2856
  1701-10           942          3033         2613
  1711-20           991          3304         2765

Of particular epidemics, we hear of a malignant fever at Harwich in 1709.
Harwich was then an important naval station, and the fever may have arisen
in connexion with the transport of troops to and from the seat of war,
just as camp- and war-fevers appeared at various ports in the next war,
1742-48.

There were rumours of a plague at Newcastle in 1710, which were
contradicted by advertisement in the _London Gazette_[91]. But, as there
was so much plague in the Baltic ports in 1710 it is possible that the
Newcastle rumour may have been one of plague imported, and not a rumour
suggested by the mortality from some other disease.

To the same period of epidemic fever in London, about 1709-10, belongs
also a curiously localized epidemic in an Oxford college, which reminds
one somewhat of the circumstances of enteric fever in our time. It was
told to Dr Rogers of Cork twenty-five or twenty-six years before the date
of his writing (1734), by one who was a student at Oxford then: "There
broke out amongst the scholars of Wadham College a fever very malignant,
that swept away great numbers, whilst the rest of the colleges remained
unvisited. All agreed that the contagious infection arose from the
putrefaction of a vast quantity of cabbages thrown into a heap out of the
several gardens near Wadham College[92]."

The next epidemic of fever in London was in 1714. Like that of 1710, it
followed a great rise in the price of wheat, or perhaps it followed the
unseasonable weather which caused the deficient harvest. Before the Peace
of Utrecht wheat in England was as low as 33_s._ 9_d._ per quarter, in
1712, the peace next year sending it no lower than 30_s._ But at
Michaelmas, 1713, it rose with a bound to 56_s._ 11_d._, doubtless owing
to a bad harvest. The fever-deaths in London began to rise in the spring
of 1714, reaching a weekly total of 103 in the week ending 20 April. All
through the summer and autumn they continued very high, the weekly totals
exceeding, on an average, those of the year 1710, as in the foregoing
table, and having corresponding large additions of "spotted fever." The
deaths from all causes in 1714 were a quarter more than those of the year
before, the epidemic of fever being the chief contributor to the rise.
This happened to be a very slack time in medical writing[93]; but, even in
the absence of such testimony as we have for earlier and later epidemics
of fever in London, we may safely conclude that the fever of 1714 was of
the type of pestilential or malignant typhus, beginning in early summer
and reaching a height in the old plague season of autumn.

A singular instance of what may be considered war-typhus belongs to the
winter of 1715-16. The political intrigues preceding and following the
death of Queen Anne in 1714 culminated in the Jacobite rising in Scotland
and the North of England in 1715. The Jacobites having been defeated at
Preston on 13 November, prisoners to the number of 450 were brought to
Chester Castle on the Sunday night before December 1st. A fortnight later
(December 15th), Lady Otway writes of the 450 prisoners in the Castle:

    "They all lie upon straw, the better and the worse alike. The king's
    allowance is a groat a day for each man for meat, but they are almost
    starved for want of some covering, though many persons are charitable
    to the sick." The winter was unusually severe, the snow lying "a yard
    deep." Many prisoners died in the Castle by "the severity of the
    season," many were carried off by "a very malignant fever." On
    February 16th Lady Otway writes again:--"So much sickness now in our
    Castle that they dye in droves like rotten sheep, and be 4 or 5 in a
    night throne into the Castle ditch ffor ther graves. The feavour and
    sickness increaseth dayly, is begun to spread much into the citty, and
    many of the guard solidyers is sick, it is thought by inffection. The
    Lord preserve us ffrom plague and pestilence[94]!"


Prosperity of Britain, 1715-65.

The fifty years from 1715 to 1765 were, with two or three exceptions,
marked by abundant harvests, low prices and heavy exports of corn. This
was undoubtedly a great time in the expansion of England, a time of
fortune-making for the monied class, and of cheapness of the necessaries
of life.

The well-being and comfort of the middle class were undoubtedly great;
also there was something peculiar to England in the prosperity of towns
and villages throughout all classes. In the very worst year of the period,
the year 1741, Horace Walpole landed at Dover on the 13th September,
having completed the grand tour of Europe. Like many others, he was
delighted with the pleasant county of Kent as he posted towards London;
and on stopping for the night at Sittingbourne, he wrote as follows in a
letter:

    "The country town delights me: the populousness, the ease, the gaiety,
    and well-dressed everybody, amaze me. Canterbury, which on my setting
    out I thought deplorable, is a paradise to Modena, Reggio, Parma, etc.
    I had before discovered that there was nowhere but in England the
    distinction of _middling people_. I perceive now that there is
    peculiar to us _middling houses_; how snug they are[95]!"

Our history henceforth has little to record of malignant typhus fevers, or
of smallpox, in these snug houses of the middle class, although not only
the middle class, but also the highest class had a considerable share of
those troubles all through the 17th century. But the 18th century, even
the most prosperous part of it, from the accession of George I. to the
beginning of the Industrial Revolution in the last quarter or third of it,
was none the less a most unwholesome period in the history of England. The
health of London was never worse than in those years, and the vital
statistics of some other towns, such as Norwich, are little more
satisfactory. This was the time which gave us the saying, that God made
the country and man made the town. Praise of rural felicity was a common
theme in the poetry of the time, as in Johnson's _London_:

  "There every bush with nature's music rings,
   There every breeze bears health upon its wings."

Both for the country and the town the history of the public health does
not harmonize well with the optimist views of the 18th century. The
historians are agreed that, under the two first Georges, during the
ministries of Walpole, the Pelhams and Pitt, the prosperity of Britain was
general. Adam Smith speaks of "the peculiarly happy circumstances of the
country" during the reign of George II. (1727-60). Hallam characterizes
the same reign as "the most prosperous that England had ever experienced."
The most recent historian of England in the 18th century is of the same
opinion[96]. The novels of Fielding give us the concrete picture of the
period with epic fidelity, and the picture is of abundance and
prodigality. Agriculture and commerce with the Colonies, India and the
continent of Europe, were the sources of the country's wealth. Farming and
stock-raising had been greatly improved by the introduction of roots and
sown grasses. In some country parishes the baptisms were three times the
burials. But the public health during this period will not appear in a
favourable light from what follows. More particularly there were three
occasions, about the years 1718, 1728 and 1741, when a single bad harvest
in the midst of many abundant ones brought wide-spread distress, with
epidemics of typhus and relapsing fever; from which fact it would appear
that the common people had little in hand. Thorold Rogers, among
economists, was of the opinion that the prosperity was all on the side of
the governing and capitalist classes, that the labourers were in
"irremediable poverty" and "without hope," and that the law of parochial
settlement, with the artificial fixing of wages by the Quarter Sessions
and the bonuses out of the poor-rates, had the effect of keeping the mass
of the people on the land "in a condition wherein existence could just be
maintained[97]." I shall not attempt an independent judgment in economics,
but proceed to those illustrations of national well-being which belong to
my subject, leaving the latter to have their due weight on the one side of
economical opinion or on the other. Besides the economical question there
is of course also an ethical one. When the pinch came about 1766, there
was the usual diversity of opinion expressed on the "condition of England"
problem, one holding that the labourers were unfairly paid, another that
the nation had been made "splendid and flourishing by keeping wages low,"
and that the distress was due to "want of industry, want of frugality,
want of sobriety, want of principle" among the common people at large. "If
in a time of plenty," wrote one austere moralist, "the labourers would
abate of their drunkenness, sloth, and bad economy, and make a reserve
against times of scarcity, they would have no reason to complain of want
or distress at any time[98]." But there must have been something wrong in
the economics and morals of their betters if it were the case that the
working class as a whole, and not merely a certain number of individuals
in it, was drunken, thriftless and slothful. The familiar proof of this is
the apathy of the Church, broken by the Methodist revival of religion.


The epidemic fevers of 1718-19.

In the fifty years from 1715 to 1765, the three worst periods of epidemic
fever in England and Scotland correspond closely to the three periods of
actual famine and its attendant train of sicknesses in Ireland, namely,
the years 1718-19, 1727-29, and 1740-42. The three divisions of the
kingdom suffered in common, Ireland suffering most. The first period,
1718-19, was an extremely slack tide in medical writing, insomuch that
hardly any accounts of the reigning maladies remain, except those by
Wintringham, of York, and Rogers, of Cork. The whole of the Irish history
of fevers and the allied maladies is dealt with in a chapter apart. Of the
Scots history, little is known for the first of the three periods beyond a
statement that there was a malignant fever and dysentery in Lorn,
Argyllshire, in January and February, 1717[99].

Wintringham gives the following account of the _synochus_, afterwards
called typhus, which attracted notice in the summer of 1718 and became
more common in the warm season of 1719: in each year it began about May,
reached its height in July and lasted all August, carrying off many of
those who fell into it.

    It began with rigors, nausea and bilious vomiting, followed by
    alternate heats and chills, with great lassitude and a feeling of
    heaviness: then thirst and pungent heat, a dry and brown tongue,
    sometimes black. The patient slept little, did not sweat, and was
    mostly delirious, or anxious and restless, tossing continually in bed.
    About the 12th day it was not unusual for profuse and exhausting
    diarrhoea to come on. In a favourable case the fever ended in a crisis
    of sweating about the 16th day. Those who were of lax habit,
    unhealthy, hysteric, or cachectic, were apt to have tremors, spasms
    and delirium, while others were so prostrated as to have no control
    over their evacuations, lying in a stupor and raving when roused out
    of it. In these the fever would continue to the 20th day; in some few
    it ended without a manifest crisis, and with a slow
    convalescence[100].

This applies to the city of York, but in what special circumstances we are
not told. However, it happens that a physician of York, two generations
after, in giving an account of the great improvement that had taken place
in its public health, throws some light on its old-world state: "The
streets have been widened in many places by taking down a number of old
houses built in such a manner as almost to meet in the upper stories, by
which the sun and air were almost excluded in the streets and inferior
apartments[101]."

In London the fever-deaths, with the deaths from all causes, rose
decidedly in 1718, and reached a very high figure in 1719, of which the
summer was excessively hot. One cause, at least, was want of employment,
especially among weavers in the East End[102]. But the epidemic fever of
1718-19 was not limited to the distressed classes; we have a glimpse of
it, under the name of "spotted fever," in the family of the archbishop of
Canterbury:

"On Friday night the archbishop of Canterbury's sixth daughter was
interred in our chancel, with four others preceding, she dying on Monday
after three days of the spotted fever. The fourth and seventh are
recovered, and hoped past danger[103]."

The following table shows the fever-mortalities for London, from 1718
onwards, and, for comparison, the excessive mortalities in the epidemics
of 1710 and 1714:

_London Mortalities from Fever, &c._

  Year    Fevers    Spotted fevers    Smallpox    All causes

  1710     4397           343           3138        24620
  1714     4631           150           2810        26569
  1718     3475           132           1884        26523
  1719     3803           124           3229        28347
  1720     3910            46           1442        25454
  1721     3331            84           2375        26142
  1722     3088            22           2167        25750
  1723     3321            51           3271        29197
  1724     3262            84           1227        25952
  1725     3277            59           3188        25523
  1726     4666            84           1569        29647
  1727     4728           102           2379        28418
  1728     4716            94           2105        27810
  1729     5235       [The entry        2849        29722
  1730     4011          ends.]         1914        26761
  1731     3225                         2640        25262
  1732     2939                         1197        23358
  1733     3831                         1370        29233
  1734     3116                         2688        26062
  1735     2544                         1594        23538
  1736     3361                         3014        27581
  1737     4580                         2084        27823
  1738     3890                         1590        25825
  1739     3334                         1690        25432
  1740     4003                         2725        30811

In country parishes, according to Short's abstracts of registers, there
was no unusual sickness in 1718 and 1719. But in market towns the
mortality rose greatly in 1719, which had an excessively hot summer; and
that was the year when the _synochus_ or typhus described by Wintringham
reached its worst at York. The mortality kept high for several years after
1719.

_Market Towns._

          Registers    Registers with     Deaths     Births
  Year    examined    excess of deaths    in same    in same

  1716       30               8             1060        845
  1717       30               9             1485       1290
  1718       30               3              249        169
  1719       30               6             1737       1320
  1720       30              10             2186       1461
  1721       33               9             1294        952
  1722       33              11             1664       1345
  1723       33              14             2532       2176

The high mortalities in 1721-23 were mostly from smallpox, exact figures
of many of the epidemics in Yorkshire and elsewhere being given in the
chapter on that disease. The country parishes shared in its prevalence:

_Country Parishes._

          Registers    Registers with     Deaths     Births
  Year    examined    excess of deaths    in same    in same

  1721       174             35             793        586
  1722       175             35            1015        775
  1723       174             63            2021       1583

Besides smallpox, diarrhoeas and dysenteries in the autumn are given by
Wintringham as the reigning maladies, fever not being mentioned.


The Epidemic Fevers of 1726-29: evidence of Relapsing Fever.

The four years 1726-29 were a great fever-period in London, the deaths
having been as follows:

  Year    Fever deaths    All deaths

  1726        4666          29,647
  1727        4728          28,418
  1728        4716          27,810
  1729        5335          29,722

In the last of those years the entry in the annual bills becomes "fever,
malignant fever, spotted fever and purples."

The following are the weekly maxima of fever deaths and deaths from all
causes during the four years, 1726-29; in nearly all the weeks the deaths
from "convulsions" (generic name for most of the maladies of infants)
contribute from a fourth to a third, or even more, of the whole mortality.

          Week       Fever      All
         ending      deaths    deaths
  1726
        Jan.  18        71       633
        March 15        81       678
        May   31       103       611
        June   7       106       607
        Aug.  30       102       711
        Sept.  6       116       680
              13       109       643
              20       109       648
  1727
        Aug.   8       103       577
              15       123       698
              22       132       730
              29       130       789
        Sept.  5       150       764
              12       134       795
              19       165       798
              26       163       715
        Oct.   3       150       684
  1728
        Feb.   6       112       748
              13       131       889
              20       121       850
              27       145       927
        March  5        93       733
        Aug.  27       138       525
        Sept.  3       131       562
        Dec.  10       122       734
  1729
        Sept.  9       109       676
        Nov.   4       213       908[104]
              11       267       993[104]
              18       166       783
        Dec.   9       132       779

These are high mortalities, whatever were the types of fever that caused
them. That the old pestilential fever of London was one of them we need
have no doubt. Dr John Arbuthnot, writing two or three years after, said,
"I believe one may safely affirm that there is hardly any year in which
there are not in London fevers with buboes and carbuncles [the distinctive
pestilential marks]; and that there are many petechial or spotted fevers
is certain[105]."

The essay of Strother also has a reference to "spotted fever" in its
title, although the text throws very little light upon it[106]. But, for
the rest, the "constitution" of 1727-29 is more than usually perplexing.
There was an influenza at the end of 1729, which can be separated from the
rest easily enough by the help of the London weekly bills of mortality;
and it is probable, unless Arbuthnot, Huxham and Rutty have erred in their
dates, that one or more epidemics of catarrhal fever had occurred before
that, in the years 1727 and 1728. The greatest difficulty is with a
certain "little fever," or "hysteric fever," or "febricula," which gave
rise to some writing and a good deal of talk. Strother does not specially
treat of it, at least under that name, although he says that "many,
especially women, have been subject to fits of vapours, cold sweats,
apprehensions, and unaccountable fears of death; every small
disappointment dejected them, tremblings and weakness attended them," etc.
(p. 116); and again, "never was a season when apoplexies, palsies and
other obstructions of the nerves did prevail so much as they do at
present, and have done for some time past" (p. 102); while he had
frequently seen hysterical and hypochondriacal symptoms, dejection of
spirits and the like remaining behind the fever (p. 109). For some years
before this, much had been heard in London of the vapours, the "hypo," the
spleen, and the like, an essay by Dr Mandeville, better known by his
'Fable of the Bees,' having first made these maladies fashionable in the
year 1711[107].

In due time it began to be noticed that symptoms which many physicians
made light of as a "fit of vapours" were really the beginning of a fever.
Dr Blackmore, in an essay on the Plague written in 1721, admitted the
ambiguity:

    "For several days a malignant fever has so near a resemblance to one
    that is only hysterick, that many physicians and standers by, I am apt
    to believe, mistake the first for the last, and look upon a great and
    dangerous disease to be only the spleen, or a fit of the vapors, to
    the great hazard of the patient[108]."

In 1730, Dr William Cockburn, in a polemic against the physicians whom he
styles "the academical cabal" (because they objected to his secret
electuary for dysentery), professes to give a history of the mistakes of
the faculty in London over this "little fever," or "hysteric fever," which
often became dangerous[109]:

    "The present fever, with a variation in some of its symptoms, has now
    subsisted twelve years [or since 1718] not in England only, but all
    over Europe [Manningham says it was peculiarly English]. Few or no
    physicians suspected the reigning and popular disease to be a fever.
    Vapours, a nervous disease, and such general appellations it had from
    sundry physicians. Others, who discovered the fever, knew it was the
    low or slow fever, first mentioned by Hippocrates.... The last were
    represented as ignorant for calling the distemper a fever, and
    affixing to it the name 'low' or 'slow,' a slow fever being, in their
    adversaries' opinion, altogether unheard of among physicians and never
    recorded in their books. Nothing was more monstrous than calling this
    distemper a fever, or confining persons afflicted with it to their
    bed, and dieting them with broth, or other liquid food of good
    nourishment, and what is easily concocted.... 'You are not hot, you
    are not dry; you are in good temper; and therefore you have no fever'
    was the common language of the town.... They might have seen
    physicians practising for a destroying distemper, and yet, after seven
    years, they confess themselves ignorant of its very name."

At length, he continues, Blackmore admitted the ambiguity of diagnosis,
while Mead, Freind and others, recognized that there was really such a
thing as a slow, nervous fever, by no means free from danger to life. It
is probably to this insidious fever that Strother refers:

    "Thus, having gone on for six or seven days in a train of indolence,
    they have been surprized on the seventh day, and have died on the
    eighth lethargick or delirious, whereas, if they had taken due care,
    the fever would have run its course in fifteen days or more." It was
    the remissions, or intermissions, he explains, that often misled
    patients, by which he seems to mean the clear intervals between
    relapses. "Others, wearied out with relapses, have hoped their
    recovery would as certainly ensue as it had hitherto, and have
    deferred asking advice until it was too late." These relapses, he
    thought, were brought on by venturing too soon into the air: "it is
    too well known that the fever has been cured, and patients have soon,
    after they have ventured into the air, relapsed and have again run the
    same circle of ill symptoms, if not worse than before." Bark failed
    conspicuously in these "remittents:" "it is therefore incumbent on me
    to examine into the reason of this _new phenomenon_. I call it _new_,"
    he explains, because bark had hitherto succeeded. "Perhaps we may find
    reason to lay some blame on the air for the frequent relapses....
    Periodical comas have of late been common; so soon as the fit was
    over, the drowsiness abated till the fit returned."

    Elsewhere he speaks of the frequent relapses as belonging to a
    "quartan," under which diagnosis bark had been tried. The fevers were
    less apt to "relapse" when treated by mild cathartics. Another symptom
    of this fever was jaundice: "If jaundice breaks forth on the fourth
    day of a fever, it is much better than if it comes at the conclusion
    of a fever.... Jaundices are now very common after the cure of these
    fevers."

These indications, dispersed throughout the rambling essay of Strother,
point somewhat plainly to relapsing fever[110]. But his theoretical
pathology comes in to obscure the whole matter. He explains everything by
obstructions. The jaundice was due to obstruction of the liver by
"styptics," the hysteric symptoms to obstructions of the nerves; there
were also theoretical obstructions of the mesentery, part of the matter
being sometimes "thrown off into the mesenteric glands"; also
"congestions" or phlegmons of the liver, spleen and pancreas. But it is
when he comes to the bowels that his subjective morbid anatomy becomes
truly misleading. There is nothing to show that Strother examined a single
body dead of this fever. He says, however, in his _a priori_ way: "The
crisis of these slow fevers is generally deposited on the bowels.... The
lent fever is a symptomatical fever, arising from an inflammation, or an
ulcer fixed on some of the bowels. A lent fever, depending on some fixed
cause of the bowels, must be cured by having regard to those causes some
of which I shall enumerate":--the first supposition being that the fever
depends on phlegmons by congestion of "the liver, spleen, pancreas, or the
mesentery"; the second, if it depends on extravasations in an equally
comprehensive range of viscera; the third, "if it depends on an ulcer,
then all vulneraries must be administered internally; but to speak truth,
when the viscera are ulcerated, there remains but small hope of life"; the
fourth supposition is worms, the fifth corruption of the humours. All
this is paper pathology. There is not a single precise fact relating to
ulcerated Peyer's patches, or to swollen mesenteric glands, or to enlarged
spleen, which last would have been equally distinctive of relapsing as of
enteric fever; it is "the viscera" that are ulcerated, or congested, or
extravasated, or it is "some of the bowels," or the pancreas and liver
obstructed as well as the spleen, the obstruction of the liver being
invoked to explain the highly significant jaundice.

It is not quite clear whether Strother's fever with relapses and jaundice
corresponded exactly to the little fever, hysteric fever, or nervous fever
of the same years; but it is worthy of note that relapsing fever in
Ireland a century later was called febricula or the "short fever." It was
not until 1746 that the excellent essay upon it by Sir Richard Manningham
was written. By that time a good deal was being said in various parts of
Britain of a slow, nervous, or putrid fever, Huxham, in particular,
identifying the nervous fever with Manningham's febricula or little
fever[111]. Some have supposed that the nervous fever of the 18th century
included cases of enteric fever, if it did not stand for that disease
exclusively. Murchison takes Manningham's essay to be "an excellent
description of enteric fever, under the title of febricula or little
fever, etc.[112]" The following are brief extracts from his description,
by which the reader will be able to form his own opinion on the question
of identity[113].

    At the beginning patients feel merely languid or uneasy, with flying
    pains, dryness of the lips and tongue but no thirst; in a day or two
    they find themselves often giddy, dispirited and anxious without
    apparent reason, and passing pale urine. They have transient fits of
    chilliness, a low, quick and unequal pulse, sometimes cold clammy
    sweats and risings in the throat. They go about until more violent
    symptoms come on, simulating those of quotidian, tertian or quartan
    fever; sometimes the malady simulates pleurisy. There may be attacks
    of dyspnoea, nausea and haemorrhage; the menses in women are checked.
    A loss of memory and a delirium occur at intervals for short periods.
    The malady is very difficult to cure and too often becomes fatal in
    the end. It will last thirty or forty days, unless it end fatally in
    stupor or syncope. A form of mania is a consequence of it, where it
    has been neglected or badly treated; "of late years this species of
    madness has been more than ordinarily frequent." All sorts were liable
    to it, but mostly valetudinarians, delicate persons, and those in the
    decline of life; the fatalities were "especially among the opulent
    families of this great metropolis[114]."

This fever-period in London corresponds on the whole closely with a series
of unhealthy years in Short's tables from the registers of market towns
and country parishes, and with high mortalities in the Norwich register.
It was not specially a smallpox period, as the last unhealthy year, 1723,
was. On the other hand the epidemiographists in Yorkshire, Devonshire and
Ireland dwell most upon fevers of the nature of typhus, some of which were
due to famine or dearth, and upon "agues."

_Market Towns._

         Registers  No. with excess  Deaths    Births
  Year   examined      of deaths     in same   in same

  1727       33           19          3606      2441
  1728       34           23          4972      2355
  1729       36           27          6673      3494
  1730       36           16          3445      2529

_Norwich._

  Year     Buried      Baptized

  1728      1417          774
  1729      1731          843

_Country Parishes._

         Registers    With excess   Burials   Baptisms
  Year   examined     of burials    in same   in same

  1726      181           22           542       495
  1727      180           55          1368      1091
  1728      180           80          2429      1536
  1729      178           62          2015      1442
  1730      176           39          1302      1022
  1731      175           24           700       614

The best epidemiologists of the time were not in London, but at York,
Ripon, Plymouth, Cork and Dublin. Leaving the Irish history to a separate
chapter, we shall find in the annals of Wintringham, Hillary and Huxham a
somewhat detailed account of the fevers which caused the very high
mortalities of the years 1727-29, with an occasional glimpse of the
circumstances in which the fevers arose. Much of what follows relates to
the same nervous, hysteric or "putrid" fever, with or without relapses,
that has been described for London. Going back a little, Wintringham
says[115] that the continued fevers of 1720 were milder than those of the
year before (which were synochus or typhus) and were often languid or
nervous, with giddiness, stupor and nervous tremblings, a quick pulse, a
whitish tongue, no thirst, and sweats of the head, neck and chest: this
fever lasted twenty days or more, and ended in a general sweat. He had
mentioned the "languid nervous fevers" first in the years 1716 and 1717,
and he mentions them again as mixed with or following the synochus or
typhus of 1727-28.

In April, 1727, there were fevers prevalent, remitting and intermitting,
but with uncertain paroxysms; in May, a fever with pleuritic pains; in
July, a putrid fever in some, but the chief diseases of that month were
"remittents and intermittents," which were often attended by cutaneous
eruptions, sometimes of dusky colour and dry, at other times full of clear
serum; which, "as they depended upon a scorbutic taint, tormented the sick
with pruritus." The sick persons in these remittents were for the most
part drowsy and stupid, especially during the paroxysm; the fevers were
followed by lassitude, debility, languor of spirits and hysteric symptoms.

Hillary[116], who practised at Ripon, not far from Wintringham, at York,
records in 1726 the prevalence of remittents and intermittents: "some had
exanthematous eruptions towards the latter end of the disease, filled with
a clear or yellowish water, which went or dried away without any other
inconvenience to the sick but an uneasy itching for a few days"--just as
Wintringham had described a miliary fever for 1727. It is also under 1726
that he describes the same drowsy and nervous symptoms of Wintringham's
summer fever of 1727:

    "Ancient and weak hysterical people had nervous twitchings and
    catchings, and were comatous and delirious; some were very languid,
    sick and faint, and had tremors; the young and robust, who had more
    full pulses, were generally delirious, unless it was prevented or
    taken off by proper evacuations and cooling medicines. I found
    blistering to be of very great service in this fever, and the sick
    were more relieved by it than ever I observed in any other fever
    whatever. People of lax, weak constitutions were very low and faint,
    and had frequent, profuse, partial sweatings, which most commonly were
    cold and clammy." Huxham also, at the other end of England, says that
    in October and November, 1727, a slow nervous fever attacked not a
    few; and under the date of January, 1728, he confirms the Yorkshire
    experiences of the prevalence of angina.

There can be little doubt that England in 1727 was already suffering in a
measure from the distress that was acutely felt in Ireland; it was much
aggravated by the hard winter of 1728-29[117], but it had begun before
that and was doubtless the indirect cause of the great prevalence of
sickness. The exports of corn under the bounty system used to bring two or
three millions of money into the country in a year. But in 1727 there was
a debt balance of 70,757 quarters of wheat imported, and in 1728 the
import exceeded the export by 21,322 quarters, the price rising at the
same time from 4_s._ to 8_s._ per bushel[118]. Under the year 1727 Hillary
says:

    "Many of the labouring and poor people, who used a low diet, and were
    much exposed to the injuries and changes of the weather, died; many of
    whom probably wanted the necessary assistance of diet and medicines."
    And after referring, under the winter of 1727-28, to the prevalence of
    a fatal suffocative angina, which fell, by a kind of metastasis, on
    the diaphragm or pleura, and sometimes on the peritoneum, he proceeds
    (p. 16):--

    "Nor did any other method, which art could afford, relieve them:
    insomuch that many of the little country towns and villages were
    almost stripped of their poor people, not only in the country adjacent
    to Ripon, but all over the northern parts of the kingdom: indeed I had
    no certain account of what distempers those who were at a distance
    died of, but suppose they were the same as those which I have
    mentioned, which were nearer to us. Bleeding, pectorals with
    volatiles, and antiphlogistic diluters and blistering, were the most
    successful. I observed that very few of the richer people, who used a
    more generous way of living, and were not exposed to the inclemencies
    of the weather, were seized with any of these diseases at this
    time.... The quartans were very subject to turn into quotidians, and
    sometimes to continual, in which the sick were frequently delirious."

The Yorkshire accounts by Wintringham and Hillary for the second year of
this epidemic period, the year 1728, are very full, as regards the
symptoms or types of the fevers; but it would be tedious to cite them at
length, and unnecessary to do so unless to answer the not inconceivable
cavil that the fevers were not of the nature of typhus in one or other of
its forms. The chief point is that the second year, towards Midsummer,
brought a fever with the symptoms of _synochus_, and not rarely marked
with small red spots like fleabites or with purple petechiae. In the
autumn of 1729, Hillary noticed a fever of a slow type, which might go on
as long as thirty days and end without a perfect crisis--the nearest
approach to enteric fever in any of the descriptions. For the same years,
1727-29, Huxham, of Plymouth, describes languid fevers of the "putrid"
type, with profuse sweating, followed by typhus of a more spotted type.
Like the Yorkshire observer, Huxham mentions also "intermittents" as mixed
with the continued fevers.

The great prevalence of these fevers, "intermittents and other fevers," in
the west of England in 1728-29 was known to Dr Rutty of Dublin, who speaks
especially of "the neighbourhoods of Gloucester and London, and very
mortal in the country places, but less in the cities." This is confirmed
by Dover:

    "I happened to live in Gloucestershire in the years 1728 and 1729,
    when a very fatal epidemical fever raged to such a degree as to sweep
    off whole families, nay almost whole villages. I was called to several
    houses where eight or nine persons were down at a time; and yet did
    not so much as lose one patient where I was concerned[119]."

Some of the cases of nervous or putrid fever in the epidemics of 1727-29
appear to have been marked by relapses in the country districts as well as
in London. Huxham says under date of April, 1728, that those who had
wholly got rid of the putrid fever were exceedingly apt to have relapses.
Hillary does not mention relapses until March, 1733, when a fever, with
many hysterical symptoms, which succeeded the influenza of that year,
relapsed in several, "though seemingly perfectly recovered before." But he
seems really to be contrasting relapsing fever and typhus when he points
out that, whereas the inflammatory type of fever in the first year of the
epidemic (1727) was greatly benefited by enormous phlebotomies, the fever
patients in the two seasons following, when the fever was more of the
nature of spotted typhus, could not stand the loss of so much blood, or,
it might be, the loss of any blood[120]. This was precisely the remark
made by Christison and others a century later, when the inflammatory
synocha, which often had the relapsing type very marked, changed to the
spotted typhus.

From the year 1731 we begin to have annual accounts (soon discontinued) of
the reigning maladies in Edinburgh, on the same plan as Wintringham's,
Hillary's and Huxham's, with which, indeed, they are sometimes collated
and compared[121]. The fevers of Edinburgh and the villages near were as
various as those of Plymouth, according to Huxham, and singularly like the
latter. Thus, in the winter of 1731-32, there was much worm fever,
comatose fever, or convulsive fever among children, but not limited to
children, marked by intense pain in the head, raving in some, stupor in
others, tremulous movements, leaping of the tendons, and all the other
symptoms described by Willis for the fever of 1661, a fatal case of
October, 1732, in a boy of ten, recorded by St Clair one of the Edinburgh
professors, reading exactly like the cases of Willis already given[122].
St Clair's case, which was soon fatal, had no worms; but in the general
accounts, both for the winter of 1731-32 and the autumn of 1732, it is
said that many of the younger sort passed worms, both _teretes_ and
_ascarides_, and recovered, the fatalities among children being, as usual,
few. In March and April, 1735, there were again "very irregular fevers of
children." Huxham records exactly the same "worm-fever" of children at
Plymouth in the spring of 1734--a fever with pains in the head, languor,
anxiety, oppression of the breast, vomiting, diarrhoea, and a comatose
state (_affectus soporosus_), which attacked the young mostly, and was
often attended by the passage of worms. He gives the same account of the
seasons as Gilchrist--the years 1734 and 1735 marked by almost continual
rains, the country more squalid than had been known for some years[123].

But it is the nervous fever that chiefly engrosses attention both in
Scotland and in England. In 1735, Dr Gilchrist, of Dumfries, made it the
subject of an essay, returning to the subject a few years after[124]. "As
_our_ fever," he says, "seems to be peculiar to this age, it is not a
little surprising that much more has not been said upon it." He is not
sure whether its frequency of late years may not be owing to the manner of
living (it was the time of the great drink-craze, which Huxham also
connects with the reigning maladies) and to a long course of warm, rainy
seasons; the winters for some years had been warm and open, and the
summers and harvests rainy. It was only the poorer sort and those a degree
above them who were subject to this fever; he knew but few instances of it
amongst those who lived well, and none amongst wine-drinkers. It was in
some insidious in its approach; those who seemed to be in no danger the
first days for the most part died. In others the onset was violent, with
nausea, heat, thirst and delirium. Among the symptoms were looseness,
pains in the belly, local sweating, tickling cough, leaping of the
tendons. Sometimes they were in continual cold clammy sweats; at other
times profuse sweats ran from them, as if water were sprinkled upon them,
the skin feeling death cold.

At Edinburgh, from October, 1735, to February, 1736, the fever became very
common, and was often a relapsing fever.

    "The sick had generally a low pulse on the first two or three days,
    with great anxiety and uneasiness, and thin, crude urine. Delirium
    began about the fourth day, and continued until the fever went off on
    the seventh day. Sometimes the disease was lengthened to the
    fourteenth day. The approach of the delirium could always be foretold
    by the urine becoming more limpid, and without sediment.... A large
    plentiful sweat was the crisis in some. Others were exposed to
    relapses, which were very frequent, and rather more dangerous than the
    former fever[125]."

These evidences, beginning with Strother's for London in 1728 and
extending to the Edinburgh record of 1735, must suffice to identify true
relapsing fever. In the chapter on Irish fevers we shall find clear
evidence of relapsing fever in Dublin in 1739, before the great famine had
begun.

Huxham's account of the fevers at Plymouth, in Devonshire generally, and
in Cornwall about the years 1734-36 is of the first importance. It is
highly complex, owing to the prevalence of an affection of the throat, so
that one part of the constitution is "anginose fever." This has been dealt
with in the chapter on Scarlatina and Diphtheria. Another part was true
typhus. In his account of the nervous fever we are introduced, as in the
Yorkshire annals, 1726-27, to a phenomenon that was almost distinctive of
the low, nervous or putrid fever from about 1750 to 1760 or longer,
namely, the eruption of red, or purple, or white watery vesicles, from
which it got the name of miliary fever. Huxham's annals are full of this
phenomenon about the years 1734-36[126]. The red pustules, or white
pustules, with attendant ill-smelling sweats, are mentioned over and over
again. He thought them critical or relieving: "Happy was then the patient
who broke out in sweats or in red pustules." These fevers are said to have
extended to the country parts of Devonshire, after they had ceased in
Plymouth, and to Cornwall in August, 1736. In Plymouth itself the type of
fever changed after a time to malignant spotted fever, synochus, or true
typhus.

The malignant epidemic seemed to have been brought in by the fleet; it had
raged for a long time among the sailors of the fleet lying at Portsmouth,
and had destroyed many of them. In March, 1735, it was raging among the
lower classes of Plymouth. About the 10th day of the fever, previously
marked by various head symptoms, there appeared petechiae, red or purple,
or livid or black, up to the size of vibices or blotches, or the eruption
might be more minute, like fleabites. A profuse, clammy, stinking sweat,
or a most foetid diarrhoea wasted the miserable patients. A black tongue,
spasms, hiccup, and livid hands presaged death about the 11th to 14th day.
So extensive and rapid was the putrefaction of the bodies that they had to
be buried at once or within twenty-four hours. It was fortunate for many
to have had a mild sweat and a red miliary eruption about the 4th or 5th
day; but for others the course of the disease was attended with great
risk. In April the type became worse, and the disease more general. There
was rarely now any constriction of the throat. Few pustules broke out; but
in place of them there were dusky or purple and black petechiae, and too
often livid blotches, with which symptoms very many died both in April and
May. In July this contagious fever had decreased much in Plymouth, and in
September it was only sporadic there. With a mere reference to Hillary's
account of somewhat similar fevers at Ripon in 1734-5 (with profuse
sweats, sometimes foetid, great fainting and sinking of spirits, starting
of the limbs and beating of the tendons, hiccup for days, etc.[127]) we
may pass to a more signal historical event, the great epidemic of fever in
1741-42, of which the Irish part alone has hitherto received sufficient
notice[128].


The epidemic fever of 1741-42.

The harvest of 1739 had been an abundant one, and the export of grain had
been large. At Lady-day the price of wheat had been 31_s._ 6_d._ per
quarter, and it rose 10_s._ before Lady-day, 1740. An extremely severe
winter had intervened, one of the three memorable winters of the 18th
century. The autumn-sown wheat was destroyed by the prolonged and intense
frost, and the price at Michaelmas, 1740, rose to 56_s._ per quarter, the
exportation being at the same time prohibited, but not until every
available bushel had been sold to the foreigners. The long cold of the
winter of 1739-40 had produced much distress and want in London, Norwich,
Edinburgh and other towns. In London the mortality for 1740 rose to a very
high figure, 30,811, of which 4003 deaths were from fever and 2725 from
smallpox. In mid-winter, 1739-40, coals rose to L3. 10_s._ per chaldron,
owing to the navigation of the Thames being closed by ice; the streets
were impassable by snow, there was a "frost-fair" on the Thames, and in
other respects a repetition of the events preceding the London typhus of
1685-86. The _Gentleman's Magazine_ of January, 1740, tells in verse how
the poor were "unable to sustain oppressive want and hunger's urgent
pain," and reproaches the rich,--"colder their hearts than snow, and
harder than the frost"; while in its prose columns it announces that "the
hearts of the rich have been opened in consideration of the hard fate of
the poor[129]." The long, hard winter was followed by the dry spring and
hot summer of 1740, during which the sickness (in Ireland at least) was of
the dysenteric type. In the autumn of 1740 the epidemic is said to have
taken origin both at Plymouth and Bristol from ships arriving with
infection among the men--at the former port the king's ships 'Panther' and
'Canterbury,' at the latter a merchant ship. At Plymouth it was certainly
raging enormously from June to the end of the year--"febris nautica
pestilentialis jam saevit maxime," says Huxham; it continued there all
through the first half of 1741, "when it seemed to become lost in a fever
of the bilious kind." It was in the dry spring and very hot summer of 1741
that the fever became general over England. Wall says that it appeared at
Worcester at the Spring Assizes among a few; at Exeter also it was traced
to the gaol delivery; and it was commonly said that the turmoil of the
General Election (which resulted in driving Walpole from his long term of
power) helped its diffusion. But undoubtedly the great occasion of its
universality was a widely felt scarcity. The rise in the price of wheat
was small beside the enormous leaps that prices used to take in the
medieval period, having been at no time double the average low price of
that generation. It was rather the want of employment that made the pinch
so sharp in 1741. The weaving towns of the west of England were losing
their trade; of "most trades," also, it was said that they were in
apparent decay, "except those which supply luxury[130]." Dr Barker, of
Sarum, the best medical writer upon the epidemic, says:

    "The general poverty which has of late prevailed over a great part of
    this nation, and particularly amongst the woollen manufacturers in the
    west, where the fever has raged and still continues to rage with the
    greatest violence, affords but too great reason to believe that this
    has been one principal source of the disease[131]."

He explains that the price of wheat had driven the poor to live on bad
bread. This is borne out by a letter from Wolverhampton, 27 November,
1741[132]. The writer speaks of the extraordinary havoc made among the
poorer sort by the terrible fever that has for some time raged in most
parts of England and Ireland. At first it seldom fixed on any but the poor
people, and especially such as lived in large towns, workhouses, or
prisons. Country people and farmers seemed for the most part exempt from
it, "though we have observed it frequently in villages near market towns";
whereas, says the writer, the epidemic fevers of 1727, 1728 and 1729 were
first observed to begin among the country people, and to be some time in
advancing to large towns. This writer's theory was that the fever was
caused by bad bread, and he alleges that horse-beans, pease and coarse
unsound barley were almost the only food of the poor. To this a Birmingham
surgeon took exception[133]. Great numbers of the poor had, to his
knowledge, lived almost entirely upon bean-bread, but had been very little
afflicted with the fever. Besides, every practitioner knew that the fever
was not confined to the poor. He pointed out that in Wolverhampton, whence
the bad-bread theory emanated, the proportion of poor to those in easier
circumstances was as six to one, poverty having increased so much by decay
of trade that many wanted even the necessaries of life. The Birmingham
surgeon was on the whole inclined to the theory of "the ingenious
Sydenham, that the disease may be ascribed to a contagious quality in the
air, arising from some secret and hidden alterations in the bowels of the
earth, passing through the whole atmosphere, or to some malign influence
in the heavenly bodies"--these being Sydenham's words as applied to the
fever of 1685-6.

Barker, also, draws a parallel between the epidemic of 1741 and that of
1685-86: the Thames was frozen in each of the two winters preceding the
respective epidemics, and the spring and summer of 1740 and 1741 were as
remarkable for drought and heat as those of 1684 and 1685.

In London the deaths from fever in 1741 reached the enormous figure of
7528, the highest total in the bills of mortality from first to last,
while the deaths from all causes were 32,119, in a population of some
700,000, also the highest total from the year of the great plague until
the new registration of the whole metropolitan area in 1838. It will be
seen from the following table (on p. 81) of the weekly mortalities that
the fever-deaths rose greatly in the autumn, but, unlike the old plague,
reached a maximum in the winter.

The effects of the epidemic of typhus upon the weaving towns of the west
of England, in which the fever lasted, as in London, into the spring of
1742, were seen at their worst in the instance of Tiverton. It was then a
town of about 8000 inhabitants, having increased little during the last
hundred years. Judged by the burials and baptisms in the parish register
it was a more unhealthy place since the extinction of plague than it had
been before that. It was mostly a community of weavers, who had not been
in prosperous circumstances for sometime past. In 1735 the town had been
burned down, and in 1738 it was the scene of riots. The hard winter of
1739-40 brought acute distress, and in 1741 spotted fever was so prevalent
that 636 persons were buried in that year, being 1 in 12 of the
inhabitants. At the height of the epidemic ten or eleven funerals were
seen at one time in St Peter's churchyard. Its population twenty years
after is estimated to have declined by two thousand, and at the end of the
18th century it was a less populous place than at the beginning[134].

_Mortality by Fever in London, 1741-42._

        Week              All
      ending     Fever   causes
  1741
      March 10    123     660
            17    103     564
            24    112     624
            31    105     573
       April 7    123     670
            14    128     687
            21     89     580
            28    123     622
         May 5    104     495
            12    141     587
            19    129     573
            26    153     600
        June 2    138     512
             9    138     483
            16    115     536
            23    127     494
            30    154     513
        July 7    149     523
            14    162     551
            21    130     485
            28    151     621
        Aug. 4    128     512
            11    142     541
            18    172     636
            25    192     665
       Sept. 1    171     675
             8    190     691
            15    182     760
            22    199     748
            29    189     733
       Oct.  6    207     784
            13    192     787
            20    232     793
            27    234     850
       Nov.  3    250     835
            10    228     772
            17    182     670
            24    214     806
       Dec.  1    224     768
             8    203     748
            15    191     761
            22    179     775
            29    180     702
  1742
        Jan. 5    221     893
            12    184     760
            19    151     724
        Feb. 2    132     675
             9    103     533
            16    108     675
            25    103     641

_Effects of the Epidemic of 1741-42 on Provincial Towns. (Short's
Abstracts of Parish Registers.)_

                  With burials
       Registers   more than   Baptisms in  Burials in
  Year  examined   baptisms     the same     the same

  1740    27          6           1409         1940
  1741    27         14           3787         6205
  1742    26          6           1721         3345

Other parts of the kingdom may be represented by Norwich, Newcastle and
Edinburgh. The record of baptisms in Norwich is almost certainly
defective; in only two years from 1719 to 1741, is a small excess of
baptisms over burials recorded, namely, in 1722 and 1726, while in a third
year, 1736, the figures are exactly equal. In 1740 there are 916 baptisms
to 1173 burials, and in 1741, 851 baptisms to 1456 burials; while in 1742,
owing to an epidemic of smallpox, the deaths rose to 1953, or to more than
double the recorded births[135]. The distress was felt most in East Anglia
in 1740. Blomefield, who ends his history in that year, says there was
much rioting throughout the kingdom, "on the pretence of the scarcity and
dearness of grain." At Wisbech Assizes fourteen were found guilty, but
were not all executed. In Norfolk two were convicted and executed
accordingly. At Norwich the military fired upon the mob and killed seven
persons, of whom only one was truly a rioter[136]. It was also in the
severe winter of 1739-40 that the distress began in Edinburgh. The mills
were stopped by ice and snow, causing a scarcity of meal; the harvest of
1740 was bad, riots took place in October, and granaries were
plundered[137]. The deaths from fever were many in 1740, but were nearly
doubled in 1741, with a significant accompaniment of fatal dysentery[138]:

_Edinburgh Mortalities, 1740-41._

(Population in 1732, estimated at 32,000.)[139]

                 1740    1741
  All causes     1237    1611
                 ----    ----
  Consumption     278     349
  Fever           161     304
  Flux              3      36
  Smallpox        274     206
  Measles         100     112
  Chincough        26     101
  Convulsions      22      16

The last four items are of children's maladies, for which Edinburgh was
worse reputed even than London.

At Newcastle the deaths in the register in 1741 were 320 more than in
1740, in which year they were doubtless excessive, as elsewhere. But there
is a significant addition: "There have also been buried upwards of 400
upon the Ballast Hills near this town[140]."

The symptoms of the epidemic fever of 1741-42 are described by Barker, of
Salisbury, and Wall, of Worcester[141]. It began like a common cold, as
was remarked also in Ireland. On the seventh day spots appeared like
fleabites on the breast and arms; in some there were broad purple spots
like those of scurvy. Miliary eruptions were apt to come out about the
eleventh day, especially in women. In most, after the first six or seven
days, there was a wonderful propensity to diarrhoea, which might end in
dysentery. The cough, which had appeared at the outset, went off about the
ninth day, when stupor and delirium came on. Gilchrist, of Dumfries,
describes the fever there in November, 1741, as more malignant than the
"nervous fever" which he had described in 1735. It came to an end about
the fourteenth day; the sick were almost constantly under a coma or
raving, and they died of an absolute oppression of the brain; a profuse
sweat about the seventh day was followed by an aggravation of all the
symptoms[142]. An anonymous writer, dating from Sherborne, uses the
occasion to make an onslaught upon blood-letting[143].


Sanitary Condition of London under George II.

The great epidemic of fever in 1741-42 was the climax of a series of years
in London all marked by high fever mortalities. If there had not been
something peculiarly favourable to contagious fever in the then state of
the capital, it is not likely that a temporary distress caused by a hard
winter and a deficient harvest following should have had such effects.
This was the time when the population is supposed to have stood still or
even declined in London. Drunkenness was so prevalent that the College of
Physicians on 19 January, 1726, made a representation on it to the House
of Commons through Dr Freind, one of their fellows and member for
Launceston:

    "We have with concern observed for some years past the fatal effects
    of the frequent use of several sorts of distilled spirituous liquor
    upon great numbers of both sexes, rendering them diseased, not fit for
    business, poor, a burthen to themselves and neighbours, and too often
    the cause of weak, feeble and distempered children, who must be,
    instead of an advantage and strength, a charge to their country[144]."

"This state of things," said the College, "doth every year increase."
Fielding guessed that a hundred thousand in London lived upon drink alone;
six gallons per head of the population per annum is an estimate for this
period, against one gallon at present. The enormous duty of 20_s._ per
gallon served only to develope the trade in smuggled Hollands gin and
Nantes brandy. In the harvest of 1733 farmers in several parts of Kent
were obliged to offer higher wages, although the price of grain was low,
and could hardly get hands on any terms, "which is attributed to the great
numbers who employ themselves in smuggling along the coast[145]."

The mean annual deaths were never higher in London, not even in plague
times over a series of years, the fever deaths keeping pace with the
mortality from all causes, and, in the great epidemic of typhus in 1741,
making about a fourth part of the whole. The populace lived in a bad
atmosphere, physical and moral. As Arbuthnot said in 1733, they "breathed
their own steams"; and he works out the following curious sum:

    "The perspiration of a man is about 1/34 of an inch in 24 hours,
    consequently one inch in 34 days. The surface of the skin of a
    middle-sized man is about 15 square feet; consequently the surface of
    the skin of 2904 such men would cover an acre of ground, and the
    perspir'd matter would cover an acre of ground 1 inch deep in 34 days,
    which, rarefi'd into air, would make over that acre an atmosphere of
    the steams of their bodies near 71 foot high." This, he explains,
    would turn pestiferous unless carried away by the wind; "from whence
    it may be inferred that the very first consideration in building of
    cities is to make them open, airy, and well perflated[146]."

In the growth of London from a medieval walled city of some forty or sixty
thousand inhabitants to the "great wen" of Cobbett's time, these
considerations had been little attended to so far as concerned the
quarters of the populace. The Liberties of the City and the out-parishes
were covered with aggregates of houses all on the same plan, or rather
want of plan. In the medieval period the extramural population built rude
shelters against the town walls or in the fosse, if it were dry, or along
the side of the ditch. The same process of squatting at length extended
farther afield, with more regular building along the sides of the great
highways leading from the gates. Queen Elizabeth's proclamation of 1580
was designed to check the growth of London after this irregular fashion;
but as neither the original edict nor the numerous copies of it, reissued
for near a hundred years, made any provision for an orderly expansion of
the capital, these prohibitions had merely the effect of adding to the
hugger-mugger of building, "in odd corners and over stables." The
outparishes were covered with houses and tenements of all kinds, to which
access was got by an endless maze of narrow passages or alleys; regular
streets were few in them, and it would appear from the account given by
John Stow in 1598 of the parish of Whitechapel that even the old country
highway, one of the great roads into Essex and the eastern counties, had
been "pestered[147]." The "pestering" of the field lanes in the suburban
parishes with poor cottages is Stow's frequent theme[148]. The borough of
Southwark, as part of the City, may have been better than most: "Then from
the Bridge straight towards the south a continual street called Long
Southwark, built on both sides with divers lanes and alleys up to St
George's Church, and beyond it through Blackman Street towards New Town or
Newington"--the mazes of courts and alleys on either side of the Borough
Road which may be traced in the maps long after Stow's time. So again in
St Olave's parish along the river bank eastwards from London
Bridge--"continual building on both sides, with lanes and alleys, up to
Battle Bridge, to Horsedown, and towards Rotherhithe." In the Western
Liberty, the lanes that had been laid out in Henry VIII.'s time, Shoe
Lane, Fetter Lane and Chancery Lane, served as three main arteries to the
densely populated area between Fleet Street and Holborn, but for the rest
it was reached by a plexus or _rete mirabile_ of alleys and courts,
notorious even in the 19th century. In like manner Drury Lane and St
Martin's Lane were the main arteries between High Holborn and the Strand.
One piazza of Covent Garden was a new centre of regular streets, to which
the haberdashers and other trades were beginning to remove from the City,
for greater room, about 1662. The Seven Dials were a wonder when they were
new, about 1694, and had the same intention of openness and regularity as
in Wren's unused design for the City after the fire. The great speculative
builder of the Restoration was Nicholas Barbone, son of Praise-God
Barbones. He built over Red Lion Fields, much to the annoyance of the
gentlemen of Gray's Inn[149], and his manner of building may be inferred
from the following:

    "He was the inventor of this new method of building by casting of
    ground into streets and small houses, and to augment their number with
    as little front as possible, and selling the ground to workmen by so
    much per foot front, and what he could not sell build himself. This
    has made ground-rents high for the sake of mortgaging; and others,
    following his steps, have refined and improved upon it, and made a
    superfoetation of houses about London[150]."

In these mazes of alleys, courts, or "rents" the people were for the most
part closely packed. Overcrowding had been the rule since the Elizabethan
proclamation of 1580, and it seems to have become worse under the Stuarts.
On February 24, 1623, certain householders of Chancery Lane were indicted
at the Middlesex Sessions for subletting, "to the great danger of
infectious disease, with plague and other diseases." In May, 1637, one
house was found to contain eleven married couples and fifteen single
persons; another house harboured eighteen lodgers. In the most crowded
parishes the houses had no sufficient curtilage, standing as they did in
alleys and courts. When we begin to have some sanitary information long
after, it appears that their vaults, or privies, were indoors, at the foot
of the common stair[151]. In 1710, Swift's lodging in Bury Street, St
James's, for which he paid eight shillings a week ("plaguy deep" he
thought), had a "thousand stinks in it," so that he left it after three
months. The House of Commons appears to have been ill reputed for smells,
which were specially remembered in connexion with the hot summer of the
great fever-year 1685[152].

The newer parts of London were built over cesspools, which were probably
more dangerous than the visible nuisances of the streets satirized by
Swift and Gay. There were also the "intramural" graveyards; of one of
these, the Green Ground, Portugal Street, it was said by Walker, as late
as 1839; "The effluvia from this ground are so offensive that persons
living in the back of Clement's Lane are compelled to keep their windows
closed." But that which helped most of all to make a foul atmosphere in
the houses of the working class, an atmosphere in which the contagion of
fever could thrive, was the window-tax. It is hardly possible that those
who devised it can have foreseen how detrimental it would be to the public
health; it took nearly a century to realize the simple truth that it was
in effect a tax upon light and air.


The Window-Tax.

Willan, writing of fever in London in 1799, mentions that even the
passages of tenement houses were "kept dark in order to lessen the
window-tax," and the air therefore kept foul[153]. Ferriar, writing of
Manchester in the last years of the 18th century, mentions, among other
fever-dens, a large house in an airy situation which had been built for a
poor's-house, but abandoned: having been let to poor families for a very
trifling rent, many of the windows and the principal entrance were built
up, and the fever then became universal in it[154]. The Carlisle typhus
described by Heysham for 1781 began in a house near one of the gates,
tenanted by five or six very poor families; they had "blocked up every
window to lessen the burden of the window-tax[155]." John Howard's
interest having been excited in the question of gaol-fever, he noted the
effects of the window-tax not only in prisons but in other houses. The
magistrates of Kent appear to have paid the tax for the gaols in that
county from the county funds; but in most cases the burden fell on the
keepers of the gaols.

    "The gaolers," says Howard, "have to pay it; this tempts them to stop
    the windows and stifle their prisoners;" and he appends the following
    note: "This is also the case in many work-houses and farm-houses,
    where the poor and the labourers are lodged in rooms that have no
    light nor fresh air; which may be a cause of our peasants not having
    the healthy ruddy complexions one used to see so common twenty or
    thirty years ago. The difference has often struck me in my various
    journeys[156]."

Such impressions are known to be often fallacious; but in the history of
the window-tax, which we shall now follow, it will appear that there was a
new law, with increased stringency, in the years 1746-1748, corresponding
to the "twenty or thirty years ago" of Howard's recollection.

The window-tax was originally a device of the statesmen of the Revolution
"for making good the deficiency of the clipped money." By the Act of 7 and
8 William and Mary, cap. 18, taking effect from the 25th March, 1696,
every inhabited house owed duty of two shillings per annum, and, over and
above such duty on all inhabited houses, every dwelling-house with ten
windows owed four shillings per annum, and every house with twenty
windows eight shillings. In 1710 houses with from twenty to thirty windows
were made to pay ten shillings, and those with more than thirty windows
twenty shillings. Various devices were resorted to to check the evasions
of bachelors, widows and others. A farmer had to pay for his servants,
recouping himself from their wages. A house subdivided into tenements was
to count as one; which would have made the tax difficult to gather except
from the landlord. The machinery of collection was a board of
commissioners, receivers-general and collectors.

But in the 20th of George II. (1746) the basis of the law was changed. The
tax was levied upon the several windows of a house, so much per window, so
that it fell more decisively than before upon the tenants of
tenement-houses, and not on the landlords. The two-shillings house duty
was continued; but the window-tax became sixpence per annum for every
window of a house with ten, eleven, twelve, thirteen or fourteen windows,
or lights, ninepence for every window of a house with fifteen, sixteen,
seventeen, eighteen or nineteen windows, and one shilling for every window
of a house with twenty or more windows. An exemption in the Act in favour
of those receiving parochial relief was decided by the law officers of the
Crown not to apply to houses with ten or more windows or lights, which
would have included most tenement-houses; on the other hand they ruled
that hospitals, poor-houses, workhouses, and infirmaries were not
chargeable with the window duty. To remove doubts and check evasions
another Act was made in 21 George II. cap. 10. All skylights, and lights
of staircases, garrets, cellars and passages were to count for the purpose
of the tax; also certain outhouses, but not others, were to count as part
of the main dwelling whether they were contiguous or not. The 11th
paragraph of the Amendment Act shows how the law had been working in the
course of its first year: "No window or light shall be deemed to be
stopped up unless such window or light shall be stopped up effectually
with stone or brick or plaister upon lath," etc.

This remained the law down to 1803, when a change was made back to the
original basis of rating houses as a whole, according to the number of
their windows, the rate being considerably raised and fixed according to a
schedule. The tax for tenement houses was at the same time made
recoverable from the landlord. The window-tax thus became a form of the
modern house-tax, rated upon windows instead of upon rental, and so lost a
great part of its obnoxious character.

The law of 1747-48, which taxed each window separately, and was enforced
by a galling and corrupt machinery of commissioners, receivers-general and
collectors paid by results, could not fail to work injuriously; for light
and air, two of the primary necessaries of life, were in effect taxed.
Even rich men appear to have taken pleasure in circumventing the
collectors[157]. But it was among the poor, and especially the inhabitants
of tenement houses, that the effect was truly disastrous; a tax on the
skylights of garrets and on the lights of cellars, staircases and
passages, taught the people to dispense with them altogether. Towards the
end of the 18th century the grievance became now and then the subject of a
pamphlet or a sermon.


Gaol-Fever.

Besides these ordinary things favouring contagious epidemic fever both in
town and country, there were two special sources of contagion, the gaols
and the fleets and armies. I shall take first the state of the gaols,
which has been already indicated in speaking of the window-tax. In the
opinion of Lind, a great part of the fever, which was a constant trouble
in ships of the navy, came direct from the gaols through the pressing of
newly discharged convicts.

The state of the prisons in the first half of the 18th century was
certainly not better than Howard found it to be a generation after; it was
probably worse, for the administration of justice was more savage. About
the beginning of the century, many petitions were made to Parliament by
imprisoned debtors, complaining of their treatment, and a Bill was
introduced in 1702. Sixty thousand were said to be in prison for
debt[158]. On 25 February, 1729, the House of Commons appointed a
committee "to inquire into the state of the gaols of this Kingdom"; but
only two prisons were reported on, the Fleet and the Marshalsea, in
London, the inquiries upon these being due to the energy of Oglethorpe,
then at the beginning of his useful career. The committee found a
disgraceful state of things:--wardens, tip-staffs and turnkeys making
their offices so lucrative by extortion that the reversion of them was
worth large sums, prisoners abused or neglected if they could not pay,
some prisoners kept for years after their term was expired, the penniless
crowded three in a bed, or forty in one small room, while some rooms stood
empty to await the arrival of a prisoner with a well-filled purse. On the
common side of the Fleet Prison, ninety-three prisoners were confined in
three wards, having to find their own bedding, or pay a shilling a week,
or else sleep on the floor. The "Lyons Den" and women's ward, which
contained about eighteen, were very noisome and in very ill repair. Those
who were well had to lie on the floor beside the sick. A Portuguese debtor
had been kept two months in a damp stinking dungeon over the common sewer
and adjoining to the sink and dunghill; he was taken elsewhere on payment
of five guineas. In the Marshalsea there were 330 prisoners on the common
side, crowded in small rooms. George's ward, sixteen feet by fourteen and
about eight feet high, had never less than thirty-two in it "all last
year," and sometimes forty; there was no room for them all to lie down,
about one-half of the number sleeping over the others in hammocks; they
were locked in from 9 p.m. to 5 a.m. in summer (longer hours in winter),
and as they were forced to ease nature within the room, the stench was
noisome beyond expression, and it seemed surprising that it had not caused
a contagion; several in the heat of summer perished for want of air.
Meanwhile the room above was let to a tailor to work in, and no one
allowed to lie in it. Unless the prisoners were relieved by their friends,
they perished by famine. There was an allowance of pease from a casual
donor who concealed his name, and 30 lbs. of beef three times a week from
another charitable source. The starving person falls into a kind of
hectic, lingers for a month or two and then dies, the right of his corpse
to a coroner's inquest being often scandalously refused[159]. The prison
scenes in Fielding's _Amelia_ are obviously faithful and correct.

Oglethorpe's committee had done some good since they first met at the
Marshalsea on 25th March, 1729, not above nine having died from that date
to the 14th May; whereas before that a day seldom passed without a death,
"and upon the advancing of the spring not less than eight or ten usually
died every twenty-four hours." Two of the chief personages concerned were
found by a unanimous vote of the House of Commons to have committed high
crimes and misdemeanours; but when they were tried before a jury on a
charge of felony they were found not guilty.

About a year after these reports to the Commons there was a tragic
occurrence among the Judges and the Bar of the Western Circuit during the
Lent Assizes of 1730. The Bridewell at Taunton was filled for the occasion
of the Assizes with drafts of prisoners from other gaols in Somerset,
among whom several from Ilchester were said to have been more than
ordinarily noisome. Over a hundred prisoners were tried, of whom eight
were sentenced to death (six executed), and seventeen to transportation.
As the Assize Court continued its circuit through Devon and Dorset several
of its members sickened of the gaol fever and died: Piggot, the
high-sheriff, on the 11th April, Sir James Sheppard, serjeant-at-law, on
13th April at Honiton, the crier of the court and two of the Judge's
servants at Exeter, the Judge himself, chief baron Pengelly, at Blandford,
and serjeant-at-law Rous, on his return to London, whither he had posted
from Exeter as soon as he felt ill[160]. It is said that the infection
afterwards spread within the town of Taunton, where it arose, "and carried
off some hundreds"; but the local histories make no mention of such an
epidemic in 1730, and no authority is cited for it[161]. Something of the
same kind is believed to have happened at a gaol delivery at Launceston
in 1742, but the circumstances are vaguely related, and it does not appear
that any prominent personage in the Assize Court died on the
occasion[162].

The great instance of a Black Assize in the 18th century, comparable to
those of Cambridge, Oxford and Exeter in the 16th[163], was that of the
Old Bailey Sessions in London in April, 1750. It has been fully related by
Sir Michael Foster, one of the justices of the King's Bench, who had
himself been on the bench at the January sessions preceding, and was the
intimate friend of Sir Thomas Abney, the presiding judge who lost his life
from the contagion of the April sessions[164].

    "At the Old Bailey sessions in April, 1750, one Mr Clarke was brought
    to his trial; and it being a case of great expectation, the court and
    all the passages to it were extremely crowded; the weather too was
    hotter than is usual at that time of the year[165]. Many people who
    were in court at this time were sensibly affected with a very noisome
    smell; and it appeared soon afterwards, upon an enquiry ordered by the
    court of aldermen, that the whole prison of Newgate and all the
    passages leading thence into the court were in a very filthy
    condition, and had long been so. What made these circumstances to be
    at all attended to was, that within a week or ten days at most, after
    the session, many people who were present at Mr Clarke's trial were
    seized with a fever of the malignant kind; and few who were seized
    recovered. The symptoms were much alike in all the patients, and in
    less than six weeks time the distemper entirely ceased. It was
    remarked by some, and I mention it because the same remark hath
    formerly been made on a like occasion [Oxford, 1577], that women were
    very little affected: I did not hear of more than one woman who took
    the fever in court, though doubtless many women were there.

    "It ought to be remembered that at the time this disaster happened
    there was no sickness in the gaol more than is common in such places.
    This circumstance, which distinguisheth this from most of the cases of
    the like kind which we have heard of, suggesteth a very proper
    caution: not to presume too far upon the health of the gaol, barely
    because the gaol-fever is not among the prisoners. For without doubt,
    if the points of cleanliness and free air have been greatly neglected,
    the putrid effluvia which the prisoners bring with them in their
    clothes etc., especially where too many are brought into a crowded
    court together, may have fatal effects on people who are accustomed to
    breathe better air; though the poor wretches, who are in some measure
    habituated to the fumes of a prison, may not always be sensible of any
    great inconvenience from them.

    "The persons of chief note who were in court at this time and died of
    the fever were Sir Samuel Pennant, lord mayor for that year, Sir
    Thomas Abney, one of the justices of the Common Pleas, Charles Clarke,
    esquire, one of the barons of the exchequer, and Sir Daniel Lambert,
    one of the aldermen of London. Of less note, a gentleman of the bar,
    two or three students, one of the under-sheriffs, an officer of Lord
    Chief Justice Lee, who attended his lordship in court at that time,
    several of the jury on the Middlesex side, and about forty other
    persons whom business or curiosity had brought thither."

The same thing was remarked here as at Exeter in 1586 that those who sat
on the side of the Court nearest to the dock were most attacked by the
infection[166]. When the cases of fever began to occur, after the usual
incubation of "a week or ten days," there was much fear of the infection
spreading, so that many families, it is said, retired into the
country[167]. But Pringle wrote on 24 May, "However fatal it has been
since the Sessions, it is highly probable that the calamity will be in a
great measure confined to those who were present at the tryal[168];" and
Justice Foster gives no hint of anyone having taken the fever who was not
present in court.

The tragedy of gaol-fever at the Old Bailey in 1750 secured increased
attention to the subject of scientific ventilation. The great bar to fresh
air indoors throughout the 18th century was the window-tax. It bore
particularly hard on prisoners, for the gaolers had to pay the window-tax
out of their profits, and they naturally preferred to build up the
windows. Scientific ventilation of gaols was something of a mockery in
these circumstances; but it is the business of science to find out cunning
contrivances, and ingenious ventilators were devised for Newgate, the
leading spirit in this work being the Rev. Dr Hales, rector of a parish
near London, and an amateur in physiology at the meetings of the Royal
Society.

A ventilating apparatus had been erected at Newgate about a year before
the fatal sessions of 1650, but it does not seem to have answered. It
consisted of tubes from the various wards meeting in a great trunk which
opened on the roof. A committee of the Court of Aldermen in October 1750
resolved, after consulting Pringle and Hales, to add a windmill on the
leads over the vent, and that was done about two years after. Pringle, who
inspected the ventilator on 11 July, 1752, says that a considerable
stream of air of a most offensive smell issued from the vent; and it
appeared that no fewer than seven of the eleven carpenters who were
working at the alterations on the old ventilator caught gaol-fever (of the
petechial kind), which spread among the families of some of them[169].
Pringle and Hales were of opinion that the wards furnished with tubes were
less foul than the others; and they claimed, on the evidence of the man
who took care of the apparatus, that only one person had died in the gaol
in two months, whereas, before the windmill was used, there died six or
seven in a week[170]. But Oglethorpe had claimed an improvement of the
same kind at the Marshalsea in 1729 merely from having the prisoners saved
from hunger; and Lind, who was a most matter-of-fact person, did not think
that the ingenious contrivances for ventilation had answered their
end[171].

Howard's visitations of the prisons, which began in 1773 and were
continued or repeated during several years following, brought to light
many instances of epidemic sickness therein, which was nearly always of
the nature of gaol-typhus. The following is a list compiled from his
various reports, the two or three instances of smallpox infection being
given elsewhere.

    _Wood Street Compter, London._ About 100 in it, chiefly debtors.
    Eleven died in beginning of 1773; since then it has been visited by Dr
    Lettsom at the request of the aldermen.

    _Savoy, London._ On 15 March, 1776, 119 prisoners. Many sick and
    dying. Between that date and next visit, 25 May, 1776, the gaol-fever
    has been caught by many.

    _Hertford._ Inmates range from 20 to 30. In the interval of two
    visits, the gaol-fever prevailed and carried off seven or eight
    prisoners and two turnkeys. (The interval probably corresponded to the
    admission of an unusual number of debtors.)

    _Chelmsford._ Number of inmates varies from 20 to 60, about one-half
    debtors. A close prison frequently infected with the gaol-distemper.

    _Dartford, County Bridewell._ A small prison. About two years before
    visit of 1774 there was a bad fever, which affected the keeper and his
    family and every fresh prisoner. Two died of it.

    _Horsham, Bridewell._ The keeper a widow: her husband dead of the
    gaol-fever.

    _Petworth, Bridewell._ Allowance per diem a penny loaf (7-1/2 oz.).
    Th. Draper and Wm. Godfrey committed 6 Jan., 1776: the former died on
    11 Jan., the other on 16th. Wm. Cox, committed 13 Jan., died 23rd.
    "None of these had the gaol-fever. I do not affirm that these men were
    famished to death; it was extreme cold weather." After this the
    allowance of bread was doubled, thanks to the Duke of Richmond.

    _Southwark, the new gaol._ Holds up to 90 debtors and felons. "In so
    close a prison I did not wonder to see, in March, 1776, several felons
    sick on the floors." No bedding, nor straw. The Act for preserving the
    health of prisoners is on a painted board.

    _Aylesbury._ About 20 prisoners. First visit Nov., 1773, second Nov.,
    1774: in the interval six or seven died of the gaol-distemper.

    _Bedford._ About twenty years ago the gaol-fever was in this prison;
    some died there, and many in the town, among whom was Mr Daniel, the
    surgeon who attended the prisoners. The new surgeon changed the
    medicines from sudorifics to bark and cordials; and a sail-ventilator
    being put up the gaol has been free from the fever almost ever since.
    (This was the gaol which is often said to have started Howard on his
    inquiries when he was High Sheriff.)

    _Warwick._ Holds up to fifty-seven. The late gaoler died in 1772 of
    the gaol-distemper, and so did some of his prisoners. No water then;
    plenty now.

    _Southwell, Bridewell._ A small prison. A few years ago seven died
    here of the gaol-fever within two years.

    _Worcester._ Has a ventilator. Mr Hallward the surgeon caught the
    gaol-fever some years ago, and has ever since been fearful of going
    into the dungeon; when any felon is sick, he orders him to be brought
    out.

    _Shrewsbury._ Gaol-fever has prevailed here more than once of late
    years.

    _Monmouth._ At first visit in 1774, they had the gaol-fever, of which
    died the gaoler, several of his prisoners, and some of their friends.

    _Usk (Monmouth) Bridewell._ The keeper's wife said that many years ago
    the prison was crowded, and that herself, her father who was then
    keeper, and many others of the family had the gaol-fever, three of
    whom, and several of the prisoners, died of it.

    _Gloucester, the Castle._ Many prisoners died here in 1773; and always
    except at Howard's last visit, he saw some sick in this gaol. A large
    dunghill near the stone steps. The prisoners miserable objects: Mr
    Raikes and others took pity on them.

    _Winchester._ The former destructive dungeon was down eleven steps,
    and darker than the present. Mr Lipscomb said that more than twenty
    prisoners had died in it of the gaol-fever in one year, and that the
    surgeon before him had died of it.

    _Liverpool._ Holds about sixty, offensive, crowded. Howard in March,
    1774, told the keeper his prisoners were in danger of the gaol-fever.
    Between that date and Nov., 1775, twenty-eight had been ill of it at
    one time.

    _Chester, the Castle._ Dungeon used to imprison military deserters.
    Two of them brought by a sergeant and two men to Worcester, of which
    party three died a few days after they came to their quarters. (For
    fever in this prison in 1716 see the text, p. 60.)

    _Cowbridge._ The keeper said, on 19 August, 1774, that many had died
    of the gaol-fever, among them a man and a woman a year before, at
    which time himself and daughter were ill of it.

    _Cambridge, the Town Bridewell._ In the spring of 1779, seventeen
    women were confined in the daytime, and some of them at night, in the
    workroom, which has no fireplace or sewer. This made it extremely
    offensive, and occasioned a fever or sickness among them, which so
    alarmed the Vice-Chancellor that he ordered all of them to be
    discharged. Two or three of them died within a few days.

    _Exeter, the County Bridewell._ Between first visit in 1775 and next
    on 5 Feb., 1779, the surgeon and two or three prisoners have died of
    the gaol-fever. In 1755 a prisoner discharged from the gaol went home
    to Axminster, and infected his family, of whom two died, and many
    others in that town afterwards.

    _Exeter, the High Gaol for felons._ Mr Bull, the surgeon, stated that
    he was by contract excused from attending in the dungeons any
    prisoners that should have the gaol-fever.

    _Winchester, Bridewell._ Close and small. Receives many prisoners from
    other gaols at Quarter Sessions. It has been fatal to vast numbers.
    The misery of the prisoners induced the Duke of Chandos to send them
    for some years 30 lbs. of beef and 2 gallon loaves a week.

    _Devizes, Bridewell._ Two or three years ago the gaol-fever carried
    off many. An infirmary added since then.

    _Marlborough._ The rooms offensive. Saw one dying on the floor of the
    gaol-fever. One had died just before, and another soon after his
    discharge.

    _Launceston._ Small, with offensive dungeons. No windows, chimneys, or
    drains. No water. Damp earthen floor. Those who serve there often
    catch the gaol-fever. At first visit, found the keeper, his assistant
    and all the prisoners but one sick of it (on 19 Feb., 1774, eleven
    felons in it). Heard that, a few years before, many prisoners had died
    of it, and the keeper and his wife in one night. A woman confined
    three years by the Ecclesiastical Court had three children born in the
    gaol.

    _Bodmin, Bridewell._ Much out of repair. The night rooms are two
    garrets with small close-glazed skylight 17 in. x 12 in. A few years
    ago the gaol-fever was very fatal, not only in the prison but also in
    the town.

    _Taunton, Bridewell._ Six years ago, when there was no infirmary
    provided, the gaol-fever spread over the whole prison, so that eight
    died out of nineteen prisoners.

    _Shepton Mallet._ Men's night room close, with small window. So
    unhealthy some years ago that the keeper buried three or four in a
    week.

    _Thirsk._ Prisoners had the gaol-fever not long ago.

    _Carlisle._ During the gaol-fever which some years ago carried off
    many of the prisoners, Mr Farish, the chaplain, visited the sick every
    day.

I shall add some medical experiences of gaol-fever in London from the
notes of Lettsom[172]:--

    May, 1773. A person released from Newgate "in a malignant or
    jail-fever" was brought into a house in a court off Long Lane,
    Aldersgate Street; soon after which fourteen persons in the same
    confined court were attacked with a similar fever: one died before
    Lettsom was called in, one was sent to hospital, eleven attended by
    him all recovered, though with difficulty. Two deaths in Wood Street
    Compter: 1. Rowell, an industrious, sober workman, who had supported
    for many years a wife and three children; some of these having been
    lately sick, he fell behind with his rent, a little over three
    guineas; he offered all he had (more than enough) to the landlord, but
    the latter preferred to throw the man and his family into the Compter,
    where Rowell died of fever. 2. Russell, once a reputable tradesman on
    Ludgate Hill, fell into a debt of under three guineas, sent to the
    Compter with his wife and five children, took fever and died; attended
    in his sickness in a bare room by his eldest daughter, elegant and
    refined, aged seventeen; his son, aged fourteen, took the fever and
    recovered.

There was one Black Assize at this period, at Dublin in April 1776. A
criminal, brought into the Court of Sessions without cleansing, infected
the court and alarmed the whole city. Among others who died of the
contagion were Fielding Ould, High Sheriff, the counsellors Derby, Palmer,
Spring and Ridge, Mr Caldwell, Messrs Bolton and Eriven, and several
attorneys and others whose business it was to attend the court[173].

There were two notorious outbreaks of malignant fever among foreign
prisoners of war, one in 1761[174] and another in 1780[175], the first
among French and Spaniards at Winchester and Portchester, the second among
Spaniards at Winchester.

Howard found so little typhus in the gaols in his later visits that it
seemed as if banished for good. But it was heard of frequently about
1780-85--at Maidstone, at Aylesbury, at Worcester, costing the lives of
some of the visiting physicians.


Circumstances of severe and mild Typhus.

The circumstances of the gaol distemper bring out one grand character of
typhus which will have to be stated formally before we go farther.
Ordinary domestic typhus was not a very fatal disease. Haygarth says that
of 285 attacked by it in the poorer quarters of Chester in the autumn of
1774, only twenty-eight died. Ferriar, in Manchester, had sometimes an
even more favourable experience than that: "The mortality of the epidemic
was not great, ... out of the first ninety patients whom I attended, only
two died." This was before the House of Recovery was opened; so that the
low mortality was of typhus in the homes of the people.

The fever was often an insidious languishing, without great heat, and
marked most by tossing and wakefulness, which might pass into delirium;
when it went through the members of a family or the inmates of a house,
there would be some cases concerning which it was hard to say whether they
were cases of typhus or not. Misery and starvation brought it on, and
often it was itself but a degree of misery and starvation. "I have found,"
says Ferriar, "that for three or four days before the appearance of
typhus in a family consisting of several children, they had subsisted on
little more than cold water." "It has been observed," says Langrish, "that
those who have died of hunger and thirst, as at sieges and at sea, etc.,
have always died delirious and feverish." The fever was on the whole a
distinct episode, but in many cases it had no marked crisis. "Those women
who recovered," says Ferriar, "were commonly affected with hysterical
symptoms after the fever disappeared;" and again: "Fevers often terminate
in hysterical disorders, especially in women; men, too, are sometimes
hysterically inclined upon recovering from typhus, for they experience a
capricious disposition to laugh or cry, and a degree of the globus
hystericus." These were probably the more case-hardened people, inured to
their circumstances, their healthy appetite dulled by the practice of
fasting or "clemming," or by opium, and their blood accustomed to be
renovated by foul air. If the limit of subsistence be approached
gradually, life may be sustained thereat without any sharp crisis of
fever, or with only such an interlude of fever as differs but little from
a habit of body unnamed in the nosology.

The worst kind of typhus, often attended with delirium, crying and raving,
intolerable pains in the head, and livid spots on the skin, ending fatally
perhaps in two or three days, or after a longer respite of stupor or
waking insensibility, was commonly the typhus of those not accustomed to
the minimum of well-being--the typhus of hardy felons newly thrown into
gaol, of soldiers in a campaign crowded into a hospital after a season in
the open air, of sailors on board ship mixing with newly pressed men
having the prison atmosphere clinging to them, of judges, counsel,
officials of the court and gentlemen of the grand jury brought into the
same atmosphere with prisoners at a gaol-delivery, of the wife and
children of a discharged prisoner returned to his home, of the
gaol-keeper, gaol-chaplain, or gaol-doctor, of the religious and
charitable who visited in poor localities even where no fever was known to
be, and most of all of country people who crowded to the towns in search
of work or of higher wages or of a more exciting life.

It was in these circumstances that the most fatal infections of typhus
took place. Such extraordinary malignancy of typhus happened often when
the type of sickness (if indeed there was definite disease at all) among
the originally ailing failed to account for it; it was the great
disparity of condition that accounted for it. There were, however, more
special occasions when a higher degree of malignancy than ordinary was
bred or cultivated among the classes at large who were habitually liable
to typhus. But even the old pestilential spotted fever which used to
precede, accompany, and follow the plague itself, was fatal to a
comparatively small proportion of all who had it. Thus, towards the end of
the great London plague of 1625, on 18th October, Sir John Coke writes to
Lord Brooke: "In London now the tenth person dieth not of those that are
sick, and generally the plague seems changed into an ague[176]." One in
ten is probably too small a fatality for the old pestilential fever; but
that is the usually accepted proportion of deaths to attacks in the typhus
fever of later times. The rate of fatality is got, naturally, by striking
an average. But in truth an aggregate of typhus cases, however homogeneous
in conventional symptoms or type-characters, was not always really
homogeneous. We have seen that ninety cases of typhus could occur in the
slums of Manchester with only two deaths. On the other hand there were
outbreaks of gaol-fever in which half or more of all that were attacked
died; and I suspect that the average fatality in typhus of one in ten was
often brought up by an admixture of cases of healthy and well-conditioned
people who caught a much more malignant type of fever from their contact
with those inured to misery. To strike an average is in many instances a
convenience and a help to the apprehension of a truth; but for the average
to be instructive, the members of the aggregate must be more or less
comparable in their circumstances. It has been truly said that there is no
common measure between Lazarus and Dives as regards their subjective views
of things; it is not a little strange to find that they are just as
incommensurable in their risk of dying from the infection of typhus fever.
The rule seems to be that the degree of acuteness or violence of an attack
of typhus was inversely as the habitual poor condition of the victim. In
adducing evidence of the tragic nature of typhus infection conveyed across
the gulf of misery to the other side, I shall endeavour to keep strictly
to the scientific facts, leaving the moral, if there be a moral (and it is
not always obvious), to point itself.

Let us take first the common case of country-bred people migrating to the
towns. Any lodging in a crowded centre of industry and trade would be
high-rented compared with the country cottage which they had left, and
they would naturally gravitate to the slums of the city.

    "Great numbers of the labouring poor," says Ferriar of Manchester,
    "who are tempted by the prospect of large wages to flock into the
    principal manufacturing towns, become diseased by getting into dirty
    infected houses on their arrival. Others waste their small stock of
    money without procuring employment, and sink under the pressure of
    want and despair.... The number of such victims sacrificed to the
    present abuses is incredible." And again:

    "It must be observed that persons newly arrived from the country are
    most liable to suffer from these causes, and as they are often taken
    ill within a few days after entering an infected house, there arises a
    double injury to the town, from the loss of their labour, and the
    expense of supporting them in their illness. A great number of the
    home-patients of the Infirmary are of this description. The horror of
    these houses cannot easily be described; a lodger fresh from the
    country often lies down in a bed filled with infection by its last
    tenant, or from which the corpse of a victim to fever has only been
    removed a few hours before[177]."

Two instances from the same author will show the severe type of the fever.

    The tenant of a house in Manchester, who was herself ill of typhus
    along with her three children, took in a lodger, a girl named Jane
    Jones, fresh from the country. The lodger fell ill, but the fact was
    kept concealed from the visiting physician until her screams
    discovered her: "She was found delirious, with a black fur on the lips
    and teeth, her cheeks extremely flushed, and her pulse low, creeping,
    and scarcely to be counted." Treatment was of no use; she "passed
    whole nights in shrieking," and in her extremity, she was saved, as
    Ferriar believed, by affusions of cold water. Another case, exactly
    parallel, proved fatal in three days:

    "In 1792 I had two patients ill of typhus in an infected
    lodging-house. I desired that they might be washed with cold water;
    and a healthy, ruddy young woman of the neighbourhood undertook the
    office. Though apparently in perfect health before she went into the
    sick chamber, she complained of the intolerable smell of the patients,
    and said she felt a head-ache when she came down stairs. She sickened,
    and died of the fever in three days[178]."

These are instances of country-bred people, plunging abruptly into the
fever-dens of cities and catching a typhus severe in the direct ratio of
their ruddy, healthy condition. Another class of cases is that of persons
carrying the atmosphere of a gaol into the company of healthy and
otherwise favourably situated people. Howard gives a case: at Axminster a
prisoner discharged from Exeter gaol in 1755 infected his family with the
gaol-distemper, of which two of them died, and many others in that town.
The best illustrations of the greater severity and fatality of typhus
among the well-to-do come from Ireland, in times of famine, and will be
found in another chapter. But it may be said here, so that this point in
the natural history of typhus fever may not be suspected of exaggeration,
that the enormously greater fatality of typhus (of course, in a smaller
number of cases) among the richer classes in the Irish famines, who had
exposed themselves in the work of administration, of justice, or of
charity, rests upon the unimpeachable authority of such men as Graves, and
upon the concurrent evidence of many.


Ship-Fever.

The prevalence of fevers in ships of war and transports from the
Restoration onwards can be learned but imperfectly, and learned at all
only with much trouble. Sir Gilbert Blane, who was not wanting in aptitude
and had the archives of the Navy Office at his service, goes no farther
back than 1779, from which date an account was kept of the causes of death
in the naval hospitals. But the deaths on board ships of the fleet were
not systematically recorded until 1811, when the Board of Admiralty
instructed all commanders of ships of war to send to the Naval Office an
annual account of all the deaths of men on board[179]. The sources of
information for earlier periods are more casual.

The war with France, which dated from the accession of William III. and
continued until the Peace of Ryswick in 1697, led to numerous conflicts
with French and Spaniards in the West Indies, and to naval expeditions
year after year. The loss of life from sickness in the British ships for a
few years at the end of the century was such as can hardly be realized by
us. Some part of it happened on the outward voyages, but by far the
greater part of it was from the poison of yellow fever which had entered
the ships in the anchorages of West Indian colonies. It was probably to
that cause that the enormous mortality in the fleet under Sir Francis
Wheeler was owing. After some ineffective operations against the French in
the Windward Islands in the winter of 1693-4, he sailed for North America
with the intention of attacking Quebec. This he failed to do, having
sailed from Boston for home on the 3rd of August without entering the St
Lawrence. The reason of the failure was probably the extraordinary
fatality which Cotton Mather, of Boston, professes to have heard from the
admiral himself, namely, that he lost by a malignant fever on the passage
from Barbados to Boston 1300 sailors out of 2100, and 1800 soldiers out of
2400[180].

Another instance comes from Carlisle Bay, Barbados. The slave ship
'Hannibal' arrived there in November, 1694, during a disastrous epidemic
of yellow fever. Phillips, the captain, whose journal of the voyage is
published[181], had great difficulty in saving his crew from being pressed
into the king's ships, which were short of men owing to the yellow fever.
Captain Sherman, of the 'Tiger,' who convoyed the 'Hannibal' and other
merchantmen back to England in April, 1695, told Phillips that he buried
six hundred men out of his ship during the two years that he lay at
Barbados, though his complement was but 220, "still pressing men out of
the merchant ships that came in, to recruit his number in the room of
those that died daily."

These and other similar experiences of yellow fever in the West Indies,
which might be collected from the naval history, do not come properly into
this chapter; and I pass from them to ship-fever proper, having indicated
how much of the loss of life abroad was due to yellow fever.

Some light is thrown upon the state of health on board ships of war on the
home station by Dr William Cockburn, physician to the fleet, afterwards
the friend of Swift, who calls him "honest Dr Cockburn." He had a secret
remedy for dysentery, which he succeeded in getting adopted by the
Admiralty, greatly to his own emolument for many years after. Dining on
board one of the ships at Portsmouth, in 1696, with Lord Berkeley of
Stratton, he brought up the subject of his electuary, and arranged for a
public trial of it next day on board the 'Sandwich.' An uncertain number,
which looks to have been about seven in Cockburn's own account, but became
seventy in the pamphlet which advertised the electuary after his death,
were available for the trial and were speedily cured. Cockburn's three
essays on the health of seamen[182] leave no doubt as to the extensive
prevalence of scurvy and the causes thereof; while his references to
"malignant fever," although they are, as usual, brought in to illustrate
some doctrinal or theoretical point, give colour to the belief that
ship-typhus may have been as common then as we know it to have been in the
ships at Portsmouth and Plymouth, on the more direct testimony of Huxham
in 1736, and of Lind twenty years later.

A naval surgeon of the time of William III. and Anne, was induced by his
enthusiasm for blood-letting in fevers to record some of his experiences
on board ship[183]. It was usually the lustiest, both of the young, strong
and healthy people, and likewise of the elder sort, that died of fevers,
the symptoms which proved so mortal having been delirium, phrenitis, coma
or stupor, whether they occurred in the [Greek: synochoi] (of Sydenham) or
in the [Greek: synecheis] (of the same author):

    "I had observed in a ship of war whose complement was near 500, in a
    Mediterranean voyage in the year 1694, where we lost about 90 or 100
    men, mostly by fevers, that those who died were commonly the young,
    but almost always the strongest, lustiest, handsomest persons, and
    that two or three escaped by means of such [natural] haemorrhagies,
    which were five or six pounds of blood"--the point being that the
    amount of blood drawn by phlebotomy should be in proportion to the
    robustness and body-weight of the patient.

In 1703 and 1704 he was surgeon to two of Her Majesty's ships "where a
delirium, stupor and phrenitis" were found as symptoms of the fevers. In
the summer of 1704, cruising in the latitudes of Portugal and Spain, the
men brought on board from Lisbon unripe lemons with which they made great
quantities of punch. This was the evident cause of a cholera morbus and
dysentery: "after this we had a pretty many taken with the _synochus
putris_, and some with the _causus_" [malignant fever]. Most of these
fevers went off by a crisis in sweating, "which was so large I had good
reason to believe it judicatory." In several the fevers left on the 9th,
10th or 11th day, and in almost all by the 14th. "About the latter end of
July, and in August, there were many taken with a delirium and stupor or
coma, and some with the phrenitis in their fever." Among the symptoms was
one which we find described for fevers on board ship on the West Coast of
Africa at the same time--"soreness all over as if from blows with a cane,"
a symptom afterwards associated with dengue. "Sometimes the bones (as they
term it) don't pain them much." In some cases there were petechial spots
as well as a stupor. In the month of August "the fevers with a stupor and
phrenitis" came on apace. The treatment was to take ten ounces of blood
every day from the second to the eighth day of the fever, to give tartar
emetic in five-grain doses at the outset, and to administer cathartic
glysters in the second half of the fever. "Seeing the lustiest men now ran
no more hazard of their lives than any other who were usually taken with
this fever, nor indeed so much, in the beginning of September I resolved,
after all the phlebotomy was done in these fevers, to try the cathartic
sooner." Many of these who had accustomed themselves to the liberal use of
spirituous liquors miscarried in the phrenitis.

White left the navy in 1704 and settled in practice at Lisbon, where he
saw much fever. He had seen epidemics break out in British ships of war at
anchor in the Tagus, crowded with men and prisoners. One case he mentions
in a Lisbon woman, with continual synochus, stupor, and petechiae on the
fifth day: "This was contagious, for she got it by going often to assist a
gunner of a man-of-war, who came to her house with this distemper upon
him: for many at the same time on board that ship were sick of that
disease." Among the causes of fever on board ship he mentions the effluvia
of the bilge-water.

    Exposed to these emanations were "a multitude of people breathing and
    constantly perspiring in a close place, such as a ship's _allop_ or
    lower deck next the hould, where is the entry to a certain vacant
    space near the ship's center, which leadeth to the bottom, for
    gathering all the water together which the ship draweth by leakage,
    and is called the well. Several times there is occasion for some
    people to go down to examine the quantity of the water, and in some
    ships to bore an augur hole to let in as much as will preserve a good
    air. I have often known two or three men killed at a time, as it is
    said; and the reason may be understood from what I said of the general
    effects of that fluid in ordinary fever [he is now writing on heat
    apoplexy], where there is not above two or three inches, but just as
    much as may make a surface, almost equal to the square of the well, of
    stagnant salt water which had been a long while in gathering; and the
    air over the whole _allop_ extremely rarified, and here not at all
    ventilated[184]."

We owe it to the accident of the celebrated Dr Freind having accompanied
Lord Peterborough's expedition to Spain in 1705 that some account has been
preserved of the sickness among the troops ashore and afloat[185].

The expedition of some 8000 men being then in its second year, fever and
dysentery were by far the most common diseases, so common that "we can
hardly turn, whether at sea or in camp, without finding them as if our
inseparable companions and as if domesticated among us." In the summer of
the previous year there had been much fever both in the ships of the fleet
and in the camp before Barcelona: "It was of the continual kind, though it
usually remitted in the day time, and seemed to approach nearly to the
stationary one which Sydenham has described in the years 1685 and 1686."
He then gives symptoms, which were on the whole those of the hospital
fever to be afterwards described from Pringle's medical account of the
campaigns in 1743-48. Persons of a robust habit were affected more than
others, and more severely, and carried off sooner. The others were
generally taken away by a lingering death. "Some, when the fever seemed to
have been wholly gone off lay four or five days without pain or sickness,
though weak; afterwards being suddenly seized with convulsions of the
nerves they in a short time expired"--perhaps the phenomenon of relapse,
which Lind recorded for ship-fever fifty years after and was seen among
the troops landed from Corunna in 1809. In some few the parotids, or
abscesses formed about the groin, carried off the disease.

    He then gives the case of a lieutenant on board the 'Barfleur.' At
    first he was restless and delirious; on the 7th and 8th days he had
    _subsultus tendinum_; on the 8th day his tongue was sometimes fixed,
    and his eyes sparkled; on the 9th day, he was wholly deprived of his
    understanding; he pulled off the fringe of the bed and plucked the
    flocks; when he had before faultered in his speech, he was sometimes
    seized with hiccough. But on the 10th day, after 12 oz. of blood had
    been drawn from the jugular vein, his delirium went off on a sudden,
    and he began to mend, making a perfect recovery.

Until the middle of the 18th century there are few other notices of
ship-fever, but it is probable that Huxham's accounts of a very malignant
typhus among the crews of ships of war at Plymouth in 1735 (as well as at
Portsmouth according to report), and again in 1741, are to be taken as
samples of what might have been recorded on many occasions[186].


Fever and Dysentery of Campaigns: War Typhus, 1742-63.

The war in Ireland after the accession of William III. produced two
remarkable instances of war-sickness, which are fully given in another
chapter. The campaigns of Marlborough against the armies of Louis XIV.,
from 1704 to the Treaty of Utrecht in 1713, appear to have found no
historian from the medical side, nor does the duke refer to these matters
in his dispatches or letters, beyond a remark in a letter to his wife from
near Munich, 30 July, 1704, a fortnight before the battle of Blenheim:
"There having been no war in this country for above sixty years, these
towns and villages are so clean that you would be pleased with them[187]."

The war of 1742-48, in which George II. joined Austria against France,
produced the first good accounts of war typhus, on land and on board ship,
in the writings of Pringle[188]. After the battle of Dettingen, 27 June,
1743, the men were exposed all night in the wet fields; during the next
eight days five hundred of them were attacked with dysentery, and in a few
weeks near half the army were either ill of it or had recovered from it.
The dysentery continued all July and part of August, while the army lay at
Hanau. The village of Feckenheim, a league from the camp, was used as a
hospital, some 1500 being quartered in it, most of them ill at first of
dysentery. The latrines appear to have been ill designed and badly kept.
"A malignant fever began among the men, from which few escaped: for
however mild or bad soever the flux was for which the person was sent to
hospital, this fever almost surely supervened. The petechial spots,
blotches, parotids, frequent mortifications, and the great mortality,
characterized a pestilential malignity: in this it was worse than the true
plague.... Of 14 mates employed about the hospital five died; and,
excepting one or two, all the rest had been ill and in danger. The
hospital lost nearly half of the patients; but the inhabitants of the
village of Feckenheim, where the sick were, having first received the
bloody flux, and afterwards the fever by contagion, were almost utterly
destroyed[189]." The survivors from the sick troops in Feckenheim were
removed to Neuwied, where they were relieved; "but the rest, who were
mixed with them, caught the infection." The mixed troops were sent still
down the Rhine in bilanders, during which voyage "the fever became so
virulent that above half the number died in the boats, and many of the
remnant soon after their arrival." A parcel of tents sent in these
bilanders to the Low Countries were given to a Ghent tradesman to refit;
he employed twenty-three journeymen upon them, "but these unhappy men were
quickly seized with this fever, whereof seventeen died." They had no
other communication with the infected but through the tents.

"These," says Pringle, "are instances of high malignity. The common course
of the infection is slow, and only catching to those constantly confined
to the bad air. Sometimes one will have this fever about him for several
days before it confines him to his bed; others I have known complain for
weeks of the same symptoms without any regular fever at all; and some,
after leaving the infectious place, have afterwards fallen ill of
it[190]."

After the battle of Fontenoy on 11 May, 1745, the army was in good health:
"the smallpox was the only new disease; it came with the recruits from
England, but did not spread; and indeed we have never known it of any
consequence in the field."

On the Jacobite rebellion breaking out in Scotland later in the same year,
some of the returning troops were ordered to disembark at Newcastle, Holy
Island and Berwick. They had a long voyage, so that a kind of remitting
fever which some of them had acquired in the autumn in the Low Countries
was "by the crowds and the foul air of the hold soon converted into the
jail distemper and became infectious." At Newcastle most of the nurses and
medical attendants of the extemporized hospital were seized with it, of
whom three apothecaries, four apprentices and two journeymen died. But the
most remarkable experience was on Holy Island. Of ninety-seven men taken
out of the ships there, ill of the gaol-fever, forty died, "and the people
of the place receiving the infection, in a few weeks buried fifty, the
sixth part of the inhabitants of that island." At Nairn and Inverness
there was a singular experience in the spring of 1746. The ships which
brought Houghton's brigade to Nairn carried also thirty-six deserters to
be tried by court-martial at the headquarters at Inverness: these men had
deserted to the French in Flanders, had been found on board of a captured
French transport carrying men to aid the Pretender, and had been thrown
into gaol in England till an opportunity arose of sending them to their
trial. Three days after the landing at Nairn of the force with which these
deserters sailed, six of the officers were seized with fever and many of
the men, of whom eighty were left sick at Nairn; in the ten days that the
regiment remained at Inverness it sent one hundred and twenty more to
hospital, ill of the same fever, which became frequent also among the
inhabitants of the town. "Though the virulence of the distemper diminished
afterwards in their march to Fort Augustus and Fort William, yet the corps
continued sickly for some time." From the middle of February, 1746, when
the army crossed the Forth, to the end of the campaign, there were two
thousand sick in hospital, including wounded, of which number near three
hundred died, mostly of the contagious fever[191].

After the Peace of Aix-la-Chapelle in 1748, the English troops embarked at
Willemstad for home; "but the wind being contrary, several of the ships
lay above a month at anchor, and, after all, meeting with a tedious and
stormy passage, during which the men kept mostly below deck, the air was
corrupted and produced the jail or hospital fever." The ships that came to
Ipswich were in the worst state, about four hundred men having been landed
sick there, most of them ill of this contagious fever. The infection was
at first as active and the mortality as great on shore as on board; but
the virulence of the fever was at length subdued by dispersing the sick
and convalescents as much as possible[192].

Monro gives a similar account of the camp sickness among the British
troops during the campaigns in North Germany in 1760-63. In the autumn of
1760, before he joined the forces, there had been much malignant fever and
dysentery: the camp at Warburg was near the battlefield (31 July, 1760),
where many of the dead were scarce covered with earth; there were also
many dead horses, and in a time of heavy rains, the camp, with the
neighbouring villages and fields, was filled with the excrements of a
numerous army. Not only the soldiers, but the inhabitants of the country,
who were reduced to the greatest misery and want, were infected, and whole
villages almost laid waste. When Monro joined at Paderborn in January,
1761, he found the hospitals overcrowded, and the malignancy of the fever
thereby much increased, so that a great many died. "The 1st and 3rd
regiments suffered most, owing to all the sick of each regiment being put
into a particular hospital by themselves, which kept up the infection, so
that they lost one-third of those left ill of this fever, and many of the
nurses and people who attended them were seized with it." He distributed
the sick men of the Coldstreams among the houses in the town, and lost few
in comparison with the 1st and 3rd regiments. The contagion, under this
bold policy, did not spread.

Two points in the symptoms are noteworthy: first the occurrence of
suppurating buboes of the groins and armpits in several; and, secondly,
the frequency of round worms.

    "In this fever it was common for patients to vomit worms, or to pass
    them by stool, or, what was more frequent, to have them come up into
    the throat or mouth, and sometimes into their nostrils, while they
    were asleep in bed, and to pull them out with their fingers. The same
    thing happened to most of the British soldiers brought to the
    hospitals for other feverish disorders as well as this."

He cannot explain the commonness of round worms in the sick, unless it was
from the great quantity of crude vegetables and fruits eaten, and the bad
water. Patients in convalescence often suffered from deafness, and from
suppurating parotids. Some had frequent relapses into the fever, "which
seemed to be owing to the irritation of these insects," namely the worms.
Most of those who fell into profuse, kindly, warm sweats recovered, the
sweats lasting from twelve to forty-eight hours, and carrying off the
fever. He never saw any miliary eruptions, and only sometimes petechiae,
or small spots, or marbling as in measles[193].


Ship-Fever in the Seven Years' War and American War.

Ship-fever would appear to have been at its worst after the middle of the
18th century. Dr James Lind joined Haslar Hospital in 1758, and brought to
the naval medical service the same high qualities which Pringle and Monro
brought to that of the army[194]. The smaller ships, such as the 'Saltash'
sloop, the 'Richmond' frigate, and the 'Infernal' bomb were full of fever
of the most malignant kind; of 120 men in the 'Saltash,' 80 were infected
with a contagion much more virulent and dangerous than that in the
guard-ships. The explanation was that the smaller ships were receiving
vessels for the larger ships, and were manned from the gaols; drafts from
them carried the infection to the guard-ships and to the ships fitting out
for foreign service. Malignant fever also arose on the voyage home from
America[195]. In September and October 1758, after the reduction of
Louisburg, several of the ships arriving at Spithead were infected with a
malignant fever; three hundred men were received from them at Haslar
Hospital (some with scurvy), of whom twenty-eight died. The 'Edgar,'
having been manned at the Nore from gaols, sailed for the Mediterranean,
and lost sixty men from fever and scurvy. The 'Loestoffe,' having lain in
the St Lawrence for eight months in perfect health, took on board six
convalescent men from Point Levi Hospital before sailing for home; in
forty-eight hours, fifty out of her two hundred men were seized with
fevers and fluxes, and six died on the voyage home. The 'Dublin' on the
homeward voyage from Quebec buried nineteen, and on her arrival reported
ninety men sick of fever, fluxes and scurvy. The 'Neptune' was said to
have lost one hundred and sixty men in a few months, and reported 136
sick. The 'Cambridge,' with 650 men in health, sent three of her crew to
the 'Neptune' laid up, to prepare her for the dock; of these three, one on
the fifth day became spotted and died, and another narrowly escaped with
life. The 'Diana' developed fever during a rough passage home from
America. The 'St George,' having sailed from Spithead in 1760, met with
rough weather and had to return on account of sickness. On the other hand,
Hawke's fleet of twenty ships of the line with fourteen thousand men,
which defeated the French in November 1759, kept the Bay of Biscay for
four months in the most perfect health.

From 1 July, 1758, to 1 July, 1760, there were 5743 admissions to Haslar
Hospital, the chief diseases being as follows:

  Fevers         2174
  Scurvy         1146
  Consumption     360
  Rheumatism      350
  Fluxes          245

Of the fevers some were of an intermittent type, but by far the most were
continued ship-typhus. Relapses were common, even to the sixth or seventh
time. The fever varied a good deal in malignity, but never produced
buboes, livid blotches or mortifications, and seldom parotids. Twenty-four
men received from January to March 1760 out of the 'Garland' had most of
them petechial spots accompanied with other symptoms of malignity, and of
these, five died or 20 per cent. But of 105 received during the same
months from the 'Postilion' and 'Liverpool' only eight died, and those
mostly of a flux. The infection had little tendency to spread among the
attendants at Haslar. In the first six months only one nurse died; in
1759, two labourers and two nurses died, one of the nurses by infection,
having concealed some infected shirts under her bed, the other by decay of
nature. Of more than a hundred persons employed in various offices about
the sick there died only those five in the course of eighteen months.

    Although Lind's account of ship-fever in the British navy is bad
    enough, he has collected some far worse particulars of foreign ships.
    Febrile contagion destroyed two-thirds of the men in the Duc
    d'Anville's fleet at Chebucto (now Halifax), in 1746, the complete
    destruction of which was afterwards accomplished by the scurvy. It was
    ship-fever which ravaged the Marquis d'Antin's squadron in 1741, the
    Count de Roquesevel's in 1744, and the Toulon squadron in 1747. He
    takes the following from Poissonnier's _Traite de Maladies des Gens de
    Mer_: The fleet commanded by M. Dubois de la Mothe sailed in 1757 from
    Rochefort for Louisburg, Canada, having some men sickly. The ships
    touched at Brest, and sent 400 ashore sick. They sailed from Brest on
    3 May, and arrived at Louisburg on 28 June. There was then sickness in
    only two ships, but in a short time it appeared in all the fleet. On
    14 October the fleet sailed from Louisburg for home, embarking one
    thousand sick, and leaving four hundred supposed dying. In less than
    six days from sailing most of the thousand sick were dead. When the
    fleet arrived at Brest on 22 November there were few seamen well
    enough to navigate the ships; 4000 men were ill, the holds and decks
    being crowded with the sick. The hospitals at Brest were already
    occupied, two ships from Quebec shortly before having sent a thousand
    men to them. Fifteen hospitals were soon filled, attended by five
    physicians and one hundred and fifty surgeons. Two hundred almoners
    and nurses fell victims. The infection passed to the lower class of
    the citizens, the havoc became general, and houses everywhere were
    filled with the dying and the dead. At length it got among the
    prisoners in the hulks. This dreadful infection began to abate in
    March, 1758, and ceased in April, having carried off in less than five
    months upwards of 10,000 people in the hospitals alone, besides a
    great number of the Brest townspeople. The stench was intolerable. No
    person could enter the hospitals without being immediately seized with
    headache; and every kind of indisposition quickly turned to fatal
    fever, as in the old plague times. The state of the bodies showed the
    degree of malignity that had been engendered: the lungs were engorged
    with blood, and looked gangrenous; the intestines often contained a
    green offensive liquor, and sometimes worms. Lind's other instances
    are chiefly of the Dutch East Indiamen that anchored at Spithead with
    fever on board. In Nov., 1770, the 'Yselmonde' bound to Batavia, came
    to anchor at Spithead, and buried a number of men every day; two
    custom-house officers caught the fever and died. He gives two other
    instances of Dutch ships bound to Batavia, which came in to
    Portsmouth with fever[196]. The Dutch were said to send annually 2000
    soldiers to Batavia, and to lose three-fourths of them by the
    ship-fever before they arrived. In 1769 Lind saw ship-fever in the
    Russian fleet at Spithead.

Brownrigg, of Whitehaven, gives a good instance of the diffusion of typhus
in a newly-commissioned ship of war, and thence to the civil population,
which bears out Lind's favourite notion that the gaols and the press-gang
had far-reaching effects. In the year 1757 a sloop of war had been hastily
manned at the Nore to protect the shipping between the Irish and
Cumberland ports. She reached Whitehaven in May, with fever on board. The
men were landed and lodged in small houses. Brownrigg found about forty
lying on the floor of three small rooms, very close together, many of them
in a dying state; seven days after he was himself seized with fever, and
had a narrow escape with life. The ship's surgeon died of it, his mate
recovered with difficulty, two surgeons of the town died of it, and two
more in Cockermouth. The contagion spread widely among the inhabitants of
Whitehaven, Cockermouth and Workington[197].

Lind showed to Howard in one of the wards of Haslar Hospital a number of
sailors ill of the gaol fever; it had been brought on board their ship by
a man who had been discharged from a prison in London, and it spread so
much that the ship had to be laid up[198].

With the outbreak of the American War we begin to hear of still more
disastrous epidemics of fever in the English fleets. Some instances from
Robertson's full collection must suffice[199]. The 'Nonsuch' left England
in March, 1777, and fifty of her men were carried off by fever before
December; in that month, the 'Nonsuch,' 'Raisonable' and 'Somerset' had
each from 130 to 150 men on the sick list, chiefly fever in the
'Somerset,' and scurvy in the other two. In April, 1778, the 'Venus,' with
a crew of 240, was at Rhode Island very sickly; the surgeon told Robertson
that they had lost about fifty men of fever, which still continued to rage
on board: they became sickly from being crowded with prisoners and
cruising with them on board in bad weather. The 'Somerset' had buried 90
men of the fever since she left England, 70 of them being of the best
seamen. On arriving at Spithead in October, 1779, Robertson found much
fever in the Channel Fleet which had lately come in, especially in the
'Canada,' 'Intrepid,' 'Shrewsbury,' 'London' and 'Namur,' three or four of
which were put past service, so much were they disabled by sickness. At
Gibraltar Hospital from 12 January to 31 March, 1780, there were admitted
570 men from twenty-seven ships, of whom 57 died; of 110 sick from the
'Ajax,' 18 died; of 437 Spanish prisoners, 37 died. Next year, in May,
1781, at Gibraltar, the 'Bellona' had buried 27 men since she left
England, and had 108 on the sick list. The 'Cumberland' had buried 15; of
the 'Marlborough's' men, 40 had died at the hospital. Robertson had to
purchase at his own expense vegetable acids, fruit and vegetables for the
sick.

    Some statistics remain of the loss of men in the navy by sickness in
    the Seven Years' War (1756-62) and in the American War[200]. The House
    of Commons had ordered a return of the number of seamen and marines
    raised and lost in the former; but the return was too general to be of
    much use, the number "lost" having included all those men who had been
    sent to hospital and never returned to their ships, all those who had
    been discharged as unserviceable, and all deserters. The number raised
    was 184,899, and the number "lost" 133,708, besides 1512 killed. The
    Return by the Navy Board for the period of the American War was more
    specific, showing only the number of the dead and killed.

    _Seamen and Marines raised, dead or killed, during the American War,
    29 Sept., 1774, to 29 Sept., 1780_:

        Year     Raised      Dead    Killed

        1774        345        --        --
        1775      4,735        --        --
        1776     21,565      1679       105
        1777     37,457      3247        40
        1778     31,847      4801       254
        1779     41,831      4726       551
        1780     28,210      4092       293
                -------    ------      ----
                175,990    18,545      1243

Fully a tenth part of the men raised were lost by sickness. Fever was the
chief sickness, and as it happened rarely that more than one in ten cases
of fever died, it will be easy to form an approximate estimate of the
proportion of all the men raised for the ships that were on the sick list
at one time or another with fever--nearly the whole, one might guess.

During the three last years of the period Haslar Hospital was constantly
full of typhus fever. Admiral Keppel's fleet arrived at Spithead on 26
October, 1778, and soon began to be infected with contagious fever; before
the end of December, 3600 men had been sent to Haslar, which could make up
at a pinch 1800 beds. But the great epidemic at Portsmouth was the next
year, 1779, when the very large Channel Fleet under Sir Charles Hardy came
in. During the month of September, 2500 men were received into hospital,
and more than 1000 ill of fevers remained on board for want of room in the
hospitals. In the last four months of 1779, 6064 sick were sent to Haslar,
which had 2443 patients on 1 January, 1780. There was an additional
hospital at Foston, holding 200, as well as two hospital ships holding
600. The infection was virulent during the winter, when Portsmouth was
crowded with ships; and in the first five months of 1780, when 3751 cases
of fever were admitted during the decline of the epidemic, one in eight
died. The following shows how much fever preponderated at Haslar Hospital
in 1780. In 8143 admissions on the medical side, the chief forms of
sickness were as follows[201]:

        Continued Fevers     5539
        Scurvy               1457
        Rheumatism            327
        Flux                  240
        Consumption           218
        Smallpox               42

    Blane gives the instance of the 'Intrepid,' one of the Channel Fleet
    under Hardy in 1779: "Almost the whole of her crew either died at sea
    or were sent to the hospital upon arriving at Portsmouth. This ship,
    after refitting, was pretty healthy for a little time; but probably
    from the operation of the old adhering infection, she became extremely
    sickly immediately after joining our fleet and sent 200 men to the
    hospital after arriving in the West Indies. Most of these were ill of
    dysentery[202]." During a voyage of three weeks of the 'Alcide' and
    'Torbay' from the Windward Islands to New York in September, 1780,
    nearly a half of the men were unfit. In the 'Alcide' it was a fever
    that raged, in the 'Torbay' it was a dysentery[203].

These experiences of fever in the ships of the Royal navy continued to the
end of the 18th century. In Trotter's time, as in Lind's, receiving ships
were a source of contagion to others, one ship of the kind, the
'Cambridge' having diffused fever among many ships of the Channel Fleet by
men drafted from her[204].

Ship typhus was also an incident of the voyages of the East India
Company's ships, which nearly always carried troops. In the voyage of the
'Talbot,' 22 March--25 August, 1768, with 240 persons on board, "towards
the end of July a fever of a very bad kind made its appearance, attended
with delirium, low pulse, petechiae or livid vibices and haemorrhages from
the nose, of which one died and three or four escaped hard." The sick were
isolated, and the infection did not spread. Such outbreaks of typhus were
not uncommon at sea, although the loss of life from them was small beside
that from the fevers of Madagascar, Sumatra, Batavia and Bengal. The ship
typhus usually began on board among the soldiers. The most notable point
is that relapses were common, as Lind also observed at Haslar Hospital;
some on board the 'Lascelles' in 1783 (150 attacks among 151 soldiers) had
relapsed seven times. It does not appear, however, that the best class of
merchantmen suffered greatly from fevers. Dr Clark, who compiled a report
of the practice in fevers in the ships of the East India Company from 1770
to 1785, had reason to congratulate the Company on the general healthiness
of their fleet:

    "When ships set out at a proper season, when they are not too much
    crowded, when the weather is favourable, and no mismanagement appears,
    fewer lives are lost in these long voyages than in the most healthy
    country villages. And in perusing the medical journals I have the
    peculiar pleasure of finding that many ships have arrived in India
    without the loss of a single life by disease," e.g. the 'Valentine' in
    1784, seven months out, with 300 souls, no deaths, and the
    'Barrington' in 1789, no deaths outward bound[205].

On the other hand, these English reports give incidentally the most
unfavourable accounts of the Dutch East Indian ships. Three Dutch ships,
then in Praya Bay, St Jago (Cape de Verde Islands), had buried 70 to 80
men each, and had some hundreds of sick on board. Another report says:
"Before we left Table Bay several Dutch ships arrived, some of which had
buried 80 people in the voyage from Holland. None lost less than 40 men. I
am informed that some of their ships last year buried 200 men"--the causes
of the sickness being overcrowding, filth, and the slowness of the
voyages. One experience of the very worst kind happened to an English
expedition consisting of the 100th regiment, the 98th regiment, the second
battalion of the 42nd, and four additional companies. They had formed part
of the force for the reduction of the Cape of Good Hope, whence they
re-embarked for Bombay. During the voyage from Saldanha Bay a contagious
fever and scurvy broke out among the troops, who were crowded and badly
clothed; dead men were thrown overboard by dozens, and the regiments were
reduced to a third of their original numbers. Six officers of the 100th
regiment died, and an equal if not greater proportion of those of the 98th
and 42nd.

The other chief occasion of ship typhus was the emigration to the American
and West Indian colonies from Britain and Ireland. The Irish emigration
was especially active from the beginning of the 18th century, owing to
rack-renting and other causes. Madden[206] professed to know that
one-third of the Irish who went to the West Indies (perhaps he should have
included Carolina) perished either on the voyage or by diseases caught in
the first weeks after landing; and as we know that typhus attended the
Irish emigration in the 19th century, we may infer that the same was the
cause of mortality in the 18th.

The trouble from ship-fever in the navy was so great all through the 18th
century that many ingenious shifts were tried to overcome it. Towards the
end of the century, the favourite device was fumigation with the vapour of
mineral acids; one such plan, for which the Admiralty paid a good sum,
ended in the burning of several ships to the water's edge. An earlier plan
was ventilation of the hold and 'tween decks by means of Sutton's
pipes[207], which found a strong advocate in the Rev. Stephen Hales, of
the Royal Society[208].

Twice in the course of a paper to that learned body[209] he asserts that
the noxious, putrid, close, confined, pestilential air of ships' holds and
'tween decks "has destroyed millions of mankind"; on the other hand,
according to the testimony of a captain of the navy, Sutton's pipes had
kept his ship free from fever. Lind caps this with the case of H.M.S.
'Sheerness,' bound to the East Indies. She was fitted with Sutton's pipes,
the dietary being at the same time so arranged that the men had salt meat
only once a week. After a very long passage of five months and some days
she arrived at the Cape of Good Hope without having had one man sick. "As
the use of Sutton's pipes had been then newly introduced into the king's
ships, the captain was willing to ascribe part of such an uncommon
healthfulness in so long a run to their beneficial effects; but it was
soon discovered that, by the neglect of the carpenter, the cock of the
pipes had been all this while kept shut[210]."

Ship-fever was at length got rid of by more homely and more radical means
than scientific ingenuity. Lind had shown one root of the evil to lie in
the pressing of men just out of gaol. Admiral Boscawen, by his unaided
wits, discovered another means of checking it. He avoided the mixing of
fresh hands with crews seasoned to their ships, unless when some evident
utility or necessity of service made it proper; "and upon this principle
he used to resist the solicitation of captains, when they requested to
carry men from one ship to another when changing their command[211]."
Towards the end of the 18th century many reforms were made in the naval
service--in the dietary, in the allowance of soap, in keeping the bilges
clean, in the use of iron and lead instead of timber; so that Blane dates
from the year 1796 a new era in the health of the navy[212].


The "Putrid Constitution" of Fevers in the middle third of the 18th
Century.

Resuming the history of fevers among the people at large from the great
typhus epidemic of 1741-42 to the end of the century, we find the
conditions somewhat different in the earlier and later divisions of the
period. The time of prosperity, when England exported large quantities of
wheat in every year except two or three, is reckoned from 1715 to 1765;
after the latter date England gradually ceased to be an exporting country,
owing to various causes, including the increase of pasture farming and the
growth of industrial populations in the northern counties. The year 1765
marks the beginning of what has been called the Industrial Revolution; and
it is also an important point of time in the history of the fevers of the
country, for it is in the generation after that we obtain all the best
information on what may be called industrial typhus, in the writings of a
group of physicians who were at once philanthropic and exact. But there
was an earlier period of fever, which is somewhat difficult to the
historian. It is perhaps the last period in which Sydenham's language of
"epidemic constitutions" seems to be appropriate, whether it be that the
writers of the time were still under his influence, or because the
prevalent maladies could not well be accounted for in any other way. The
constitution in question was a "putrid" one. It coincided with the great
outburst of putrid or gangrenous sore-throat, to be described elsewhere;
and it included an extensive prevalence of fevers which were also called
putrid or nervous, and sometimes called miliary. Fevers of the same kind,
and with the same miliary rash, are described by earlier writers, such as
Huxham. Perhaps the most correct view of the matter is to consider this
type of fever as corresponding roughly to the middle third of the century,
and as having been interrupted by the typhus epidemic of 1741-42, during a
time of special distress. Besides the great outburst of putrid or
malignant sore-throat, there was also a disastrous murrain of cattle for
several years; and at Rouen there was a remarkable fever which some
English writers of the time took to be the highest manifestation of the
same "putrid" constitution that they discovered also in the English and
Irish fevers.

    The fever at Rouen which Le Cat specially described to the Royal
    Society was an outbreak from the end of November, 1753, to February,
    1754. This outbreak was only one of a series; but as it attacked a
    great number of persons of distinction and made great havock among
    them, it attracted unusual notice and was regarded as something new,
    the rumour spreading over Europe that Rouen had been visited by
    plague. The same fever, however, had occurred there in previous years;
    and allied forms of sickness, of the same gangrenous character,
    including gangrenous sore-throat, could be traced back for twenty or
    thirty years. It will suffice to mention of these the malignant fever
    which appeared in 1748 and continued in 1749, 1750 and 1751. There was
    a fixed pain in the head, pain about the heart, a low fever with
    delirium, often miliary eruptions, continual faint sweating,
    drowsiness, scanty or suppressed urine, abdominal distension. After
    death the stomach was found "inflamed" at places, as well as the small
    intestine. In some cases there were ulcerations which almost
    penetrated the coats. The lungs were engorged with blood. In one case,
    of a young woman aged twenty, the mesentery was filled with obstructed
    glands and the intestines mortified in different places. In another,
    almost the whole mesentery was mortified and there was an anthrax or
    carbuncle at the upper fore part of the armpit. At the same time some
    cases of smallpox, with miliary eruption, also had ulcerations of the
    stomach, with inflammatory spots on other parts of it and of the
    intestine, the mesenteric glands being enlarged and hard. Some of the
    cases at the Hotel Dieu in 1750 were traced to infection from bales of
    horse-hair; but the type of the disease in those cases did not differ
    essentially from that of other cases. Some rapidly fatal cases in the
    winter of 1752-53 had suppurative inflammation about the heart. (In
    1739 there had been deaths from continued fever at the Hotel Dieu,
    after an illness of six or seven days, marked by frequent faintings,
    small abscesses being found after death in the substance of the heart
    near the auricles.) The fever among the upper classes in the winter of
    1753-54 was marked, in its most mortal form, by lowness, continued
    fever, pain in the head, cough, sore-throat, nausea, dry black tongue,
    delirium, sweats, stupor, some oppression of the heart, spitting of
    blood, sometimes swelling of the belly, these symptoms being followed
    often by miliary eruption, and sometimes by a slight flux with blood.
    Many were affected with a dejection of spirits, and with a feeling of
    terror which made them tremble at the ordinary sound of the voice. The
    fever ran a full course of thirty or forty days (the miliary eruption
    coming about the 21st day), while death usually ensued about the 25th.
    The appearances after death were remarkable (many bodies were opened):
    "In some a part of the villous coat of the stomach and of the small
    guts was inflamed; and the rest of these organs were filled with an
    eruption of the miliary crystalline kind, except that it was larger;
    and there was likewise an obstruction in the glands of the mesentery.
    In others a strong inflammation had seized the whole stomach and a
    small portion of the oesophagus, but the intestines were free.... In
    those cases where the delirium had continued long and violent, we
    found either ulceration on the stomach, or its villous coat separated,
    together with a great inflammation, and even some gangrenous spots, on
    the other coats of that organ." Some recovered by critical abscesses.
    Others who escaped death by the poison carried its terrible effects
    for many months; their limbs and joints were feeble, and they were
    troubled with vertigo, lassitude and fears[213].

Exactly covering the period of these fevers at Rouen, there were low
putrid fevers in London, in Worcestershire, in Ireland, and among the
English colonists in Barbados. It was certainly not a mere fashion in
medicine which produced the accounts of a similar fever, for these
accounts came from places far apart and were independent of each other. Dr
Fothergill, of Lombard Street, published in the _Gentleman's Magazine_
every month for five years a short account of the weather and prevalent
diseases of London, beginning with April, 1751, and ending with December,
1755. He had the weekly bills of mortality before him, and he makes
various comments upon them; but his accounts of prevalent diseases are
from his own observation and by way of illustrating the bills. His first
reference to a fever is under October, 1751: "A slow continual fever, with
acute pain in the forehead: not many attacked, few mortally." The year
1752 was remarkably free from fevers until November, when we read of a
fatal fever which had rheumatic symptoms at first (as at Rouen in 1744),
attacking the head later, with coma-vigil and a dark- ichor on the
tongue and lips. It continued into January and February, 1753, proving
fatal to several. In the summer and autumn months there were fevers of the
low, depressed kind, sometimes called "remittents," with copious sweats,
or "slow, remitting, dangerous fever," or "slow, treacherous, remittent
fever, too often fatal." The references to it are most numerous in the
months from November, 1753, corresponding to Le Cat's Rouen narrative. It
was slow and imperceptible in its approach, the sick often going about ill
for a week before seeking advice; it was attended with profuse sweats
which never relieved, and was fatal to many. It continued more or less
through the summer, and from August, 1754, it is again prominent. In
September, it was the most alarming form of disease, and was then commonly
vehement in its access, with lassitude, and pain in the head and back;
unrelieving sweats are again mentioned, with dry tongue, delirium,
coma-vigil, and death about the 14th-15th day. Fothergill was at a loss to
know whether he should order blood to be drawn, owing to the low depressed
nature of the fever. In February, 1755, the fever is still "too much of
the nature of those which prevailed in the preceding months to allow a
repetition of bleeding." In April it is called the petechial and miliary
fever, the miliary eruption being of a white sort with a very noisome
scent; the petechial spots turned livid, black and gangrenous; few
patients escaped who had been sweated at the beginning. The fever was
truly malignant, the patient restless from the outset, the sweats
weakening. Fothergill's last entries of it are important, under the months
of May and June, 1755. In May, 1755, the fevers were "for the most part
allied to that dangerous remittent which has for some years past more or
less prevailed in different places of this kingdom." In June: "It does not
appear that either in the hospitals or any part of the city a disease has
broken out of so dangerous a nature as has been reported. The same kind of
fever that has long continued in this city with some small variations in
its type, still remains, but it is by no means more frequent than it has
been in the preceding months, nor is it attended with more unfavourable
symptoms."

It is impossible to say how general over England this fever may have been
in the years 1751-57. Our fullest accounts come from Worcestershire; but
the putrid fever is heard of more widely. Thus a short Latin piece in the
_Gentleman's Magazine_, dated 14 April, 1755, is on the putrid fever
lately epidemic, and not yet extinct, in some parts of the county of
Somerset and adjoining places; its signs were contagiousness, pains of the
head and loins, nausea and vomiting, diarrhoea, quick weak pulse, purple
spots, delirium and coma[214]. Grainger, writing from Edinburgh in 1753,
declares his motive for publishing an account of the anomalous fever of
the Netherlands in 1746-48 to be that the same had lately been raging over
almost the whole of Britain.

We have some particulars for Kidderminster, which can hardly have been
exceptional for an industrial town, and according to the accounts were
true also for villages and market towns near. Kidderminster was, in the
year 1756, a town of about four thousand inhabitants, mostly hand-loom
weavers of worsted and silk. There were no power-looms anywhere in England
at that time; and the condition of the Kidderminster weavers' houses was
doubtless what that of the Tiverton community had been fifteen years
before. Many of the weavers, we are told, are lodged in small nasty
houses, for the most part crowded with looms and other utensils[215]. Many
of these houses were built on a low flat of the river Stour, whence rose
putrid vapours after floods. Its situation had served to render the town
specially unhealthy before, as in the epidemic of 1727-29[216].

The first notice by Dr Johnstone is of a low miliary fever from Midsummer
1752 to the end of the year. This was a comparatively mild affair,
although it carried off several. But after Christmas it was succeeded by a
fever which would then have been classed as of the putrid kind. The first
great season was in 1753, it ceased in the fine years 1754-55, but came
back in 1756 and 1757. It began with languor, lowness, flutterings,
faintness, vague pains in the limbs, a low quick pulse, giddiness and
slight sickness. Some had a propensity to loose stools and to profuse
hurtful sweats; some bled at the nose, others coughed and spit blood; some
had pain in the throat, and crimson-red tongue, the sweat and breath of
the sick had a strong, offensive, putrid smell. In some of the worst cases
livid petechiae, large livid blotches, and dark brown spots occurred over
the trunk and limbs. The successful treatment was by mineral acids, bark,
port wine, and vesication. "This malignant fever was very often (though
not constantly) complicated with, and in general bore great analogy to the
malignant sore-throat which at this time prevailed in many parts of
England." The fever which prevailed during that remarkable year (1753) was
very evidently contagious, for whole families were either all together or
one after another seized with it. One of the most distinctive symptoms was
a tendency to trembling of the whole body, as well as leaping of the
tendons at the wrists. In some the tonsils were beset with aphthous
sloughs, and towards the decline there would be aphthae of the mouth, but
symptomatic only, and not the dominant lesion as in the ulcerous
sore-throat. About the 15th day the fever was generally at its height. The
miliary eruptions were critical to the few that had them; the flat livid
petechiae appeared at all times of the disorder. Johnstone then compares
the fever with that described by Le Cat at Rouen in the winter of the same
year; and although he had been unable to satisfy his curiosity by opening
any body dead of the fever, he felt sure that these dreadful symptoms
arose from some affection of the stomach and small guts, at first
erysipelatous, afterwards gangrenous, and at last truly sphacelous.

Johnstone's statement that the putrid fever in Worcestershire in 1752-53
was often complicated with and bore great analogy to the malignant
sore-throat is borne out by Huxham's accounts for Plymouth during the same
season:

    "In all sorts of fevers," he writes, "there was a surprising
    disposition to eruptions of some kind or other [including miliary], to
    sweats, soreness of throat and aphthae." It is hardly possible to make
    out all his cases of "malignant anginose fever" to have been scarlet
    fever with sore-throat. Thus there occurred stench, swelling, and
    samious haemorrhages "commonly in those that died of malignant
    anginose fever above described. I have known the whole body swell
    vastly, even to the ends of the fingers and toes, with a cadaveric
    lividity, though almost quite cold, and an intolerable stench, even
    before the person was actually dead, blood issuing at the same time
    from the ears, nose, mouth and guts[217]."

The first years of this putrid or miliary fever were not seasons of
scarcity, there having been no failure of the crops since 1741 (unless in
Ireland, in the province of Ulster mostly, in 1744); on the contrary, many
of the seasons had been unusually fine and abundant, the exports from
England of wheat, barley, malt and rye in the three years 1748, 1749 and
1750 amounting to four million quarters. Prices were at the same time
favourable to the poorer classes[218]. But there had been a destructive
murrain for several years (30,000 cows are said to have died in Cheshire
in 1751), and the harvest of 1756 was a failure.

To the month of February, 1756, the season had been very forward, but the
early promise of spring was blighted by cold, a wet summer and autumn
ensued, the fruit crop was ruined, and the corn harvest spoiled by long,
heavy rains. A dearth, bread-riots, &c. ensued[219]; but it is to be noted
that the revival of the dangerous malignant contagious fever began at
Kidderminster as early as April, becoming much worse after harvest. "Many
for weeks or months laboured under an uncommon depression of spirits, felt
their strength abate, with great lassitude, and very often a great
proneness to faint away." As the summer advanced the fever became truly
epidemic not only in Kidderminster but in many other parts of the West and
North-west of England.

    It went through whole families, who succumbed either all together or
    one member after the other, and was carried from place to place by the
    attendants on the sick. "It prevailed chiefly in poor families, where
    numbers were lodged in mean houses, not always clean, but sordid and
    damp. It seemed to affect such poor families most where there was
    reason to think a sufficiency of the necessaries of life, on account
    of the dearth, had for some time been scantily supplied; yet the other
    poor persons, given to the intemperate use of malt liquors and ardent
    spirits, were observed to be very much liable to its influence. And
    not a few persons in easy circumstances of life were affected with
    this fever like others."

Frost in October checked it, and then measles of a malignant type had its
turn among the children, the whooping-cough succeeding the measles. From
November to Christmas the putrid fever, which chiefly affected persons
from ten to fifty, and more women than men, returned with increased force.
In fatal cases, the face was ghastly, sunken and livid (the facies
Hippocratica), the patient sweated profusely, but seldom became cold till
death was at hand. There was an abominable cadaverous stench in the
breath, perspiration and stools. In these cases death took place from the
12th to the 14th day.

The intense and long frost of the opening months of 1757 nearly put a stop
to the fever at Kidderminster.

    "But in other neighbouring villages and market towns it has since the
    spring hitherto (Dec. 1757) been very frequent in places that were
    little affected with it last year. The families of the poorer sort of
    people universally are the most subject to it. And it is observable
    that the fever in some places first broke out in the parish
    workhouses, and from thence spread among the neighbouring people with
    great malignity. Wherever it has appeared it has given very apparent
    and fatal evidence of its infectious nature[220]."

Parliament was summoned to meet in December, 1756, on account of the
dearth, which formed the topic of the Speech from the throne. The export
of corn (which had reached a million quarters a year not long before) was
prohibited, and the use of grain in distilling stopped for two months. The
distress was more acute in 1757, and was enhanced by the greed of
corn-dealers and millers, who used French bolting-mills to grind the mere
husks of wheat, pease, rye and barley together into meal. Short, who
practised at Sheffield, says that the fever in October and November, 1757,
"was neither so rife nor fatal as in 1741[221]." It raged fiercely in
several towns at a distance, "where it went by the name of the miliary
fever," and was mostly among the poor, half-starved in the dearth of
1756-57. It is heard of again in the district of Cleveland in the winter
of 1759-60, where it seems to have been mostly a disease of children
complicated with sore-throat, and allied more to scarlet fever than to the
putrid fever of adults[222]. But at Sunderland, near at hand, there was
spotted fever at the same time, and in Newcastle there was dysentery.

The accounts of fever in Ireland in the same period as in England (see
chapter II.) are not without value, as showing that the "putrid" or
nervous type of fever, contrasting with the ordinary typhus of the
country, had been remarked there also. Rutty and Sims describe, during a
certain period, the symptoms of the low, putrid fever, sometimes with
miliary eruptions, identifying it both by name and in character with the
fever then prevalent in England. The most significant thing in Rutty's
annals is that there occurred in the midst of the low, putrid fever with
miliary pustules in 1746, a more acute fever, ending after five or seven
days in a critical sweat, and relapsing. The same fever, not very fatal,
reappeared in 1748. Sims brings the history of the nervous or putrid or
miliary fever in Ireland (Tyrone) continuously down to the year 1772, as
elsewhere related. The remarkable phenomenon of tremors or shakings, which
most witness to, was seen by him in perfection in the year 1771:

    The tremulousness of the wrists, he says, extended to all the body,
    "insomuch that I have seen the bed-curtains dancing for three or four
    days, to the no small terror of the superstitious attendants, who, on
    first perceiving it, thought some evil spirit shook the bed. This
    agitation was so constant a concomitant of the fever as to be almost a
    distinguishing symptom." These were not the shakings of an ague, for
    there might be no intermission for days[223].

Perhaps the most surprising testimony to the existence of an "epidemic
constitution" of slow, continued nervous fever comes from the island of
Barbados. Hillary, who had kept a record of the prevalent diseases at
Ripon, continued the same when he settled in Barbados in 1751[224]. There
can be no doubt as to the appearance of this fever in February 1753, its
prevalence all over the island for eighteen months, and its disappearance
in September 1754, when, as he writes, "It now totally disappeared and
left the island, and, I think, has not been seen in it since" (1758). He
gives the same account of it as the observers in England and Ireland,
except that he does not describe miliary eruptions and describes jaundice
in convalescent children. It was insidious in its onset (as in London),
the patient often keeping afoot five or six days; the symptoms included
pains in the head, vertigo, torpor, lassitude, vigil, delirium, faintings,
partial sweats, involuntary evacuations, gulpings, tremors, twitchings,
catchings, coma and convulsions. Recovery was marked by copious equable
sweats and plentiful spitting. "This slow, nervous fever was certainly
infectious, for I observed that many of those who visited, and most of
them that attended the sick in their fever were infected by it, and got
the disease, and especially those who constantly attended them and
performed the necessary offices of the sick." It was last heard of in the
remoter parts of the island.


Miliary Fever.

It will have been observed in the foregoing accounts of the predominant
fevers of the years (roughly) from 1750 to 1760 that there was often a
miliary eruption, but that it was far from constant. The constant things
were the lowness, depression, ill-smelling sweats, tremors of the whole
body or of the wrist-tendons, and other nervous or ataxic symptoms. But we
hear more of a miliary eruption in connexion with that than with any other
period of fevers in the history; and this was the time when a controversy
arose as to whether there was in reality a distinctive kind of fever
marked by miliary eruption. Some of the school of Boerhaave contended that
the phenomenon of miliary vesicles was due solely to the heating and
sweating treatment of the alexipharmac physicians. De Haen and others
answered that miliary fever was a natural form, independent of the mode of
treatment. The Boerhaavian contention may be admitted as good for such
miliary fevers as were described under that name in 1710 by Sir David
Hamilton[225]; nearly the whole of his sixteen cases appear to have been
made miliary by treatment, in so far as they became miliary at all. What
this physician did was to foretell the approach of miliary symptoms in
various maladies (about one-half of the cases being of lying-in women, and
the rest various), and then to prescribe Gascoign's powder, Goa stone,
Gutteta powder, Venice treacle or other diaphoretics, along with diluents
and the application of blisters; the miliaria appeared about the breast,
neck, and clefts of the fingers in due course (tenth to fourteenth day).

So far as his clinical cases are concerned, the late appearance of miliary
vesicles, lasting a few days, is sufficiently explained by the powerful
drenches administered; and it can hardly be doubted that much of what was
called miliary fever was of that factitious kind. But even in Hamilton's
essay we find indications of a real miliary type of fever; thus he
mentions a class of cases which look to be the same as those described by
Johnstone, Rutty, Sims and others forty years after--cases with
wakefulness, depression, tremblings of the tongue and hands, convulsive
movements and delirium. He mentions also a complication of this with
sore-throat in 1704, which destroyed many.

As to the association of miliary eruption with the low putrid fever so
characteristic of the sixth decade of the 18th century, it is asserted by
too many and in too various circumstances for any doubt as to its reality.
There is nothing to show that the alexipharmac treatment was the one
always used; and it is not certain that some in Ireland and elsewhere who
had miliary eruption received any medical treatment at all. Again, miliary
vesicles, not always with perspiration, were commonly found in the
relapsing fever of Irish emigrants in London during the great famine of
Ireland in 1846-47, by which time the powerful drenches of the
alexipharmac treatment had been long disused[226]. The controversy as to
the reality of miliary fever was one of the kind usual in medicine:
certain physicians, of whom Hamilton in 1710 was an obvious instance, took
up an untenable position; they were answered according to the weakness of
their argument; and that has been held in later times to be an answer to
all who alleged the existence of a type of fever marked by miliary
eruptions. There can be no question as to a low, "putrid" kind of fever in
which miliary eruptions were usual; but offensive sweats were perhaps
more usual, whence the name of putrid in a literal sense, different from
the theoretical sense of Willis; more constant also were the starting of
tendons, the tremors and shakings, together with very varied hysteric
symptoms, from which the fevers received the name of nervous. Dr John
Fordyce in his 'History of a Miliary Fever' (1758) really describes under
that name the symptoms of the low, nervous, putrid fever, often attended
with miliary vesicles, which had been the common type in England in the
years immediately preceding, and was a common type for some time after,
although less is heard of the miliary eruptions in the later history[227].

About the last quarter of the 18th century medical writers were inclined
to drop the names of nervous and putrid as distinctive of certain fevers.
Pringle, in his edition of 1775, says he had been careful to avoid the
terms nervous, bilious, putrid and malignant, which conveyed either no
clear idea or a false one. Armstrong, another army physician, writing in
1773, says: "Nervous, putrid, bilious, petechial or miliary, they are all
of the malignant family; and in this great town [London] these are almost
the only fevers that have for many years prevailed, and do so still, to
the great destruction of mankind. For inflammatory fevers ... have for
many years been remarkably rare[228]." Dr John Moore becomes sarcastic
over the variety of names given to continued fever, some such generic name
as Cullen's "typhus," then newly introduced, being what he desired[229].

Haygarth, writing of the Chester fevers in 1772, said that the miliary
fever had been "supposed" endemic there for more than thirty years past,
but he thought it probable that the eruption had generally, or always,
been fabricated "by close, warm rooms, too many bed-cloaths, hot medicines
and diet." He had seen only one case in the epidemic that year, and he
believed its rarity at that time was due to the treatment by fresh air and
by "such regimen and medicines as are cooling and check
putrefaction[230]." We shall see later that Percival, for Manchester,
contents himself with saying that miliary fevers, which were formerly very
frequent in that town and neighbourhood, now [1772] rarely occur[231]. In
Scotland as late as 1782 the type was still nervous or low, and hardly
ever inflammatory[232].

_Mortalities in London from fever and all causes._

        Fever     All
  Year  deaths   deaths

  1741   7528    32169
  1742   5108    27483
  1743   3837    25700
  1744   2670    20606
  1745   2690    21296
  1746   4167    28157
  1747   4779    25494
  1748   3981    23069
  1749   4458    25516
  1750   4294    23727
  1751   3219    21028
  1752   2070    20485
  1753   2292    19276
  1754   2964    22696
  1755   3042    21917
  1756   3579    20872
  1757   2564    21313
  1758   2471    17576
  1759   2314    19604
  1760   2136    19830
  1761   2475    21063
  1762   3742    26326
  1763   3414    26148
  1764   3942    23202
  1765   3921    23230
  1766   3738    23911
  1767   3765    22612
  1768   3596    23639
  1769   3430    21847
  1770   3214    22434

It is singular to observe that in the five successive years in this period
with lowest fever-deaths and deaths from all causes, the years 1757-61
England was at war on the Continent. A similar low fever-mortality
corresponded with the wars under Marlborough and Wellington.

The era of agricultural prosperity in England, which had its only
considerable interruptions in the years 1727-29 and 1740-42, may be said
to have met with a more serious check from the bad harvest of 1756. There
was a recurrence of agrarian troubles in 1764-67, partly through actual
scarcity caused by the extreme drought of 1764, partly through the pulling
down of cottages and the discouragement of country villages, which
Goldsmith has pathetically described in his poem of the time. Short says
that the country in 1765 was in general very healthy but for children's
diseases. "In some parts the putrid fever roamed about from place to place
in the highest degree of putrefaction, so as several dead bodies were
obliged to be buried the same day as they died." The price of provisions
was excessive, meal riots broke out, and the export of corn was stopped,
Parliament having been summoned for the occasion in November, 1766[233].
In 1769, at the time of the formation of Chatham's ministry, the same
train of incidents recurred,--bread-riots, flour-mills wrecked, corn and
bread seized by the populace and sold at low prices, collisions with the
military, the gaols full of prisoners[234]. The long period of cheapness,
having lasted half a century, was coming to an end. Moralists and
economists had much to say as to the meaning of the national distress
which began to be felt in the sixties. Want of industry, want of
frugality, want of sobriety, want of principle, said one, had brought
trouble on the working class. "The tumults that have lately arisen in many
counties of England are no other than the murmurs of the people, which
have been heard for some years, bursting forth at last into riot and
confusion." The English, it seems, had returned to their old medieval
taste for the best food they could get; they would not give up the finest
bread, although the Irish lived on potatoes, and the French on turnips and
cabbage: "The ploughman, the shepherd, the hedger and ditcher, all eat as
white bread as is commonly made in London, which occasions a greater
consumption of wheat." Women must have tea and snuff, though children go
naked and starved. Another writes: "The poorest people will have the
finest or none." The enclosures had made a want of tillage. "What must
become of our poor, destitute of work for want of tillage?" The country
had for the most part been sickly, labourers scarce, and the farmers not
able to get their usual quantity threshed out. The profligacy of the poor,
profane swearing, etc., are remarked upon[235].

In the last thirty years of the 18th century the accounts of fever in
England became more detailed as to its circumstances, and more numerically
precise. I shall accordingly bring together all that I can find relevant
to fever in London, Liverpool, Newcastle and Chester, and thereafter in
those towns, such as Manchester, Leeds, and others in the North, which
were specially touched in their public health by the movement known as the
Industrial Revolution.


Typhus Fever in London, 1770-1800.

In the London bills of mortality the item of fevers diminishes steadily
during the latter part of the 18th century, the deaths from all causes
diminish, the births come nearer to the number of the deaths, and in three
years of the last decade they exceed them. This statistical result is
doubtless roughly correct; but the bills were becoming more and more
inadequate to the whole metropolitan area; and even for the original
parishes which they included they have not the same value for fever in the
later period as they had for plague at their beginning[236]. On the other
hand, from about the year 1770 we begin to have more exact medical
accounts of fever in London, which are not indeed numerically exhaustive,
but good as samples of what was going on. Whatever improvement there was
in the prevalence of typhus fever touched the richer classes. The Paving
Act of 1766 is credited with having improved the health of the City, and
there were many new streets and squares being built in the west end that
were, of course, free from typhus. It is to these desirable residential
quarters that the eulogies of Sir John Pringle[237], Dr John Moore[238]
and others apply. The slums of London were as yet unimproved, and but
little known to the physicians. Lettsom, who was one of the first of his
class to visit among the poor in their homes, has much to say of typhus
fever; but he is emphatic that it was nearly all an infection of the poor.
"In the airy parts of this city," he writes in 1773, "and in large, open
streets, fevers of a putrid tendency rarely arise.... In my practice I
have attentively observed that at least forty-eight out of fifty of these
fevers have existed in narrow courts and alleys." The same is remarked by
Currie for Liverpool, by Clark for Newcastle, by Percival and Ferriar for
Manchester, by Haygarth for Chester, and by Heysham for Carlisle.

The quarters of the rich had gradually become detached from those of the
poor. I have shown this more especially for Chester, where the old walls
made a clear division; but it was general in the second half of the 18th
century[239].

Medical practice lay mostly among the richer classes; the physicians knew
little of the state of health in the cellars and tenement-houses of large
towns. Those physicians who did know how much typhus fever there was in
these purlieus had to enter a caveat against the incredulity of the rest.
Dr Currie of Liverpool, whose facts I shall give in their place, protested
that he was not exaggerating; a protest the more necessary that a
contemporary of his own, Mr Moss, a middle-class practitioner, who wrote a
book specially on the medical aspects of Liverpool, declares that fever is
"rare" in that city, while Currie was treating from his dispensary a
steady average of three thousand cases of typhus every year. In the same
years, in February, 1779, a physician to the army, Dr John Hunter, who had
commenced practice in Mayfair, found on visiting in the homes of the
poorer classes in the west of London cases of fever for which he had no
other name than the gaol or hospital fever of his military experience; it
was so much a novelty to him, apart from campaigns or transport ships,
that he gave an account of his discovery of domestic typhus to the College
of Physicians[240]. At length he found so many cases steadily winter after
winter that he had them sent to the infirmary of the Marylebone Workhouse.
The practitioners who knew most of the sicknesses of the poor were such as
Robert Levett, Dr Samuel Johnson's dependant, who lived with the doctor
in the house in Gough Square. Levett had been a waiter in a Paris
coffee-house frequented by the medical fraternity, and had acquired a
taste for and perhaps some knowledge of the healing art. He made his
modest living by the small fees or articles of food and drink which his
poor patients gave him. He had only to issue from the back of Gough Square
by the courts and alleys behind Fleet Street, and he would find in the
region between Chancery Lane and Shoe Lane hundreds of families seldom
visited by a physician or by a qualified surgeon-apothecary. The good
Levett was only one of a class. There had always been such humble medical
attendants of the poor in London. An Act of the third year of Henry VIII.
was directed against them at the instance of the privileged practitioners;
but the regular faculty is said to have proved in the sequel both greedy
and incompetent, and after thirty years there came another Act, couched in
terms that the bluff king himself might have indited (31-32 Henry VIII.),
which asserts those qualities of the profession in so many words, and
establishes the right of any subject of the king to practise minor surgery
and the medicine of simples upon his or her neighbours. That Act is still
part of the law of England, and under it Levett exercised a statutory
right, perhaps without knowing it[241]. There were many other regions of
courts and alleys all round the City on both sides of the water, which
must have been medically served by such as Levett, if served at all. It
was there that typhus was found and at length clinically described by
competent physicians, among the earliest of whom was Lettsom.

The General Dispensary in Aldersgate Street having been started in 1770
with one physician, Lettsom was chosen additional physician in 1773, and
threw himself into the work with great zeal[242]. In the first twelvemonth
he saw many cases of fever, as in the following table:

_Lettsom's practice in Fevers at the Aldersgate Dispensary._

                                     1773

    Febris      April  May  June  July  Aug.  Sept.  Oct.  Nov.  Dec.

  hectica         2     2     4    13     4     2      3     4     9
  inflammatoria  --    --    --    --    --    --     --     1     1
  intermittens    3     1     7     1     1     1      1    --     2
  nervosa         4     3     4    14     7    11      4     5     1
  putrida        14    19    14    25    14    21     34    22    11
  remittens       6    10     5     4     3     6      7     3    12
  simplex vel    --     2     1     6     2     5      4     5    --
    diarium

                       1774
                                     Total in
    Febris        Jan.  Feb.  March  12 months  Died

  hectica          12    18    13       86        3
  inflammatoria     1    --     2        5       --
  intermittens      1     2     2       22       --
  nervosa           1     5     4       65        3
  putrida           6     7     5      192        8
  remittens        13    10     3       82       --
  simplex vel      --    --     4       29       --
    diarium

The nervous, putrid and remittent fevers, belonging, to the same group,
make up the bulk of the fevers. The hectic fevers were almost all of
children. The fatal cases of fever were fourteen, the fatal cases in all
diseases for the year having been forty-four. What these putrid, nervous
and remittent fevers were, will now appear from some of Lettsom's
descriptions. Fevers with symptoms of putrescency were marked by nausea,
bitter taste, and frequent vomiting, by laboured breathing and deep
sighing, offensive breath, sweats offensive and sometimes tinged with
blood, almost constant delirium, the tongue dry, the tongue, teeth and
lips covered with black or brown tenacious foulness, thrush and ulceration
in the mouth and throat, the urine with a dark sediment, the stools
excessively nauseous and foetid, and blackish or bloody, the eyes horny or
glassy, with the whites often tinged of a deep blood colour, spots on the
skin like fleabites, or larger haemorrhagic vibices, bleeding from the
gums, nose or old ulcers, hiccup near death, often a cough through the
fever. Lettsom's treatment consisted in good liquors, Peruvian bark, and
above all fresh, or "cold" air: "When it is considered that putrid fevers
originate in close unventilated places, the introduction of fresh air
seems so natural a remedy that I have often admired its aid should have
been so long neglected[243]." Accordingly he persuaded the poor people to
open their windows, and dragged the sick out of doors as soon as it was
safe to do so; the effects, he says, were wonderful. His fifty-one cases
are most valuable illustrations of the perennial fever in the crowded
parts of London:

    Case 1 is of a man aged forty who had occasion to visit a miserable
    crowded workhouse in Spitalfields. He was instantly seized with such a
    nausea and debility as induced him to keep his room as soon as he got
    home. At the end of a week Lettsom found him in "the true jail-fever,
    or, what is the same, a true workhouse-fever." He had involuntary
    stools and leaping of the tendons, and took more wine in a week than
    he had done for many years.

    Cases 2 to 12 were of several families in one house in a court in Long
    Lane, Aldersgate Street, who had been infected by a discharged
    prisoner from Newgate. Other cases follow, where the infection was
    caught from visiting the sick. In Case 17, Lettsom applied blisters
    "owing to the importunity of the friends," but without advantage. Case
    30, on 26th October, 1773, was of a family of six persons near Christ
    Church, Lambeth, father, mother, boy of seventeen, child of two
    (slight attack) and two maids. Other localities were courts off
    Whitecross Street, Jewin Street, Little Moorfields, Chiswell Street,
    and St Martin's-le-Grand. Case 43 was of a woman, aged thirty, in
    Bunhill Row; she attended a relation who died of a putrid fever, and
    was herself attacked; her eyes were bloodshot, her skin marbled and
    interspersed with a general deep- eruption, her cheeks and
    nose mortified. Cases 44-47 were of people in a "very helpless
    situation" in Gloucester Court, Whitecross Street.

The year 1773, to which these experiences in a small part of London
relate, was one of high febrile mortality, according to the Bills. Two
years after, Dr William Grant was moved to write an 'Essay on the
Pestilential Fever of Sydenham, commonly called Gaol, Hospital, Ship and
Camp Fever[244],' which, as he said in his preface, "I often see in this
city: and though so common and fatal, appears not at present to be
generally understood." It was, he says, "an indigenous plant, frequent in
this city, being produced by close confinement; but it often passes
unnoticed, because unknown." The deaths by "fever" in the London Bills
were as follows until the end of the century:

_Deaths from Fever and from all causes in London._

          Fever      All
  Year    deaths    deaths

  1771     2273     21780
  1772     3207     26053
  1773     3608     21656
  1774     2607     20884
  1775     2244     20514
  1776     1893     19048
  1777     2760     23334
  1778     2647     20399
  1779     2336     20420
  1780     2316     20517
  1781     2249     20719
  1782     2552     17918
  1783     2313     19029
  1784     1973     17828
  1785     2310     18919
  1786     2981     20454
  1787     2887     19349
  1788     2769     19697
  1789     2380     20749
  1790     2185     18038
  1791     2013     18760
  1792     2236     20213
  1793     2426     21749
  1794     1935     19241
  1795     1947     21179
  1796     1547     19288
  1797     1526     17014
  1798     1754     18155
  1799     1784     18134
  1800     2712     23068

There were higher figures in the years immediately before 1771, the years
to which the generalities of Fordyce and Armstrong relate. There is a
decline in the fever-mortality towards the end of the century; but it is
just from the years 1799-1800 that we have an account by Willan of the
prevalence and conditions of London typhus, than which nothing can well be
imagined worse. The intermediate glimpses we get of typhus in London in
the writings of Dr Hunter, physician, and of Dr James Sims, show that the
disease was perennial.

    "In the month of February, 1779," says Hunter[245], "I met with two
    examples of fever in the lodgings of some poor people whom I visited
    that resembled in their symptoms the distemper which is called the
    jail or hospital fever. It appeared singular that this disease should
    show itself after three months of cold weather. Being therefore
    desirous of learning the circumstances upon which this depended I
    neglected no opportunity of attending to similar cases. I soon found a
    sufficient number of them for the purpose of further information. It
    appeared that the fever began in all in the same way and originated
    from the same causes. A poor family, consisting of the husband, the
    wife, and one or more children, were lodged in a small apartment not
    exceeding twelve or fourteen feet in length, and as much in breadth.
    The support of them depended on the industry and daily labour of the
    husband, who with difficulty could earn enough to purchase food
    necessary for their existence, without being able to provide
    sufficient clothing or fuel against the inclemencies of the season. In
    order therefore to defend themselves against the cold of the winter,
    their small apartment was closely shut up, and the air excluded by
    every possible means. They did not remain long in this situation
    before the air became so vitiated as to affect their health and
    produce a fever in some one of the miserable family. The fever was not
    violent at first, but generally crept on gradually ... soon after the
    first a second was seized with the fever, and in a few days more the
    whole family perhaps were attacked, one after another, with the same
    distemper. I have oftener than once seen four of a family ill at one
    time and sometimes all lying on the same bed. The fever appeared
    sooner or later as the winter was more or less inclement, as the
    family was greater or smaller, as they were worse or better provided
    with clothes for their persons and beds, and with fuel, and as their
    apartment was more or less confined. The slow approach of the fever,
    the great loss of strength, the quickness of the pulse with little
    hardness or fulness, the tremors of the hands, and the petechiae or
    brown spots upon the skin, to which may be added the infectious nature
    of the distemper, left no doubt of its being the same with what is
    usually called the jail or hospital-fever."

Dr James Sims, who had seen much of Irish typhus in Tyrone in his earlier
years, and had removed to London, wrote of typhus among the poor there in
1786, ten years before the more systematic and more circumstantial
descriptions by Willan[246].

This fever was exceedingly mortal, several medical men, he had reason to
believe, falling sacrifices to it. Sims never saw the cases till the 7th
or 8th day, when they were desipient, insensible, with pulse scarcely to
be felt and not to be counted, all having petechiae. None had scarlet rash
or sore-throat. They sank and died quietly; the strongest cordials did not
produce the smallest effect, and blisters in many did not even raise the
skin[247].

It is in the year 1796 that we begin to have the full and accurate records
by Willan of the prevailing diseases of London month by month as he saw
them at the Carey Street Dispensary, situated in the crowded quarter
between Holborn and the Strand[248]. His first reference to typhus is as
follows:

    "In September, also, fevers usually appear which from their
    commencement exhibit symptoms of malignancy; being attended with a
    brown dry tongue, violent pain of the head, delirium, or coma,
    deep-seated pains of the limbs, petechial spots and haemorrhagy. These
    fevers become highly contagious, especially when they occur in close,
    confined situations, and in houses where little attention is paid to
    ventilation or cleanliness. The disease is extended by infection
    during the months of October and November, but its progress is
    generally stopped by the frosts of December."

Willan says little more of fever in London until September, 1798, when
these contagious malignant fevers became more numerous, both in the city
and adjacent villages, than had been known for many years before; also the
fever was more fatal than usual, one in five or six dying, whereas one in
seven was formerly a very unfavourable death-rate, and one in twenty not
unknown. Haemorrhages, aphthae, diarrhoea, starting of the tendons,
picking the bedclothes, violent delirium, ending in deafness, stupor,
hiccough and involuntary evacuations, were the usual accompaniments of
this fever. In the corresponding months of 1799 he recurs to the symptoms
of this "malignant contagious fever," and depicts typhus as clearly as may
be. In September, 1799, it was "attended with a dull pain of the head,
great debility or sense of lassitude and pains referred to the bones,
tremblings, restlessness with slight delirium, a querulous tone of voice,
a small and frequent pulse, heat of the skin, thirst and a fur upon the
tongue, first of a dirty white colour, but turning in the latter stage of
the disease to a yellowish brown. In this form the fever continued
thirteen days without any dangerous symptoms, and then suddenly
disappeared, leaving the patient, for some time after, languid and
dispirited. All the individuals of a family were successively affected
with the same train of symptoms; many of them so slightly as not to be
much confined to their beds." In October and November he describes the
symptoms of the disease in a more dangerous form. By this fever, he was
informed, some houses of the poor had been almost depopulated, the
infection having extended to every inmate. "The rumour of a plague was
totally devoid of foundation."

He then describes the state of the dwellings where such fevers
occurred--the unwashed bed-linen, the numbers in one bed, the rooms
encumbered with furniture or utensils of trade, the want of light and air
in the cellars and garrets and in the passages thereto, the excremental
effluvia from the vault at the bottom of the staircase. It cannot be
wondered at, he concludes, that contagious diseases should be thereby
formed, and attain their highest degree of virulence; and he estimates
that "hundreds, perhaps thousands" of labourers in and near London, heads
of families and in the prime of life, perished annually from such fevers.
He denies that his account is exaggerated, and appeals for the truth of it
to medical practitioners whose "situation or humanity has led them to be
acquainted with" the localities[249].


Typhus in Liverpool, Newcastle and Chester in the last quarter of the 18th
century.

Liverpool, in the last quarter of the 18th century, came next in size to
London, having a population (in 1790) of 56,000 to the capital's estimated
800,000. According to a medical author, whose experiences lay among the
middle classes, it was everything that could be wished in the way of
healthfulness and prosperity; but it had a dark side as well. About 7,000
of the people lived in cellars underground, and nearly 9,000 in back
houses, in small confined courts with a narrow passage to the street.
"Among the inhabitants of the cellars," says Currie[250], "and of these
back houses, the typhus is constantly present; and the number of persons
under this disease that apply for medical assistance to the charitable
institutions, the public will be astonished to hear, exceeds three
thousand annually.... In sixteen years' practice I have found the
contagious fever of Liverpool remarkably uniform among the poor. Seldom
extending itself in any considerable degree among the other classes of the
community, it has been supposed that Liverpool was little subject to
fever; but this will be shewn from authentic documents to be a great and
pernicious error." At the Dispensary in the year 1780 the cases of typhus
averaged 160 per month, the numbers being as remarkably steady from month
to month as from year to year. In the ten years from 1 January, 1787, to
31 December, 1796, 31,243 cases of fever were entered on the books of the
Dispensary, an average of 3124 per annum[251].

Of 213,305 cases of all diseases at the Dispensary in seventeen years,
1780 to 1796, 48,367, nearly one-fourth, were labouring under typhus.
Supposing that these were all the cases of typhus in Liverpool, and that 1
in 15 died, we should have some 150 deaths from typhus in a year.
Supposing also that typhus was relatively as common at that time in
London, it will follow that nearly all the deaths under "fever" in the
bills of mortality might well have been from typhus fever; for London in
its several densely populated out-parishes was the fever-quarter of
Liverpool a dozen times over[252].

The Newcastle Dispensary was opened in October, 1777, by the exertions of
Dr John Clark, who was in correspondence with Lettsom in London[253]. Dr
Clark had been in the East India Company's service, and had seen much of
ship-fever and of the fevers of the East. During a visit to his home in
Roxburghshire in the summer of 1770, between his voyages, he attended
several persons in continued fever. When he settled at Newcastle he saw
the worst kinds of contagious fever, in workhouses and "in the sordid and
crowded habitations of the indigent." Putrid fever, or typhus, was by far
the most common disease attended from the new dispensary, although less
than at Liverpool, the operations of the charity being on a much smaller
scale. It was seldom out of Newcastle a whole year; and in some years, as
1778, 1779, 1783, 1786 and 1787 it was unusually rife in particular
districts, often attacking whole families. Scarlet fever was epidemic and
very fatal in 1778 and 1779, while dysentery attacked great numbers of the
poor in the autumns of 1783 and 1785. The following Table shows the
principal diseases attended from the Dispensary during the first
twenty-three months of its working, 1 Oct. 1777, to 1 Sept. 1779:

_Newcastle Dispensary 1777-79._

                          Cases          Too far
                         visited  Cured  advanced  Dead

  Putrid fever             391     357       9      16
  Ulcerated sore-throat    146     125      11       9
  Dysentery                 72      55       5       4
  Smallpox                  45      29       5       6

From 1 Oct. 1777, to 1 Sept. 1789, the cases of typhus visited were 1920,
of which 121 were fatal. During the winter of 1790 and the spring and
summer of 1791 it was prevalent amongst the poor, and was frequently
introduced into genteel families and sometimes even into those of the
first distinction. That outbreak was supposed to have been generated in
the Gateshead poorhouse. For some time its ravages were confined chiefly
to the low, ill-aired, narrow street called Pipewell Gate. In September
it made its appearance in Newcastle; at first the contagion was easily
traced from Pipewell Gate, and afterwards from one house to another. In
that outbreak, 188 poor persons were visited from the Newcastle
Dispensary, the Gateshead poor having been attended by the parochial
surgeon. Clark's ten cases recorded of the epidemic were all of people in
good circumstances. The Dispensary Tables show cases of typhus every year
down to 1850, the largest totals being in 1793 (374, 18 deaths), 1801
(435, 20 deaths), and 1819 (368, 14 deaths); and these, we may take it,
were but a small fraction of all the cases in Newcastle.

Perhaps the most unexpected revelation of typhus is at Chester, from the
time when Haygarth began to write upon its public health in 1772. Chester
was then one of the most desirable places of residence in England. Boswell
wrote to Johnson, "Chester pleases me more than any town I ever saw." The
old city within the walls was occupied by a superior class of residents,
including the cathedral clergy, county families, retired officers and
Anglo-Indians, professional men, merchants and tradesmen. It had the best
theatre out of London. Squares, crescents and broad streets were replacing
most of the old buildings. The six parishes that lay entirely within the
walls had a population, in 1774, of 3502, and an annual average death-rate
(in the ten years 1764 to 1773) of 1 in 58 or 17.2 per 1000, the central
parish of St Peter having a rate of 1 in 62, and the cathedral parish 1 in
87. It passed as one of the healthiest cities in the kingdom, being far
before Shrewsbury and Nottingham, to say nothing of the large towns where
the burials exceeded the baptisms. But its moderate death-rate over all, 1
in 42 living, would have been much lower but for the four poor suburban
parishes, with a population of 11,211, which had a death-rate of 1 in 35.
Haygarth gives a deplorable account of them. The houses were small, close,
crowded and dirty, ill supplied with water, undrained, and built on ground
that received the sewage from within the walls. The people were ill-fed
and they seldom changed or washed their clothes; when they went abroad
they were noisome and offensive to the smell. Many of them worked on the
large farms around Chester, others at shipbuilding and shipping (Chester
had then a considerable foreign trade), others at the mills and markets,
others at a nail-factory, while others were employed by the tradesmen
within the walls. Fever seems to have been perennial among them, the
deaths from typhus having been 23 in 1772, 33 in 1773 and 35 in 1774. "In
these poor habitations," says Haygarth, "when one person is seized with a
fever, others of the family are generally affected with the same fever in
a greater or less degree." It became rifer than usual in August, 1773, and
attacked 285, proving fatal to 28, or to one in ten. It had the common
symptoms of malignant fevers produced by human effluvia, and particularly
affected the head with pain, giddiness and delirium. It attacked in
general the lowest, few of the middle rank, and none (or only one) of the
highest rank[254].

Chester had no manufactures. Its population had grown rapidly of late, as
that of Liverpool had grown, the poorer classes being the prolific part of
the community; but it had no share in the industrial revolution, it did
not employ its women and children in factories, and it was in some
respects better than Leeds, Warrington, Manchester, or Carlisle. It is a
good illustration of a town growing rapidly without manufactures, and of a
community divided by the old walls into two quite distinct sections, a
rich and a poor. Such had been the drift of things in England apart from
the industrial revolution; but it is the latter which furnishes the best
illustrations of a poor prolific populace, of a growing struggle, and of
the attendant typhus fever.


Fever in the Northern Manufacturing Towns, 1770-1800.

The prosperity of the first two-thirds of the 18th century had been
attended with a very small increase of population. From 1700 to 1750 the
numbers in England are estimated to have grown no more than from about six
millions to six millions and a half. The fecundity of many rural parishes
was swallowed up by emigration to the American and West Indian colonies,
by the army and navy, and by the great waste of life in London and some
other towns. The increase was nearly all north of the Trent, while the old
weaving towns of the south-west had actually declined. Gloucestershire,
Somerset and Wilts were the most crowded counties in 1700. During the next
fifty years, the greatest increase was as in the following rough
estimate[255]:

                                              Increase
                             1700      1750   per cent.

  Lancashire               166,200    297,400    78
  West Riding of Yorks.    236,700    361,500    52
  Warwickshire              96,600    140,000    45
  Durham                    95,500    135,000    41
  Staffordshire            117,200    160,000    36
  Gloucestershire          155,200    207,800    34

In the counties where population had increased most, much of the increase
was still rural or semi-rural. Defoe describes how the land near Halifax
was divided into lots of from two to six or seven acres, hardly a house
out of speaking distance from another, at every house a tenter, and on
almost every tenter a piece of cloth, or kersey or shalloon. Every
clothier kept one horse at least, to carry his manufactures to the market,
and nearly every one kept a cow, or two or more, for his family. The
houses were full of lusty fellows, some at the dye-vat, some at the looms,
others dressing the cloths, the women and children carding or spinning,
being all employed from the youngest to the oldest: not a beggar to be
seen, nor an idle person[256]. We have no accounts of the health of this
population, except Nettleton's statistics of smallpox in and around
Halifax in 1721 and 1722, given elsewhere, and the "epidemic
constitutions" recorded by Wintringham at York during the same period, and
by Hillary at Ripon.

Before the earliest of the inventions of spinning by machinery, the
weavers were gathering to the towns of Yorkshire, Lancashire and other
counties north of the Trent. The spinning-jenny of Hargreaves was wrecked
by a Blackburn mob in 1768, and a mob wrecked the cotton-mill built by
Arkwright at Chorley eleven years later. This was decidedly a time of
movement from the country to the towns, a movement which preceded the
spinning ingenuity of the sixties and may have been stimulated by the
earlier use of the fly-shuttle in weaving.

Much of the country round Manchester, though it doubtless retained those
farm-houses, hedgerows, and field paths which come into the idyllic
opening of 'Mary Barton' more than half a century later, was "crowded with
houses and inhabitants," as Percival says: so populous were the environs
of Manchester that every house in the township had been found by a late
survey to contain an average of six persons. The proportion of deaths was
less than in 1757; but that was chiefly due to the accession of new
settlers from the country, which raised the ratios of marriages and
births[257]. Manchester had increased from a population of about 8000 in
1717 to one of 19,839 (inclusive of Salford) in 1757. When the inhabitants
were next counted in 1773, they were found to be 22,481 in Manchester
(5317 families in 3402 houses) and 4765 in Salford (1099 families in 866
houses). According to Percival, who gives these figures, the death-rate in
1773 was 1 in 28.4, the births exceeding the deaths by forty in a year.
The poor, he says, were now better lodged, and some of the most dangerous
malignant distempers were less violent and less mortal. Manchester,
however, was still an unhealthy place compared with the country,
especially to young children. Thus, the thirty-one townships in the parish
of Manchester contained, exclusive of the city, 13,786 inhabitants (2525
families in 2371 houses), and of these only 1 in 56 died annually
(compared with 1 in 28 in the city)--the births being to the deaths as 401
to 246 in the year 1772.

Again, the bleak upland parish of Darwen with a population in the year
1774 of 1850 souls mostly occupied in the cotton manufacture, had, during
the seven years before, more than twice as many baptisms as burials (508
to 233), the birth-rate (1 in 25.5) being high and the death-rate (1 in
56) low.

Leeds had a population of some six or seven thousand at the time of the
Civil Wars, and lost 1325 in nine months of the year 1645 from plague, all
of them the poorer class. A generation or two later, in the time of
Thoresby's 'Diary,' it was a centre of the cloth trade; and it appears to
have grown steadily throughout the 18th century. In 1775 it had a
population of 17,117. We hear from Lucas of an epidemic typhus in it
previous to 1779[258]. Eighty persons had died of that fever in one year,
and many who struggled through the disease died afterwards of lingering
complaints. In two courts or yards (such as might have been the Lantern
Yard which Silas Marner found pulled down when he revisited Leeds) forty
persons were affected with the fever; some families had received ten
shillings a week from the assessment for the poor. As early as 1779 Lucas
proposed a house of reception for contagious fever, a proposal which was
carried into effect in 1804, after a whole generation of typhus and at a
time when there was little fever in Leeds or elsewhere. The infectious
fevers, being chiefly confined to the poor, often prevailed, says this
writer, for a length of time without exciting much alarm, or without their
fatality being attended to; but, he adds about the year 1790, "should a
few of the higher rank receive the infection, then the disease is
described in most exaggerated terms."

Carlisle was a good instance of the increase of urban population and the
breeding of typhus. In seventeen years, from 1763 to 1780, the inhabitants
had increased from 4158 to 6229, many of the immigrants being Scots and
Irish with their families. The chief industry was the making of calico, in
which the women and children were employed as well as the men. When Dr
Heysham surveyed the town and suburbs for his census of 1779, he had
"opportunity of seeing many scenes of poverty and filth and
nastiness[259]"; and in the bill of mortality for that year he confesses
himself astonished that there should be so little fever.

The great outburst of typhus at Carlisle began in the end of March, 1781,
with no very obvious special provocation[260]. Upwards of 600 had typhus
to February 7th, 1782, at which date 12 or 15 were still suffering from
it. The deaths were less than 1 in 10 of all attacked: viz. 2 in May, 4 in
June, 8 in July, 8 in August, 7 in September, 9 in October, 8 in November,
6 in December, and 3 in January, 1782, a total of 55. Of this total of
fatal cases, 3 were boys, 4 bachelors, and 15 husbands: 3 girls, 2 maids,
22 wives, and 6 widows. Two-thirds of all the deaths were of married
people; Heysham saw no case in a child under three years. It affected
about a tenth part of the inhabitants of Carlisle (6299), and raged most
among the lower class who lived in narrow, close, confined lanes and in
small crowded apartments, of which there were a great many in Carlisle,
generally going through all the inmates of a house where it had once
begun. On seeking to trace the origin of the epidemic, he found that it
began in the end of March, 1781, in a house in Richard-gate, which
contained about half-a-dozen very poor families. Every window that could
be spared was shut up, to save the window-tax. The surgeon who attended
some of these poor wretches told Dr Heysham that the smell was so
offensive that it was with difficulty he could stay in the house. One of
the typhus patients in this house was a weaver, who, on his recovery, went
to the large workshop where he worked, and there, it was supposed, gave
the infection (in his clothes) to his fellow workmen, by whom new centres
of infection were made in various other houses. In August, a young man
just recovered from the fever went to his mother's in the small village of
Rockliffe, four or five miles from Carlisle, to get back his strength in
the country air; his mother soon took the fever and died, and a neighbour
woman who came to her in her sickness likewise caught it and died. These
were all the cases known in the village, and they show the enormously
greater fatality of typhus in those not inured to its atmosphere and
conditions.

The state of population and health at Warrington was peculiar, and is
given fully in another chapter. There could be no more striking instance
of the growth of what the foreign writers call the proletariat; an old
market-town, with a small sail-cloth industry from Elizabethan times, it
became a busy weaving town owing to the demand for sail-cloth during the
war with the American colonies. The whole population of some 9000 men,
women and children, were wage-earners; the women were all the while
unusually prolific, and the sacrifice of infant life was enormous,
especially by smallpox. We have no particular accounts of fevers; but in
the bill of mortality for 1773, the year of a disastrous smallpox
epidemic, there were 25 deaths from fever, of which 10 were of "worm
fever," or the remittent of children[261].

By the year 1790, when Ferriar's accounts of fever in Manchester begin,
the industrial revolution had been accomplished, mills were everywhere,
and the characteristic hardships and maladies of a prolific working class
in a time of slack trade were already much the same as we find them
pictured with fidelity and pathos in the pages of Mrs Gaskell half a
century after.

But, so as not to exaggerate the ill health of the working class in
Manchester at the end of the 18th century, let us compare the births with
the deaths according to the doubtless imperfect registers[262]:

_Manchester, Births and Deaths, 1770-91._

  Year   Births   Deaths

  1770    1050     988
  1771    1169     993
  1772    1127     904
  1773    1168     923
  1774    1245     958
  1775    1359     835
  1776    1241    1220
  1777    1513     864
  1778    1449     975
  1779    1464    1288
  1780    1566     993
  1781    1591    1370
  1782    1678     984
  1783    1615    1496
  1784    1958    1175
  1785    1942    1734
  1786    2319    1282
  1787    2256    1761
  1788    2391    1637
  1789    2487    1788
  1790    2756    1940
  1791    2960    2286

The mean lodging-houses in the outskirts of the town, says Ferriar, in
1790[263], were the principal nurseries of febrile contagion: some of
these were old houses with very small rooms, into each of which four or
more people were crowded to eat, sleep, and frequently to work. They
commonly bore marks of a long accumulation of filth, and some of them had
been scarcely free from infection for many years past. As soon as one poor
creature dies or is driven out of his cell he is replaced by another,
generally from the country, who soon feels in his turn the consequences of
breathing infected air. There was hardly any ventilation possible, many of
these old houses being in dark narrow courts or blind alleys. In other
parts of the town the lodging-houses were new, and not yet thoroughly
dirty; but in these there was a long garret under the tiles, in which
eight or ten people often lodged, the beds almost touching. Again, many
lived in cellars, sleeping on the damp floor with few or no bedclothes;
the cellars of Manchester, however, were better ventilated than those of
Edinburgh, and freer from fever. These cellar-tenants were subject to the
constant action of depressing passions of the mind. "I have seen
patients," says Ferriar, "in agonies of despair on finding themselves
overwhelmed with filth and abandoned by everyone who could do them any
service, and after such emotions I have seldom found them recover."
Addressing the Literary and Philosophical Society of Manchester previous
to 1792, he pointed out in an _argumentum ad hominem_ that "the situation
of the poor at present is extremely dangerous, and often destructive to
the middle and higher ranks of society[264]." And again, "the poor are
indeed the first sufferers, but the mischief does not always rest with
them. By secret avenues it reaches the most opulent, and severely revenges
their neglect or insensibility to the wretchedness surrounding them[265]."

In an address to the Committee of Police in Manchester, he instances the
following cases:

    A family of the name of Turner in a dark cellar behind Jackson's Row:
    they have been almost constantly patients of the Infirmary for three
    years past on account of disorders owing to their miserable dwelling.
    There are other instances of the same kind in Bootle Street.

    In Blakely Street, under No. 4, is a range of cellars let out to
    lodgers, which threatens to become a nursery of disease. They consist
    of four rooms communicating with each other, of which the two centre
    rooms are completely dark; the fourth is very ill-lighted and chiefly
    ventilated through the others. They contain four or five beds in each,
    and are already extraordinarily dirty.

    In a nest of lodging-houses in Brook's entry near the bottom of
    Longmill-gate, a very dangerous fever constantly subsists, and has
    subsisted for a considerable number of years. He had known nine
    patients confined in fevers at the same time in one of those houses
    and crammed into three small dirty rooms without the regular
    attendance of any friend or of a nurse. Four of these poor creatures
    died, absolutely from want of the common offices of humanity and from
    neglect in the administration of their medicines. Another set of
    lodging-houses constantly infected is known by the name of the Five
    Houses, in Newton Street[266].

The fever in Manchester was not always malignant typhus: sometimes it had
the symptoms and low rate of mortality that suggest relapsing fever. Thus,
in the winter epidemic of 1789-90, very prevalent in Manchester and
Salford, out of Ferriar's first ninety patients only two died; in some the
skin had a remarkable, pungent heat, in others there were profuse watery
sweats; women were commonly affected with hysterical symptoms during
convalescence, which was often tedious[267]. A certain number of these
cases would run into "a formed typhus," with petechiae and all the other
signs of malignity; and in some seasons, as in the distressful year 1794,
typhus was the usual form. Two fatal cases in children, examined after
death, had peritonitis; "in the one no marks of the disease were
discernible within the cavity of the [intestinal] tube;" in the other, the
patient was covered with petechiae[268]. These cases of localized
inflammation in typhus he compares with Pringle's cases of spotted fever
complicated with abscess of the brain.

The years 1792 and 1793 passed, says Ferriar, without any extraordinary
increase of fever patients, although the noxious influences were always
present. But in the summer and autumn of 1794 "the usual epidemic fever"
became very prevalent among the poor in some quarters of the town,
particularly after a bilious colic had raged among all ranks of people.
This was a time when work was slack; many workmen enlisted and left their
families. In November and December 1794, as many as 156 sent applications
to the Infirmary in a week to be visited in fever at their homes.

This was a memorable time of scarcity and distress all over the country,
the beginning of a twenty-years' period of so-called "war-prices," when
farmers' profits were so large that they could afford to double or treble
their rents to the landlords. The history of epidemics comes at this point
into close contact with the economic history, which I shall touch on in
the sequel, after giving a few more particulars of typhus in England and
Scotland generally, previous to the outbreak of the war with France in
1793.


Typhus in England and Scotland generally, in the end of the 18th century.

The introduction of machinery and the building of mills brought typhus
fever to places much less crowded than Leeds, or Manchester, or Carlisle.

Dr David Campbell of Lancaster saw much of typhus in that town, and in
mill villages near it, in the years 1782, 1783, and 1784. In Lancaster
town he saw about 500 cases, of which 168 were in men, with 20 deaths, 236
in women, with 11 deaths, and 94 in children under fourteen, with 3
deaths. At Backbarrow cotton mill, twenty miles from Lancaster, there were
180 cases, of which 38 were in men, with 5 deaths, 11 in women, with 2
deaths, and 131 in children under fourteen, with no deaths[269]. At this
mill there was an extremely offensive smell in the rooms, which came from
the privy; the doors of the latter, "for indispensable reasons in the
economy of these works, where so many children are employed, always
communicate with the workrooms." Every care had been taken to keep the air
sweet, but without effect. The offensive smell was in all the cotton mills
from the same cause; and in the Radcliffe mill belonging to Mr Peel, the
typhus was ascribed to that source, the nuisance having been at length got
rid of. Both at Backbarrow and Radcliffe the houses of the workpeople were
new, airy and comfortable. In the same years typhus raged with uncommon
severity at Ulverston and in various parts of Lancashire, where
cotton-mills had been set up[270].

The typhus of Liverpool and Newcastle was reproduced in Whitehaven and
Cockermouth on a scale proportionate to their size. Whitehaven, the port
of the Cumberland coal-field, was the Newcastle of the west coast, and had
a large trade with Ireland. Many of the labourers lived in cellars.
Brownrigg's experiences of typhus fever in it went back to near the middle
of the 18th century. The Whitehaven Dispensary was opened in 1783, the
occasion for it being thus explained:--

    "Previous to the establishment of dispensaries Whitehaven and
    Cockermouth were infested by nervous and putrid fever. Many of their
    respectable inhabitants became its victims; and among the lower class
    of people it prevailed with deplorable malignancy. The present period
    happily exhibits a different picture. Notwithstanding our connection
    with the metropolis of Ireland, and other commercial places, contagion
    rarely appears; or, when accidentally introduced, is readily
    suppressed[271]."

The following is the abstract of "contagious fever cases" from the records
of the Whitehaven Dispensary from 30 June, 1783, to 9 June, 1800[272]:

  Year  Cured  Dead  Total

  1783    75     1     76
  1784   401     9    410
  1785   350    20    370
  1786    91     6     97
  1787    21     1     22
  1788    53     7     60
  1789   103     2    105
  1790   288    21    309
  1791    74     6     79
  1792    17     2     19
  1793     7     3     10
  1794    13     1     14
  1795    28     2     30
  1796    48     1     49
  1797    35     2     37
  1798    12     1     13
  1799    11     1     12
          ----  ---   ----
  Total   1627   85   1712

The year 1790 is indicated as an unhealthy one, by the excess of burials
over christenings, also at Macclesfield, where there were 316 christenings
to 380 burials, the proportion being usually the other way[273].

Dr John Alderson of Hull wrote in 1788 an essay on the contagion of fever,
in which there are no authentic details for Hull: "The calamity itself is
the constant complaint of every neighbourhood, and almost every newspaper
presents us with an example of the direful consequences of infection"--the
reference being to gaols more particularly[274]. Whatever was the reason,
there was undoubtedly a great deal of typhus in England in the eighties of
the eighteenth century. Oxfordshire, Gloucestershire, Worcestershire,
Wiltshire and Buckinghamshire experienced much typhus from 1782 to 1785,
although we have few particulars. "The remembrance of its ravages at
Gloucester, Worcester and Marlborough," says Dr Wall of Oxford, "is still
fresh in every mind, where its virulence proved so peculiarly fatal to the
medical world." At Aylesbury, Dr Kennedy survived an attack of the
"contagious fever," to write an account (1785) of the epidemic, which he
traced to the gaol (the date, be it observed, is subsequent to Howard's
visitations)[275]. At Maidstone, also, in 1785, the gaol fever was the
subject of a special account[276].

At Worcester in 1783 the younger Dr Johnstone caught typhus while visiting
the gaol, which was thereafter rebuilt at great expense. A prisoner took
it to Droitwich where 14 died[277].

Dr Wall gives clinical details of fifteen cases of typhus treated by him
in private practice at Oxford in 1785; one of his patients was an
apothecary whose business had exposed him very much to the influence of
contagion, as he was much employed amongst the poor in the suburbs of the
town and neighbouring villages and in the House of Industry[278]. In the
year 1783-85, much of the epidemic fever was of the nature of ague, as
described in another chapter. It is not always easy to separate it from
typhus; but there is no doubt that both were prevalent together. Thus in
the parish of Painswick, Gloucestershire, in the spring of 1785 there
occurred both "a contagious fever" and an "epidemic ague," the latter
having left a good many persons dropsical and cachectic[279]. This had
been part of an epidemical fever which had raged for some time in the
county of Gloucestershire, and is said to have lately carried off a great
number of poor. At Norton, within five miles of Gloucester, there lived in
two adjoining tenements two families: in one a man and his wife and three
children, in the other a man and his wife, of whom only one remained alive
on the 1st of March, 1785[280].

The extraordinary failure of the harvest in Scotland in 1782 produced much
distress, and with it fever, in the winter following. The Glasgow and
Edinburgh municipalities imported grain for the public benefit. Various
traces of the scarcity and fever appear in the Statistical Account written
a few years after. Thus, in Holywood parish, Dumfriesshire, some fevers
were wont to appear in February and March among people of low
circumstances living in a narrow valley; and the unusual mortality in the
dear year 1782 was owing to an infectious fever in the same cottages. In
the regular bills of mortality of Torthorwald parish, Dumfriesshire, the
deaths from "fever" fall in the dear years, 1782-3, 1785, &c. In Dunscore
parish, in the same county, the burials of 1782 rose to the most unusual
figure of 30 (the baptisms being 17), "owing to a malignant fever[281]."

But Scotland was now past the danger of actual famine from even a total
failure of the harvest. Some farmers were ruined, and many more were
unable to pay the year's rent; but the very poorest were enabled to find
food, one source being "the importation of white pease from America." From
Delting, in Shetland, one of the poorest parishes, the report is: "There
is reason to believe that none died from mere want; but there is no doubt
that many, from the unwholesome food, contracted diseases that brought
them to their graves."

The following relating to the parishes of Keithhall and Kinkell,
Aberdeenshire, in the scarcity following the lost harvest of 1782, is a
curiously detailed glimpse of the time:

    "Several families who would not allow their poverty to be known lived
    on two diets of meal a day. One family wanted food from Friday night
    till Sunday at dinner. On the last Friday of December, 1782, the
    country people could get no meal in Aberdeen, as the citizens were
    afraid of a famine; and a poor man, in this district, could find none
    in the country the day after. But the distress of this family being
    discovered, they were supplied. Next day the [Kirk] session bought at
    a sale a considerable quantity of bere, which was made into meal. This
    served the poor people until the importation at Aberdeen became
    regular, and every man of humanity rejoiced that the danger of famine
    was removed[282]."

We hear most of fevers in the Highland parishes, with their subdivisions
of holdings and an excess of population. Thus of Gairloch, Ross-shire, it
is said: "Fevers are frequent, sometimes they are of a favourable kind, at
other times they continue long and carry off great numbers"--the poor in
this parish, upon the Kirk Session roll, numbering 84 in the year 1792,
and the aggregate money paid to the whole number averaging L6. 7_s._ in a
year, whereas the fertile parish of Ellon, Aberdeenshire, with 40 on the
poor's roll, paid them L43 per annum.

Again, of the fishing village of Eyemouth, it is said: "The only
complaints that prove mortal in this place are different kinds of fevers
and consumptions; and these are mostly confined to the poorest class of
people, and ascribed to their scanty diet." And of another fishing parish,
in Banffshire, Fordyce, including Portsoy, it is said: "The most prevalent
distemper is a fever, and that for the most part not universal, but
confined to particular districts. It is sometimes thought to arise from
infection and communication with other parts of the country; at other
times from local situations and circumstances of the people's houses and
habits of living in particular districts[283]."

The beginning of the great French war was the occasion of a considerable
increase of fever; although no records make it appear so fatal a time as
the years 1783-86. The commercial distress and want of work which began in
the autumn of 1792, were intensified by the bad harvests of 1794 and 1795,
which followed two harvests also deficient. This was the period of
distress and of epidemic fever to which Wordsworth referred in the passage
in the first book of the 'Excursion,' where he is relating the story of
Margaret's ruined cottage[284].

There is little medical writing upon the epidemic fever of 1794-95; and,
in the very district of Wordsworth's story, the records of the Whitehaven
Dispensary bear no traces of a great concourse of patients. There is
reason to think that the fever, if slow and weakening, was seldom fatal,
that it was _typhus mitior_, and that it was sometimes, perhaps often,
relapsing. One glimpse we get of it in the family of the afterwards
celebrated Dr Edward Jenner of Berkeley, in the winter of 1794-95. He thus
writes to a friend about the visitation of "grim-visaged typhus:"

    "You shall hear the history of our calamities. First fell Henry's [his
    nephew and assistant] wife and sister. From the early use of bark,
    they both appeared to recover; but the former, after going about her
    ordinary business for some days, had a dreadful relapse which nearly
    destroyed her. It was during my attendance on this case that the
    venomed arrow wounded me.... Like Mrs Jenner's fever, at an early
    period there was a clear intermission for four days.... On the eighth
    day after the first seizure it again set in, in good earnest, and
    continued one-and-twenty days.... Dr Parry was with me from Bath five
    times, Dr Hicks and Dr Ludlow as many, and my friend George was never
    absent from my bedside.... But, to return to that mansion of
    melancholy, Henry's. His infant girl has now the fever; a servant maid
    in the house is dying with it; and to complete this tragical
    narrative, about five days ago fell poor Henry himself. His symptoms
    at present are such as one might expect: violent pain in the head,
    vertigo, debility, transient shiverings.... His pulse this evening is
    sunk from 125 to 100. The stench from the poor girl is so great as to
    fill the house with putrid vapour; and I shall remove him this morning
    by means of a sedan-chair to a cottage near my own house[285]."

This is a tolerably clear picture of a short-period fever with relapses,
or of relapsing fever strictly so-called; the stench, also, of one patient
is characteristic. Barker, of Coleshill or Birmingham, has much to say
under the same year 1794, of a slow, tedious fever, marked by "sluggish
action and comatose symptoms," and much subject to relapses; but he does
not give the duration of the first or subsequent paroxysms, as Jenner
does, or the usual length of the clear intervals, his most definite case
being of a young woman who died in twenty-four hours from a relapse which
came on about three weeks after the fever had left her[286].

It was the access of fever in 1794-5, and the alarm that it caused among
the richer classes, that led to the opening of the Manchester House of
Recovery in 1796. In certain streets in the neighbourhood chosen for the
hospital, Portland Street, Silver Street and others in the same block, the
cases of contagious fever for nearly three years before the hospital was
opened are given by Ferriar as follows:

  Sept. 1793 to Sept. 1794, cases of fever, 400
  Sept. 1794 to Sept. 1795,   "   "    "    389
  Sept. 1795 to May 1796,     "   "    "    267

The cases began to be sent to the hospital on the 27th May, 1796, and an
attempt was made to extinguish contagion in the houses, by white-washing,
disinfecting and the like; so that in the same group of streets there were
only 25 cases of fever from 13 July, 1794 to 13 March, 1797. Meanwhile the
admissions to the hospital were few until the dearth of 1799-1802. One of
the manufacturing towns which is known to have shared in the epidemic
fever of 1794-96 was Ashton-under-Lyne, where upwards of three hundred
cases (with few deaths) occurred in less than three months at the end of
1795. This epidemic must have been somewhat special to Ashton, for it
produced much alarm in neighbouring places and caused Ashton to be avoided
from fear of infection.

Shortly after 1796, Ferriar made an inquiry into an epidemic of fever at a
village within a mile of Manchester; the houses were many of them new,
built for the convenience of a large cotton mill; but even the new houses
were offensive, with cellars occupied by lodgers, and almost every house
overcrowded. This was the first fever in the village, and it was traced to
a family who had come from Manchester with infected clothes. Stockport
about the same time erected a House of Recovery, having "the same general
causes of fever which render the disease so common in Manchester"; and
Ferriar adds: "I believe there is not a town in the kingdom containing
four thousand inhabitants which would not be greatly benefited by similar
establishments."

The bad harvest of 1794 raised the price of wheat to 55_s._ 7_d._ on 1
January, 1795, and the prospect of another short harvest to 77_s._ 2_d._
on 1 July. A famine being threatened, the Government caused neutral ships
bound to French ports with corn to be seized, and brought into English
ports, the owners receiving an ample profit. Agents were also sent to the
Baltic to buy corn. By these means the price of wheat, which had risen in
August to 108_s._ 4_d._, fell in October to 76_s._ 9_d._ Parliament met on
the 29th October, and various measures were taken[287]. In the spring of
1796, the climax of distress was reached, wheat being at 100_s._ per
quarter. The harvest of 1796 was abundant and wheat fell to 57_s._ 3_d._
The harvests of 1797 and 1798 were not equally good, but they were not
altogether bad, and the price of wheat kept about 50_s._ for nearly three
years, which were years of comparative comfort between the dearth of
1794-96 and the dearth of 1799-1802.


Fevers in the Dearth of 1799-1802.

Although Willan chooses the end of the year 1799 to enlarge upon the
London fever, he does not connect it with the dearth that was already
beginning to be felt (soup kitchens having been opened in various parts of
London). The price of wheat, which had been steadily about 50_s._ in 1797
and 1798, rose in May, 1799 to 61_s._ 8_d._, after a hard winter which had
probably injured the autumn-sown corn. The harvest turned out ill, and the
price of wheat rose in December, 1799, to 94_s._ 2_d._ Bounties were
offered on imported foreign grain, but in June, 1800, the price was
134_s._ 5_d._, falling in August to 96_s._ 2_d._ on the crops promising
well. The latter end of harvest proved wet, much of the grain being lost,
so that the price per quarter of wheat rose to 133_s._ in December. There
was much suffering, and some rioting. Parliament met on the 11th November,
1800, on account of the dearth, the opinions of the members being much
divided as to the causes of the high prices. In March, 1801, wheat was at
156_s._ 2_d._ per quarter, beef from 10_d._ to 10-1/2_d._ per pound,
mutton 11_d._ to 12_d._ per pound. It is to this year, when the quartern
loaf was at one-and-eightpence, that a comparison by Arthur Young belongs,
showing the great change in the purchasing power of wages[288]. By the end
of summer, 1801, wheat rose to 180_s._, and the quartern loaf was for
four weeks at 1_s._ 10-1/2_d._

Whatever statistics were then kept of fever-cases, show a decided rise in
the years 1800 and 1801:

          Manchester   Glasgow                      London
          House of      Royal       Newcastle       Bills of
          Recovery    Infirmary    Dispensary      Mortality
  Year (fever-cases) (fever-cases) (fever-cases) (fever-deaths)

  1796       371          43            201           1547
  1797       339          83             65           1526
  1798       398          45             67           1754
  1799       364         128             --           1784
  1800       747         104             --           2712
  1801      1070          63            425           2908
  1802       601         104             --           2201
  1803       256          85            352           2326
  1804       184          97            255           1702
  1805       268          99             74           1307

The London Fever Hospital was not opened until February, 1802, a small
house in Gray's Inn Lane containing sixteen beds. It came at the end of
the epidemic, and was in small request during the next fifteen years. The
same epidemic at Leeds was the occasion of opening a House of Recovery
there in 1804, twenty-five years after Lucas had first called for it. The
state of affairs in Leeds, which at length moved the richer classes to
that step, is thus described by Whitaker[289]:

    "In the years 1801 and 1802 an alarming epidemic fever spread in Leeds
    and the neighbourhood. The contagion extended so rapidly and proved so
    fatal that some hundreds were affected at the same time, and two
    medical gentlemen, with several nurses, fell victims to the
    disease.... In 1802 whole streets were infected house by house; in one
    court, of crowded population, typhus raged for four months
    successively."

One of the Leeds physicians, Dr Thorp, seized the occasion to urge the
need of a fever hospital, in a pamphlet written in 1802, in which he said:

    "In a visit made a few days ago to those abodes of misery, I saw in
    one particular district upwards of twenty-five families ill in
    contagious fever. In some houses two, in others six or seven
    [families] were confined, many of whom appeared to be in extreme
    danger." The superintendent of the sick poor stated to Dr Thorp "that
    sixty families in epidemic fever are under his care at this time. New
    applications are making daily. In some families three, in others six
    or seven, are in the disease. Forty persons in fever have applied to
    him for medical aid within the present week[290]."

The wonder is that, with the enormous prices of food, things were not
worse. At the time when provisions were dearest, work was slack in several
industries. A commercial report of 1 April, 1801, speaks of the trade of
Birmingham as very distressed, a large proportion of the men being out of
work; the ribbon trade of Coventry was deplorable, and the woollen trade
of Yorkshire still worse. Evidence of epidemic typhus in various parts of
England came out in connexion with the reports on influenza in 1803.
Holywell, in Flintshire, with a large cotton-making industry, had not been
free from a bad kind of typhus for two years previous to the influenza of
1803[291]. In Bristol there was a good deal of fever in 1802-3, which
found its way, through domestic servants, into good houses in Clifton,
"and proved fatal in some instances[292]." It is probable that these are
only samples, the writings on epidemics being singularly defective at this
period. The following, dated 10th April, 1802, by a surgeon at Earlsoham,
near Framlingham, Suffolk, gives us a glimpse of malignant contagious
fever in a farm-house:

    "The most prevailing epidemics for the last twelve months have been
    typhus maligna and mitior, scarlatina anginosa, measles, and mumps.
    Many of the former have proved alarmingly fatal in several of our
    villages, whilst those of the second class of typhoid fevers have put
    on the appearance of the low nervous kind attended with great
    prostration of strength, depression of spirits, loss of appetite,
    etc., which frequently continue many weeks before a compleat recovery
    ensues." Five cases, of "the most malignant kind of typhus," occurred
    in a farmer's family: one of the sons, aged eighteen, died in a few
    days with delirium, and black sordes of the mouth, tongue and throat;
    then the father, two daughters, and another son, took the infection
    but all escaped with their lives. Of four persons who nursed them, one
    caught the fever, and died. Four persons in a neighbouring family, who
    visited them, took infection, of whom two died[293].

There was perhaps nothing very unusual in such instances of country fevers
at the beginning of the century. The incident is exactly in the manner of
one that figures prominently in a story of Scottish life and customs at
the same period, which long passed current as a faithful picture and as
enforcing a much-needed moral[294].


Comparative immunity from Fevers during the War and high prices of
1803-15.

From 1803 to 1816 there was comparatively little fever in this country.
This was notably the case in London, but it was also true of all the
larger towns where fever-hospitals had been established, and it was as
true of Ireland as of England. This was, indeed, a time of great
prosperity, which reached to all classes, the permanent rise of wages
having more than balanced the increased cost of the necessaries of life.
The following prices of wheat will show that a dear loaf did not
necessarily mean distress while the war-expenditure lasted:

Prices of wheat (from Tooke).

                _s._   _d._

  1802           57     1

  1803           52     3

  1804 Lady Day  49     6
       Dec.      86     2

  1805 Aug.      98     4
       Dec.      74     5

  1806           73     5

  1807 Nov.      66

  1808 May       73     6
       Dec.      92

  1809 March     95
       July      86     6
       Dec.     102     6

  1810 June     113     5
       Dec.      94     7

  1811 June      86    11
       Nov.     101     6

  1812 Aug.     155
       Nov.     113     6

  1813 Aug.     112
       Dec.      73     6

  1814 July      66     5

  1815 Dec.      53     7

  1816 May       74
       Dec.     103

  1817 June     111     6

  1817 Sept.     77     7

  1818 Dec.      78    10

  1819 Aug.      75

  1820           72

  1821 July      51
       Dec.      50

  1822           42

  1823 Feb.      40     8
       June      62     5
       Oct.      46     5
       Dec.      50     8

  1824           65

The only years in the period from 1803 to 1816 in which there was some
slight increase of fever were about 1811-12. There was undoubtedly some
distress in the manufacturing districts at that time, owing to the much
talked-of Orders in Council, which had the effect of closing American
markets to British manufactures[295].

The small amount of fever in London between the year 1803 and the
beginning of the epidemic of 1817-19 rests on the testimony of
Bateman[296], who in 1804 took up Willan's task of keeping a systematic
record of the cases at the Carey Street Dispensary. He has only two
special entries relating to typhus: one in the autumn of 1811, when some
cases occurred in the uncleanly parts of Clerkenwell and St Luke's ("but I
have not learned that it has existed in any other districts of London");
the other in October and November 1813, when there was more typhus among
the Irish in some of the filthy courts of Saffron Hill, near Hatton
Garden, than for several years past, the infection having spread rapidly
and fatally in several houses. The best evidence of this lull in typhus in
London is the almost empty state of the new fever-hospital:

  Year   Admissions

  1802      164
  1803      176
  1804       80
  1805       66
  1806       93
  1807       63
  1808       69
  1809       29
  1810       52
  1811       43
  1812       61
  1813       85
  1814       59
  1815       80
  1816      118
  1817      760

Until it was removed to Pancras Road, in September, 1816, the London
fever-hospital had only sixteen beds. But Bateman says that no one was
refused admission, and that for several years the house was frequently
empty three or four weeks together. Also at the Dispensary, in Carey
Street, he had an opportunity during the period 1804-1816,

    "Of observing the entire freedom from fevers enjoyed by the
    inhabitants of the numerous crowded courts and alleys within the
    extensive district comprehended in our visits from that charity." And
    again, writing in the winter of 1814-15, Bateman says: "To those who
    recollect the numerous cases of typhoid fevers [this term did not then
    mean enteric] which called for the relief of dispensaries twelve or
    fourteen years ago, and the contagion of which was often with great
    difficulty eradicated from the apartments where it raged, and even
    seized the same individuals again and again when they escaped its
    fatal influences, the great freedom from these fevers which now
    exists, even in the most close and filthy alleys in London, is the
    ground of some surprise." And once more, in the summer of 1816, just
    as the new epidemic period was about to begin, he says: "The
    extraordinary disappearance of contagious fever from every part of
    this crowded metropolis during the long period comprehended by these
    Reports [since 1804], cannot fail to have attracted the attention of
    the reader."

Bateman concluded, not without reason, that this immunity of London from
fever was due to the high degree of well-being among the poorer classes in
times of plenty; and although he made out that the poor of Dublin, Cork
and some Scotch towns did not profit by times of plenty so much as those
in London, yet his reason for the abeyance of fever from 1804 to 1816
applied to England, Ireland and Scotland at large, and was doubtless the
true reason.

The following figures from Manchester[297], Leeds[298] and Glasgow[299]
hospitals, as well as the Irish statistics elsewhere given, are closely
parallel with those of London:

_Manchester House of Recovery._

  Year         Cases   Deaths

  1796-7        371      40
  1797-8        339      16
  1798-9        398      27
  1799-1800     364      41
  1800-1        747      63
  1801-2       1070      84
  1802-3        601      53
  1803-4        256      33
  1804-5        184      34
  1805-6        268      29
  1806-7        311      33
  1807-8        208      15
  1808-9        260      21
  1809-10       278      30
  1810-11       172      15
  1811-12       140      18
  1812-13       126      13
  1813-14       226      17
  1814-15       379      29
  1815-16       185      14
  1816-17       172       6

_Leeds House of Recovery._

  Year         Cases   Deaths

  1804 (2 mo.)   10       0
  1805           66       6
  1806           75       2
  1807           35       1
  1808           80       3
  1809           93       8
  1810           75      14
  1811           92       4
  1812           80      12
  1813          137      11
  1814           79       4
  1815          146      15
  1816          121      13
  1817          178       8
  1818(10 mo.)  254      20

_Glasgow Royal Infirmary (Fever Wards)._

  Year         Cases

  1795           18
  1796           43
  1797           83
  1798           45
  1799          128
  1800          104
  1801           63
  1802          104
  1803           85
  1804           97
  1805           99
  1806           75
  1807           25
  1808           27
  1809           76
  1810           82
  1811           45
  1812           16
  1813           35
  1814           90
  1815          230
  1816          399
  1817          714
  1818         1371

Even such fever as there was in Britain from 1804 to 1817 was not all
certainly typhus. The high death-rates at the Manchester fever-hospital in
1804 and 1805 (1 death in 7.5 cases and 1 death in 5.25 cases) may mean a
certain proportion of enteric cases in those years. "From 1804 to 1805,"
says Ferriar, "many cases were admitted of a most lingering and dangerous
kind.... Many deaths took place from sudden changes in the state of the
fever, contrary to the usual course of the disease, and only imputable to
the peculiar character of the epidemic. Similar cases occurred at that
time in private practice." Next year, 1806, there was an epidemic among
the troops at Deal, described under the name of "remittent fever," which
Murchison claims to have been enteric[300]. In September, 1808, says
Bateman, several were admitted into the London House of Recovery, with
malignant symptoms; "and some severe and even fatal instances occurred in
individuals in respectable rank in life." He still uses the name of
typhus; but he is aware that the cases of continued fever, especially in
the summer and autumn of 1810, had often symptoms pointing to a
bowel-fever rather than to a head-fever[301].

The years 1807 and 1808 appear to have been the most generally unwholesome
during this period of comparative immunity from fever; they were marked by
the occurrence of dysenteries, agues, and infantile remittents, as well as
of fevers of the "typhus" kind. The chief account comes from
Nottingham[302]. The cases of "typhus" there were very tedious, but not
violent, nor attended with any unfavourable symptoms, only one case having
petechiae, and all having diarrhoea. The following table of admissions
for various kinds of fever (as classified by Cullen) at the Nottingham
General Hospital, 25 March, 1807, to 25 March, 1808, shows the
preponderance of "synochus" and next to it, of infantile remittent:

_Admitted to the Nottingham General Hospital, 1807._

  Intermittent fever              7
  Synocha                        10
  Typhus                         27
  Febris nervosa                 26
  Synochus                      155
  Febris infantum remittens      88
  Dysentery                       5

The state of war in the Peninsula was favourable to epidemic or spreading
diseases, and there is a good deal to show that such diseases did exist
among the British troops[303]. But there is only one good instance of
England getting a taste of that experience of war-typhus which the
Continent had to endure for many years. This was on the return of the
remnant of the army after the defeat at Corunna on 16 January, 1809. The
troops were crowded pell-mell on board transports, which had a very rough
passage home. Dysentery broke out among them, and was the most urgent
malady when they landed at Plymouth in a state of filth and rags. Typhus
fever followed, but in the first three weeks at Plymouth, to the 18th of
February, it was not of a malignant type, only 8 dying of it in the Old
Cumberland Square Hospital; in the next three weeks, 28 died of it there.
Up to the 27th of March, 1809, the sick at Plymouth from the Corunna army
numbered 2432, of whom 241 died. Of 4 medical officers, 3 took the
contagion, of 29 orderlies, 25 took it. The fever was in some cases
followed by a relapse, which was more often fatal than the original
attack[304]. This was a typical instance of typhus bred from dysentery or
other incidents of campaigning, a contagion more dangerous to others than
to those who had engendered it. "Within a few yards of the spot where I
now write," says Dr James Johnson, of Spring Gardens, London, "the greater
part of a family fell sacrifices to the effects of fomites that lurked in
a blanket purchased from one of these soldiers after their return from
Corunna[305]." In August, 1813, an Irish regiment passing through
Leyburn, a small market-town of the West Riding of Yorkshire, in an airy
situation, was obliged to leave behind a soldier ill of typhus, who died
of the fever after a few days. The infection appeared soon after in the
cottages adjoining, and remained in that end of the town for several
months, choosing the clean and respectable houses. In a farmer's family, a
son, aged twenty-nine, died of it, while another son and two daughters had
a narrow escape. The disease appeared also in the village of Wensby, a
mile distant, and in other villages. Few lives were lost[306].

These were, perhaps, not altogether solitary instances in Britain of
typhus spread abroad by the movements of troops during the great French
war. Let us multiply such instances by hundreds, and we shall vaguely
realize the meaning of the statement that the period of the Napoleonic
wars, and more particularly the period from the renewal of the war in 1803
until its close in 1815, was one of the worst times of epidemic typhus in
the history of modern Europe. It was precisely in those years that
England, Scotland and Ireland enjoyed a most remarkable degree of freedom
from contagious fever.


The Distress and Epidemic Fever (Relapsing) following the Peace of 1815
and the fall of wages.

The long period of comparative immunity from typhus near the beginning of
the 19th century was first broken, both in Great Britain and in Ireland,
by the very severe winter of 1814-15; but it was not until the great
depression of trade following the peace of 1815 (which made a difference
of forty millions sterling a year in the public expenditure) and the bad
harvest of 1816 that typhus fever and relapsing fever became truly
epidemic, chiefly in Ireland but also in Scotland and England. The lesson
of the history is unmistakable: with all the inducements to typhus from
neglect of sanitation in the midst of rapidly increasing numbers, there
was surprisingly little of the disease so long as trade was brisk and the
means of subsistence abundant. The reckoning came in the thirty years
following the Peace.

In London, says Bateman[307], the epidemic began in the autumn of 1816,
before the influence of scarcity was acutely felt, in the courts about
Saffron Hill, the same locality in which he mentioned fever in the winter
of 1813-14 among the poor Irish. But this means little more than that the
Irish, whether in Ireland or out of it, are the first to feel the effects
of scarcity in producing fever. At the very same time that it began among
them in Saffron Hill, it began among some young people at a silk factory
in Spitalfields. In March, 1817, there was a good deal more of it in
Saffron Hill, as well as among the silk-weavers in Essex Street,
Whitechapel, in Old Street, in Clerkenwell, and in Shadwell workhouse.
Many poor-houses, and especially those of Whitechapel, St Luke's, St
Sepulchre's and St George's, Southwark, were getting crowded in 1817 with
half-starved persons, among whom fever was rife in the summer and autumn.
There was also much of it in the homes of working people in the eastern,
north-eastern and Southwark parishes, with more occasional infected
households in Shoe Lane, Clare Market, Somers Town and St Giles's in the
Fields ("in the filthy streets between Dyot Street and the end of Oxford
Street")[307]. The hospitals and dispensaries were fully occupied with
fever, and the new House of Recovery in Pancras Road, with accommodation
for seventy patients, was soon full. At the Guardian Asylum for young
women, more than half of the forty inmates were seized with the fever in
one week. The cases were on the whole milder than in ordinary years; of
678 admitted to the House of Recovery in 1817, fifty died or 1 in 13.5. In
two-thirds of these patients the fever lasted two weeks or to the
beginning of the third week; of the remaining third, a few lost the fever
on the 7th, 8th or 9th day, a larger number on the 12th to the 14th day,
while a considerable number kept it to the end of the third week or
beginning of the fourth. Of the whole 678, only 75 had a free
perspiration, and in only 19 of these was the perspiration critical so as
to end the fever abruptly. The fever relapsed in 54 of the 678, a
proportion of relapsing cases which seemed to Bateman to be "remarkably
great[308]." In most the symptoms continued without break throughout the
illness. Besides other febrile symptoms, there were pains in the limbs and
back, aching of the bones, and soreness of the flesh, as if the patients
had been beaten. There was a certain proportion of severe complicated
cases of typhus. Bateman held that the differences in type depended on the
differences of constitution, giving the following reason for and
illustration of his opinion:

    "Thus, in the instance of a man and his wife who were brought to the
    House of Recovery together, the former was affected with the mildest
    symptoms of fever, which scarcely confined him to bed, and terminated
    in a speedy convalescence; while his wife was lying in a state of
    stupor, covered with _petechiae_ and _vibices_; in a word, exhibiting
    the most formidable symptoms of the worst form of typhus. Yet these
    extreme degrees of the disease manifestly originated from the same
    cause; and it would be equally unphilosophical to account them
    different kinds of fever and give them distinct generic appellations
    as in the case of the benign and confluent smallpox, which are
    generated in like manner from one contagion." Besides this woman, only
    eight others had petechiae.

The House of Commons Committee were unable to find out with numerical
precision how much more prevalent the fever was in 1817-18 than in the
years preceding[309]. To their surprise they found that in six of the
general hospitals of London, which admitted cases of fever, "no register
is kept in the hospital to distinguish the different varieties of
disease." The apothecary of St Luke's Workhouse told them that he
attended, on an average of common years, about 150 cases of fever; in the
last year [1817] the number rose to 600; and they were assured by several
besides Bateman, that the great decrease of the deaths from "fever" in the
London bills of mortality during a space of fourteen years at the
beginning of the century (1803-17), was not a mere apparent decrease, from
the growing inadequacy of the bills, but was a real decrease.

The epidemic which began in 1817 continued in London throughout the years
1818 and 1819, chiefly in the densely populated poorer quarters of the
town. Two instances of the London slums of the time came to light before
the House of Commons Committee on Mendicity and Vagrancy in 1815-16:
firstly, Calmel's Buildings, a small court near Portman Square, consisting
of twenty-four houses, in which lived seven hundred Irish in distress and
profligacy, neglected by the parish and shunned by everyone from dread of
contagion; and, secondly, George Yard, Whitechapel, consisting of forty
houses, in which lived two thousand persons in a similar state of
wretchedness. The dwellings of the poorer classes in London at this
period, before the alleys and courts began to disappear, were described
thus generally by Dr Clutterbuck[310]:

    "The houses the poor occupy are often large, and every room has its
    family, from the cellar to the garret. Thirty or forty individuals are
    thus often collected under the same roof; the different apartments
    must be approached by a common stair, which is rarely washed or
    cleansed; there are often no windows or openings of any kind
    backwards; and the _privies_ are not unfrequently within the walls,
    and emit a loathsome stench that is diffused over the whole house. The
    houses are generally situated in long and narrow alleys, with lofty
    buildings on each side; or in a small and confined court, which has
    but a single opening, and that perhaps a low gateway: such a court is
    in fact little other than a well. These places are at the same time
    the receptacles of all kinds of filth, which is only removed by the
    scavenger at distant and uncertain intervals, and always so
    imperfectly as to leave the place highly offensive and disgusting."

In England, generally, this epidemic of 1817-19 is somewhat casually
reported. One writes from Witney, Oxfordshire, "on the prevailing
epidemic," which began there in July, 1818, among poor persons, in
crowded, filthy and ill-ventilated situations. At first it was like the
ordinary contagious fever of this country, "a disease familiar to common
observation"; but afterwards it showed choleraic and pneumonic
complications. Sometimes the parotid and submaxillary glands were
inflamed; petechiae were absent[311]. The type of fever at Ipswich in the
spring of 1817 was contagious (e.g. six cases in one family) and sthenic,
or of strong reaction, admitting of bloodletting, according to the
teaching which Armstrong, Clutterbuck and others had been reviving for
fevers[312]. Those instances, one from Oxfordshire the other from Suffolk,
must stand for many. Hancock says that the fever of 1817-19 "visited
almost every town and village of the United Kingdom[313]." Prichard says
that it began in Ireland, "where the distress was most urgent, and
afterwards prevailed through most parts of Britain," some of the more
opulent also being involved in the calamity. As to its prevalence in the
manufacturing towns of Yorkshire we have ample testimony. The Leeds House
of Recovery, which had not been fully occupied at any time since its
opening in 1804, received 178 cases in 1817, and 254 in the first ten
months of 1818. Of the latter, 66 came from low lodging-houses, of whom
upwards of 50 were strangers. Of 50 admitted in January, 1818, 20 came
from four or five lodging-houses in March Lane, and from another locality
equally bad--Boot and Shoe Yard; while the rest of the 50 in that month
came from houses and streets in the same vicinity. March Lane was one of
the worst seats of the great Leeds plague in 1645. By the month of April,
1820, the epidemic had decreased a good deal in Leeds, the cases becoming
at the same time more anomalous[314].

The following is one of the Rochdale cases:

    June 2, 1818, Alice Eccles, a delicate young woman living in a crowded
    and filthy court from which fever had not been absent for nearly a
    year, was bled to ten ounces, purged, and recovered. On September 20th
    the same woman returned, desiring to be bled again. She was labouring
    under her former complaint; "since her last illness she had been
    repeatedly exposed to contagion, or rather, she had been living in an
    atmosphere thoroughly saturated with infectious effluvia, the house in
    which she resided, and generally the room in which she slept, having
    had one or more cases of fever in them," and the windows kept
    closed[315].

At Halifax in the summer of 1818, typhus (or relapsing fever) had
increased so much that fever-wards were added to the Dispensary. It had
been alarmingly fatal in a high-lying village near Settle. It was
prevalent in Ripon, Huddersfield and Wakefield; and had been brought from
Leeds to Atley. A Bradford physician visited 27 cases of fever in one day
at a neighbouring village. Throughout Yorkshire, it was confined to the
lower orders, and was not very fatal[316]. At Carlisle it began about
July, 1817, and became somewhat frequent in the winter and spring
following; of 457 cases treated from the Dispensary 46 died, or 1 in
10[317]. At Newcastle, a mild typhus (typhus mitior) broke out in the
autumn of 1816, not in the poorer quarters, but mostly among the domestics
of good houses in elevated situations. There was much privation at
Newcastle, as elsewhere, at this time, among the poor. Murchison takes
this fever of the autumn of 1816 at Newcastle to have been enteric or
typhoid; but it is described as a simple continued fever, with vertigo,
headache, and bloodshot eyes, lasting from five or six days to four or
five weeks, ending usually without a marked crisis, and causing few
deaths[318]. The epidemic continued in Newcastle for three years, the
admissions to the Fever Hospital from 4 Sept. 1818, to 4 March, 1819,
having been 160, with 12 deaths. Dr McWhirter wrote, in April, 1819, that
he saw on his rounds as dispensary physician "too many of the obvious
causes of fever," including the filth and wretchedness of the poor
inhabitants: "one rather wonders that so many escape it than that some are
its victims[319]."

Thus far there has been little besides Bateman's essay to indicate the
nature or type of the fever in England. In Ireland it was to a large
extent relapsing fever, and, as we shall see, it was so also in Scotland.
Bateman found less than a tenth part of the cases at the London Fever
Hospital to have relapses, which was an unusually large proportion, in his
experience. Elsewhere in England the tendency to relapse was either
wanting or the relapses were described or accounted for in other ways; to
understand this it has to be kept in mind that the epidemic was the
occasion of a great revival of blood-letting, a practice which had fallen
into disuse in fevers since the last half of the 18th century, and was
something of a novelty in 1817. The fever of that year was undoubtedly
abrupt in its onset, strong, "inflammatory," with full bounding pulse,
beating carotids, hot and dry skin, intense headache, suffused eyes, and
the like symptoms, which seemed to call for depletion. The common practice
was to bleed _ad deliquium_, which meant to ten, or fourteen, or twenty
ounces, at the outset of the fever. There was hardly one of the writers
upon the epidemic, unless it were Bateman, an advocate of the cordial and
supporting regimen, who did not consider the stages or duration of the
fever as artificially determined by the blood-letting, and not as
belonging to the natural history.

In order to show how much the treatment by blood-letting dominated the
view of the fever itself, of its type, its stages, or duration, I shall
take the Bristol essay of Prichard, who adopted phlebotomy, as he says, at
first tentatively and with some fear and trembling, but at length
practised it vigorously, having found it to answer well[320]. The epidemic
of fever in Bristol began about June, 1817, and lasted fully two years.
The first cases brought to St Peter's Hospital, which was the general
workhouse of the city, were of wretched vagrants found ill by the wayside
or abandoned in hovels. About the same time forty-two felons in the
Bristol Newgate, "one of the most loathsome dungeons in Britain, perhaps I
might say in Europe," were infected, of whom only one died, and he of a
relapse. From June, 1817, to the end of 1819, there were 591 cases in the
poor's house, 647 in the General Infirmary, and 975 treated from the
Dispensary, making 2213 cases, of which a record was kept. But there were
also many cases in private practice among the domestics, children, and
others in good houses, such as those on Redcliff Hill. The cases in the
poor's house were classified by Prichard as follows:

                              1817  1818  1819

  Simple Fever                 22    45    40
    with cephalic symptoms     24    27    25
      "  pneumonic symptoms     7    10    16
      "  gastric symptoms       3    11     5
      "  enteric symptoms       3     4     5
      "  hepatic symptoms       5     3     3
         exhausted and }        1     6     4
           moribund    }
         not characterised     30    44     2
                              ---   ---    --
                               95   150   105
                              ---------------
        Of these there died    20    16    11

The "genuine form," or ground-type, according to Prichard, was "simple
fever," of which the cases with cephalic symptoms were merely the more
protracted or more serious. "The pneumonic, hepatic, gastric, enteric and
rheumatic forms may be regarded as varieties"--the gastric and hepatic
being cases mostly in summer with jaundice, the enteric in autumn and
winter with diarrhoea and dysentery. Nearly all these patients were bled
within four or five days from the commencement of the disease: "in a very
large proportion of the cases the fever was immediately cut short"; when
it did not end thus abruptly, its symptoms declined gradually, and the
attack was over within eight or ten days. After the blooding "sleep very
frequently followed, and a partial or sometimes a complete remission of
the symptoms." Only one case of relapse is mentioned, No. 118, of the year
1818, and that was a relapse in a very prolonged case: the patient was
admitted on 6 October, had a relapse on 18 November, and was discharged on
23 December. Prichard has not one word in his text to suggest relapsing
fever; the bulk of his cases were simple continued fever, with or without
cephalic or other local symptoms, ending in four, six, eight or ten days,
while some were cases of _typhus gravior_. The fever was undoubtedly
contagious: it spread through whole families, and in St Peter's Hospital
itself it attacked seventy of the ordinary pauper inmates, including a
good many lunatics.


The Epidemic of 1817-19 in Scotland: Relapsing Fever.

Let us now turn to the epidemic in Scotland, where the relapsing type was
as marked as in Ireland, if not more so. The destitution in the Scots
towns in the autumn of 1816, and following years, was fully as great as
anywhere in the kingdom, although the peasantry of Scotland were not
famine-stricken, as those of Ireland were. The state of the poorer classes
in Edinburgh was graphically set forth in an essay by Dr Yule, in
1818[321], and in an article in _Blackwood's Magazine_ the year after.
Vigorous efforts to relieve the distress were made by the richer classes,
and a special fever-hospital was opened at Queensbery House, the
admissions to which, together with the fever-cases at the Royal Infirmary,
were as follows:[322]

  Year   Admitted   Died   Ratio of deaths

  1817     511       33     1 in 15-16/33
  1818    1572       75     1 in 21
  1819    1027       30     1 in 34
  (to 1 Dec.)

Of this epidemic several accounts were published at the time, including
one by Welsh, superintendent of the fever hospital, which is dominated,
like the Bristol account of Prichard, by the idea that blood-letting cut
short the fever[323]. Christison, who had experience of the relapsing
form in his own person[324], describes also two other forms mixed with the
cases of relapsing fever: a mild typhus, the _typhus mitior_ (_typhus
gravior_ being exceedingly rare in that epidemic), and a form which began
like the inflammatory relapsing _synocha_, and gradually after a week put
on the characters of mild typhus.

The admissions for fever to the Glasgow Infirmary, which was then the only
charity that received fever cases, had been at a somewhat low level since
the last epidemic in 1799-1801. They began to rise again with the distress
of 1816:--

_Admissions for Fever, Glasgow Infirmary._

  Year     Cases

  1814      90
  1815     230
  1816     399
  1817     714
  1818    1371
  1819     630
  1820     289
  1821     234
  1822     229
  1823     269

At the height of the epidemic in 1818 an additional fever hospital was
opened at Spring Gardens, to which 1929 cases were admitted in that and
the following year. Great efforts were made in Glasgow to "stamp out" the
contagion by disinfectants and removal to hospital[325]; but the course of
the epidemic seemed to follow the economic conditions more than anything
else.

The outbreak at Aberdeen was later than in the south of Scotland, having
begun in August, 1818. The infection was said to have been brought to the
city by a woman who found a lodging in Sinclair's Close. A group of houses
in the close, covering an area of seventy by fifty feet and containing
one hundred and three inmates, became the first centre of the fever. The
scenes described are like those of the Irish epidemics: in one room, a
man, his wife, and five children were lying ill on the floor; in another,
a man, his wife and six children; in a third, a young girl, whose mother
had just died of fever, was left with three infant brothers or sisters.
More than three-fourths of the denizens of the close were "confined to bed
in fever, and all the others crawling about during the intervals of their
relapses." The value of all the furniture and clothing belonging to 103
persons could little exceed L5. There was a horrible stench both within
and without the houses (relapsing fever being remarkable for its odour).
Yet this close was usually as healthy as any other part of the town. A
House of Recovery, with sixty beds, was opened in the Gallowgate, and
thirty beds were given up to fever-cases in the Infirmary of the city.
Besides those ninety hospital cases at the date of 17 December, 1818, it
was estimated that were three hundred more. Begging had been put down, so
that the contagion had not spread to the richer classes. Despite these
removals to hospital, the epidemic became more general about the New Year,
1819, and of a worse type; two physicians died of it, and some others had
a narrow escape. At the outset, the fever had been of the relapsing
kind--"subject to relapses for a third and fourth time, more especially
when they return too early to their usual labour[326]." At a later period
the epidemic seems to have become ordinary typhus, as it did also in
Ireland and elsewhere; and it was called typhus in the essay upon it by Dr
George Kerr[327].

The extent of this epidemic of 1818-19 over Scotland generally is not
known; but the following notice of it in a country parish of Forfarshire
was probably a sample of more that might have been given.

    Early in the summer of 1818 an epidemic of continued fever appeared in
    a manufacturing village seven miles from Lintrathen; it attacked at
    first young and plethoric subjects, and ran through whole families. In
    August it reached Lintrathen parish, in which one practitioner had
    forty cases, with no deaths. The fever was of an inflammatory nature;
    the bulk of the cases fell in October, and were nearly all of young
    women. They were bled to syncope, which then meant usually to 32
    ounces. There was a prejudice against blooding among the old people,
    who said "they had had many fevers, and in their time no such thing
    was ever allowed." But, according to the doctor, this withholding of
    the lancet had the effect of protracting their illnesses: "they
    toasted sick for six weeks, and were often confined to bed for
    months[328]."

The epidemic of 1817-19 brought into prominence two questions, the one
theoretical, the other practical. The theoretical question (not debated at
the time) was touching the place or affinities of relapsing fever in the
nosology. Christison maintained that it was the inflammatory fever, or
_synocha_ of Cullen, showing a peculiar tendency to relapse. The fever of
the same epidemic period in England was also undoubtedly a fever of strong
or inflammatory reaction, corresponding to Cullen's definition of
_synocha_, but it relapsed much less frequently than in Ireland and
Scotland in the same years. Even in Ireland and Scotland there were always
many cases of "relapsing fever" which did not relapse. The law of its
relapses was reduced to great simplicity by a physician learned in fevers,
Dr John O'Brien, in the Dublin epidemic of 1827. The bulk of that epidemic
was a fever of short periods--three, five, seven or nine days, most of the
attacks ending on the fifth or seventh night of the fever. The attack
being ended in a free perspiration, there might or might not happen, after
an interval, a relapse, and again a relapse after that, or even a third.
The five-days' fever was more liable to relapse than the seven-days'
fever, the seven-days' fever more liable than the nine-days' fever, the
fevers of the longest periods not liable at all. In other words, the
sooner the patient "got the cool," by a night's sweating, the more liable
he was to have one or more relapses[329].

The logical position of relapsing fever was completed by Dr Seaton Reid,
of Belfast, when he proposed, in his account of the epidemic in 1846-7, to
call it Relapsing Synocha[330]. Other fevers have shown a tendency to
relapse in certain circumstances. Three fevers which have many points in
common, the sweating sickness, dengue and influenza, are all subject to
relapses. It was doubtless of the sweating sickness that Sir Thomas More
was thinking when he wrote: "Considering there is, as physicians say, and
as we also find, double the peril in the relapse that was in the first
sickness." Plague, also, might relapse, or recur in an individual once,
twice, three times, or oftener in the same epidemic season. Enteric is an
instance of a long-period fever which has at times a tendency to
relapses[331]. None of these, however, can dispute the claim of relapsing
synocha to be relapsing fever _par excellence_. For whatever reason, the
short-period fever of times of distress and dearth or famine has shown a
peculiar tendency to relapse, and has shown that tendency more in the 19th
century than in the 18th, and more among the Irish and Scotch poor than
among the English.

The practical question that came to the front in the epidemic fever of
1817-19 was that of isolation hospitals for the sick. It was thus stated
by Dr Millar, of Glasgow, in a letter of advice to the authorities of
Aberdeen:

    "It is only by a universal, or nearly universal sweep of the sick into
    Fever Hospitals, joined to a universal or nearly universal
    purification of their dwellings, that anything is to be hoped for in
    the way of suppressing our epidemic. So far as this grand object is
    concerned, all the rest is folly: it is worse than folly[332]."

This was the well-meant but somewhat fanatical application of a trite and
commonplace notion. It was well understood by reflective persons at that
time, who were quite sound on the contagiousness of fever, that the whole
question of segregating the poor in fever hospitals was beset with
difficulties, not merely of expense but also of expediency. A Select
Committee of the House of Commons sat upon it in 1818, and published their
report, with the minutes of evidence, on the 20th May. So much had been
said in Parliament by Peel and others, and said so truly, of the spreading
of fever all over Ireland by whole families turned adrift in beggary, that
the Select Committee were full of ideas of contagion, and of the great
opportunity of suppressing fever by destroying its germs or seeds. But
they had soon occasion to learn that a fever may be potentially
contagious, yet not contagious in all circumstances, and that segregation
in fever hospitals had a rival in dispersion through general hospitals.
Half-a-dozen London physicians of position, answering respectively for
Guy's, St Thomas's, the London, St Bartholomew's, St George's, the
Westminster and the Middlesex Hospitals, declared that they mixed their
cases of contagious fever in the ordinary wards among the other patients;
and when asked by the astonished Committee whether the fever did not
spread, they answered one after another with singular unanimity, "Never,"
which under cross-examination, became in one or two instances, "hardly
ever," as, for example, in the evidence for St Thomas's Hospital, where a
sister and a nurse had caught fever and died. The point of this London
evidence was that the great safeguard against febrile contagion was free
dilution with air, and that the great provocation of a contagious
principle was to "concentrate" the cases of fever[333]. The Bristol
experience in the same epidemic, although it did not come before the
Select Committee, was wholly in agreement with medical opinion in London.
The fever-cases there were received either into St Peter's Hospital, which
was the city poor-house, or into the General Infirmary. The former was an
old irregular building, badly ventilated, in which the contagion spread
freely to the ordinary inmates and became very virulent. Contrasting with
the apartments of the old poor's house, the wards of the Bristol General
Infirmary were spacious, lofty, well-ventilated:

    "Here the patients labouring under fever were dispersed among invalids
    of almost every other description; so that, whatever effluvia emanated
    from infected bodies became immediately diluted in the mass of air
    free from such pollution. Here, accordingly, no instance occurred of
    the propagation of fever. None of the nurses were attacked, nor were
    patients lying in the adjacent beds in any instance infected, though
    cases of the worst description, some of them exhibiting all the
    symptoms of typhus gravior, were placed promiscuously among the other
    patients, scarcely two feet of space intervening between the
    beds[334]."

The same practice was kept up in the Edinburgh Infirmary until 1858 or
longer; Christison, who gives a diagram of an ordinary ward with four
fever-beds in it, declared in 1850 that there had been no spread of fever
for fifteen years before, except on one occasion, when the rules of the
house were neglected[335]. The bold policy of dispersing fever-patients
among the healthy was begun by Pringle and Donald Monro during the
campaigns of 1742-48 and 1761-63 in the Netherlands and North Germany.
They found that concentration raised the contagion to high degrees of
virulence and that dispersion weakened it to the point of non-existence,
Monro's success at Paderborn in 1761 having been of the most signal
kind[336].

The Select Committee of 1818 were more influenced by what they were told
of the good effects of the earliest Houses of Recovery, at Waterford,
Manchester and other places in the end of the last century. For several
years after their opening they were little needed, the epidemic which gave
the immediate impulse to their establishment having subsided in due time
both in the towns provided with Houses of Recovery and in the innumerable
places where no such provision had been made. The recommendations of the
Committee do not appear to have been carried out; for the London Fever
Hospital, in Pancras Road, which had been enlarged to seventy beds when
the epidemic began in 1817, remained the only special fever hospital in
London until the establishment of the hospitals of the Metropolitan
Asylums Board in 1870[337].

       *       *       *       *       *

The confusion of commerce, depression of trade and lack of employment
which followed the Peace of Paris, and gave occasion to the British and
Irish epidemic fevers of 1817-19, gradually righted themselves. The price
of wheat, which would have been still higher after the four-months drought
of 1818, but for large imports, gradually fell, and was about 50_s._ in
1821, and 40_s._ in the winter of 1822-23. After that, it rose somewhat
again, and the third decade of the century, in the middle of which
occurred the great speculative crash of 1825, was on the whole a hard time
for the working classes. The history of fever has few illustrations
between the epidemic of 1817-19 and that of 1826-27, excepting the great
famine-fever of Connemara and other parts of the West of Ireland in 1822,
elsewhere described, which coincided with a somewhat prosperous time in
England and called forth a princely charity[338].


The Relapsing Fever of 1827-28.

The epidemic of relapsing fever which was at a height in Dublin in 1826,
did not culminate in Edinburgh, Glasgow, and other towns of Scotland until
1828. It was a somewhat close repetition of the epidemic of 1817-19,
except that it was chiefly an affair of the towns, owing to depression of
trade and want of work following the great crash of commercial credit in
1825-26. In Glasgow, the admissions for fever to the Royal Infirmary began
to rise in 1825[339]:

_Glasgow: Admissions for Fever._

  Year

  1824    523
  1825    897
  1826    926
  1827   1084[340]
  1828   1511[340]
  1829    865
  1830    729

At Edinburgh the cases of fever treated in hospital were fewer in ordinary
years than at Glasgow, but they rose to a higher point in the epidemic
years[341]:

_Edinburgh: Admissions for Fever._

  Year

  1824                  177
  1825                  341
  1826 (nine months)    456
  1827                 1875
  1828                 2013
  1829                  771
  1830                  346

Christison gives the following account of the epidemic in Edinburgh in
1827-28:

    "Like that of 1817-19, it arose in Edinburgh during a protracted
    period of want of work and low wages among the labouring classes and
    tradespeople; it prevailed only among the working classes and
    unemployed poor--in the Fountainbridge and West Port districts, the
    Grassmarket 'closes,' the Cowgate and the narrow 'wynds' descending on
    either side of the long sloping back of the High Street and
    Canongate." The fever had the same three types as in 1817-19--many
    cases of inflammatory, or relapsing, or synocha, a few of low fever
    (typhus), and some between the two--militant or inflammatory for a
    week, then becoming low, and running the continuous course of
    typhus.... "The inflammatory fever presented the same extreme violence
    of reaction as in the former epidemic--the same tendency to abrupt
    cessation, with profuse sweating--the same liability to return
    abruptly a few days afterwards--and the same disposition to depart
    finally in a few days more, and again abruptly with free perspiration.
    The cases of typhus were more frequently severe than in 1818-19.
    Icteric synocha occurred also oftener, although far from
    frequently[342]."

The epidemic of relapsing fever in 1826-28, which made a great impression
in the towns of Ireland and Scotland, has left few traces in specially
English records. But it is clear that there was some increase of fever
about the same time in London; and it becomes a matter of interest, as
well as of no little difficulty, to ascertain the type or types of the
same. It was just after this quasi-epidemic in London that Dr Burne
published his essay on fevers, the preface bearing the date of 28th
February, 1828[343]. The materials of this essay came from Guy's Hospital,
and they were both clinical and anatomical. The author seeks to find a
common name for all varieties of continued fever, the name that he chooses
being "Adynamic Fever." "By far the greater number of cases," he says,
"are of the first or second degree only of severity, and not dangerous."
These were cases of "simple continued fever," or fever of short duration,
with flushed face, suffused eyes and other signs of the "inflammatory"
type, or of synocha. Although Burne does not give the exact proportion of
cases with relapse, as Bateman had done for the London epidemic of
1817-18, yet he makes it clear that relapses did occur, and he discusses
the phenomenon in a manner which makes his testimony interesting:
"Convalescents are more liable to a relapse after the adynamic fever than
after any other disease; and this may be accounted for by the very
enfeebled and exhausted state in which the powers of the system are
left." His relapses were obviously a return of the original fever,
beginning again suddenly in the midst of convalescence with flushing of
the face, headache, dry tongue, and scanty urine, and with a great access
of febrile heat in the night, a disturbance of the system which generally
continued for several days, while in some it went off sooner with a
diarrhoea. He assigned three principal causes for the relapse--overloading
the enfeebled but craving stomach, walking out in the open air too soon,
and giving way to emotion[344].

The references to relapse apply almost certainly to fevers of the shorter
periods (synocha or "inflammatory" fever), and not to those cases of
enteric fever which did undoubtedly occur in the practice of Guy's
Hospital in the same seasons.


Typhoid or Enteric Fever in London, 1826.

The identification of enteric fever and relapsing fever respectively, or
the separation of each from typhus, became actual in Britain at one and
the same time. I have already said all that seems necessary as to the
earlier appearances of relapsing fever on the stage of epidemiological
history. This will be the fitting point in the chronology, the third
decade of the 19th century, to bring in the question of enteric or typhoid
fever. As to its identification, or recognition as a distinct species,
that was not really completed, to the satisfaction of everyone, until the
elaborate analysis of the symptoms respectively of typhus and enteric
fevers by Sir William Jenner in 1849-51[345]. But, for ten years before
that, the co-existence with maculated typhus of a different long-period
fever, having abdominal symptoms and abdominal lesion, had been
recognised, and the characteristic ulceration or sloughing of the
lymph-follicles of the ileum, with sphacelation of the mesenteric
lymph-glands, had been clearly described by several London physicians and
depicted in  plates, in the years 1826 and 1827, during an unusual
prevalence of such cases in London. The authentic history of enteric fever
in Britain really begins with these writings by physicians of St George's
and Guy's Hospitals. But, as it is improbable that the type of fever was
absolutely new in the years 1825 and 1826, it may be asked whether the
enteric type cannot be discovered in the old accounts of British fevers,
and if so, whether we may assume in the past as much enteric fever
relatively to spotted typhus, relapsing fever, or simple continued fever,
as in the period after 1850.

Having adverted to this point from time to time in the preceding history
as it arose, for example in connexion with Willis's fever of 1661,
Strother's fever of 1727-29, the Rouen fever of 1750, and other instances
both in children (remittent or convulsive or comatose fever of children)
and in adults, I shall not recapitulate farther back than the beginning of
the 19th century.

There was a certain amount of post-mortem observation in the 18th century,
especially in camp sicknesses, by Pringle and others; but there is no
trace of intestinal ulceration among their fatal fevers. It was found,
however, in the epidemic of 1806 among the troops at Deal, and it is
probable that Ferriar's cases at Manchester about 1804, and Bateman's
cases of continued fever in London from 1804 to 1816, were in some part
enteric, although the anatomical test is wanting. That was a period when
there was singularly little of the old London fever in the houses of the
poorer class. Then came the remarkable "constitution" of relapsing or
simple continued fever, from about 1816 to 1828, the relapsing character
of which was far more obvious in Ireland and Scotland, than in London,
Bristol, or elsewhere in England, but was not altogether unobserved in
London, whether in 1817-19 or in 1827-28. The relapsing type disappeared
after that for fifteen or twenty years, and was replaced by typhus more
maculated than had been seen for many years. But, before the relapsing or
simple continued fever disappeared for a time, enteric fever was seen in
London in company with it.

The chief season of enteric fever in London was the autumn of 1826,
following a long period of great drought and heat. The remarkable weather
of that season was the same in England, Ireland and Scotland, and is thus
described for the last by Christison:

    "The spring and summer seasons of that year were remarkable for the
    extraordinary drought and heat which prevailed for many continuous
    months. No such seasons could be recollected by anybody, and assuredly
    there has been nothing similar in this country since.... The fine
    weather set in with the beginning of March, and continued, with
    scarcely a check, well into the autumn.... The drought prevailed and
    the heat increased till the middle of June, when a thunderstorm with
    heavy rain cooled the air for a day or two. But the heat then became
    greater than ever, and there was continuous sunshine and no rain till
    after the middle of July, when again there was thunder and rain, after
    which sun, heat and drought ruled the season once more." The shade
    temperature at Edinburgh was 84 deg. Fahr., at 3 p.m. on three
    successive days of July[346]. The two summers preceding had also been
    exceptional, that of 1824 having been hot and moist, that of 1825 hot
    and dry, with dysentery in Dublin.

In August, 1826, Dr Cornwallis Hewett, of St George's Hospital, published
ten fatal cases of enteric fever, four of which had occurred in his own
practice, six in the practice of his colleagues[347]. The first was
admitted on 23 April, 1825, the latest on 3 July, 1826. While his paper
was under hand, he had read in the _Medico-chirurgical Review_ for July,
1826, some extracts from Bretonneau's paper on "Dothienenterite" (enteric
fever), and he pronounced the London cases to be the same as those
recently observed at Tours. Several other cases occurred at St George's
Hospital in the autumn of 1826, three of them reported by Dr
Chambers[348]. At the very same time, there was a run of enteric cases at
Guy's Hospital. Dr Bright says: "Fever occurred with considerable
frequency among the patients who presented themselves for admission into
Guy's Hospital, during the months of October, November and December, 1826.
On the whole, the disease was not severe." The more comprehensive account
of these cases was given by Burne, early in 1828, from which it appears
that the bulk of them were fevers of the shorter period, that there were
relapsing cases among them, and that some were cases of enteric fever,
verified by post-mortem examination[349]. It was the enteric cases that
attracted the notice of Dr Bright, who says nothing of the relapsing
cases, or of cases of simple continued fever. The fact that the intestinal
mucous membrane may become diseased during fever was, he says, "long known
in particular cases, but never suspected to be so general till brought
into view by the French physicians, and which has lately been illustrated
in this country with great beauty [this does not mean in plates] by the
pens of my able and assiduous friends Dr Chambers and Dr Hewett." He gives
ten fatal cases, with  plates of the intestinal or mesenteric
lesion in some of them, the earliest  plate having been made from
a case admitted on 13 October, 1825, and the most typical plate of the
sloughing Peyer's follicles from a case admitted on 25 November, 1826. He
gives also eleven cases of recovery, to show the benefit of treating the
diarrhoea by calomel[350]. Nearly all the cases occurred in the end of the
year, either of 1825 or 1826; and Burne confirms this when he says that
the cases with enteric lesion were found at Guy's Hospital only in autumn.
Some two years after, in 1830, Drs Tweedie and Southwood Smith, physicians
to the London Fever Hospital, described cases of fever with ulcerated
intestine and sphacelated mesenteric glands. After that, the interest
shifted to typhus, which reappeared in London of an unusually maculated
type; so that the years 1826-30 make a somewhat distinct period in which
the new fever, with enteric lesion, was an engrossing medical topic. It is
tolerably certain that it was the unusual seasons of 1825 and 1826 which
brought enteric fever into prominence; while, as soon as it became
frequent, it could hardly have escaped the systematic apparatus of
clinical case-taking and post-mortem examination, with preservation and
drawing of specimens, for which Guy's Hospital was already noted under the
influence of Bright and his colleagues, and in which the staff of St
George's Hospital would appear to have been not less competent. Although
Dr Hewett, in 1826, identified his cases with the _dothienenterite_ of
Bretonneau, yet neither he nor Dr Bright took the abdominal ulcerations or
sloughs as distinctive of a new kind of fever. They regarded them rather
as a new complication of "idiopathic" typhus fever, a "complication" which
appealed to them more on the side of treatment than of systematic
nosology; hence the writings of both physicians are occupied mainly with
the benefit of calomel in relieving the congestion of the bowels and in
checking the diarrhoea.

It is undoubted that cases of enteric fever in 1826-27 were relatively
more numerous in London than in Dublin and Edinburgh, where the epidemic
fever was almost wholly of the relapsing type. In Edinburgh, at least, the
comparative infrequency of enteric fever for years after it had been
recognized in Paris, Tours and other French cities, and had been found in
London as a common autumnal type, can be proved beyond cavil. Writing long
after of the first epidemic of relapsing fever in Edinburgh, Christison
said:

    "Of enteric typhus (typhoid fever) we saw nothing then [1817-20], nor
    for many years afterwards. If it might have been overlooked during
    life, it could not have been missed after death. For our dissections
    were many, and, to meet the bias of the day for finding a local
    anatomical cause for all fevers [the doctrine of Broussais], every
    important organ in the body was habitually looked to. Nevertheless we
    were constantly met with the want of morbid appearances anywhere,
    unless slight signs of vascular congestion in various membranous
    textures be considered such[351]."

These vascular congestions were, indeed, scanned closely for traces of
ulceration, after Bright's plates of 1828, and any little irregularity on
the surface of a congested Peyer's patch was liberally construed in that
sense, as in Craigie's reports subsequently. But in the Edinburgh epidemic
of 1827-29, the anatomical signs of enteric fever were wanting until the
end of it. Writing in 1827, Alison said that he had dissected 26 cases
dead of the epidemic fever, without finding intestinal ulceration in one
of them. Christison, however, says that a very few cases of enteric fever
were dissected in Edinburgh in 1829[352].

In Dublin, also, the anatomical mark of enteric fever was missed in
1826-27, in the few dissections that were made during the epidemic[353].
An opinion in a widely different sense was given on that point by Stokes
twelve years after the event, to which I refer in a note[354].


Return of Spotted Typhus after 1831: "Change of Type." Distress of the
Working Class.

A fever with relapses, and a fever with sloughing of the follicles and
lymph glands of the intestine, were not the only novelties in the first
thirty or forty years of the 19th century. Relapsing fever and enteric or
typhoid fever were each clearly separated, at a later date, from typhus
fever. But what was the "typhus fever" from which they were at length
separated? It was a fever which came prominently into notice after the
"constitution" of 1826-29 was ended--a fever with a mottled, measly, or
rubeoloid rash, and with various other spots, on account of which it was
described by Dr Roupell in 1831, in a lecture before the College of
Physicians of London, as a "new fever[355]." It was a new fever only in
the sense in which each new febrile "constitution," whether it were an
influenza, an epidemic ague, or a malignant typhus, was apt to be called
popularly "the new fever," in the 16th and 17th centuries. There were, of
course, erudite men at the College of Physicians in 1831 who knew that a
fever with a mottled rash, with vibices and petechiae, and with all other
symptoms of typhus gravior, had often occurred in England, Scotland and
Ireland in former times. The "spotted fever" was perhaps the most familiar
name of typhus in the 17th century. The mottled rash, like that of
measles, was described for the fever of Cork by Rogers in the beginning of
the 18th century, and for various other English and Irish epidemics by
Huxham, O'Connell, Rutty and others. But undoubtedly the maculated typhus
was somewhat new to the generation who saw it about 1830 and following
years, the continued fevers which had prevailed in England, Scotland and
Ireland since 1816 having been for the most part the simple continued, or
synocha, with or without the relapsing character, and to some extent
enteric fever[356].

It was from 1830 to 1834 that a change in the reigning type of fever began
to be remarked in London, Dublin, Edinburgh and Glasgow, the new type
becoming more and more evident as fevers became more prevalent in the
'thirties' and 'forties.' Typhus at length became so much a spotted fever
that the question arose whether it should not be classed among the
exanthemata. In 1840, Dr Charles West, having observed "the alteration in
character which fever has undergone within the last few years," went over
the history (but more the foreign than the English) with a view "to
illustrate the question whether typhus ought not to be classed among the
exanthematous fevers[357]:" of course he found many old descriptions of a
mottled rash or other spots, but saw no reason to make spotted typhus one
of the exanthemata. Dr Kilgour, of Aberdeen, who treated more than a
thousand cases in his fever-ward at the infirmary there from 1838 to 1840,
wrote in 1841, "I am perfectly satisfied that this fever, call it by what
name we will, is truly an exanthematous fever[358]." Previous to 1835, the
spots of fever-cases in the Glasgow Infirmary had hardly been remarked;
but after that date all cases were classed either as spotted or not, the
spotted cases being three-fourths of the whole. Besides being spotted, the
fever of the new constitution was insidious in its approach and low in its
reaction, very unlike the sthenic, militant, inflammatory synocha of the
generation before. The blood-letting which had been all but universally
used in the fever from 1816 to 1828, and had seemed to answer well, was
continued for a time in the fever of the 'thirties.' But it was soon found
to be injurious: the patients in the new fever were apt to faint when only
a few ounces of blood (four or six) had been drawn, whereas in the other
fever (whether relapsing or simple continued) they had often lost thirty
ounces before deliquium was reached. It was found, on the other hand, that
fever-cases in the 'thirties' needed wine and other cordial regimen. There
was nothing new in these revolutions, whether of the fevers themselves, or
of the opinions as to their treatment. Sydenham's method of taking his cue
for treatment from the "constitution" of the season, which was the method
of Hippocrates, appeared to be once more the best suited to the
circumstances.

It is not easy to make out what were the circumstances of the time that
led to the supersession of simple continued fever (or relapsing fever in
Ireland and Scotland), by spotted fever or typhus gravior in all parts of
the kingdom. Sydenham would have looked, among other things, to the
weather and the character of seasons; but from 1830 onwards there was no
season so notable as the dry and hot summer of 1826, although the end of
the year 1836 was remarkably wet. The period of typhus gravior was a time
of much sickness of other kinds--the Asiatic cholera of 1831-32, the
influenza of 1831, 1833, and 1836-37, and the general unhealthiness of the
year 1837. This was also the decade when the "condition-of-England
question" was a common topic, a time of strikes and of much distress among
the working classes, as shown in the reports of the Poor Law Commission.

In Glasgow there was a considerable prevalence of fevers year after year
from the relapsing-fever epidemic of 1827-29, according to the following
table of admissions for fever to the Royal Infirmary and the special
fever-hospitals[359]:

_Admissions for Fever, Glasgow._

  Year   Fever cases

  1827    1084
  1828    1511
  1829     865
  1830     729
  1831    1657
  1832   {1589
         {1148[360]
  1833    1288
  1834    2003
  1835    1359
  1836    3125
  1837    5387[361]
  1838    2047
  1839    1529

The worst year of the series for fever was 1837, and the worst month of
that year was May, when the fever-deaths were 1 in 3.22 of the mortality
from all causes. That great access of fever in Glasgow followed
immediately upon the great strike of the cotton-spinners, on 8th April,
1837, by which eight thousand persons, mostly women, were thrown out of
work[362]. The death-rate in Glasgow was in those years as high as
anywhere in the kingdom, and was higher in the nine years from 1831 than
in the nine years preceding. The population of Glasgow, says Cowan, had
increased on the industrial side, out of proportion to its middle and
wealthiest class[363]; and to that he would attribute the higher
death-rates in the second period (right-hand side), of the following
table:

_Glasgow Death-rates._

              1822-1830         |             1831-1839
                                |
         Death-rate  Death-rate |       Death-rate  Death-rate
         over all.   under five.|       over all.   under five.
  Year    One in      One in    | Year   One in      One in
  1822     44.4        101      | 1831    33.8         79
  1823     36.4         78      | 1832    21.67        63
  1824     37.0         81      | 1833    35.7         77
  1825     36.3         81      | 1834    36.3         81
  1826     40.6        105      | 1835    32.6         67
  1827     37.0         84      | 1836    28.9         62
  1828     33.0         79      | 1837    24.6         65
  1829     37.9        100      | 1838    37.9         83
  1830     41.5         97      | 1839    36.1         72

The high death-rates in some of the years in the second column were owing
to special causes--Asiatic cholera in 1832, smallpox of children in 1835
and 1836, and to influenza, as well as to typhus, in 1831, 1833 and 1837.
As to the fever which prevailed from 1831 to 1836, as it was not relapsing
in type, so it was not associated with scarcity.

    "The increase of fever in Glasgow," says Cowan, "during the seven
    years prior to 1837, had taken place, not in years of famine or
    distress, but during a period of unexampled prosperity, when every
    individual able and willing to work was secure of steady and
    remunerating employment. From the close of 1836, one of those
    periodical depressions in trade, arising from the state of our
    monetary system, had visited this city, and deprived a large
    proportion of the population of the means of subsistence[364]."

It was then that the cases of typhus trebled in number.

The epidemic of fever reached its height in Dundee about the same time as
in Glasgow, and in both towns sooner than anywhere else in Scotland or
England. One reason of this was the labour-troubles culminating in
strikes. In the twelvemonth from 15 June, 1836, to 12 June, 1837, more
than three-fourths of all the admissions to the Dundee Infirmary on the
medical side were for fever (700 cases). After the wet autumn of 1836
there were a good many cases of dysentery, of which 22 were treated in the
infirmary, with two deaths[365].

At Edinburgh, as at Glasgow, there had been an unusual amount of fever in
1831 and 1832, and a steady prevalence of it thereafter. The epidemic of
1836-39 was for the most part typhus of the winter seasons, declining each
spring and disappearing each summer, except in the summer of 1836, when
many cases came in June, July and August from airy parts of the town[366].
The climax of the epidemic was in 1838, a year later than in Glasgow and
Dundee, according to the admissions to the fever-wards of the
infirmary[367]:

_Admissions for Fever, Edinburgh Infirmary._

  Year    Cases

  1831     758
  1832    1394
  1833     878
  1834     690
  1835     826
  1836     652
  1837    1224
  1838    2244
  1839    1235
  1840     782

At Aberdeen the epidemic appears to have been later even than at
Edinburgh, if the following admissions to one of the two fever-wards (Dr
Kilgour's) may be taken as a fair measure of it[368]:


_Admissions for Fever, Aberdeen._

  Year                        Cases   Deaths

  1838 (March to December)     189      26
  1839                         286      29
  1840                         534      53

In all these large towns of Scotland, the fever was purely typhus. The
various observers all describe the fever as of the spotted kind, the
proportion of cases with spots varying somewhat.

    Thus, at Glasgow Infirmary, from 1835 to 1839, there were 4202 cases
    with eruption, 1270 without eruption, and 143 doubtful. And, that the
    cases without eruption were not cases of enteric or typhoid, is
    probable from the record kept of the fatalities in Dr Anderson's
    fever-wards[369]:

        In 1885 cases with eruption,   275 deaths, or 14.58 per cent.
         "  324 cases without eruption, 11 deaths, or  3.33 per cent.
         "  143 cases doubtful,          7 deaths, or  4.89 per cent.

    At Aberdeen, Kilgour counted 59 cases spotted in a total of 189 in
    1838, 96 in a total of 286 in 1839, and 278 in a total of 534 in 1840,
    all the cases, whether spotted or not, being of the same fever, which
    he considered an exanthematous malady as a whole. Of 169 cases
    tabulated by Craigie at Edinburgh, from 28 June, 1836, to 12 February,
    1837, there were 79 with an eruption, which was usually the mottled or
    rubeoloid rash.

The fatalities were relatively more in Edinburgh than in Dundee, comparing
two periods which were not the same. Of 700 cases at Dundee, from June,
1836, to June, 1837, only 50 died, or 1 in 14, notwithstanding a good many
complications from chest complaints and bowel complaints[370]. At
Edinburgh during fifteen months of 1838-39, there died 276 in 2037 cases,
or 1 in 7.3; of those cases, 1075 were in females, with 116 deaths, or 1
in 9, and 962 males, with 160 deaths, or 1 in 6[371]. The most common age
for the fever at Dundee was from twenty to forty years (416 out of 700
cases, with 26 deaths, or 1 in 16), while the most fatal age, as usual,
was from forty to sixty years, at which one person died of three attacked.
At Aberdeen, in the last year of the epidemic, the years of life from ten
to twenty had more cases (233 in a total of 657) than any other decade of
life. The average stay of a patient in the Aberdeen fever-wards was 18.67
days. The great preponderance of deaths in adolescents or adults was
clearly shown in the Glasgow fever-statistics, 1835-39.

                                       Fever-deaths per cent.
  Deaths from      Under        Over     of deaths from
  typhus fever   ten years   ten years      all causes

     4788           752         4036          11.57

The corresponding epidemic of typhus in England had the fortune to be
recorded in great part under the new system of Registration, which came
into force on the 1st of July, 1837. At the beginning of registration of
the causes of death, and until a good many years after, no distinction was
made in the published tables between typhus fever and enteric fever. But
we happen to know that the epidemic of 1837-38 was in London almost
wholly typhus, just as it was in the large towns of Scotland. Of sixty
cases in 1837-38, of which notes were kept by West, under Latham at St
Bartholomew's Hospital, none that died and were examined post-mortem had
ulcerations, although some had congestion, of Peyer's patches, the cases
being all reckoned typhus exanthematicus[372]. Sir Thomas Watson, who was
then physician to the Middlesex Hospital, says of the ulceration of
Peyer's patches in continued fever:

    "Since attention has been drawn to the subject, the patches of glands,
    and the whole tract of mucous membrane, from the stomach to the
    rectum, have been diligently explored, and the result seems to be
    that, at certain times and places (in other words, in certain
    epidemics), the ulceration of the inner surface of the intestine is
    far less common than at others. It was comparatively rare in an
    epidemic of which I witnessed some part in Edinburgh [1827-29]. Then I
    came to London; and for several years I never saw a body opened after
    death by continued fever without finding ulcers of the bowels. More
    recently, however, and especially during the present epidemic (1838),
    I have looked for them carefully, in many cases that have proved fatal
    in the Middlesex Hospital, and have discovered neither ulceration nor
    any other apparent change in the follicles of the intestines." And
    elsewhere he confirms the purely typhus character of the epidemic of
    1838: "Our wards at the Middlesex are full of it, and scarcely a case
    presents itself without these spots. We speak of it familiarly as the
    _spotted_ fever; or, from the resemblance which the rash bears to that
    of measles, as the _rubeoloid_ fever[373]."

From which it would appear that not even the ordinary average number of
endemic cases of enteric fever, such as might have been expected at a
hospital in the west end of London, were forthcoming in the epidemic of
1837-38, so purely was the type of fever typhus.

The deaths from this epidemic in London, from the 1st of July, 1837, to
the 31st of December, 1838, were as follows[374]:

        1837                           1838
    3rd      4th          1st      2nd      3rd      4th
  Quarter  Quarter      Quarter  Quarter  Quarter  Quarter

    826     1107         1285     1176      829      788

--a total of 6011 deaths from fever, nearly all typhus, in eighteen
months. The worst London parishes were Whitechapel and St Pancras, in
which latter the fever-hospital was situated. The high mortality from
fever, which had begun before the 1st of July, 1837, continued into the
year 1839, when the deaths in London (probably including some enteric)
were 1819.

Over all England and Wales, including London, the last six months of 1837
produced 9047 deaths from "typhus," and the twelve months of 1838, 18,775
deaths, the winter of 1837-38 having been the most fatal period. After
London, the large towns most affected by the epidemic in the latter half
of 1837 were as follows:

               Deaths from
                typhus in
               six months

  Liverpool       524
  Manchester }
  and Salford}    274
  Birmingham       75
  Bolton           75
  Sunderland       72
  Leeds            71
  Sheffield        68
  Bradford         65
  Stockport        63
  Dudley           54
  Abergavenny      53
  Wolverhampton    45
  Newcastle        44
  Wigan            43
  Chorley          41
  Swansea          36
  Halifax          33
  Macclesfield     33
  Norwich          27

In each of the next two years the number of deaths from typhus in the four
largest towns was as follows:

                  Typhus      Typhus
                  deaths      deaths
                 in 1838     in 1839

  Manchester}
  and Salford}     627         416
  Liverpool        573         358
  Leeds            245         150
  Birmingham       123         141

From nearly all the registration districts of England and Wales, deaths
from fever were returned in 1837-39, so that the contagion must have been
very widely spread in town and country[375]. In London the epidemic
declined greatly in 1839, but in many parts of England the deaths
registered as "typhus" were hardly less numerous than in 1838, and in some
country divisions they were more, as if the contagion had taken longer to
reach the villages[376]. One village epidemic in North Devon in the latter
half of the year 1839 had been observed by Dr W. Budd, afterwards of
Bristol:

    The first case in the village (North Tawton, 1100 to 1200 inhabitants)
    was of a young woman in a poor and crowded cottage, who sickened on 11
    July, 1839; her mother, brother, and sister sickened in succession,
    her father and a young infant escaping the infection. In another
    cottage, four out of six were ill of fever, in another, three persons
    had it, and so on, the whole number of cases treated by Dr Budd in the
    village until the beginning of November being about eighty. It was
    carried from North Tawton to neighbouring hamlets: thus, a sawyer who
    lodged next door to the first infected cottage sickened of the fever
    and, on 2 August, returned to his home in the hamlet of Morchard. As
    he lay there, he was visited by a friend, who assisted to raise him in
    bed: "While thus employed, the friend was quite overpowered by the
    smell from the sick man's body," and on the tenth day thereafter
    sickened of fever, which spread to two of his children and to a
    brother who came from a distance to see him. Another sawyer who lodged
    with the former left North Tawton ill a week after him (9 August) for
    his home, also at Morchard, where he died after a period not stated;
    ten days after his death his two children took the fever, his widow
    escaping it. In a third instance, a widow L---- left North Tawton on
    21 August to visit her brother, a farmer in the hamlet of Chaffcombe,
    seven miles distant. Two days after her arrival she fell ill of fever
    and recovered slowly. In the same farmhouse the mistress caught it a
    month or two later and died on 4 November; the farmer himself took to
    bed with the fever on the day his wife died, and came safe through the
    attack. Three weeks after, an apprentice on the farm sickened, then a
    lad (the fifth in order) in the end of December, then the farmer's
    sister, then another apprentice, then a serving-man, then a
    maidservant, and lastly the daughter of the widow L---- from North
    Tawton, who had been the first case in the house months before. This
    farmhouse at Chaffcombe sent off two distinct offshoots of contagion.
    The lad, who was fifth in the above series, was sent home ill to his
    mother's cottage, between Bow and North Tawton, in the end of
    December. His mother sickened on 24 January, 1840, and died on 2
    February. Next door to her lived a married daughter, whose whole
    household were attacked. Another married daughter, who came from a
    distance to visit the sick, took the infection on her return home, and
    so started a new focus. From the same farm at Chaffcombe, the maid,
    who was ninth in order in the above series, was sent home to her
    father's cottage in the hamlet of Loosebeare, four miles away; her
    father caught the fever from her, and a farmer K----, who lived across
    the road, having visited this man several times in his illness, took
    the fever next, other cases following under farmer K's. roof, and
    thereafter throughout the whole hamlet of Loosebeare[377].

This was doubtless the way the epidemic spread in all the country
districts of England, the unwholesome state of labourers' cottages, as
revealed in the reports of the Poor Law Commission, favouring it. In the
chapter on the fevers of Ireland we shall find that the contagion of
typhus and relapsing fever was dispersed in the same way, but to a much
greater extent, owing to the amount of vagrancy.

In the manufacturing towns of the North of England the fever continued at
a somewhat steady epidemic level for several years. The pathetic scenes of
typhus among the poor of Manchester in Mrs Gaskell's famous tale of _Mary
Barton_ belong to the early part of the year 1839; but they might have
been drawn from almost any months of the two or three years following,
according to the passage cited below from the same work[378]. In 1839 the
Lancashire deaths from typhus were 1343; in Wales, Monmouth and
Herefordshire they were 1548. There is, indeed, little improvement in the
statistical returns as late as 1842. The deaths from "typhus" were as
follows in all England and Wales:

         1838    1839    1840    1841    1842
        18,775  15,666  17,177  14,846  16,201

    The deaths from the epidemic maladies of infants and children during
    the same five years were also very high.

                       1838       1839     1840     1841     1842

        Smallpox      16,268     9,131    10,434    6,368    2,715
        Measles        6,514    10,937     9,326    6,894    8,742
        Hooping cough  9,107     8,165     6,132    8,099    8,091
        Scarlatina     5,802    10,325    19,816   14,161   12,807
        Croup          4,463     4,192     4,336    4,177    4,457
        Diarrhoea      2,482     2,562     3,469    3,240    5,241

    The epidemic of smallpox corresponded closely to the epidemic of
    fever, the former being fatal chiefly to infants and young children,
    the latter fatal chiefly to adults. Before the smallpox epidemic had
    subsided scarlet fever became unusually mortal, especially in 1840,
    and kept its higher level of deaths for a generation after. The
    epidemic of fever, although it affected the mortality of the young
    comparatively little, was indirectly a reason why many of them died of
    other diseases; for the prostration of the parents, the
    impoverishment, and all the other troubles associated with an epidemic
    of typhus, led to inevitable sufferings among the young, which
    weakened their power of resistance.

The registration returns were not tabulated (except for London) from the
end of 1842 to the beginning of 1847, but there is reason to think that
the epidemic fever was not active in the interval. It is undoubted that
the enormous construction of railroads in England during those years gave
employment and wages to multitudes, and ended the distress the sooner.
This effect of railroad-making in England was so obvious that Lord George
Bentinck desired to relieve the distress in Ireland in 1846-47 by the same
means.


Enteric Fever mixed with the prevailing Typhus, 1831-42.

While there is complete agreement among the hospital physicians of the
great towns that the fever of 1837-39 was maculated typhus, to the total
exclusion of cases with ulceration of the bowel, as in the experience of
Watson at the Middlesex Hospital and of West (under Latham) at St
Bartholomew's, yet some allowance should be made, in interpreting the
figures of fever mortality in those years throughout England and Wales,
for admixture of enteric fever. Budd's statement that the only case which
was dissected in the epidemic at North Tawton, Devonshire, in 1839, had
the bowel-lesion of enteric fever, if it is to count in the absence of the
usual details (place, date, objective description), would mean that at
least one case there was not of the prevailing type of contagious epidemic
typhus. The coincidence of some such cases is made the more probable by
the evidence from Anstruther, Fifeshire, reported by John Goodsir,
afterwards Professor of Anatomy at Edinburgh, who was assisting his father
in practice there from 1835 to 1839. During that period, which was the
time of the typhus epidemic in the larger towns of Scotland, he attended
about one hundred cases of fever annually in Anstruther and the
neighbourhood; the fever was usually mild, only some sixteen of the cases
having proved fatal; of those sixteen he examined ten after death, finding
"ulceration" of the Peyer's patches in all, and perforation of the
intestine in four of them. These facts he gave orally to Dr John Reid,
pathologist to the Edinburgh Infirmary, whose experience of the morbid
anatomy of fever was altogether different. Goodsir, having kept the
specimens, made them the subject of a paper some years after (1842), in
which he described very minutely the stages and degrees of congestion,
ulceration, sloughing and perforation in the lymph-follicles of the
intestine in fever, placing congestions at one end of the scale and
sloughing at the other, as the French pathologists then did[379]. Reid
examined, at the Edinburgh Infirmary from October, 1838, to June, 1839,
forty-one bodies dead of fever, to see whether the intestinal lesion,
which Goodsir had told him of, occurred in them. The distinctness of the
Peyer's patches varied a good deal (differences which are known to be in
part congenital and in part to depend on age), and in only two instances
were they elevated and seemingly "ulcerated."

    One of these was the case of an Irishman, from Sligo, aged 25, who had
    been so constipated that he was purged with colocynth, etc.: "at the
    lower part of the ileum, the elliptical patches were irregular on the
    surface, and presented several superficial and ill-defined depressions
    (ulcerations)." The other was the case of a girl, aged 15, who had not
    suffered from diarrhoea, but had the intestinal patches elevated and
    superficially "ulcerated[380]." Neither of these cases would probably
    be reckoned typhoid or enteric fever at the present time on the
    anatomical evidence only. The early French observers, Chomel, Louis,
    Andral and others, included in a scale all the appearances of the
    Peyer's patches in fever that they thought morbid, from mere
    prominence of the lymphatic tissue and distinctness of the follicular
    pits, up to extensive sloughing and ulceration of the same, as if they
    were all the signs of one and the same fever in its various stages of
    development. But simple prominence or congestion of Peyer's patches
    may occur in typhus fever, or in relapsing fever; nor would a slight
    erosion, or "superficial ulceration" raise in all cases a suspicion of
    enteric fever.

The observations of Home, Reid's predecessor as pathologist to the
Edinburgh Infirmary, from 1833 to 1837, were however conclusive that true
enteric fever had occurred now and again during the steady prevalence of
typhus fever from year to year. In that space he made 101 post-mortem
examinations in fever-cases; in 29 the Peyer's patches were distinct, in 7
of those 29 there was "a greater or less degree of ulceration," and in 2
of those 7 there was perforation[381]. Murchison examined the post-mortem
register of the Edinburgh Infirmary for the years 1833 to 1838, and found
only fifteen cases of fever with ulceration of the bowel. But in the eight
months from 1 November, 1846, to June, 1847, there were nineteen
dissections with the characteristic lesion of typhoid, the season having
been remarkable everywhere for that disease.

In the following series of years the fatal cases of fever in the Edinburgh
Infirmary with ulceration were few[382]:

  Year    Enteric deaths

  1854          5
  1855          2
  1856          1
  1857          8
  1858          1
  1859          2
  1860          1
  1861          6

It was thought remarkable that the form of continued fever which was most
usually found in the great continental cities, in Paris, Berlin, Prague
and Vienna, namely that with ulceration of the lymph-follicles of the
intestine, should be but occasionally mixed with the old typhus in
England, Ireland and Scotland in the very same years. But there was
nothing to discredit the British observations, anatomical and clinical;
and in 1836 Dr Lombard, of Geneva, having visited various cities in
England, Scotland and Ireland bore witness to the matter of fact, strange
as it was to him. Writing to Graves, of Dublin, on 16 June, 1836, he said:
"Before I leave Ireland, allow me to express to you my great astonishment
at what I have seen in this country respecting your continued fever;" and
in a second letter, of 18 July, after his return to Geneva, he added, that
in Liverpool, ulceration of the ileum in continued fever was "occasional,"
that in Manchester he had been told it occurred "by no means always," that
in Birmingham the cases of fever were not many, but "always" with
intestinal ulceration, and that in London "not a fourth part" of the cases
of fever had the latter condition, and these mostly in autumn[383]. This
was before the great epidemic of typhus had begun in the English towns. To
the same non-epidemic period (1834) belongs the statement of Carrick, for
Bristol, that fever was often observed to be infrequent or altogether
absent in the most crowded and dirty parts of the city at times when there
were a good many cases "in institutions and dwellings where cleanliness
and free air are most carefully attended to," and that ulceration of the
bowel was the most common post-mortem appearance[384].

The comparative rarity of enteric fever in the chief towns of Scotland and
Ireland continued for a good many years longer, indeed until after the
differences between typhus and typhoid were perceived and admitted by all.
Even at the London Fever Hospital, during twenty-four years (1848-71)
after Sir William Jenner's diagnostic points were strictly looked to in
its wards, much the greater part of the admissions were of typhus; in only
two periods, 1850-55 and 1858-61, during both of which there was
comparatively little fever of any kind in London, did the admissions for
enteric fever slightly exceed those for typhus; on an annual average of
the twenty-four years ending 1871, the cases of the former were only about
a fifth part of the whole. The cases of enteric fever increased decidedly
after 1865. Murchison thought that the increase might be accounted for in
part by the enlargement of the Fever Hospital, and by the unusually high
temperature of certain years, the summers and autumns of 1865, 1866, 1868
and 1870 having been remarkable for their great heat and prolonged
drought; but, he adds, "it is not a little remarkable that this increased
prevalence of enteric fever in the metropolis has been contemporaneous
with the completion of the main drainage scheme[385]."

Still more recently, the relative proportions of typhus and enteric fever
have been reversed, so that there have been years with little or no typhus
but with a good deal of enteric fever. There are some persons,
unacquainted with the history, who cannot imagine that it was ever
otherwise than now, who think of the former times of medicine, not as
differing in social, economic, and various other respects from their own,
but only as being less clever at diagnosis. There are others who realize
clearly enough the historical matter of fact, but find it necessary to
explain the almost contemporaneous decline of typhus and rise of typhoid
by some hypothesis of the latter being "evolved" out of the former. This
evolutional doctrine makes the mistake of ascribing to the species of
disease the same comparative fixity of characters that belongs to the
species of animals and plants. Beside the latter, the species of disease
are the creatures of a day. In the nosological field, the origin of
species is not analogous to the evolution of a new species of animal or
plant out of an old, as in the hypothesis of Darwin, for the reason that
every species of disease is evolved directly and, as it were, _pro re
nata_, out of a few simple conditions of human life, variously mixed but
always there to give occasion to one infective malady or another, which
may have a shorter existence, like sweating sickness, or a longer, like
plague. Edinburgh experiences offer a ready criticism of the evolutional
doctrine. Typhus declined, and typhoid rose; but it was in the old
tenement houses of the Canongate, Cowgate, Grassmarket, and High Street
that typhus declined, and it was mostly in the new streets across the
valley, or in the New Town of Edinburgh, that enteric fever arose, having
sometimes no more mysterious an origin than the results of defective or
cheap plumber-work, for example, the leakage of a soil-pipe fermenting, a
foot deep, beneath the basement floor. But it was not until a good many
years after that these new experiences became common; and meanwhile
Edinburgh and other towns in Scotland saw much of typhus and relapsing
fever.


Relapsing Fever in Scotland, 1842-44.

The epidemic of 1836-39 had been typhus of a specially maculated kind. The
period or "constitution" of synocha, rising twice to epidemics of
relapsing fever, had lasted from near the beginning of the century until
1828 or 1829. Then came the new constitution of low, depressed, spotted
fever, which would not stand blood-letting. But in 1842-44 relapsing fever
reappeared in Scotland. This reappearance was a blow to two doctrines of
the time--first that Ireland was the original breeding-place of all such
fevers, and secondly, that a return of the "constitution" of relapsing
fever would warrant a return to the practice of blood-letting, which had
fallen into disuse during the epidemic of typhus. The epidemic of 1842-44
was at first purely a Scots affair, with some extension to England, but
none to Ireland. As to blood-letting, once it had been given over in
fevers it was not readily taken up again, notwithstanding the theory that
relapsing fever belonged to those sthenic or inflammatory types of
sickness in which the lancet was still thought admissible. Moreover,
Christison, who remembered the relapsing synocha of 1817-19 and of
1827-28, said of the third epidemic: "The synocha of 1843-44, though so
prevalent, by no means presented the same strong phlogistic or sthenic
character as in the earlier epidemics of 1817-20 and 1826-29. The pulse
was neither so frequent nor so strong; the heat was not so pungent; the
glow of the integuments was less lively and less general[386]."

I take conveniently from Murchison the following succinct account of the
Scots relapsing fever of 1842-44[387]:

    "The next epidemic of fever in 1843 differed from those that preceded
    it, inasmuch as it did not originate in or implicate Ireland, but was
    mainly confined to Scotland. There was no increase of fever in the
    Irish hospitals during this year, whereas the number of admissions
    into the Glasgow Infirmary rose from 1,194 to 3,467; in the Edinburgh
    Infirmary from 842 to 2,080; and in the Aberdeen Infirmary from 282 to
    1,280. These numbers, too, are far from representing the true extent
    of the epidemic, for thousands of sick were sent from the hospital
    doors. The fever was almost exclusively relapsing fever; typhus was
    comparatively rare. The first cases were observed on the east coast of
    Fife, in 1841-2 (by H. Goodsir), and not in the crowded localities of
    large towns. In Dundee, where the proportion of typhus cases was
    comparatively great, the fever appeared early in the summer of 1842,
    and raged to a considerable extent during the whole of the autumn,
    before it showed itself elsewhere. In Glasgow the first cases occurred
    in September, 1842; but the fever was not generally prevalent until
    December, from which month the cases rapidly increased until October,
    1843, when the epidemic began to decline. The number of cases in
    Glasgow was estimated at 33,000, or 11-1/2 per cent. of the entire
    population. In Edinburgh relapsing fever was first observed in
    February, 1843. It rapidly spread until October, after which it
    gradually abated, until, by the following April, it had well nigh
    disappeared. In the month of October, 1843, the number of fever cases
    admitted into the Edinburgh Infirmary amounted to 638, and during
    several months, from thirty to fifty cases were daily refused
    admission. The total number of cases in Edinburgh was calculated by
    Alison at 9,000. In Aberdeen the epidemic commenced about the same
    time, and followed the same course as in Edinburgh. At Leith,
    curiously enough, it did not appear until September, 1843; it then
    spread rapidly for two months, after which it declined, and by the end
    of February, 1844, it had almost ceased; but during this brief period
    it attacked 1,800 persons, or one in every fourteen of the population.
    The disease was general over Scotland, and was not restricted to the
    large towns; it prevailed in Greenock, Paisley, Musselburgh, Tranent,
    Penicuick, Haddington, Dunbar, the Isle of Skye, etc. Although the
    epidemic was mostly confined to Scotland, the same fever was observed
    in some of the large towns of England. The number of admissions into
    the London Fever Hospital rose from 252 in the preceding year to 1,385
    in 1843: and the annual report for 1843 makes it evident that a large
    proportion of these cases were relapsing fever. The rate of mortality
    of the epidemic was small, not exceeding from two-and-a-half to four
    per cent. Although this was the same fever as prevailed in 1817-19,
    even local bleeding was rarely resorted to, and many of the cases were
    thought to demand stimulants. All accounts agree in stating that the
    epidemic supervened upon a period of great distress among the Scottish
    poor, and that it was restricted throughout to the poorest and most
    wretched of the population."

This epidemic, which was the subject of an altogether unusual amount of
writing in Edinburgh[388], partly on the supposition that relapsing fever
was a "new disease," proved once for all that one had not to go to Ireland
for the engendering or making of a famine-fever. The demonstration came
just in time; for the epidemic was hardly over in Scotland, when the
series of great potato-famines in Ireland began in 1845, soon to be
followed by the disastrous epidemics of dysentery, relapsing fever and
typhus from 1846 to 1848. Indeed, so near was the Scots epidemic to the
Irish, that in the North of Ireland the first of the relapsing fever, in
1846, was called "the Scotch Fever," on the supposition that it had
reached them from its recent focus in the West of Scotland[389]. The Irish
and original part of the great epidemic of 1846-48 has been fully
described in another chapter; much of the mortality was due to dysentery,
and the most prevalent fever was relapsing fever, with a very low rate of
fatality among the poorer classes. But in Ireland itself there was also
much typhus, very mortal to the richer classes who came in contact with
the starving multitudes.


The "Irish Fever" of 1847 in England and Scotland.

The contagion that reached England and Scotland from the scene of famine
in Ireland was more apt to produce typhus than relapsing fever. That the
Irish contagion was the principal source of the great epidemics in England
and Scotland in 1847-48, seems to be proved by every fact in their
progress, direction and other circumstances. But it is not so clear that
England and Scotland would not have had an unusual amount of typhus in the
same years even if the Irish had been kept out by an ideally strict
quarantine. What touched Ireland most, touched Scotland and England in a
measure. The seasons were bad in all parts of the kingdom; many were out
of work in the manufacturing towns; but as soon as the price of provisions
fell in 1848, the epidemic in England came to a sudden end.

The epidemic of fever in England in 1847 was almost wholly typhus; in
Scotland, it was to some extent relapsing fever, but there also it was
mainly typhus. It was more severe, while it lasted, than the epidemic of
1837 and following years; but it was of shorter duration, ceasing almost
abruptly in 1848. The rise of the epidemic of 1847 in London is shown by
the following quarterly returns of the deaths from fever:

  1st Quarter  2nd Quarter  3rd Quarter  4th Quarter

      442         568           895         1279

In the last quarter of 1846, the deaths from fever in London had been
619. In all England, the last quarter of 1846 was also most unhealthy, its
deaths from all causes being 53,055 (only 43,850 in the first quarter of
the year). The summer of 1846 had been remarkable for heat and drought,
and the end of the year was, according to precedent, an unwholesome time.
It was just the season for enteric fever, as in the still more memorable
circumstances of 1826. There is evidence from various parts of England and
Scotland that much of the fever of the end of 1846 was enteric; and it was
doubtless the unusual prevalence of that disease, and of other maladies
that are favoured, like it, by extreme fluctuations of the ground-water,
that explains the very high mortality of the last quarter of 1846[390].
But it is equally certain that it was typhus which raised the fever deaths
in London in the last quarter of 1847 to 1,279, and the deaths from all
causes in all England to the enormous total of 57,925. In the whole of the
year 1847, typhus alone claimed 30,320 deaths in England and Wales, the
total in 1848 falling to 21,406. Lancashire and Cheshire had the largest
share of this epidemic, and Liverpool the largest share in Lancashire. In
that Registration Division (the North-western) the deaths from typhus in
1847 were 9,076, and in 1848 they were 3,380. Next in order (excluding
London and suburbs) came the West Midland Division, and next to that
Yorkshire. At Liverpool, and in other places of the north-west of England,
the fever was very clearly connected with the enormous Irish immigration,
and was in great part among the Irish. There were floating lazarettos on
the Mersey, filled with fever and dysentery, workhouses overflowing, and
sheds hastily built to hold each 300 patients. The following returns from
the several sub-divisions of Liverpool for the months of July, August and
September, 1847, show the proportions of dysentery and fever, as well as
the mortality from diarrhoea, which last was mostly an affair of the
infants and young children[391]:

_Liverpool deaths, July-Sept. 1847._

                     Fever   Dysentery   Diarrhoea
  St Martin's         291       82          174
  Dale Street         250       20          111
  St Thomas      (301 deaths on the floating lazarettos)
  Mount Pleasant      324       18           73
  Islington           105       37           78
  Great Howard Street (the fever extending to the upper classes)

In his report for the quarter before (April, May and June, 1847) the
registrar of the Great Howard Street sub-district says: "Eight Roman
Catholic priests, and one clergyman of the Church of England, have fallen
victims to their indefatigable attentions to the poor of their
church[392]."

In Manchester there were causes of fever independently of the Irish
contagion. The registrar of the Deangate sub-district writes in the third
quarter of 1847: "In the calamitous season just passed, manufactures have
been almost at a stand-still; food has been unattainable by the poor, for
employment they had none; Famine made her dwelling in their homes &c." The
hardships of the children caused an immense mortality from summer
diarrhoea. The same registrar gives an account of the epidemic fever in
his report for the second quarter of 1847, from which it appears that,
although nearly all the hospital cases were distinctly maculated, and the
fever was undoubtedly typhus in all other respects and in its conditions,
yet tympanitis, with abdominal tenderness and diarrhoea, were specially
noted[393].

Besides Liverpool and Manchester, many other towns in Lancashire had the
"Irish fever" in them; also Birmingham, Dudley, Wolverhampton, Shrewsbury,
Leeds, Hull, York and Sunderland. Except in London, the fever mortality
was not unusual in the southern half of England[394].

In Scotland the epidemic was a mixture of relapsing fever and typhus. The
following were the proportions of each admitted to the Glasgow Royal
Infirmary:

  Year   Relapsing Fever  Typhus

  1846         777          500
  1847       2,333        2,399
  1848         513          980
  1849         168          342

In the Barony Fever Hospital, Glasgow, open from 5 August 1847 to July
1848, the relapsing cases were double the typhus cases at the opening of
the hospital, at the end of 1847 they were nearly equal, and from February
1848 the typhus cases were double the relapsing. In Edinburgh, where the
epidemic was less severe, the same relations were observed--relapsing
fever most at the beginning, typhus fever (much more fatal) most at the
end[395]. Some relapsing fever occurred also in London, among destitute
Irish, which was often attended by a miliary eruption (Ormerod).


Subsequent Epidemics of Typhus and Relapsing Fevers.

By midsummer, 1848, there was a most marked improvement in the public
health, corresponding with the great fall in the prices of food, under the
influence of free trade, and with a good harvest and the commencement of
an era of steady employment for workers. The improvement is strikingly
shown in the following comparison of the deaths from all causes in
Lancashire and Cheshire in the third quarter of each of the years 1846,
1847 and 1848:

                                  1846    1847    1848

  Deaths in the 3rd Quarter      15,221  17,080  11,720

Since the epidemic of 1847, which was not unfairly called "the Irish
fever," there has been no such extensive and fatal outbreak of typhus or
relapsing fever in England, Scotland or Ireland. The fever deaths rose
somewhat in Ireland and in Glasgow in 1851-53, the type of disease being
relapsing and typhus. In London there was a considerable increase of
typhus in 1856, at the end of the Crimean War. From 1861 to 1867 there was
a considerable epidemic of the same fever in England and Scotland (not
much of it in Ireland until 1864), the chief centres in England having
been the Lancashire towns, Preston, Manchester, Accrington, Chorley,
Salford and Blackburn, and the occasion of it the "cotton famine" of the
American Civil War[396]. Greenock was the chief seat of typhus in 1863-64
in Scotland; indeed, in the whole kingdom, its death-rate from that cause
was approached by that of Liverpool only. Fevers had been very mortal
there in the epidemic of 1847 (it is said 353 deaths); in the next
fever-period they rose as follows[397]:

  1860  1861  1862  1863  1864

   19    57    63    98    274

This epidemic was more easily dealt with than those of the same kind
before it. Very large sums were subscribed by the wealthy, of which,
indeed, a considerable balance remained undistributed. Rawlinson, as
engineer, and Villiers, as Minister, devised extensive relief works, in
the form of main drainage for the distressed Lancashire towns, the whole
cost being defrayed eventually by the municipalities themselves. The
following table, from Murchison, shows the admissions for typhus to the
fever hospitals of various towns, subsequently to the great epidemic of
1847-48. The first rise in London was in 1856; the next rise, which was
somewhat prolonged, coincided with the epidemic in Lancashire.

_Hospital Cases of Typhus, 1849-71._

       London   Edin.  Glasgow Glasgow Dundee  Aberdeen     Cork
        Fever   Royal   Royal   Fever   Royal   Royal       Fever
  Year  Hosp.  Infirm. Infirm.  Hosp.  Infirm. Infirm.      Hosp.

  1849   155     --      342    --       --      --           --
  1850   130     --      382    --       --      --           --
  1851    68     --      919    --       --      --           --
  1852   204     --     1293    --       --      --           --
  1853   408     --     1551    --       --      --           --
  1854   337     --      760    --       --      --           --
  1855   342     --      385    --       --      --           --
  1856  1062     --      385    --       --      --           --
  1857   274     --      314    --       --      --           --
  1858    15     --      175    --       17      --           --
  1859    48     --      175    --      128      --           --
  1860    25     --      229    --       67      --           --
  1861    86     --      509    --      129      --           116
  1862  1827     14      780    --       54      --           272
  1863  1309     74     1286    --      236      379 (4 mos.) 692
  1864  2493    212     2150    --      264      811         1021
  1865  1950    447     2334   1154     891      422          791
  1866  1760    847     1055    384     706      167          247
  1867  1396    303      761    795     225       68          124
  1868  1964    280      620   1023     502       78          245
  1869  1259    259     1430   2023     402      170          136
  1870   631    287      947    702     232       61          165
  1871   411    101      418    511     257        3          397

During the unusual prevalence of fever in Scotland, 1863-65, it was made
clear by the diagnosis in hospitals, that the excess was caused by typhus,
and not by enteric.

    Of 440 cases of fever treated in the Royal Infirmary of Edinburgh, in
    1864, 212 were cases of pure typhus, 140 were enteric fevers, while 88
    were simple continued fever and febricula. In the Royal Infirmary of
    Glasgow in 1864, of 2,190 cases of fever, 2,150 were reported to be
    cases of typhus fever, while only 40 were cases of enteric fever. In
    the Aberdeen Royal Infirmary not a case of enteric fever was observed:
    of 396 cases in the year 1863, 387 were pure typhus, and 9 febricula;
    and in 1864, of 926 cases, 897 were pure typhus and 29 febricula. In
    the Royal Infirmary of Dundee, of 355 cases of fever treated in 1864,
    318 were typhus, 16 enteric fever, and 21 febricula. It was only at
    Perth, and there not exclusively in hospital practice, that an excess
    of typhoid fever was observed; from 1st August, 1863, to 30th April,
    1864 (months which included the special typhoid season), there were
    101 cases of gastro-enteric or typhoid fever, 46 cases of typhus, 19
    of relapsing fever, and 59 of simple continued fever[398].

The last considerable prevalence of contagious fever in England and
Scotland was in 1869 and 1870. It was relapsing fever, mixed with some
typhus, and it was restricted almost to a few large towns, including
London, Liverpool, Manchester, Leeds, Bradford, Glasgow, and
Edinburgh[399]. It was first seen in London in 1868 among Polish Jews. It
was heard of as late as 1872 at Newcastle. It was observed during this
epidemic in Liverpool, Bradford and Edinburgh that the subjects of the
relapsing fever were not suffering from want[400]. The same observation
has been made in some foreign countries. Still, on the great scale and in
a broad view, relapsing fever has been _typhus famelicus_ or famine-fever,
occurring in association with other maladies due to want, and especially
in the circumstances which have been discussed fully in the chapter on
fevers in Ireland.


Relative prevalence of Typhus and Enteric Fevers since 1869.

It was not until the year 1869, or about the time when typhus fever ceased
to be epidemic or common, that the deaths from typhus fever, simple
continued fever and enteric fever began to be tabulated separately in the
Registrar-General's reports. The following tables show for England and
Wales and for London a steady decline of the deaths from typhus and simple
continued fever since the end of the epidemic period 1869-71, which was
the last epidemic of typhus and relapsing fever in this country hitherto.
The deaths from enteric fever, it will be seen, remained somewhat steady
(in a growing population) for about ten years after the separation, and
then began to decline.

_Continued-fever Deaths in England and Wales, 1869-91._

                  Simple or
  Year   Typhus  Ill-defined  Enteric

  1869    4281      5310       8659
  1870    3297      5254       8731
  1871    2754      4248       8461
  1872    1864      3352       8741
  1873    1638      3081       8793
  1874    1762      3089       8861
  1875    1499      2599       8913
  1876    1192      1974       7550
  1877    1104      1923       6879
  1878     906      1776       7652
  1879     533      1472       5860
  1880     530      1490       6710
  1881     552      1159       5529
  1882     940      1016       6036
  1883     877       963       6068
  1884     328       768       6380
  1885     318       662       4765
  1886     245       505       5061
  1887     211       502       5165
  1888     168       436       4848
  1889     140       413       4971
  1890     160       361       6146
  1891     148       325       5075

_Continued-fever Deaths in London, 1869-91._

                  Simple or
  Year   Typhus  Ill-defined   Enteric

  1869    716        615        1069
  1870    472        570         976
  1871    384        436         871
  1872    174        322         867
  1873    277        325         968
  1874    312        337         879
  1875    128        272         817
  1876    159        202         769
  1877    157        194         901
  1878    151        197        1033
  1879     71        160         849
  1880     74        134         702
  1881     92        134         971
  1882     53         95         975
  1883     55        102         963
  1884     32         75         925
  1885     28         78         597
  1886     13         73         618
  1887     19         44         612
  1888      9         35         694
  1889     16         42         538
  1890     10         35         604
  1891     11         44         557

Such being the proportions of typhus and enteric fever since 1869, when
the separation was made, it remains to ask what share each of them may
have had in the total of "typhus," or of continued fever generally, in the
years before the two forms were distinguished in the annual registration
reports. Of course, they were distinguished by many of the profession long
before that; so that there are means of forming a judgment. At the London
Fever Hospital, enteric fever and typhus were distinguished after 1849. If
the admissions of each kind of fever to that hospital be assumed to have
been proportionate to the prevalence of each in London from year to year,
we should get in the following table a means of estimating which of the
two forms of continued fever furnished most of the deaths in all London,
as given in the first column:

                          Admissions to London
            Deaths in        Fever Hospital
           London from
  Year     both fevers      Typhus  Typhoid

  1838        4078            --      --
  1839        1819            --      --
  1840        1262            --      --
  1841        1151            --      --
  1842        1184            --      --
  1843        2094            --      --
  1844        1721            --      --
  1845        1324            --      --
  1846        1838            --      --
  1847        3297            --      --
  1848        3685            --      --
  1849        2564           155     138
  1850        2032           130     137
  1851        2374            68     234
  1852        2183           204     140
  1853        2617           408     212
  1854        2816           337     228
  1855        2410           342     217
  1856        2717          1062     149
  1857        2195           274     214
  1858        1919            15     180
  1859        1840            48     176
  1860        1476            25      95
  1861        1848            86     161
  1862        3673          1827     220
  1863        2871          1309     174
  1864        3782          2493     253
  1865        3217          1950     523
  1866        2688          1760     582
  1867        2184          1396     380
  1868        2468          1964     459

From this it will appear that every great annual rise in the London deaths
from "fever," since the last great typhus epidemic of 1847-48, has
corresponded to a greatly increased admission, not of enteric cases, but
of typhus cases into the London Fever Hospital. On the other hand, enteric
fever has been at a somewhat steady or endemic level for a good many
years. Even at that level it would have had a small share of the whole
fever-mortality in the old London; in modern London, especially in its
residential quarters, its rate has probably been higher than in former
times; while in recent years, owing to the absolute decline of typhus, it
has been by far the most common continued fever. If the conditions were
the same in London as in Edinburgh, it was the very creation of
residential streets and new quarters of the town that called forth typhoid
fever; while the more the town was remodelled, the more were the _fomites_
of typhus destroyed. Thus it seems probable that the same progress in
well-being among all classes, which has gradually brought typhus down
almost to extinction (or apparently so for the present), has been attended
with an increase of typhoid, an increase which has happily fallen within
the last few years from its highest point.

The disappearance, during the last twenty years, of typhus and relapsing
fevers from the observation of all but a few medical practitioners in
England, Scotland and Ireland, is one of the most certain and most
striking facts in our epidemiology. Most of the recent English cases have
occurred in Lancashire, especially in Liverpool, and in Sunderland,
Gateshead, Newcastle and other shipping places of the north. In the
decennial period 1871-80 the death-rate from typhus, per 1000 living, was
0.58 in Liverpool and 0.33 in Sunderland, rates which were about the same
as those from enteric fevers. The rates in 1881-83 were also high in the
same group of towns. As to other industrial centres, including the
coal-districts of Cumberland, Wales and Scotland, it is probable that a
good deal of typhus passes under the name of "typhoid," the change in
medical fashion having outrun somewhat the real change in the relative
prevalence of each fever[401]. In Scotland the disease is still heard of
from time to time in Glasgow, Edinburgh, Leith, Dundee, Aberdeen,
Inverness and Thurso. In London the recent immunity from it is remarkable,
but intelligible. First, the populace is better housed: we have got rid of
the window-tax, rebuilt the houses in regular streets opening upon wide
thoroughfares, pulled down most of the back-to-back houses, dispersed the
working population over square miles of suburbs easily accessible from the
heart of the town by tramways and railways, perfected the sewerage and the
water-supply. These great structural changes are so far an earnest that
typhus cannot come back in the old way. Secondly, food has been for a long
time cheap and wages good. During the remarkable lull in typhus from 1803
to 1816, Bateman pointed out that the unwholesome state of the dwellings
of the working class remained the same as before, but that money was
flowing freely among all classes (thanks to the special war-expenditure).
Under free trade, the same abundance of the necessaries of life has been
secured in another way. Typhus, it need hardly be said, is an indigenous
or autochthonous infection; the conditions of its engendering are never
very far off. In a small and remote island off the coast of Skye, which I
happened to know in its pleasing aspects from having landed upon it during
a summer vacation, typhus fever was reported by the newspapers a few
months after to have broken out in the hamlet of twenty or thirty
families, the winter storms having prevented the fishers from leaving
their cottages or any stranger from approaching the island. In a sparsely
populated parish of the east coast of Scotland, two cases of genuine
typhus (one of them fatal), and two only, have occurred, to medical
knowledge, within the last ten years, each in a very poor cottage in a
different part of the parish and in a different season. So long as our
cheap supplies of food, fuel and clothing are uninterrupted, there is
small chance of typhus or relapsing fever. But the population of England
being now twice as great as the home-grown corn can feed, a return of
those fevers on the great scale is not out of the question in the event of
the foreign food-supply being interfered with, or the necessaries of life
becoming permanently dearer from any other cause.

The following Table of the fever-deaths in Scotland since the beginning of
Registration does not distinguish enteric from typhus, relapsing and
simple continued during the first ten years of the period; but it is
probable, from all that is known non-statistically or by hospital figures
only, as to the history of enteric fever in Scotland, that it made the
smaller part of the generic total of fever-deaths so long as typhus and
relapsing fevers were common.

_Scotland--Deaths from the Continued Fevers since the beginning of
Registration._

  Year

  1855  2419     }
  1856  2363     }
  1857  3087     }
  1858  2790     }
  1859  2436     } Inclusive of typhus, relapsing, enteric
  1860  2344     } and other continued fevers.
  1861  2579     }
  1862  3021     }
  1863  3441     }
  1864  4804[402]}

                                 Simple   Infantile  Cerebro-Spinal
       Typhus Enteric Relapsing continued Remittent

  1865  3272    1048     62       839        164        --
  1866  2172    1404     34       249        159        --
  1867  1745    1378     40       105        119        --
  1868  1561    1404     45       100        132        --
  1869  2059    1335     29       121        157        --
  1870  1460    1207    205       151        141        --
  1871  1129    1234    411       108        124        --
  1872   795    1223    115       103        118        --
  1873   628    1495     31       192        117        --
  1874   726    1455     27       104         80        --
  1875   615    1625     17        98         85        --
  1876   471    1448     18        65         88        --
  1877   265    1427      5       164         --        --
  1878   263    1477      2       147         --        --
  1879   210    1013      5       133         --        --
  1880   170    1338      4       155         --        --
  1881   229    1004      0       115         --        --
  1882   180    1204      2        90         --        --
  1883   152     998      1        71         --         7
  1884   138    1050      2        63         --         9
  1885   111     889      1        58         --         8
  1886    80     755      2        62         --        10
  1887   126     835      7        65         --         4
  1888   102     665      6        58         --         6
  1889    69     795      1        45         --         2
  1890    77     777     --        30         --         3
  1891   107     799      4        23         --         6


Circumstances of Enteric Fever.

The circumstances of typhus and relapsing fevers need no general stating
after what has been said of particular epidemics in England and Scotland,
or remains to be said, for the most distinctive instances of all, in the
chapter on fevers in Ireland. There has been so little typhus in the
country at large since the disease began to be registered apart in the
mortality returns, in 1869, that hardly anything can be inferred except
the fact of its disappearance. It is significant, however, that
Sunderland, one of the two great towns which have kept typhus longest and
in largest measure (Liverpool being the other) is distinguished for the
overcrowding of its dwelling-houses (7.24 persons to a house in the Census
of 1881, 7.00 in the Census of 1891).

But the circumstances of enteric fever are not only not so obvious as
those of typhus in the historical way; they are also more complex and
disputable. One fact in the natural history of enteric fever has been made
clear in the chronology, namely, its greater frequency after a severe
drought. It was in the autumn of 1826, after the driest and hottest summer
of the century, that cases of fever with ulceration of the bowel were
first described and figured in London. It was in the autumn of 1846, after
the next very dry and hot summer, that cases of the same fever again
became unusually common in many parts of England and Scotland. The same
sequence has been remarked on more recent occasions and in various
countries. It is explained by taking into account some other facts in the
natural history of enteric fever. In nearly all countries in our
latitudes, autumn is its principal season, and autumn is the season when
the level of the water in the soil, or in the wells, is lowest. Virchow
states the law of enteric fever in the following simple and concrete way:
"We [in Berlin] have a certain number of cases of typhoid at all times.
The number increases when the sub-soil water falls, and decreases when it
rises. Every year, at the time of the lowest level of the sub-soil water,
we have a small epidemic." A sharp rise above the mean level of the year,
from the first week of September to the end of October, has been well
shown for London from the admissions to the hospitals of the Metropolitan
Asylums Board, 1875-1884. The curve has an equally sharp descent, passing
below the mean line of the year in the second week of December[403]. There
are indications that it is the partial filling of the pores of the
sub-soil with water, after they have long been occupied with air only,
that makes the virus of typhoid active, or, in other words, that the
rains of late summer and autumn are the occasion of the seasonal increase
of the infection.

Yet it is not the changes in the ground-water by themselves, just as it is
not rainfall and temperature by themselves, that make enteric fever to
prevail. The soil in which those vicissitudes of drought and saturation
are potent for evil must be one that is befouled with animal organic
matters, more especially with excremental matters. For that and other
reasons (such as the geological formation), enteric fever shows, in its
more steady or endemic prevalence from year to year or from decade to
decade, certain marked preferences of locality. Since 1869, when the
deaths from it began to be registered apart, it has been much more common,
per head of the population, in the quick-growing manufacturing and mining
towns than in any other parts of England and Wales, the districts with
highest enteric death-rates being the mining region of the East Coast from
the mouth of the Tees to somewhat north of the Tyne, the mining region of
Glamorgan, certain manufacturing towns of Lancashire and the West Riding
of Yorkshire, and some districts in the valley of the Trent in
Staffordshire and Nottinghamshire. The following Table shows, by
comparison with all England and Wales and with London, the excessive
death-rates from enteric fever in the registration divisions which head
the list:

_Highest mortalities from Enteric Fever in Registration Divisions of
England and Wales_[404].

  ------------------------------------------------------------------
                           Decennium                     | Decennium
                            1871-80                      |  1881-90
  -------------------------------------------------------|----------
                         |  Annual   |  Annual   |       |
                         |death-rate,|death-rate,|Enteric| Deaths,
                         |all causes,| Enteric,  |Deaths | Enteric,
                         | per 1000  | per 1000  | in 10 |  in 10
                         |  living   |  living   | years |  years
  -----------------------|-----------|-----------|-------|----------
  England and Wales      |   21.27   |    0.32   | 78421 |   53509
    London               |   22.37   |    0.24   |  8536 |    7497
  -----------------------|-----------|-----------|-------|----------
    Durham co.           |   23.77   |    0.56   |  4525 |    2590
    South Wales          |   21.09   |    0.45   |  3715 |    2550
    W. Riding, Yorks.    |   23.24   |    0.45   |  9166 |    5170
    N. Riding, Yorks.    |   19.68   |    0.44   |  1259 |     896
    Nottinghamshire      |   21.23   |    0.43   |  1707 |    1263
    Lancashire           |   25.17   |    0.39   | 12388 |    9874

_Durham Mining Districts._

  Stockton incl. part of |           |           |       |
    Middlesborough       |           |           |       |
    (4-3/4 years)        |   26.64   |    1.09   |   561 |      --
                         |           |           |       |
  Stockton (5-1/4 years) |   22.49   |    0.62   |   208 |     258
                         |           |           | (5-1/4|
                         |           |           | years)|
  Guisborough, incl. part|           |           |       |
    of Middlesborough    |           |           |       |
    (4-3/4 years)        |   24.80   |    1.17   |   251 |      --
                         |           |           |       |
  Guisborough            |           |           |       |
    (5-1/4 years)        |   20.45   |    0.38   |    71 |     106
                         |           |           |       |
  Middlesborough[405]    |           |           |       |
    (5-1/4 years)        |   19.93   |    0.63   |   272 |     460
                         |           |           | (5-1/4|
                         |           |           | years)|
                         |           |           |       |
  Auckland               |   24.52   |    0.71   |   541 |     318

_South Wales Mining Districts._

  Pontypridd[406]        |   23.16   |    0.71   |   515 |     541
  Merthyr Tydvil         |   24.23   |    0.62   |   639 |     249
  Swansea                |   22.38   |    0.63   |   505 |     387
  Llanelly               |   20.93   |    0.8    |   330 |     165

In the second decennium of the Table, 1881-90, the total deaths from
enteric fever (the death-rates are still unpublished) are much below those
of 1871-80. All the counties of England and Wales have shared in that
notable decline, including Durham and Glamorgan. But these two great
districts of the coal and iron mining are, by the latest returns, still
keeping the lead; and it is probable that we shall find in them, or in
particular towns within them, the conditions that have been most
favourable to enteric fever in the earlier decennia of this century and
are still favourable to it. First it is to be observed that one of the
most noted of the old typhoid centres in Glamorgan, namely Merthyr Tydvil,
has ceased to be in that class; its enormous rate of growth has been
checked (to 18.9 per cent. from 1881 to 1891) and it has at the same time
become a more uniform and better-ordered municipality.

On the other hand, on the same river <DW75>, and in the tributary valley of
the Rhondda, there is an immense population of miners, among whom the
enteric fever death-rate will probably be found to have been higher in
1881-90 than in any other registration district. The most populous part of
the district is the town of Ystradyfodwg, which had 44,046 inhabitants in
1881 and 68,720 in 1891, an increase of over fifty per cent., the highest
urban rate of increase in the country. On the mean of the last three
years, 1891-93, its enteric fever death-rate has been .62 per 1000. There
are several populous towns or townships in the mining districts of the
north-east which have in like manner kept their high rate of typhoid
mortality--Auckland, Easington, Bellington (Morpeth) and Middlesborough.
It is held by many that enteric fever has been most characteristically a
product of the modern system of closet-pipes and sewers. It is, of course,
the defects of the system that are, in this hypothesis, to blame,
including its partial adoption, the transition-state from the older
system, the tardy extension to new streets, as well as cheap and faulty
construction. All those things, together with the inherent difficulty of
connecting with a main sewerage the irregular squattings of a mining
community, are probably to be found in highest degree in those districts
of Durham and South Wales that are most subject to enteric fever. While
enteric fever is in some places steady or endemic from year to year, in
others its force is felt mostly in great and sudden explosions.

    One such happened in the city and district of Bangor in the summer of
    1882. The registration district had only 95 deaths from enteric fever
    in the ten years 1871-80, but in the single year 1882 it had 87 deaths
    registered under that name. Of 548 attacks (with 42 deaths) which were
    known from 22 May to 12 September, 407 fell in August and the first
    twelve days of September[407]. In the following year and throughout
    the rest of the decennium the district had its usual low average of
    enteric-fever deaths. One thing relevant to the explosion was probably
    the excessive rainfall of June and July (9.5 inches, as compared with
    4.8 inches about London).

    Another explosion, probably unique in the history of enteric fever,
    took place at Worthing, on the Sussex coast, in the summer of 1893.
    The enteric death-rate of the town had been much below the average of
    England and Wales from 1871 to 1880, the rate being 0.15 per 1000 and
    the whole deaths in ten years 36. During the next ten years, 1881-90,
    the whole enteric deaths were 43 in the entire registration district
    (population in 1891, 32,394). In 1891 the typhoid deaths were two, in
    1892 they were six. In 1893 a severe outbreak of typhoid took place
    within the municipal borough (population 16,606): In the first quarter
    of the year Worthing was one of the places mentioned for typhoid,
    having had 5 deaths; in April there were no deaths, in May 25, in June
    19, in July 61, in August 64, in September 11, and in the last quarter
    of the year 8, making 193 deaths in the year. The highest weekly
    number of cases notified was 253 in the second week of July. The
    enormously wide dispersion of the poison, in a town little subject to
    enteric fever, caused suspicion to fall on the water-supply, the more
    reasonably that the district of West Worthing, which had a separate
    water-supply, was said not to have suffered from the outbreak. A new
    water-supply was at once undertaken. A relief fund of L7000 was raised
    for the sufferers.

    The towns of Middlesborough, Stockton and Darlington, in the lower
    valley of the Tees, were together the scene of two remarkable
    explosions of enteric fever, the first from 7 September to 18 October,
    1890, the second from 28 December, 1890, to 7 February, 1891. The
    phenomenal nature of these outbreaks in the autumn and winter of
    1890-91 will appear from the following table of deaths by enteric
    fever:

                         Darlington  Stockton  Middlesborough
        Ten years 1881-90   104        258        460
                  -----------------------------------
                   1890      21         66        130
                   1891      17         59         93

    In the first of the two explosions the three towns were almost equally
    attacked per head of their populations; in the second explosion, in
    mid-winter, Darlington had relatively only half as many cases as each
    of the other two, which had about the same number of cases as in the
    former six-weeks' period. In both periods, of six weeks each, the
    three towns had together 1334 cases of typhoid, while the country
    districts near them had a mere sprinkling. A flooded state of the Tees
    appeared to be a relevant antecedent to each of the explosions. The
    Tees is a broad shallow river flowing rapidly, subject to frequent
    inundations, tortuous in its lower course, forming at its mouth, where
    Middlesborough stands, a wide estuary bordered by low flat grounds.
    The rainfall at Middlesborough was 6.3 inches in August, of which 2.2
    inches fell on the 12th of the month, the river being high in flood
    thereafter. There were again high floods in November, chiefly caused
    by the melting of snow in the upper basin (5 inches fell at Barnard
    Castle in November, 3.1 inches at Middlesborough, while the December
    fall was 1.2 inches at the former and 1.4 inches at the latter). To
    apply correctly the ground-water doctrine of enteric fever to these
    explosions, other particulars would have to be known, more especially
    the extent of the previous dryness of the subsoil (the rainfall at
    Middlesborough was 9.3 inches in the first half of 1890, 15.6 in the
    second half, and below average for the whole year). But the flooded
    state of the Tees valley in August and November must have changed
    abruptly the state of the ground-ferments within the areas of the
    respective towns and so afforded, according to the general law, the
    conditions for an abrupt increase of enteric fever in these its
    endemic or perennial soils[408].

While the more or less steady or endemic prevalence of typhoid fever is
due to the formation and reproduction in the soil of an infective
principle (probably of faecal origin) which affects more or less
sporadically the individuals living thereon, after the manner of a miasma
rising from the ground, there have been some hardly disputable instances
of the infection being conveyed to many at once from a single source in
the drinking water and by the medium of milk[409]. But such instances,
suggestive though they be and easy of apprehension by the laity, must not
be understood as giving the rule for the bulk of enteric fever. In like
manner, the escape or reflux of excremental gases from pipes or sewers, or
the leakage into basements or foundations from faulty plumber-work, are
causes, real no doubt, but of limited application, which do not conflict
with, as they do not supersede, the more comprehensive and cognate
explanation of enteric fever as an infection having its habitat in the
soil and an incidence upon individuals after the manner of other miasmatic
infections. Sex has little or nothing to do with the incidence of the
infective virus. As to age, enteric fever rarely befalls infants, and, in
the general belief of practitioners, is a less frequent cause of death
among children than among adolescents and adults.

    In the following Table from the Registrar-General's Decennial Review,
    1871-80, enteric fever is not separated from other continued fevers.
    It is probable that a considerable ratio of the deaths from 0 to 5
    years are due to febrile disorders other than enteric.

    _Annual Mortality per million living at all ages and at eleven groups
    of ages, males and females, from fever (including Typhus, Enteric
    Fever and Different Forms of Continued Fever) 1871-80._

                All
               ages   0-   5-  10-  15-  20-  25-  35-  45-  55-  65-  75+

    Both sexes  484  651  518  439  543  509  411  379  402  458  553  498
    Males       494  644  483  390  513  579  436  395  437  503  629  593
    Females     477  658  550  487  573  445  387  362  369  418  488  425

The cases notified under the Act in 1891 and 1892 have been found to
average five or six for every death registered in the corresponding
districts, the rate of fatality ranging widely. It is matter of familiar
knowledge that many of the attacks and fatalities occur among the richer
classes. New comers to an endemic seat of the disease are most apt to take
it (this has been elaborately shown for Munich, and holds good for the
British troops in India). There are undoubtedly constitutional
proclivities to it among individuals, which may run strongly in families.
As in other miasmatic infective diseases, such as yellow fever, Asiatic
cholera, and (formerly) plague, there seem to be occasions in the varying
states of body and mind, as well as in the external circumstances, when
the infection of enteric fever is specially apt to find a lodgement and to
become effective. The old plague-books gave lists of the things that were
apt to invite venom or to stir venom (see former volume pp. 212, 674); and
it is probable that some of these hold good also for the incidence of
enteric fever.




CHAPTER II.

FEVER AND DYSENTERY IN IRELAND.


The history of the public health in Ireland has been so remarkable that it
may be useful to take a continuous view of it in a chapter apart, so far
as concerns flux, or dysentery, and typhus with relapsing fever.

Ireland is a country which would have given Hume, had he thought of it,
the best of all his illustrations of the difficult problem handled in the
essay "Of National Characters"--how far the habits, customs, temperaments
and, he might have added, morbid infections have been determined by
climate, and how far by laws and government, by revolutions in public
affairs, or by the situation of the nation with regard to its neighbours.
Not only is there something special and peculiar in the actual
epidemiology of Ireland, but its political and social history has been apt
to borrow the phrases of medicine in a figure. "First the physicians are
to take care," says Burke, "that they do nothing to irritate this
epidemical distemper. It is a foolish thing to have the better of the
patient in a dispute. The complaint, or its cause, ought to be removed,
and wise and lenient arts ought to precede the measures of vigour[410]."
And this singular use of the imagery of disease in Irish history might be
illustrated from many other passages of the same orator and essayist, just
as it may be seen any day in the columns of newspapers in our own time.
Giraldus Cambrensis began it, within a few years of the first English
conquest of Irish territory by Henry II. Writing of that singular effect
upon the English settlers by contact with the native Irish, whereby they
became, in the words of another medieval author, _ipsis Hibernis
hiberniores_, he resorts to the medical figure of "contagion" as the best
way to account for it. So again, to overleap six centuries, Bishop
Berkeley in his query "whether idleness be the mother or daughter of
spleen[411]," is trying upon the Irish both Hume's problem of national
character and the use of the medical figure. And, to take a modern
instance, Lord Beaconsfield used the same figure of the old humoral
pathology, and gave his adhesion to a theory of national characters
adverse to the sense of Hume, when he ascribed the habits and manners of
the Irish, and the course of their national history, to their propinquity
to a "melancholy" ocean.

As far back as we can go in the history, two diseases are conspicuous--the
flux or "the country disease," and the sharp fever or "Irish ague." When
Henry II. invaded Ireland in 1172, his army suffered from flux, which the
contemporary chronicler, Radulphus de Diceto, dean of St Paul's, set down
to the unwonted eating of fresh meat (_recentium esus carnium_), the
drinking of water, and the want of bread[412]. Less than a generation
after, Giraldus of Wales wrote his "Topography of Ireland," wherein he
remarks that hardly any stranger, on his first coming to the country,
escapes the flux by reason of the juicy food (_ob humida
nutrimenta_)[413]. At that time Ireland was almost wholly a pastoral
country, and a pastoral country it has remained to a far greater extent
than England or Scotland. It is to this comparative want of tillage, an
almost absolute want when Giraldus was there, that we shall probably have
to look in the last resort for an explanation of the two national maladies
that here concern us--the "country disease" and the "Irish ague." The same
dietetic reason that the dean of St Paul's gave in 1172 for the prevalence
of flux in the army of Henry II., the want of bread and the eating of
fresh meat, can be assigned for the country disease long after, and, in
some periods, on the explicit testimony of observers. As to the Irish
ague, or typhus fever, Giraldus mentions it in the medieval period; and
Higden, copying him exactly, says: "The inhabitants of Ireland are vexed
by no kind of fever except the acute, and that seldom"--the word _acuta_
being the original of "the ague," or, as in another translation of the
passage, "the sharp axes[414]." In this pastoral country, according to
Giraldus, there was little sickness and little need of physicians; but
there is hardly an instance of military operations by the English
unattended with sickness among the troops, and famine with sickness among
the native Irish.

The generalities of Fynes Moryson, a traveller of the time of James I.,
who included Ireland among the many countries that he visited and
described, throw light upon the dietetic peculiarities of the Irish.
Having little agriculture, and at that time no general cultivation of the
potato (although they adopted it much sooner than the English and Scots),
they lived, says Moryson, mostly on milk (as Giraldus Cambrensis also
records in the twelfth century), and upon the flesh of unfed calves, which
they cooked and ate in a barbarous fashion. "The country disease" is also
noted. The experience in Ireland from time immemorial, that a bellyful was
a windfall, must have been the origin of a habit observed by Moryson:

    "I have known some of these Irish footemen serving in England to lay
    meate aside for many meales to devoure it all at one time." And again:
    "The wilde Irish in time of greatest peace impute covetousnesse and
    base birth to him that hath any corne after Christmas, as if it were a
    point of nobility to consume all within these festivall dayes." The
    Irish slovenliness or filthiness in their food, raiment and lodging
    was apt, he says, "to infect" the English who came to reside in their
    country[415].

About a generation after we come to the earliest medical account of the
sicknesses of Ireland, by Gerard Boate, compiled during the Cromwellian
occupation[416]. The following occurs under the head of The Looseness:

    The English have given it the name of the Country Disease. The
    subjects of it are often troubled a great while, but take no great
    harm. It is easily cured by good medicines: "But they that let the
    looseness take its course do commonly after some days get the bleeding
    with it; ... and last it useth to turn to the bloody flux, the which
    in some persons having lasted a great while, leaveth them of itself;
    but in far the greatest number is very dangerous, and killeth the most
    part of the sick, except they be carefully assisted with good
    remedies."

The other reigning disease is the "Irish Ague," a continued fever of the
nature of typhus:

    "As Ireland is subject to most diseases in common with other
    countries, so there are some whereunto it is peculiarly obnoxious,
    being at all times so rife there that they may justly be reputed for
    Ireland _endemii morbi_, or reigning diseases, as indeed they are
    generally reputed for such. Of this number is a certain sort of
    malignant feavers, vulgarly in Ireland called Irish agues, because
    that at all times they are so common in Ireland, as well among the
    inhabitants and the natives, as among those who are newly come thither
    from other countries. This feaver, commonly accompanied with a great
    pain in the head and in all the bones, great weakness, drought, loss
    of all manner of appetite, and want of sleep, and for the most part
    idleness or raving, and restlessness or tossings, but no very great
    nor constant heat, is hard to be cured." If blood-letting be avoided
    and cordial remedies given, "very few persons do lose their lives,
    except when some extraordinary and pestilent malignity cometh to it,
    as it befalleth in some years." Those who recover "are forced to keep
    their beds a long time in extreme weakness, being a great while before
    they can recover their perfect health and strength."

The occasion of Boate's writing was the subjugation of Ireland by
Cromwell, in the course of which we hear from time to time of sickness.
The greatest of the calamities was the utter destruction of the prosperity
of Galway by the frightful plague of 1649-50, and by the suppression of
the Catholics, who had brought the port of Connaught to be a place of
foreign commerce[417].

Cromwell's troops in 1649 incurred dysentery through the hardships of
campaigning. On 17 September, 1649, the Lord General writes from Dublin to
Mr Speaker Lenthall after the storming of Tredah or Drogheda: "We keep the
field much; our tents sheltering us from the wet and cold. But yet the
country-sickness overtakes many: and therefore we desire recruits, and
some fresh regiments of foot, may be sent us." And on 25 October, "Colonel
Horton is dead of the country-disease[418]."

Another general reference to the "country disease" of Ireland, by Borlase,
is very nearly the same as Boate's. It is introduced early in the history,
on the occasion of the death in 1591 of Walter, Earl of Essex, earl
marshal of Ireland:

    "The dysentery, or flux, so fatal to this worthy person, is commonly
    termed the country disease; and well it may, for it reigns nowhere so
    epidemically as in Ireland; tainting strangers as well as natives. But
    whether it proceeds from the peculiar disposition of the air, errour
    in diet, the laxity and waterishness of the meat, or some occult
    cause, no venomous creature living there to suck that which may be
    thought (in other countries) well distributed amongst reptilious
    animals, I shall not determine, though each of these circumstances may
    well conduce to its strength and vigour. Certain it is that regular
    diet preserves most from the violence, and many from the infection of
    this disease; yet as that which is thought very soveraign--I must say
    that the stronger cordial liquors (viz. brandy, usquebeh, treacle and
    Mithridate waters) are very proper, or the electuaries themselves, and
    the like[419]."

From the Restoration to the Revolution little is known of epidemics in
Ireland. It is probable that Dublin and the other considerable towns fared
much the same as English towns. A Dublin physician writing to Robert Boyle
on 27 February, 1682, speaks of a petechial fever, marked by leaping of
the tendons, which had been fatal to very many in that city for these
twelve or fourteen months[420]. With the Revolution the troubles of the
country begin again, and enter on their peculiarly modern phase. For our
history, two characteristic incidents come at the very beginning of the
new period of disorder among the Irish--the sicknesses of the siege of
Londonderry and the unparalleled havoc of disease among the troops of
Schomberg in the camp of Dundalk. In both, the old "country disease,"
which had affected Cromwell's troops, was the primary malady, occurring,
of course, in circumstances special enough to have bred it anywhere; in
both, the dysentery was attended or followed by typhus fever, the old
"Irish ague;" and although the epidemics of Londonderry and Dundalk in
1689 are properly examples of war sickness, yet the circumstances of each
may help to realize the connexion between dysentery and typhus in the
ordinary history of the Irish.


Dysentery and Fever at Londonderry and Dundalk, 1689.

The siege of Londonderry[421] by the Catholic Irish army of James II.
began in April and ended on 28 July, having lasted 105 days. On 19 April
the garrison numbered 7020 men, and the total of men, women and children
in the town was estimated at 30,000, a number which included refugees from
the neighbouring country and would have been more but for many Protestants
at the beginning of the siege leaving the city and taking "protection" at
the hands of the besiegers. On 21 May, a collection was made for the poor,
who began to be in want. Sickness is heard of on 5 June, when several that
were sick were killed in their beds by the enemy's bombs. The dread of the
bombs in the houses caused the people to lie about the walls or in places
remote from the houses all night, so that many of them, especially the
women and children, caught cold, which along with the want of rest and
failing food, threw them into fluxes and fevers. The pinch of hunger began
to be felt before the middle of June, about which time and for six weeks
after the fluxes and fevers were rife. A great mortality spread through
the garrison as well as the inhabitants; fifteen captains and lieutenants
died in one day, and it was estimated that ten thousand died during the
siege, "besides those who died soon after." The want, the dysentery, the
fever and the vast numbers of dead every day must have produced a horrible
state of things; when, on 2 July, five hundred useless persons were put
outside the walls, to disperse as they best could, the besiegers are said
to have recognized them when they met them "by the smell."

About the middle of June large quantities of provisions were found in
cellars and places of concealment under ground; after that the garrison
had always bread, although the allowance was small. An ingenious man
discovered how to make pancakes of starch and tallow, of which articles
there was no lack; the pancakes not only proved nutritious, but are said
to have been an infallible cure of the flux, or preservative from it. At
length, on 28 July some of the victuallers and ships of war which had been
in Lough Foyle since the 15th of June, sailed up to the head of the Lough
on the evening flood tide, finding little resistance from the enemy's
batteries and none from "what was left of" the tide-tossed boom of logs
across the mouth of the river. Provisions poured in, and the siege was
raised; but it is clear that the infection continued for some time after,
having been found among such of the released garrison as repaired to
Schomberg's camp at Dundalk.

The Catholic army is said (by the Protestants) to have lost 8000 or 9000
before the walls of Londonderry, "most by the sword, the rest of fever and
flux, and the French pox, which was very remarkable on the bodies of
several of the dead officers and soldiers[422]."

Not far off, at Dundalk, there began, a few weeks after, an extraordinary
outbreak of war-sickness, which, unlike the pestilence in Londonderry, was
altogether inglorious in its circumstances. In many respects it resembled
the disaster to Cromwell's troops at the first occupying of Jamaica in
1655-56[423]; but it was worse than that, and it is probably unexampled in
the military annals of Britain[424].

Supplies had been voted in Parliament for quelling the Catholic rebellion
in Ireland, and an expedition was got together under the illustrious
Marshal, Duke of Schomberg. The force consisted of some ten thousand foot,
most of them raw levies from the English peasantry, with one regiment of
seasoned Dutch troops ("the blue Dutch"), and cavalry. While the bulk of
the force was undisciplined, their clothes, food, tents and other
munitions of war were bad or insufficient through the fraud of
contractors. The expedition embarked at Hoylake on the Dee and landed on
the 15th of August, 1689, nearly three weeks after the relief of
Londonderry, at Bangor, on the south side of Belfast Lough. Schomberg took
Carrickfergus, and began to advance on Dublin; but finding the towns
burned and the country turned into a desert, he threw himself into an
entrenched camp around the head of Dundalk Bay, nearly a mile from the
town of Dundalk. His camp was on a low moist bottom at the foot of the
hills. The Irish Catholic army took up a position among the hills "on high
sound ground," not more than two miles distant from the English lines,
and, being in superior force, in due time they offered battle, which was
declined. Schomberg, who had been joined by the Enniskillen regiments of
dragoons and by men from Londonderry, had under him some 2000 horse and
not less than 12,000 foot at the time when James II. offered battle. The
undisciplined state of his English troops and the suspected treachery of a
body of French Protestants were among the causes that held Schomberg back;
but he had to reckon also with sickness almost from the moment of sitting
down at Dundalk. At a muster on 25 September, several of the regiments
were grown thin "by reason of the distemper then beginning to seize our
men." The distemper was dysentery and fever. The two maladies were mixed
up, as they usually are in war and famines, the flux commonly preceding
the fever, and perhaps affording the virulent matters in the soil and in
the air upon which the epidemic prevalence of the fever depends. It was
easy to account for the dysentery among the troops at Dundalk; but as to
the fever, there was an ambiguity at the outset which Story is careful to
note: "And yet I cannot but think that the feaver was partly brought to
our camp by some of those people that came from Derry; for it was
observable that after some of them were come amongst us, it was presently
spread over the whole army, yet I did not find many of themselves died of
it." Where the cause of death is specially named, it is fever, as in the
cases of Sir Thomas Gower, Colonel Wharton and other officers on the 28th
and 29th October. The fever was a most malignant form of typhus, marked by
the worst of all symptoms, gangrene of the extremities, so that the toes
or a whole foot would fall off when the surgeon was applying a
dressing[425].

It seems probable that most of the enormous mortality was caused by
infection, and not by dysentery due to primary exciting causes.

The primary exciting causes were obvious, but seemingly irremovable.
Schomberg had a great military reputation, but he was now over eighty, and
it does not appear that he made himself personally felt in the camp,
although he issued incessantly orders to inspect and report. As the
mortality proceeded apace during the six or eight weeks of inactivity,
murmurings arose against the commander. He was unfortunate in his choice
of a camping ground, and in an unusually cold and wet season. The newly
raised English troops seem to have been lacking equally in intelligence
and in moral qualities. Their foul language and debauchery were the
occasion of a special proclamation; their laziness and inability to make
themselves comfortable called forth numerous orders, but all to no
purpose. The regiment of Dutch troops were so well hutted that not above
eleven of them died in the whole campaign; but the English would not be
troubled to gather fern or anything else to keep themselves dry and clean
withal: "many of them, when they were dead, were incredibly lousy."

The camping ground not only received the drainage of the hills, but,
strange to say, the rain would be falling there all day while the camp of
the enemy, only a few miles farther inland, would not be getting a drop.
On 1 October the tents on the low ground were moved a little higher up. On
the same date there were distributed among the regiments casks of
brandy--Macaulay says it was of bad quality--which appears to have been
the trusted remedy against camp sickness, as in the Jamaica expedition of
1655. There were twenty-seven victuallers or other ships riding in Dundalk
Bay; but the stores were bad, and the regimental surgeons had come
unprovided with drugs that might have been useful in flux or fever. While
the weather continued cold and wet, there was also a scarcity of firing
and forage. On 14 October all the regimental surgeons were ordered to meet
at ten in the morning to consult with Dr Lawrence how to check the
sickness[426]. Several officers having died on the 16th and 17th, the camp
was shifted on the 20th to new ground, the huts being left full of the
sick. Gower's regiment had sixty-seven men unable to march, besides a good
many dead before or sent away sick. Story, the chaplain, went every day
from the new camp to visit the sick of his regiment in the huts, and
always at his going found some dead. He found the survivors in a state of
brutal callousness, utterly indifferent to each other, but objecting to
part with their dead comrades as they wanted the bodies to sit or lie on,
or to keep off the cold wind. The ships at anchor had now received as many
sick as they could hold, and the deaths on board soon became as many as on
shore. On 25-27 October, the camp was again shifted, but the sickness
continued apace. At length on 3 November, the Catholic army having
dispersed to winter quarters, the sick were ordered to be removed to
Carlingford and Newry. "The poor men were brought down from all places
towards the Bridge End, and several of them died by the way. The rest were
put upon waggons, which was the most lamentable sight in the world, for
all the rodes from Dundalk to Newry and Carlingford were next day full of
nothing but dead men, who, even as the waggons joulted, some of them died
and were thrown off as fast." Some sixteen or seventeen hundred had been
left dead at Dundalk. The ships were ordered to sail for Belfast with the
first wind, and the camp was broken up. There was snow on the hills and
rain in the valleys; on the march to Newry, men fell out of the ranks and
died at the road side. When the ships weighed anchor from Dundalk and
Carlingford, they had 1970 sick men on board, but not more than 1100 of
these came ashore in Belfast Lough, the rest having died at sea in coming
round the coast of County Down. Such was the violence of the infection on
board that several ships had all the men in them dead and nobody to look
after them whilst they lay in the bay at Carrickfergus. An infective
principle, once engendered in circumstances of aggravation such as these,
is not soon extinguished. Belfast was the winter quarters, and in the
great hospital there from 1 November, 1689, to 1 May, 1690, there died
3762, "as appears by the tallies given in by the men that buried them."
These numbers together make fully six thousand deaths, which agrees with
the general statement that Schomberg lost one half of the men whom he had
embarked at Hoylake in August. The Irish Catholic army began to sicken in
their camp in the hills above Dundalk Bay just before they broke up, and
they are said to have lost heavily by sickness in their winter quarters.

The war ended with the Treaty of Limerick, in 1691. The Seven Ill Years
followed,--ill years to Scotland, in a measure to England, and almost
certainly to Ireland also; but it does not appear that the end of the 17th
century was a time of special sickness and famine to the Irish, and it may
be inferred from the fact of Scots migrating to Ireland during the ill
years that the distress was not so sharp there. The epidemiology of
Ireland is, indeed, a blank until we come to the writings of Dr Rogers, of
Cork, in some respects the best epidemiologist of his time, which cover
the period from 1708 to 1734. His account of the dysentery and typhus of
the chief city of Munster in the beginning of the 18th century will show
that the old dietetic errors of the Irish, noted in medieval times, had
hardly changed in the course of centuries.


A generation of Fevers in Cork.

Rogers is clear that typhus fever was never extinct, while the three
several times when it "made its appearance amongst us in a very signal
manner," are the same as its seasons in England, namely 1708-10, 1718-21
and 1728-30[428]. His experience relates only to the city of Cork, and, so
far as his clinical histories go, only to the well-to-do classes therein;
and although those seasons were years of scarcity and distress all over
Ireland, yet Rogers does not seem to associate insufficient food with the
fever, and never mentions scarcity. The fevers were in the winter, for the
most part, and were usually accompanied by epidemic smallpox of a bad
type, which in 1708 "swept away multitudes." Nothing is said of dysentery
for the earliest of the three fever-periods; but for 1718 and following
years we read that "dysentery of a very malignant sort, frequently
producing mortification in the bowels," prevailed during the same space;
and that the winters of the third fever-period, namely, those of 1728,
1729 and 1730 were "infamous for bloody fluxes of the worst kind." It is
clear that the fever spread to the richer classes in Cork, for his five
clinical histories are all from those classes. The following is his
general account of the symptoms:

    The patient is suddenly seized with slight horrors or rather
    chilliness, to which succeed a glowing warmth, a weight and fixed pain
    in the head, just over the eyebrows; soreness all over his flesh, as
    if bruised, the limbs heavy, the heart oppressed, the breathing
    laboured, the pulse not much altered, but in some slower; the urine
    mostly crude, pale and limpid, at first, or even throughout, the
    tongue moist and not very white at first, afterwards drier, but rarely
    black. An universal petechial effloresence not unlike the measles
    paints the whole surface of the body, limbs, and sometimes the very
    face; in some few appear interspersed eruptions exactly like the
    _pustulae miliares_, filled with a limpid serum. The earlier these
    petechiae appear, the fresher in colour, and the longer they continue
    out, the better (p. 5). The fixed pain in the head increasing, ends
    commonly in a coma or stupor, or in a delirium with some. Some few
    have had haemorrhage at the nose, a severe cough, and sore throat. In
    some he had observed a great tendency to sweats, even from the
    beginning: these are colliquative and symptomatic, not to be
    encouraged. In but few there have appeared purple and livid spots, as
    in haemorrhagic smallpox: some as large as a vetch, others not bigger
    than a middling pin's head, thick set all over the breast, back and
    sometimes the limbs, the pulse in these cases being much below normal.
    The extremities cold from the 6th or 7th day, delirium constant,
    tongue dry and black, urine limpid and crude, oppression greater, and
    difficulty of breathing more. It is a slow nervous fever (p. 18).

Rogers believed that mere atmospheric changes could not be the cause of
these epidemics: "they may favour, encourage and propagate such diseases
when once begun; but for the productive cause of them we must have
recourse to such morbid effluvia as above described [particles of all
kinds detached from the animal, vegetable and mineral kingdoms]; or
resolve all into the [Greek: theion ti] so often appealed to by
Hippocrates[429]."

But, as regards Cork itself, special interest attaches to the following
"four concurring causes:"

    "1st, the great quantities of filth, ordure and animal offals that
    crowd our streets, and particularly the close confined alleys and
    lanes, at the very season that our endemial epidemics rage amongst us.

    2nd, the great number of slaughter-houses, both in the north and south
    suburbs, especially on the north ridge of hills, where are vast pits
    for containing the putrefying blood and ordure, which discharge by the
    declivities of those hills, upon great rains, their fetid contents
    into the river.

    3rd, the unwholesome, foul, I had almost said corrupted water that
    great numbers of the inhabitants are necessitated to use during the
    dry months of the summer.

    4th, the vast quantities of animal offals used by the meaner sort,
    during the slaughtering seasons: which occasion still more mischief by
    the quick and sudden transition from a diet of another kind."

In farther explanation of the fourth concurring cause, he says that in no
part of the earth is a greater quantity of flesh meat consumed than in
Cork by all sorts of people during the slaughtering season--one of the
chief industries of the place being the export of barrelled beef for the
navy and mercantile marine. The meat, he says, is plentiful and cheap, and
tempts the poorer sort "to riot in this luxurious diet," the sudden change
from a meagre diet, with the want of bread and of fermented liquors, being
injurious to them[430].


Famine and Fevers in Ireland in 1718 and 1728.

Thus far Rogers, for the city of Cork in the three epidemic periods,
1708-10, 1718-21, and 1728-30, two of which, if not all three, were
periods of dysentery as well as of typhus. But it was usual in Ireland for
the country districts and small towns to suffer equally with the cities.
The circumstances of the Irish peasantry in the very severe winter of
1708-9 are not particularly known; if there was famine with famine-fever,
it was not such as to have become historical. But for the next
fever-period, 1718-20, we have some particulars. Bishop Nicholson, of
Derry, writes: "Never did I behold even in Picardy, Westphalia or
Scotland, such dismal marks of hunger and want as appeared he
countenances of most of the poor creatures I met with on the road." One of
the bishop's carriage horses having been accidentally killed, it was at
once surrounded by fifty or sixty famished cottagers struggling
desperately to obtain a morsel of flesh for themselves and their
children[431].

This was a time when the population was increasing, but agriculture, so
far from increasing in proportion to the number of mouths to feed, was
positively declining, unless it were the culture of the potato. In a
pamphlet of about 1724, on promoting agriculture and employing the poor,
the complaint is of beef and mutton everywhere, and an insufficiency of
corn. "Such a want of policy," says one, "is there, in Dublin especially,
on the most important affair of bread, without a plenty of which the poor
must starve." Another, a Protestant, has the following threat for the
clergymen of the Established Church: "I'll immediately stock one part of
my land with bullocks, and the other with potatoes--so farewell
tithes[432]!" From this it is to be inferred that potatoes were not made
tithable until a later period, pasture being exempted to the last. For
whatever reason, grazing, and not corn-growing, was then more general in
Ireland than in the generations immediately preceding, much land having
gone out of tillage. The culture of the potato was driven out of the
fertile lowlands to the hill-sides, so as to leave the ground clear for
ranges of pasture. Rack-renting was the rule, doubtless owing to the same
reason as afterwards, the competition for farms. While the Protestants
emigrated in thousands, the Catholics multiplied at home in beggary. A
pamphleteer of 1727 says: "Where the plough has no work, one family can do
the business of fifty, and you may send away the other forty-nine." Thus
we find the pasturing of cattle preferred to agriculture long after the
barbaric or uncivilized period had passed, preferred indeed by English
landlords or farmers[433].

There were three bad harvests in succession, 1726, 1727 and 1728,
culminating in a famine in the latter year. Boulter, archbishop of Armagh,
who then ruled Ireland, was able to buy oats or oatmeal in the south and
west so as to sell it below the market price to the starving Protestants
of Ulster, an interference with the distribution of food which led to
serious rioting in Cork, Limerick, Clonmel and Waterford in the first
months of 1728[434]. No full accounts of the epidemic fever of that famine
remain. Rutty, of Dublin, says it was "mild and deceitful in its first
attack, attended with a depressed pulse, and frequently with
petechiae[435];" while, according to Rogers and O'Connell[436], the
epidemic fever of Munster was the same. Of the famine itself we have a
glimpse or two. Primate Boulter writes to the Duke of Newcastle on 7
March, 1727:

    "Last year the dearness of corn was such that thousands of families
    quitted their habitations to seek bread elsewhere, and many hundreds
    perished; this year the poor had consumed their potatoes, which is
    their winter subsistence, near two months sooner than ordinary, and
    are already, through the dearness of corn, in that want that in some
    places they begin already to quit their habitations[437]."

Quitting their habitations to beg was a regular thing at a later time of
the year. It was in the course of these bad years, in 1729, that Swift
wrote his 'Modest Proposal for preventing the Children of Poor People in
Ireland from being a Burden to their Parents or Country.' The scheme to
use the tender babes as delicate morsels of food for the rich, was a
somewhat extreme flight of irony, not so finished as in Swift's other
satires, but the circumstances out of which the proposal grew were more
real than usual.

    "It is a melancholy object," says the Dean of St Patrick's, "to those
    who walk through this great town, or travel in the country, when they
    see the streets, the roads and cabin doors crowded with beggars of the
    female sex followed by three, four, or six children, all in rags, and
    importuning every passenger for an alms." Having ventilated his
    project for the children, he proceeds to show that "their elders are
    every day dying and rotting by cold and famine, filth and vermin, as
    fast as can be reasonably expected."

All the while there was a considerable export of corn from Ireland. In the
beginning of 1730, two ships laden with barley were stopped at Drogheda by
a fierce mob and were compelled to unload[438].

The interval between those years of epidemic typhus in Ireland and the
next, 1740-41, was filled, we may be sure, with at least an average amount
of the endemial fever. Rutty specially mentions it in Dublin in the autumn
and winter of 1734-35: "We had the low fever, called nervous (and
sometimes petechial from the spots that frequently attended, although
probably not essential)." He then adds: "It is no new thing with us for
this low kind of fever to prevail in the winter season;" and gives figures
from the Dublin Bills of Mortality for forty years. He mentions the
petechial fever as being frequent next in January and February, 1736,
corresponding to a bad time of it in Huxham's Plymouth annals. In 1738 and
1739 the type of the Dublin fever was relapsing, in part at least, the
same type having been seen at Edinburgh shortly before.

       *       *       *       *       *

The economics of Ireland, at this time, gave occasion to Berkeley's
_Querist_, a series of weekly essays written in 1737 and 1738, and
collected in 1740, on the eve of the next great famine and mortality[439].
A few of the bishop's sarcasms, in the form of queries, will serve to show
how anomalous was the economic condition of the country, and how easily a
crisis of famine and pestilence could arise.

    "169. Whether it is possible the country should be well improved while
    our beef is exported, and our labourers live upon potatoes?

    "173. Whether the quantities of beef, butter, wool and leather,
    exported from this island, can be reckoned the superfluities of a
    country, where there are so many natives naked and famished?

    "174. Whether it would not be wise so to order our trade as to export
    manufactures rather than provisions, and of those such as employ most
    hands?

    "466. Whether our exports do not consist of such necessaries as other
    countries cannot well be without?

    "353. Whether hearty food and warm clothing would not enable and
    encourage the lower sort to labour?

    "354. Whether in such a soil as ours, if there was industry, there
    would be want?

    "418. Whether it be not a new spectacle under the sun, to behold in
    such a climate and such a soil, and under such a gentle government, so
    many roads untrodden, fields untilled, houses desolate, and hands
    unemployed?

    "514. Whether the wisdom of the State should not wrestle with this
    hereditary disposition of our Tartars, and with a high hand introduce
    agriculture?

    "534. Why we do not make tiles of our own, for flooring and roofing,
    rather than bring them from Holland?

    "539. Whether it be not wonderful that with such pastures, and so many
    black cattle, we do not find ourselves in cheese?"

In several of his queries (381, 383) Bishop Berkeley is driving at the
expediency of domestic slavery. It was two hundred years since the same
expedient had been tried by Protector Somerset in England, during the
intolerable state of vagabondage which followed the rage for pasture
farming under the first Tudors. In Scotland, it was hardly more than a
generation since the institution of domestic slavery had commended itself
to Fletcher of Saltoun, as the only expedient that could free that country
from the vagabondage of a tenth, or more, of the population. England had
surmounted the difficulty long ago, Scotland got over it easily and
speedily when she was admitted to the English and colonial markets for her
linen manufacture by the Treaty of Union[440]. But in Ireland in the year
1740, and until long after, disabilities of all kinds, not only economic,
but political and religious, were fastened upon the weaker nation by the
stronger, the unfortunate cause of their long continuance having been the
costly inheritance of loyalty to James II. and the Mass.


The Famine and Fever of 1740-41.

At the time when the bishop of Cloyne was issuing his economic queries
from week to week (not much to the satisfaction of Primate Boulter),
things were making up for the greatest crisis of famine and pestilence
that Ireland experienced in the 18th century. There had been relapsing
fever among the poor in Dublin in the autumn of 1738, and it appeared
among them again in the summer and autumn of 1739. Rutty's account of it
is as follows:

    "It was attended with an intense pain in the head. It terminated
    sometimes in four, for the most part in five or six days, sometimes in
    nine, and commonly in a critical sweat. It was far from being mortal.
    I was assured of seventy of the poorer sort at the same time in this
    fever, abandoned to the use of whey and God's good providence, who all
    recovered. The crisis, however, was very imperfect, for they were
    subject to relapses, even sometimes to the third time, nor did their
    urine come to a complete separation."

In October 1739, there appeared some dysenteries in Dublin.

The winter of 1739 set in severely with cold and wet in November, and
about Christmas there began a frost of many weeks' duration which was
more intense than anyone remembered. It is said to have made the ground
like iron to the depth of nine inches; the ice on all the rivers stopped
the corn mills, trees and shrubs were destroyed, and even the wool fell
out of the sheep's backs. In January 1740 the destitution was such that
subscription-lists were opened in Dublin, Cork, Limerick, Waterford,
Clonmel, Wexford and other places. Bishop Berkeley distributed every
Monday morning twenty pounds sterling among the poor of Cloyne (near Cork)
besides what they got from his kitchen. One morning he came down without
powder on his wig, and all the domestics of the episcopal palace followed
suit[441]. The distress became more acute as the spring advanced. The
potato crop of 1739 had been ruined, not by disease as in 1845-46, but by
the long and intense frost. It was usual at that time to leave the tubers
in the ridges through most of the winter, with the earth heaped up around
them. The frost of December found them with only that slight covering, and
rotted them: "a dirissimo hoc et diuturno gelu penitus putrescebant," says
Dr O'Connell. Besides putrid potatoes, the people ate the flesh of cattle
which had died from the rigours of the season. Owing to the want of sound
seed-potatoes, the crop of 1740 was almost a blank. The summer was
excessively dry and hot. In Dublin, the price of provisions had doubled or
trebled, and some of the poor had died of actual starvation. In July
dysenteries became common, and extended to the richer classes in the
capital. Smallpox was rife at the same time, and peculiarly fatal in Cork.
Dysentery continued in Dublin throughout the autumn and winter of 1740
(the latter being again frosty), and became the prevailing malady
elsewhere.

On 8 February, 1741, Berkeley writes that the bloody flux had appeared
lately in the town of Cloyne, having made great progress before that date
in other parts of the country. A week after he writes (15 Feb.), "Our
weather is grown fine and warm: but the bloody flux has increased in this
neighbourhood, and raged most violently in other parts of this and the
adjacent counties[442]." This prevalence of dysentery, and not of fever,
as the reigning malady of the winter of 1740-41 in Munster is confirmed
by Dr Maurice O'Connell, who says that the typhus of the previous summer
gave place to it. Dysentery in the winter and spring, preceding the fever
of summer, was also the experience in the famine of 1817. Berkeley treated
the subjects of dysentery, not with tar water, but with a spoonful of
powdered resin dissolved in oil by heat and mixed in a clyster of
broth[443].

As the year 1741 proceeded, with great drought in April and May, typhus
fever (which had appeared the autumn before) and dysentery were both
widely epidemic, so that it is impossible to say which form of disease
caused most deaths. In Dublin during the month of March, 1741, the deaths
from dysentery reached a maximum of twenty-one in a week, "though it was
less mortal than in the country, to which the better care taken of the
poor and of their food undoubtedly contributed." Bishop Berkeley writes on
the 19th of May:

    "The distresses of the sick and poor are endless. The havoc of mankind
    in the counties of Cork, Limerick and some adjacent places, hath been
    incredible. The nation probably will not recover this loss in a
    century. The other day I heard one from county Limerick say that whole
    villages were entirely depeopled. About two months since I heard Sir
    Richard Cox say that five hundred were dead in the parish where he
    lives, though in a country I believe not very populous. It were to be
    wished that people of condition were at their seats in the country
    during these calamitous times, which might provide relief and
    employment for the poor[444]."

It was said that there were twenty-five cases of fever in the bishop's own
household, which were cured by the panacea, tar-water, drunk copiously--a
large glass, milk-warm, every hour in bed, the same method being practised
by several of his poor neighbours with equal success[445]. In a "Letter
from a country gentleman in the Province of Munster to his Grace the Lord
Primate[446]" it is said:

    "By a moderate computation, very near one-third of the poor cottiers
    of Munster have perished by fevers, fluxes and downright want.... The
    charity of the landlords and farmers is almost quite exhausted.
    Multitudes have perished, and are daily perishing, under hedges and
    ditches, some by fevers, some by fluxes, and some through downright
    cruel want in the utmost agonies of despair. I have seen the labourer
    endeavouring to work at his spade, but fainting for want of food,"
    etc.

The loss of life must have been great also in Connaught. A letter of 8
July, 1741, from Galway, says: "The fever so rages here that the
physicians say it is more like a plague than a fever, and refuse to visit
patients for any fee whatever[447]." The Galway Assizes were held at
Tuam[448], the races also being transferred to the same neighbourhood, not
without their usual evening accompaniments of balls and plays.

Of this famine and sickness it might have been said, in the stock medieval
phrase, that the living were hardly able to bury the dead[449].

As in later Irish famines, there appear to have been, in 1740-41, three
main types of sickness--dysentery, relapsing fever and typhus fever. In
Dublin, as we know from the direct testimony of Rutty, there was relapsing
fever in 1739, before the distress had well begun, and again in the summer
of 1741, when the worst was over. So much is said of dysentery that we may
well set down to it, and to its attendant dropsy, a great part of the
deaths, as in the famine of 1846-47. But it is probable that true typhus
fever, sometimes of a malignant type, as at Galway, was the chief
infection in 1741, which was the year of its great prevalence in England.
It was characterized by a mild and deceitful onset, like a cold. Spots
were not invariable or essential; they were mostly of a dusky red,
sometimes purple, and sometimes intermixed with miliary pustules.
O'Connell mentions, for Munster, bleeding from the nose, a mottled rash as
in measles, and pains like those of lumbago. One of the worst features of
the Irish epidemic of 1740-41 was the prevalence of fever in the gaols. At
Tralee above a hundred were tried, most of them for stealing the means of
subsistence; the gaol was so full that there was no room to lie down, and
fifty prisoners died in six weeks. Limerick gaol had dysentery and fever
among its inmates, and the judge who held the Munster Circuit died of
fever on his return to Dublin[450].

Rutty says that the fever fell most upon strong middle-aged men, less upon
women, and least of all upon children. The number of orphans was so great
after the famine that Boulter, the Anglican primate, seized the
opportunity to start the afterwards notorious Charter Schools for the
education of the rising generation according to the Protestant creed. In
all the subsequent Irish famines it was the enormous swarms of people
begging at a distance from their own parishes that spread the infection of
fever; and there seems to have been as much of beggary in 1741, when
Ireland was underpeopled with two millions, as in 1817-18, when it was
overpeopled with six millions. A few years after the famine, Berkeley
wrote in 1749:

    "In every road the ragged ensigns of poverty are displayed; you often
    meet caravans of poor, whole families in a drove, without clothes to
    cover, or bread to feed them, both which might be easily procured by
    moderate labour. They are encouraged in their vagabond life by the
    miserable hospitality they meet with in every cottage, whose
    inhabitants expect the same kind reception in their turn when they
    become beggars themselves."

The estimates of the Irish mortality in 1741 varied greatly, as they have
done in the Irish famines of more recent times. One guessed a third of the
cottiers of Munster, another said one-fifth; and it is known that, whereas
in Kerry the hearth-money was paid in 1733 by 14,346, it was paid in 1744
by only 9372[451]. The largest estimates are 200,000 deaths or even
400,000 deaths in all Ireland in a population of less than two millions.
But Dr Maurice O'Connell, who practised in Cork, and saw in Munster the
mortality at its worst, estimated the deaths in all Ireland, in the two
years 1740 and 1741, from fevers, fluxes and absolute want, at 80,000.
Those who saw the famine, fever and dysentery of 1817-18 in a population
increased by three times were inclined to doubt whether even the smallest
estimate of 80,000 for 1740-41 was not too large; but it is clear that the
famished and fever-stricken in the 18th century were in many places
allowed to perish owing to the indifference of the ruling class or the
exhaustion of their means, so that a much higher rate of fatality may be
assumed for that epidemic than for the first of the 19th century Irish
famines.

       *       *       *       *       *

The distress came to an end before the winter of 1741, when food was so
cheap in Dublin that a shilling bought twenty-one pounds of bread. The
subsequent prevalence of typhus fever and dysentery in Ireland, whether
epidemic or endemic, is very imperfectly known to the end of the century.
It may be inferred that there was in that period no epidemic so great as
that of 1740-41; but it is clear from the records kept by Rutty in Dublin
down to 1764, and by Sims in Tyrone to 1772, that the indigenous fevers
and fluxes of the country were never long absent, being more common in
some years than in others[452].

The year 1744 was remarkable for a destructive throat distemper among
children, described elsewhere, and the year 1745 for smallpox dispersed by
swarms of beggars. In 1746 and 1748, the Dublin fever was relapsing in
part, "terminating," says Rutty, "the fifth, sixth, seventh or eighth day
with a critical sweat. A relapse commonly attended, which however was
commonly carried off by a second critical sweat." In 1748, though the
season was sickly, the diseases were not mortal, several of the fevers
being "happily terminated by a sweat the fifth or sixth day." But there
were also fevers of the low kind, sometimes with petechiae, sometimes with
miliary pustules, though not essentially with either. In the autumn of
1754 Rutty begins to adopt the language of the time concerning a "putrid"
constitution, identifying the fever with the dangerous remittents which
Fothergill was then writing about in London; "it is probable that ours was
akin to them and owing to the same general causes." In February, 1755, the
fevers were fatal to many, raising the deaths to double the usual number;
they attacked all ages, were of the low, depressed kind, and commonly
attended with miliary pustules. He again identifies them with the low,
putrid fever in London. From that time on to 1758, Rutty has frequent
references to the same fever, under the names of low, putrid, petechial
and miliary. It was at its worst in 1757, and was marked by the remarkable
tremors described by Johnstone at Kidderminster, as well as by miliary
eruptions and by a gangrenous tendency at the spots where blisters had
been applied. In November, 1757, it was fatal to not a few of the young
and strong in Dublin, "and we received accounts of a like malignity
attending this fever in the country[453]." It was still prevalent in the
North and West of Ireland in the spring of 1758. He describes also an
unusual amount of fever in the end of 1762. Sims, of Tyrone, an
epidemiologist in the same manner as Rutty, does not begin his full annals
until 1765; but he sums up the years from 1751 to 1760 as unhealthy by
agues in spring, dysenteries and cholera morbus in autumn, and "low,
putrid or nervous fevers throughout the year[454]." He adds:

    "To the unhealthiness of these years the bad state and dearth of
    provisions might not a little contribute; the poor, being incapable to
    procure sufficient sustenance, were often obliged to be contented with
    things at which nature almost revolted; and even the wealthy could not
    by all their art and power render wholesome those fruits of the earth
    which had been damaged by an untoward season."

Much of the distress, however, was owing to the continual spread of
pasture-farming, which made the labour of villagers unnecessary[455].

The nearest approach to a great Irish epidemic in the second half of the
18th century was in 1771, as described by Sims, the type of fever being
clearly the same low, putrid or nervous fever, with offensive sweats and
muscular tremors, that was commonly observed in England also in the middle
third of the 18th century. Early in the summer of 1771 a fever began to
appear which, as autumn advanced, raged with the greatest violence; nor
was it overcome by a severe winter. It claimed the prerogative of the
plague, almost all others vanishing from before its presence. It began
twelve months sooner in the eastern parts of the kingdom, pursuing a
regular course from East to West. Some symptoms suggest cerebro-spinal
fever.

    The symptoms were languor, precordial oppression, want of appetite,
    slight nausea, pains in the head, back and loins, a thin bluish film
    on the tongue, turbid urine, eyes lifeless and dejected. After the
    fourth day, constant watchfulness, the eyes wild, melancholy,
    sometimes with bloody water in them, constant involuntary sighing, the
    tendons of the wrists tremulous, the pulse quick and weak, most
    profuse sweats, small dun petechiae principally at the bend of the arm
    and about the neck. At the height of the fever, on the ninth or tenth
    day, the tremulousness of the wrists spread to all the members,
    "insomuch that I have seen the bed-curtains dancing for three or four
    days to the no small terror of the superstitious attendants, who on
    first perceiving it, thought some evil spirits shook the bed. This
    agitation was so constant a concomitant of the fever as to be almost a
    distinguishing symptom." The patients lay grinding their teeth; when
    awake, they would often convulsively bite off the edges of the vessel
    in which drink was given them. They knew no one, their delirium being
    incessant, low, muttering, their fingers picking the bed covering. The
    face was pale and sunk, the eyes hollow, the tongue and lips black and
    parched. Profuse clammy sweats flowed from them; the urine was as if
    mixed with blood: the stools were involuntary. Petechiae almost black
    came out, having an outer circle with an inner dark speck; sometimes
    there were the larger vibices. Bleedings at the nose were frequent.
    Those who were put to bed and sweated almost all died. Death took
    place about the 13th day.

Curiously enough this disease showed itself even among the middle ranks of
the people, especially those who lived an irregular life, used flesh diet
and drank much. Among the poorer sort, who used vegetable food, the fever
was more protracted and less malignant, but in the winter and spring it
made much greater havoc among them. "Bleeding, that first and grand
auxiliary of the physician in treating inflammatory disorders, seemed here
to lose much of its influence." It was, indeed, the long prevalence of
this low or nervous type of fever in Britain and Ireland in the middle of
the 18th century that drove blood-letting in fevers out of fashion until
the return of a more inflammatory type (often relapsing fever) in the
epidemic of 1817. In 1770, while such fevers more or less nervous, putrid,
miliary, were beginning to be prevalent among the adults, there was a good
deal of "worm fever" among children. They suffered from heat, thirst,
quick, full pulse, vomiting, coma, and sometimes slight convulsions,
universal soreness to the touch, and a troublesome phlegmy cough. When not
comatose they were peevish. The fever was remitting, the cheeks being
highly flushed at its acme, pale in its remission. It lasted several days,
but seldom over a week, nor was it often fatal. In children under five or
six years, it could hardly be distinguished from hydrocephalus
internus[456]. The same association of the worm fever or remittent fever
of children with the putrid or nervous fever of adults had been noticed at
Edinburgh in 1735. Neither the fever of the adults nor that of the
children will be found, on close scrutiny, to have had much in common with
our modern enteric fever.


The Epidemic Fevers of 1799-1801.

Sims left Tyrone to practise as a physician in London, and with his
departure what seems to have been the only contemporary record of
epidemics in Ireland ceased. The last quarter of the 18th century in
Ireland had probably as much epidemic fever as in England; but it is not
until the years 1797-1801 that we again hear of fever and dysentery, on
the testimony of the records of the Army Medical Board, of the Dublin
House of Industry, and of the Waterford Fever Hospital. At the end of the
year 1796 the health of the regiments in Ireland was everywhere good; but
in December of that year, and in January 1797, the poor in the towns began
to suffer more than usual from fever, and in the course of the year 1797
fever appeared in several cantonments of troops--at Armagh as early as
February or March, at Limerick, at Waterford and in Dublin[457]. The
summer and autumn were unusually wet, so that the peasantry of the
southern and western counties were unable to lay in their usual supply of
turf for fuel. In the course of the winter 1797-98 a considerable increase
of fever and dysentery was remarked among them, and these two maladies
appeared in various regiments in the early months of 1798. This was the
year of the rebellion in the south-east of Ireland, pending the efforts
for the union with England. The British troops were much engaged with the
insurgents throughout the summer, and got rid in great part of the
maladies of their quarters while they were campaigning. But in the end of
the year fever began to spread, both among the inhabitants and among the
troops. It was nothing new for English and Scots regiments to suffer from
fever or dysentery during the greater part of their first year in Ireland;
but the epidemics in the end of 1798 were more than ordinary. The
Buckinghamshire Militia quartered in the Palatine Square of the Royal
barracks, Dublin, lost by "malignant contagious fever" 13 men in October,
13 in November, and 15 in December. From November to January, the Warwick
regiment suffered greatly in the same barrack. The Herefordshire regiment,
833 strong, lost 47 men at Fermoy, mostly from fever contracted in bad
barracks; the Coldstream Guards at Limerick, the 92nd regiment at Athlone,
and the Northamptonshire Fencibles at Carrick-on-Shannon, also lost men by
fever. In July, 1799, not a single regiment in Ireland was sickly; but a
wet and very cold autumn made a bad harvest, aggravating the distresses of
the poor and causing much sickness, which the troops shared. The county of
Wexford, the principal scene of the rebellion, suffered most, and next to
it the adjacent county of Waterford. The fever-hospital of the latter
town, the earliest in Ireland[458], was projected in 1799; the statement
made in the report of a plan for the new charity, that fifteen hundred
dependent persons suffered from contagious fever every year there, showed
that the need for it was nothing new, although hardly a tenth part of the
number sought admission to the hospital when it was at work. Next year,
1800, the managers of the newly-opened hospital gave some particulars of
the causes of fever in Waterford--want of food, causing weakness of body
and depression of mind, but above all the excessive pawning of clothes and
bedding, whereby they suffered from cold and slept for warmth several in a
bed. In the winter and spring of 1799-1800 the poor of Waterford had
epidemic among them fever and dysentery, as well as smallpox. In
Donagh-a-gow's Lane nine persons died of dysentery between October 1799
and March 1800. The harvest of 1800 was again a failure, from cold and
wet, bread and potatoes being dear and of bad quality. In the autumn and
winter the distress, with the attendant fever and dysentery, became worse.
At that time in Dublin all fever cases among the poor were received into
the House of Industry (the Cork Street and Hardwick Hospitals were soon
after built for fever-cases), at which the deaths for four years were as
follows:

          Died in the Dublin
  Year    House of Industry

  1799         627
  1800        1315
  1801        1352
  1802         384

The enormous rise of the deaths in 1800 and 1801 shows how severe the
epidemic of fever must have been. Compared with the epidemic of 1817-18,
it has few records, perhaps because the political changes of the union
engrossed all attention. But the significant fact remains that the deaths
in the Dublin House of Industry in 1800 and 1801 were nearly as many as in
all the special fever-hospitals of Dublin during the two years, 1 Sept.
1817 to 1 Sept. 1819. At Cork, in 1800, there were 4000 cases of fever
treated from the Dispensary; at Limerick the state of matters is said to
have been as bad as in the great famine of 1817-18; and there is some
reason to think that the same might have been said of other places. All
the relief in 1800-1801 came from private sources, the example of Dublin
in opening soup-kitchens having been followed by other towns. The troops
shared in the reigning diseases, especially at Belfast and Dublin; in the
latter city, the spotted fever was severe both among the military and all
ranks of the civil population in August, 1801. The harvest of 1801 was
abundant, and the fever quickly declined. It had been often of the
relapsing type[459]. Dysentery appeared in the end of September, and
became severe in many places in October and November, being attributed to
the rains after a long tract of dry, hot weather. Ophthalmias and
scarlatinal malignant sore-throats were common at the same time.


The Growth of Population in Ireland.

When the history of the great famine and epidemic sicknesses of 1817-18
was written, it was found that this calamity had fallen upon a population
that had grown imperceptibly until it had reached the enormous figure of
over six millions, the census of 1821 showing the inhabitants of Ireland
to be 6,801,827. The increase from an estimated one million and
thirty-four thousand in 1695 was, according to Malthus, probably without
parallel in Europe. According to Petty, the inhabitants in 1672 numbered
about one million one hundred thousand, living in two hundred thousand
houses, of which 160,000 were "wretched, nasty cabins without chimney,
window or door-shut, and wholly unfit for making merchantable butter,
cheese, or the manufacture of woollen, linen or leather." In 1695, the war
on behalf of James II. having intervened, the population as estimated by
South was 1,034,000. When the people were next counted in 1731, by a not
incorrect method in the hands of the magistracy and Protestant clergy,
they were found to have almost doubled, the total being 2,010,221. This
increase, the exactness of which depends naturally upon the accuracy of
Petty's and South's 17th century estimates, had been made notwithstanding
the famines and epidemics of 1718 and 1728, and an excessive emigration,
mostly of Protestants, to the West Indian and American colonies, which was
itself attended by a great loss of life through disease. For the rest of
the 18th century, the estimates of population are based upon the number of
houses that paid the hearth-tax. In the following figures six persons are
reckoned to each taxed hearth:

  Year    Persons

  1754   2,372,634
  1767   2,544,276
  1777   2,690,556
  1785   2,845,932

The hearth-money was not altogether a safe basis of reckoning, for the
reason that many were excused it on account of their poverty by
certificate from the magistrates, and that hamlets in the hills, perhaps
those which held their lands in rungale or joint-lease, often compounded
with the collectors for a fixed sum; so that cabins might multiply and no
more hearth-tax be paid[460]. It is probable that a considerable increase
had taken place which was not represented in the books of the
tax-collectors; for in 1788, only three years from the last date given,
the number of hearths suddenly leapt up to the round figure of 650,000
(from 474,322), giving a population of 3,900,000, at the rate of six
persons to a cabin or house. But it is undoubted that a new impulse was
given to population in the last twenty years of the 18th century, firstly
by the bounties on Irish corn exported, dating from 1780, which caused
much grazing land to be brought under the plough, and secondly by the
gradual removal, after 1791, of various penalties and disabilities which
had rested on the Roman Catholics since the reign of Anne, affecting their
tenure of land, and serving in various ways to repress the multiplication
of families. Accordingly we find the hearths rated in 1791 at the number
of 701,102, equal to a population of 4,206,612. The estimates or
enumerations from 1788, to the census of 1831, show an increase as
follows:

  Year    Persons

  1788   3,900,000
  1791   4,206,612
  1805   5,395,456
  1812   5,937,856
  1821   6,801,827
  1831   7,784,539

The secret of this enormous increase was the habit that the Irish
peasantry had begun to learn early in the 17th century of living upon
potatoes. From that dietetic peculiarity, it is well known, much of the
economic and political history of Ireland depends. At the time when it was
losing its tribal organization (rather late in the day, although not so
late as in the Highlands of Scotland), the country was in a fair way to
pass from the pastoral state to the agricultural and industrial. It is
conceivable that, if Ireland had peacefully become an agricultural
country, wheaten bread would have become the staple food of the people, as
in England in early times and again in later times; or that the standard
might have been oatmeal in the northern province, as in Scotland: in which
case one may be sure that the population would not have increased as it
did. "Since the culture of the potatoes was known," says a topographer of
Kerry in 1756, "which was not before the beginning of the last century,
the herdsmen find out small dry spots to plant a sufficient quantity of
those roots in for their sustenance, whereby considerable tracts of these
mountains are grazed and inhabited, which could not be done if the
herdsmen had only corn to subsist on[461]." Twenty years later Arthur
Young found an enormous extension of potato culture, the pigs being fed on
the surplus crop[462]. The motive, on the part of the landlord or the
farmer, was to have the peat bogs on the hill-sides reclaimed by the
spade; the surface of peat having been removed, a poor subsoil was
exposed, which might be made something of after it had grown several crops
of potatoes, but hardly in any other way. Another motive was political;
namely, the multiplication by landlords of forty-shilling freeholder
dependent votes among the Catholics as soon as they became free to
exercise the franchise[463].

Malthus relied so much upon statistics, that he found the case of Ireland,
notable though it was, little suited to his method, and dismissed it in a
few sentences. But he indicated correctly the grand cause of
over-population:

    "I shall only observe, therefore, that the extended use of potatoes
    has allowed of a very rapid increase of population during the last
    century (18th). But the cheapness of this nourishing root, and the
    small piece of ground which, under this kind of cultivation, will in
    average years produce the food for a family, joined to the ignorance
    and depressed state of the people, which have prompted them to follow
    their inclinations with no other prospect than an immediate bare
    subsistence, have encouraged marriage to such a degree that the
    population is pushed much beyond the industry and present resources of
    the country; and the consequence naturally is, that the lower classes
    of people are in the most impoverished and miserable state."

In another section he showed that the cheapness of the staple food of
Ireland tended to keep down the rate of wages:

    "The Irish labourer paid in potatoes has earned perhaps the means of
    subsistence for double the number of persons that could be supported
    by an English labourer paid in wheat.... The great quantity of food
    which land will bear when planted with potatoes, and the consequent
    cheapness of the labour supported by them, tends rather to raise than
    to lower the rents of land, and as far as rent goes, to keep up the
    price of the materials of manufacture and all other sorts of raw
    produce except potatoes. The indolence and want of skill which usually
    accompany such a state of things tend further to render all wrought
    commodities comparatively dear.... The value of the food which the
    Irish labourer earns above what he and his family consume will go but
    a very little way in the purchase of clothing, lodging and other
    conveniences.... In Ireland the money price of labour is not much more
    than the half of what it is in England."

Lastly, in a passage quoted in the sequel, he showed how disastrous a
failure of the crop must needs be when the staple was potatoes; the people
then had nothing between them and starvation but the garbage of the
fields[464].

What the growth of population could come to on these terms was carefully
shown for the district of Strabane, on the borders of Tyrone and Donegal,
by Dr Francis Rogan, a writer on the famine and epidemic fever of
1817-18[465]. Strabane stood at the meeting of the rivers Mourne and Fin
to form the Foyle; and in the three valleys the land was fertile. All
round was an amphitheatre of hills, in the glens of which and among the
peat bogs on their sides was an immense population. The farms were small,
from ten to thirty acres, a farm of fifty acres being reckoned a large
holding. The tendency had been to minute subdivisions of the land, the
sons dividing a farm among them on the death of the father:

    "The Munterloney mountains," says Rogan, "lie to the south and east of
    the Strabane Dispensary district. They extend nearly twenty miles, and
    contain in the numerous glens by which they are intersected so great a
    population that, except in the most favourable years, the produce of
    their farms is unequal to their support. In seasons of dearth they
    procure a considerable part of their food from the more cultivated
    districts around them; and this, as well as the payment of their
    rents, is accomplished by the sale of butter, black cattle, and sheep,
    and by the manufacture of linen cloth and yarn, which they carry on to
    a considerable extent."

These small farmers dwelt in thatched cottages of three or four rooms, in
which they brought up large families[466]. Besides the farmers, there were
the cottiers, who lived in cabins of the poorest construction, sometimes
built against the sides of a peat-cutting in the bog. The following table
shows the proportion of cottiers to small farmers on certain manors of the
Marquis of Abercorn, near Strabane, at the date of the famine in 1817-18
(Rogan, p. 96):

                   Number of Families
     Manor         Farmers    Cottiers

  Derrygoon          368        335
  Donelong           243        322
  Magevelin and
  Lismulmughray      319        668
  Strabane           302        415
  Cloughognal        328        279

The cottiers rented their cabins and potato gardens from the farmers,
paying their rent, on terms not advantageous to themselves, by labour on
the farm. For a time about the beginning of the century the practice by
farmers of taking land on speculation to sublet to cottiers was so common
that a class of "middlemen" arose. One pamphleteer during the distress of
1822 speaks of the class of middlemen as an advantage to the cottiers, and
regrets that they should have been personally so disreputable as to have
become extinct. It is not easy to understand how they served the interests
of the cottiers: for the latter were answerable to the landlord for the
middleman's rent, and were themselves over-rented and underpaid for their
labour. The system of middlemen did not in matter of fact answer; they
hoped to make a profit from the tenants under them, and neglected to work
on their own farms; it appears that they were a drunken class, and that
they were at length swallowed up in bankruptcy. After the first quarter of
the century the cottiers and the landlords (with the agents and the tithe
proctors) stood face to face; but at the date of the famine of 1817 there
was subletting going on, of which Rogan gives an instructive instance in
his district of Ulster[467].

Under this system of subdividing farms and subletting potato gardens with
cabins to cottiers, the following enormous populations had sprung up in
four parishes within the Dispensary district of Strabane and in four
manors of the Marquis of Abercorn adjoining them, but not included in the
Dispensary District:

  Town of Strabane                         3896
  Parish of Camus                          2384
     "   "  Leck                           5092
     "   "  Urney                          4886
  Manor of Magevelin and Lismulmughray     5548
  Manor of Donelong                        3126
     "  "  Derrygoon                       2568
     "  " Part of Strabane                 2796

In the language of the end of the 19th century, this would have been
called a "congested district" of Ireland; but all Ireland was then
congested to within a million and a half of the utmost limit, so that the
famine, which we shall now proceed to follow in this part of Ulster, has
to be imagined as equally severe in Connaught, in Munster, and even in
parts of Leinster.


The Famine and Fevers of 1817-18.

The winter of 1815-16 had been unusually prolonged, so that the sowing and
planting of 1816 were late. They were hardly over when a rainy summer
began, which led to a ruined harvest. The oats never filled, and were
given as green fodder to the cattle; in wheat-growing districts, the grain
sprouted in the sheaf; the potatoes were a poor yield and watery; such of
them as came to the starch-manufacturers were found to contain much less
starch than usual. The peat bogs were so wet that the usual quantity of
turf for fuel was not secured[468]. This failure of the harvest came at a
critical time. The Peace of Paris in 1815 had depressed prices and wages
and thrown commerce into confusion. During the booming period of
war-prices, from 1803 to 1815, farms and small holdings had doubled or
even trebled in rent, and had withal yielded a handsome profit to the
farmers and steady work to the labourers. When the extraordinary war
expenditure stopped, this factitious prosperity came to a sudden end. The
sons of Irish cottiers were not wanted for the war, and the daughters were
no longer profitable as flax-spinners to the small farmers. Weavers could
hardly earn more than threepence a day, and labourers who could find
employment at all had to be content with fourpence or sixpence, without
their food. A stone of small watery potatoes cost tenpence; but the value
of cattle fell to one-third, and butter brought little. By Christmas the
produce of the peasants' harvest of 1816 was mostly consumed. "Many
hundred families holding small farms in the mountains of Tyrone," says
Rogan, "had been obliged to abandon their dwellings in the spring of 1817
and betake themselves to begging, as the only resource left to preserve
their lives[469]." At Galway, in January, a mob gathered to stop the
sailing of a vessel laden with oatmeal. At Ballyshannon the peasants took
to the shore to gather cockles, mussels, limpets and the remains of fish.
In some parts the seed potatoes were taken up and consumed. The people
wandered about in search of nettles, wild mustard, cabbage-stalks and the
like garbage, to stay their stomachs. It was painful, says Carleton, to
see a number of people collected at one of the larger dairy farms waiting
for the cattle to be blooded (according to custom), so that they might
take home some of the blood to eat mixed with a little oatmeal. The want
of fuel caused the pot to be set aside, windows and crevices to be
stopped, washing of clothes and persons to cease, and the inmates of a
cabin to huddle together for warmth. This was far from being the normal
state of the cottages or even of the cabins, but cold and hunger made
their inmates apathetic. Admitted later to the hospitals for fever, they
were found bronzed with dirt, their hair full of vermin, their ragged
clothes so foul and rotten that it was more economical to destroy them and
replace them than to clean them.

Some months passed before this state of things produced fever. The first
effect of the bad food through the winter, such as watery potatoes eaten
half-cooked for want of fuel, had been dysentery, which became common in
February, and was aggravated by the cold in and out of doors. It was
confined to the very poorest, and was not contagious, attacking perhaps
one or two only in a large family. Comparatively few of those who were
attacked by it in the country places came to the Strabane Dispensary; but
the dropsy which often attended or followed it brought in a larger number.
The following table of cases at the Dispensary shows clearly enough that
dysentery and dropsy preceded the fever, which became at length the chief
epidemic malady[470]:

_Cases at Strabane Dispensary._

    1817       Dropsy   Dysentery   Typhus

  June            23        2         10
  July           107       31         60
  August          40       22        206
  September        9       23        287

At a few of the larger towns in each of the provinces typhus had risen in
the autumn of 1816 somewhat above the ordinary low level which
characterized the years from 1803 to 1816 in Ireland as well as in
Britain. At that time there was steadily from year to year a certain
amount of typhus in the poorest parts of the towns and here or there among
the cabins of the cottiers. Statistically this may be shown by the table
of regular admissions to the fever hospitals of some of the chief towns
from the date of their opening.

_Admissions to Irish Fever Hospitals, 1799-1818._

           Dublin,   Dublin    Cork      Waterford  Limerick   Kilkenny
          Cork St.  House of   Fever       Fever     Fever      Fever
  Year    Hospital  Industry  Hospitals  Hospital   Hospital   Hospital

  1799       --        --       --          146        --         --
  1800       --        --       --          409        --         --
  1801       --        --       --          875        --         --
  1802       --        --       --          419       446         --
  1803       --        --      254          188        86         73
  1804      415        82      190          223        95         80
  1805     1024       709      200          297        90         69
  1806     1264      1276      441          165        86         56
  1807     1100      1289      191          166        84         81
  1808     1071      1473      232          157       100         96
  1809     1051      1176      278          222       109        116
  1810     1774      1474      432          410       120        135
  1811     1471      1316      646          331       196        153
  1812     2265      2006      617          323       146        156
  1813     2627      1870      550          252       227        183
  1814     2392      2398      845          175       221        236
  1815     3780      2451      717          403       394        249
  1816     2763      1669     1026          307       659        162
  1817     3682      2860     4866          390      2586       1100
  1818     7608     17894    10408         2729      4829       1924

In 1812 the first step was taken towards the adoption of the Poor Law,
namely the division of the country into Dispensary Districts, which
remained the units of charitable relief until 1839, when the old English
system of a poor-rate and parochial Unions was applied to Ireland. During
that intermediate period much was left to the medical profession, which
contained many well-educated and humane men, to the priests and clergy,
and to charitable persons among the laity. There was fever in many places
where there were no fever hospitals. A physician at Tralee reported that
the back lanes of the town, crowded with cabins, were seldom free from
typhus. Rogan gives two instances from the Strabane district in the summer
and winter of 1815, at a time when the district was remarkably healthy. A
beggar boy was given a night's lodging by a cottier at Artigarvan, three
miles from Strabane. Next morning he was too ill to leave; he lay three
weeks in typhus, and gave the disease to twenty-seven persons in the eight
cabins which formed the hamlet. A few months after, about a mile from
Strabane, a mother fell into typhus and was visited many times by her two
married daughters and by others of her children at service in the
neighbourhood. Nineteen cases were traced to this focus; "but the actual
number attacked was probably more than three times this, as the disease,
when once introduced into the town, spread so widely among the lower
orders as to create general alarm, and led to the establishment of the
small fever ward attached to the Dispensary." It was in April, 1816, that
this was done, two rooms, each with four beds, having been provided at
Strabane for fever cases; but at no time until the summer of 1817 were
they all occupied at once.

The epidemic really began there in May, 1817, in a large house which had
been occupied during the winter by a number of families from the
mountains; they had brought no furniture with them, nor bedding except
their blankets, and lay so close together as to cover the floors. Each
room was rented at a shilling a week, the tenant of a room making up his
rent by taking in beggars at a penny a night. The floors and stairs were
covered with the gathered filth of a whole winter; the straw bedding,
never renewed, was thrown into a corner during the day to be spread again
at night. Every crevice was stopped to keep out the cold; the rain came in
through the roof, the floors were damp, and the cellars of the house full
of stagnant water turned putrid. Meanwhile more than a fourth part of the
families resident in Strabane, to the number of 1026 persons, were being
fed from a soup-house opened early in the spring of 1817, while there were
others equally destitute but too proud to ask relief. The rumour of this
charity soon brought crowds of people from the surrounding country, with
gaunt cheeks, says Carleton, hollow eyes, tottering gait and a look of
"painful abstraction" from the unsatisfied craving for food. In the crowd
round the soup-shop, the timid girl, the modest mother, the decent farmer
scrambled "with as much turbulent solicitation and outcry as if they had
been trained, since their very infancy, to all the forms of impudent cant
and imposture." These soup-shops were opened in all the Irish towns. At
Strabane some of the richer class lent money to procure supplies, for sale
at cost price, of oatmeal, rice and rye-flour, the last being in much
request in the form of loaves of black bread.

The fever, having begun among the houseful of vagrants above mentioned,
made slow progress until June, when it spread through the town, and in the
autumn became a serious epidemic. Meantime the soup-kitchen was closed,
the supplies having ceased, and the country people returned to their
cabins carrying the infection of typhus everywhere with them. By the
middle of October, 1817, the epidemic was general in the country round
Strabane.

The following table shows the rise and decline of the epidemic of typhus
in the town itself.

_Cases of Fever attended from Strabane Dispensary_[471].

           1817   1818

  Jan.       9     83
  Feb.      13     46
  March      6     60
  April     13     48
  May        3     39
  June      10     71
  July      60    106
  Aug.     206     90
  Sept.    287     57
  Oct.     233     49
  Nov.     193     40
  Dec.     140     38

The exact particulars from the Dispensary district of Strabane show
clearly how famine in Ireland is related to fever. The epidemic of typhus
was an indirect result of the famine, and was due most of all to the
vagrancy which a famine was bound to produce in Ireland, in the absence of
a Poor Law. In the spring of 1817, said a gentleman near Tralee, "the
whole country appeared to be in motion." "It was lamentable," said Peel,
in the Commons debate, on 22 April, 1818, "at least it was affecting, that
this contagion should have arisen from the open character and feelings of
hospitality for which the Irish character was so peculiarly remarkable."
They gathered also at funerals, and, as Graves said of a later epidemic,
they were "scrupulous in the performance of wakes." The concourse of
people at the daily distributions of soup was another cause of spreading
infection, many of them having come out of infected houses[472]. Of such
houses, the lodging-houses of the towns, we have several particular
instances. At Strabane, there were four such, which sent ninety-six
patients to the fever hospital in eighteen months. At Dublin, a house in
Cathedral-lane sent fifty cases to the fever hospitals in a twelvemonth;
the house No. 4, Patrick's close sent thirty cases in eight months; No.
52-1/2 Kevin-street sent from five rooms nineteen persons in six weeks.

The spread of the disease was much aided by the ordinary annual migration
of harvest labourers. It was the custom every year for cottiers in
Connaught to shut up their cabins after the potatoes were planted, and to
travel to the country round Dublin in search of work at the hay and corn
harvests, leaving their families to beg; in the same way there was an
annual migration from Clare to Kilkenny, from Cavan, Longford and Leitrim
into Meath, and from Derry into Antrim, Down and Armagh[473]. In the
summer of 1817 some parishes of Derry were left with only four or five
families. The keeper of the bridge at Toome, over the Bann, counted more
than a hundred vagrants every day passing into Antrim, from the middle of
May to the beginning of July; and the same might have been seen at the
other bridge over the Bann at Portglenone.

As the spread of contagion came to be realized, the ordinary hospitality
to vagrants ceased. Rogan was struck with the apathy which at length arose
towards sick or dead relatives; even parents became callous at the death
of their children (of whom many died from smallpox). "For some time," he
says, "it has been as difficult for a pauper bearing the symptoms of
ill-health to procure shelter for the night, as it was formerly rare to be
refused it." In Strabane they extemporised a poor's fund by voluntary
contributions of L30 a month, by means of which eighty poor families were
kept from begging in the streets. In Dublin there was so much alarm of
infection from the number of beggars entering the shops that trade was
checked. The following, relating to a town in the centre of Ireland, is an
extreme instance of the panic which the idea of contagion at length
caused:

    "In Tullamore, when measures were proposed for arresting the progress
    of fever, by the establishment of a fever hospital, so little was the
    alarm that the design was regarded by most of the inhabitants as a
    well-intentioned project, uncalled for by the circumstances of the
    community. But when the death of some persons of note excited a sense
    of danger, alarm commenced, which ended in general dismay: military
    guards were posted in every avenue leading to this place, for the
    purpose of intercepting sickly itinerants. The town, from the shops of
    which the neighbouring country is supplied with articles of all kinds,
    was thus in a state of blockade. It was apprehended that woollen and
    cotton goods might be the vehicles of infection, and all intercourse
    between the shops and purchasers was suspended. Passengers who
    inadvertently entered the town considered themselves already victims
    of fever. No person would stop at the public inns, nor hire a carriage
    for travelling; in a word all communication between the town and the
    adjacent country was completely interrupted. Apprehension did not
    proceed in most other places to the same extent as in Tullamore[474]."

Several isolated places escaped the epidemic of typhus, either for a time
or altogether. The island of Rathlin, seven miles to the west of Antrim,
which was as famished as the mainland, had no typhus at the time when it
was epidemic along the nearest shore; the island of Cape Clear, at the
southernmost point of Ireland, had a similar experience. The whole county
of Wexford, where the soil was dry and the harvest of 1816 had been fair,
kept free from typhus until 1818, partly because it was out of the way of
vagrants. The town of Dingle, at the head of a bay in Kerry, with old
Spanish traditions, was totally free from typhus at a time when its near
neighbour, Tralee, was full of it, the immunity being set down to the
well-being of the population from their industry at the linen manufacture
(and fisheries) and their thrifty habits. But the counties of Wexford and
Waterford, and other places more or less exempted in 1817, had a full
share of the epidemic in 1818, which was the season of its greatest
prevalence in most parts of Ireland except Ulster. The harvest of 1817 had
been little better than that of the year before, although the potato crop
was hardly a failure. The fine summer of 1818 brought out crowds of
vagrants who slept in the open, and, when they took the infection, were
placed in "fever-huts" erected near the roads[475]. The harvest of that
year was abundant, and by the end of 1818 the epidemic had declined
everywhere except in Waterford.

The most carefully kept statistics of the sickness and mortality were
those by Rogan for the Strabane Dispensary district, and the adjoining
manors of the Marquis of Abercorn, for each of which a private dispensary
was established under the care of a physician.

    Abstract of Returns of the Dispensary district of Strabane, shewing
    the numbers ill of fever from the commencement of the epidemic in the
    summer of 1817, till the end of September, 1818, the numbers labouring
    under the fever at that date, and the mortality caused by the disease
    (Rogan, p. 72).

                        Population   Ill of Fever   Dead   Remaining ill

        Town of Strabane    3896         639         59          13
        Parish of Camus     2384         685         61          37
          "    "  Leek      5092        1462         96          57
          "    "  Urney     4886        1381         86          42
                          ---------------------------------------------
                          16,258        4167        302         149

    Similar return for those parts of the Marquis of Abercorn's estates
    not within the Dispensary district:

                                        Ill of fever
           Manors         Population   (to Oct. 1818)   Dead

        Magevelin and}
        Lismulmughray}       5548           1666         101
        Donelong             3126           1217          71
        Derrygoon            2568           1215          90
        Part of Strabane     2796            990          75
                           -----------------------------------
        Totals             14,038           5088         337

The proportion of attacks in these tables for a part of Tyrone, one-third
to one-fourth of the whole population, is believed to have been a fair
average for the whole of Ireland. Each attack, with the weakness that it
left behind, lasted about six weeks; cases would occur in a family one
after another for several months; in some cottages, says Rogan, only the
grandmother escaped.

One hundred thousand cases were known to have passed through the
hospitals. Harty thought that seven times as many were sick in their
cabins or houses, making 800,000 cases in all Ireland in two years; Barker
and Cheyne estimated the whole number of cases at a million and a half
(1,500,000). The mortality was comparatively small. It comes out greater
in the tables for the Strabane district than anywhere else in Ireland
except the hospital at Mallow. The following table, compiled by Harty,
shows how widely the fatality ranged (if the figures can be trusted), from
place to place and from season to season:

    Proportions of fatal cases of typhus in the chief hospitals of Ireland
    1817, 1818 and 1819 (Harty)[476].

                     1817      1818      1819     Average
                    One in    One in    One in    One in

        Dublin      14-1/2     24       18-1/4     20
        Kilkenny    16-1/2     14-5/6   12-2/3     14-1/4
        Dundalk     20-6/7     54       25         30
        Belfast     19-1/5     15-4/5   19         17-1/3
        Newry       21-1/9     34-1/2   13-1/2     26
        Cork        29         35       35         33-1/5
        Limerick    13-1/2     15-2/3   30-2/3     16-1/2
        Waterford   27-1/3     25       23-1/3     24-3/5
        Clonmel     27         18       18-1/4     19-1/3
        Mallow      22-1/2      9-3/5              12
        Killarney   74         67       33         62
        Tralee      20-3/4     69       43         39

What this meant to particular places will appear from some instances. In
the parish of Ardstraw, Tyrone, with a population of about twenty
thousand, 504 coffins are stated by the parish minister to have been given
to paupers in eighteen months. The burials were about twice as many as in
ordinary years, according to the register of the Cathedral churchyard of
Armagh:

        1815                  247 burials
        1816                  312    "
        1817                  571    "
        1 May-25 Dec. 1818    463    "

    Of the 463 burials in eight months of 1818, there were 165 from fever,
    180 from smallpox, and 118 from other causes.

Barker and Cheyne make the whole mortality of the two years from fever and
dysentery to have been 65,000; Harty makes it 44,300. But not more than a
sixth part of the latter total were registered deaths, and the estimate of
the whole may be wide of the mark. In the county of Kerry, ten Catholic
priests died of it. Many medical men took it, as well as apothecaries and
nurses, and several physicians died, of whom Dr Gillichan, of Dundalk, a
young man of good fortune, made a notable sacrifice of his life. Everyone
bore willing testimony to the devotion of the Roman Catholic clergy. Some
harrowing incidents were reported, such as those from Kanturk, in county
Cork:

    Dr O'Leary visited a low hut in which lay a father and three children:
    "There were also two grown-up daughters who were obliged to remain for
    several nights in the open air, not having room in the hut till the
    father died, when the stronger of the two girls forced herself into
    his place. On the road leading to Cork, within a mile of this town, I
    visited a woman of the name of Vaughan, labouring under typhus; on her
    left lay a child very ill, at the foot of the bed another child just
    able to crawl about, and on her right the corpse of a third child, who
    had died two days previously, and which the unhappy mother could not
    get removed. When the grant arrived from Government, I visited a man
    of the name of Brahill near the chapel gate, who with his wife and six
    children occupied a very small house, all of them ill of fever with
    the exception of one boy, who was so far convalescent as to creep to
    the door to receive charity from the passengers."

    Infants rarely took the fever. Dr Osborne, of Cork, stated that in one
    instance a physician in attendance on the poor had to separate two
    children from the bed of their dead brother, the father and mother
    being already in a fever hospital; in another instance, he had to
    remove an infant from the corpse of its mother who had just expired in
    a hovel[477].

Nosologically the epidemic of 1817-18 presented several features of
interest. It began with dysentery, and ended with the same in autumn,
1818. It was in great part typhus, but towards the end of the epidemic,
in Dublin, at Strabane, and doubtless elsewhere, it changed to relapsing
fever, that is to say, the sick person "got the cool" about the fifth or
seventh day instead of the tenth or twelfth, but was apt to have one or
more relapses or recurrences of the fever. The relapsing type was milder
in its symptoms and was more rarely fatal. The average fatality of typhus
was much less than in ordinary years, while a good many of the fatal cases
came from the richer classes, to whom the contagion reached, the
proportion of fatalities among them being noted everywhere as very high,
up to one death in three or four cases[478]. The fatalities were most
common, as usual, at ages from forty to sixty. A full share of the women
and children took the fever, perhaps an excess of women, allowing for
their excess in the population. The following were the numbers at each
period of life among 18,891 cases treated in the hospitals of Dublin and
Waterford:

  Years of age  1-10  10-20  20-30  30-40  40-50  50 and over

  Cases         2426  6116    5230   2476   1415    1228

The action of the English Government was thought by some to have been
apathetic. Nothing was done to check the export of corn from Irish ports.
Peel, who held the office of Irish Secretary in 1817, was probably
actuated in this by the same constitutional and economic considerations
which led him, as Prime Minister in 1845, to refuse O'Connell's demand for
a proclamation against the export of corn.

Carleton says that there were scattered over the country "vast numbers of
strong farmers with bursting granaries and immense haggards," and that
long lines of provision carts on their way to the ports met or
intermingled with the funerals on the roads, the sight of which
exasperated the famishing people. Several carts were attacked and
pillaged, some "strong farmers" were visited, and here or there a "miser"
or meal-monger was obliged to be charitable with a bad grace; but on the
whole there was little lawlessness, less indeed than in England in 1756
and 1766, or in Edinburgh in 1741. In September, 1817, Peel commissioned
four Dublin physicians to visit the respective provinces and report on the
causes and extent of the epidemic fever. On 22 April, 1818, Sir John
Newport, member for Waterford, for whom Dr Harty had been collecting
information, raised a debate on the epidemic in the House of Commons, and
moved for a Select Committee. The debate, after the opening speech and a
sensible brief reply by Peel, degenerated at once into irrelevant talk on
the inadequacy of the fever hospital of London. The Select Committee was
named, and quickly reported on the 8th of May.

A Bill embodying the recommendations of the Committee received the royal
assent on 30th May. The Act provided for the extension of fever hospitals,
the exemption of lodging-houses, under certain regulations, from the
hearth-tax and the window-tax, and the formation of Boards of Health with
powers to abate and remove nuisances. The Boards of Health were found
unworkable, partly by reason of expense, partly of excessive powers. The
epidemic having visited Waterford somewhat late in its progress, Sir John
Newport again called attention to it on 6th April, 1819, and moved for the
revival of last year's Committee. Mr Charles Grant, afterwards Lord
Glenelg, who was now Irish Secretary, gave much satisfaction to the
patriotic members both by his sympathetic speech on the occasion and by
his previous action at the Irish Office in the way of pecuniary help to
the fever hospitals or Dispensary district officers. The Second Report of
the Committee remarked that the rich absentee landlords had given nothing.
Another Act, of June, 1819 (59 Geo. III. cap 41), defined the duties of
officers of health, and contained an important clause (ix.) relating to
the spread of contagion by vagrants. By that time the epidemic was over;
nor can it be said that the action of the Government from first to last
had made much difference to its progress.

Vagrancy was the principal direct cause; and behind the vagrancy were
usages and traditions, with interests centuries old, which made the
landlords resolute not to pay poor-rates on their rentals. It was not
until twenty years after that the English Poor Law was applied to Ireland
(in 1839), whereby the pauper class were dealt with as far as possible in
their respective parishes. How far that measure was effective in checking
the spread of contagion will appear when we come to the great famine and
epidemic of dysentery and fever in 1846-49.

It will not be necessary to follow with equal minuteness the successive
famines and epidemics of typhus, relapsing fever and dysentery in Ireland,
to the great famine of 1846-49. After 1817 distress became chronic among
the cottiers and small farmers. Leases had been entered into at high rents
during the years of war prices, and in the struggle for holdings tenants
at will offered the highest rate. When peace came and prices fell, rents
were found to be excessive, not to say impossible. But in Ireland with a
rapidly increasing population it was easier to put the rents up than to
bring them down. Other things helped to embarrass the poor cottager: he
paid twice over for his religion, tithes to the parson, dues to the
priest; and he paid all the more of the tithe in that the graziers, who
were mostly of the established Church and the occupiers of the fertile
plains, had taken care to make potato land titheable (at what date this
innovation arose is not stated) but had used their power in the Irish
Parliament to resist the tithe on arable pastures. Again the cottiers or
cottagers paid, in effect, the whole of the poor rate in the form of alms;
for the dogs of the gentry kept all beggars from their gates.


Famine and Fever in the West of Ireland, 1821-22.

The next famine in 1821-22 is remarkable for two things besides its purely
medical interest. Owing to the number of desperate evicted tenants, it
gave occasion to an increased activity of the secret associations,
especially the Whiteboys of Tipperary and Cork[479]; and it called forth
the first great dole of English charity in the form of princely
subscriptions to a Famine Fund. The English charity in 1822 was prompt and
large-hearted, contrasting with the tardy help from the exchequer in the
much more serious famine of 1817-18. The true explanation of it is,
doubtless, that England on the second occasion had more money to spare.
The trouble in 1821-22 came from the total loss of the potato crop in
Mayo, Galway, Clare and Kerry, and from a partial loss of it in some other
counties of the south and west. There was no corn famine, and no general
dearth. Accordingly it affected the poorest class only, and the most
remote districts chiefly. The planting season of 1821 had not been
favourable, and the yield of potatoes had been poor. But the autumn was so
wet in the west that the floods in some places washed away the soil with
the potatoes in it, and in other places drowned the potatoes after they
had been pitted. The flooded state of the basin of the Shannon was a
natural calamity on the great scale that touched the imagination and
loosened the purse-strings. A Committee was formed at the London Tavern,
which sat through the spring of 1822, and quickly raised an immense sum.
The great mercantile firms of the City and of Liverpool gave each a
thousand pounds; a ball at the Opera House under the patronage of the king
(George IV.) brought six thousand, and from all sources the Committee
found themselves with three hundred thousand pounds at their disposal
(forty-four thousand of it from Ireland), while a fund at the Dublin
Mansion House amounted to thirty thousand more. Much of this was sent to
Galway, Mayo, Clare and Kerry, in time to save many thousands of families
from starvation[480]; it was, no doubt, wastefully given away, and there
was a balance of sixty thousand pounds sterling unused. More tardily in
June, 1822, Parliament voted one hundred thousand "for the employment of
the poor in Ireland," and in July two hundred thousand to meet
contingencies of the famine. It was generally admitted that the Government
grants were jobbed and misappropriated to a scandalous extent. The towns
had to be made the centres of relief and the depots of provisions; and yet
the towns were not suffering from famine or fever but only from penury.
The fever hospital at Ennis, the county town of Clare, was constantly
filled by strangers, the townspeople remaining healthy. Kerry was one of
the most afflicted counties, but Tralee and Killarney had no unusual
sickness. Limerick town had hardly more fever than in an ordinary year. In
Dublin the admissions for fever in 1822 were a good deal below the usual
number. On the other hand, Sligo town had much fever, and Galway town had
an altogether unique experience, the history of which, as related by Dr
Graves, will be the best possible view of the peculiar circumstances of
1821-22[481].

In Connemara, where the distress was acute, there were no roads over which
the provisions from England could be carted to the famished districts.
Accordingly a great store was made in Galway, to which crowds flocked from
the country in boats and on foot. Many died a few days after they arrived,
from exhaustion or from the surfeit of food after long hunger. Galway, a
crowded place at best, with narrow streets and lanes, contained thousands
of strangers, who slept about the quays and the fish-market, or in the
lanes and entries, or in crowded lodging-houses four or five in a bed. The
fever began in May, and quickly spread so much that the priests were kept
fully employed by calls to the dying. In June and July the sixty beds of
the fever hospital were filled, principally with the fugitives from
Connemara. Sixty more beds were added, and these by the middle of
September were insufficient. The infection had now spread to many good
houses. When Dr Graves and three other Dublin physicians arrived, on 26
September, they found ropes stretched across the streets to stop the wheel
traffic. The shops of tradesmen were avoided. The town was like a place in
the plague; people passing along the streets put their handkerchiefs to
their noses when they came to a house with fever in it. Yet the number of
cases was not remarkable; on 3 October, there were 404 sick in a
population of 30,000, of whom 130 were in the fever hospital and 274 at
their homes, the new cases occurring at the rate of 29 per diem. At length
it was found practicable to set up depots of provisions in country places,
and the crowd of strangers left Galway. The fever was mild but tedious
among the poor, more violent and fatal among the well-to-do. In many
country places dysentery and choleraic diarrhoea were prevalent, as well
as fever. In Erris, county Mayo, dysentery and dropsy were more common
than fever, many of the cottiers having subsisted on weeds, shell-fish, or
new potatoes dug six weeks after the seed was planted. In this famine the
people ate the flesh of black cattle dead of disease. Excepting in
Connemara the county of Galway was not so soon affected as some other
parts of Ireland; but, as in 1818, the contagion of fever was spread
abroad by vagrants. After Mayo, Galway, Clare and Kerry, the counties most
affected were Roscommon and Sligo, and next to these Leitrim, Tipperary
and Cork.


Dysentery and Relapsing Fever, 1826-27.

Fever and dysentery decreased to an ordinary level in 1823, but rose
somewhat again in 1824, the summer of which was hot and moist. But it was
in the hot and dry summers of 1825 and 1826 that dysentery became notably
common in Ireland generally and in Dublin in particular. It began in the
capital in June--among the richer class of people. About the middle of
August admissions for dysentery were perceptibly raising the number of
patients in the Cork Street Fever Hospital, and continued to do so
throughout the autumn. At one dispensary three out of four applicants had
dysentery. All those admitted to hospital were over twenty years of age;
of thirty-five cases under Dr O'Brien, nine died, all of which had
ulceration of the great intestine, in one case gangrenous. The mortality
was not nearly so great among the richer classes, in which respect
dysentery reversed the rule of typhus fever. O'Brien had one obvious case
illustrating the curious connexion between dysentery and rheumatic fever,
originally remarked by English observers in the 18th century. A hospital
porter was admitted with "fever of a mixed catarrhal and rheumatic type."
Having been blooded and subjected to free evacuations, his fever left him
on the fourth day, but he was at once seized with dysentery, which ran its
course[482].

It is to be noted that this epidemic of dysentery began in Dublin in the
hot June weather of 1825 among the richer classes, and that there was no
notable increase of fever while it lasted. It appears to have declined in
Dublin in the early part of 1826. After a cold and dry spring there began
one of the hottest and driest summers on record. The first rain for four
months fell on the 15th of July, 1826, the thermometer rose as high as
86 deg., and was on a mean several degrees above summer temperature in
Dublin. In the spring labour had become slack, and before long it was
estimated that 20,000 artizans in the Liberties (weavers and others) were
out of work. Early in May there began a most extraordinary epidemic of
relapsing fever, with which some typhus was mixed. By the 9th of May, the
220 beds of the Cork Street Hospital were full, and applicants were sent
away daily. On 4 August, a temporary hospital of 240 beds was opened in
the garden of the Meath Hospital; on the 18th, the Wellesley Hospital, in
North King Street, was opened with 113 beds; on the 15th, tents to hold
180 patients were erected on the lawn of the Cork Street Hospital, raising
its accommodation to 400; a warehouse in Kevin Street was furnished with
beds for 230 patients, and some increase was made to the beds in Sir
Patrick Dun's and Stevens's Hospitals. The whole number of fever-beds in
Dublin hospitals at length reached 1400; but not half the number of cases
was provided for. At a meeting in the Mansion House on 26 October, it was
stated that there were at that date 3200 persons sick of the fever at
their homes, besides the 1400 in the hospitals. Funds were subscribed,
soup-kitchens and dispensaries opened in various districts of Dublin, and
kept open most of the winter, "but they made little impression on the
epidemic, which continued with unabated violence." In March, 1827, it
began suddenly to decline, and fell rapidly until it was nearly extinct in
May; and that, too, although "the complaints of distress and want are to
the full as loud as at the commencement of the epidemic, and provisions
are dearer[483]." The corresponding sicknesses in Edinburgh and Glasgow
were later--the fever chiefly in 1828, the dysentery in 1827 and 1828.

This great epidemic was mainly one of relapsing fever. The patient "got
the cool," or passed the crisis of the fever, usually on the evening of
the fifth or seventh day, sometimes on the ninth, the evening
exacerbation, which was to prove critical, being ushered in generally with
a rigor, and passing off in profuse perspiration throughout the night. The
five-day fever was more certain to relapse than that of seven days, the
seven-day fever was more likely to relapse than that of nine days. The
relapses might be one or two or three or more, prolonging the illness for
weeks. The clear interval varied from twenty-four hours to fourteen days.
There were some cases with jaundice which led Stokes and Graves to speak
loosely of "yellow fever[484]." O'Brien saw only four cases with exquisite
icterus in fifteen hundred cases of relapsing fever. There was a small
proportion of cases of ordinary typhus of a severe kind, marked by
unusual delirium or phrensy and the absence of sordes on the teeth or
petechiae on the skin; the typhus cases became more numerous in the winter
season, or, in other words, the original attack lasted to nine, eleven, or
thirteen days, with little or no tendency to relapse. Gangrene was not
uncommon in one part of the body or another, and in four cases the feet
became gangrenous[485].

Even with the admixture of pure typhus cases, and with dysenteric
complications in the autumn and winter, the mortality of the whole
epidemic was small--not more than it would have been among a third part
the number of fever cases in an ordinary year. At the Cork Street Hospital
alone (including the tents) there were 8453 admissions from 4th August,
1826, to 4th April, 1827, with 332 deaths, or four deaths in a hundred
cases. The proportion of recoveries was quite as remarkable in known
instances in the squalid homes of the poor, where two or three would be
found ill of fever on one pallet, or a father and six children in one
room, shunned by the neighbours.

The strangest thing in this epidemic was the sequel of it. In the spring
of 1827, intermittent fever, which had not made its appearance for several
years in Dublin, began to prevail pretty generally; whilst the ordinary
continued fever showed a strong tendency to assume the intermittent and
remittent forms. It is not surprising, therefore, that Dr O'Brien, who had
these varied experiences of epidemic dysentery in 1825, of epidemic
relapsing fever and typhus in 1826, and of intermittent fever in 1827,
should adopt Sydenham's language of epidemic constitutions, and revert to
the old Sydenhamian doctrine of causes. While the sequence of epidemic
diseases in Dublin was some dysentery in the autumn and winter of 1825 and
relapsing fever on a vast scale during the excessively dry spring and
summer of 1826, in country districts of Ireland, such as Skibbereen,
dysentery became epidemic after the great drought and heat of 1826, while
"fever disappeared altogether," and indeed all other prevalent forms of
sickness gave way before it, so general was it. Such is the report from
Skibbereen, county Cork, a district that became early notorious, in the
great famine of 1846-47, and was perhaps a kind of barometer of Irish
distress twenty years earlier. The epidemic dysentery of 1826 attacked all
classes there, but chiefly the poorest; it was apt to begin insidiously,
and, as it was often neglected, so it often became obstinate and hard to
cure. Dr McCarthy attributed it to the drought of 1826, the commercial
distress of 1825, the lack of employment for labourers, the overgrowth of
population, and the alarming rise in the prices of food[486]. He uses the
same economic illustrations as O'Connell and Smith O'Brien in the Great
Famine twenty years after, which were, indeed, as old as the time of
Bishop Berkeley[487].

Although little is heard of the fever of 1826-27 except in Dublin, it is
probable that the same causes which produced it there were operative in
other large towns. The admissions to the Limerick Fever Hospital rose
rapidly in the end of 1826. Geary, who was appointed one of its physicians
that year, estimates that about one in twelve of the population of
Limerick (63,310) were treated for fever in 1827 at public institutions,
besides those treated in private practice. It was relapsing fever, as in
Dublin[488].


Perennial Distress and Fever.

According to all the figures of Irish fever-hospitals, and the
generalities of their physicians, fever was now constantly present in the
towns. After the relapsing epidemic of 1826-27 had subsided, there was no
rise above the steady level until the years 1831 and 1832, when a
considerable increase appears in the admissions to the hospitals of
Dublin, Limerick and Belfast. But the fever of 1831-32 was totally
eclipsed by the cholera, and little is heard of typhus in Irish writings
until 1835-36, when an epidemic arose, purely of typhus fever, which is
said to have been as severe upon some districts as that of 1817-18 had
been. This outbreak fell at the time of the Commission presided over by
the Earl of Devon, the report of which is authoritative for the state of
the Irish lower class and the causes of the same. The country cottiers and
the poor of the towns were always on the verge of starvation. Dr Geary, of
Limerick, in 1836 estimated as follows the proportion of poor to the whole
population, "the poor" being taken to mean "those who would require aid if
a Poor Law existed[489]:"

_Proportion of "Poor" in the several Parishes of Limerick, 1836._

                 St Nicholas   St John and
                 and St Mary   St Laurence   St Munchin   St Michael

  Population       14,629        15,667        4,071        16,226
  Number of Poor    7,000         6,400          930         2,500

Most of the poor lived in the old town of Limerick in lofty and
closely-built houses which the better classes had abandoned. These
dilapidated barracks were the abodes of misery and filth, two and often
three families occupying a single room: "It is here, as in the decayed
Liberties of Dublin[490], that the indigent room-keeper, the ruined
artisan, the unemployed labourer, and the ejected country cottier, with
their famishing families retreat." Their degradation, Dr Geary thought,
was owing to the delay of Parliament in giving Ireland the Poor Law. The
sanitary state of the old town was disgraceful. Heaps of manure were
carefully kept in back yards, to be sold to farmers in the spring--"a very
principal source of livelihood" for those who collected it. Certain houses
near these depots had always fever in them, dysentery was frequent, and
Exchange-lane never free from it[491]. An extensive glue-mill in the Abbey
poisoned the air with the effluvia of putrid animal matters. The following
table shows the number of fever-cases admitted to the Hospital or attended
from the Dispensary in 1827 and in four ordinary years thereafter:

_Limerick:--Table of Hospital Cases of Fever and Cases at their Homes
attended from the Dispensary._

        Hospital Cases                      Dispensary Cases
                      Average                        Average
                     mortality.                      mortality.
  Year Admitted Died  One in          Attended Died   One in     Total

  1827   2781    137    20             2800     80     35         5581
  1828    854     37    23              960     22     39         1714
  1829    506     23    22              640     18     35         1146
  1830    806     34    23-1/2          910     25     36         1716
  1831   1015     65    15-1/2          920     31     29         1935
                 -----------------------------------------------------
  Totals 5962    296    20             6130    176     34        12092

From 1831 to 1836 the admissions to hospitals were as follows:

  Year Admitted Died

  1832   1028    57
  1833    824    42
  1834    906    55
  1835   1484   121
  1836   3227   235

The last lines show the epidemic increase, which began in the autumn of
1835. It will appear from the following (by Geary) that it was largely an
epidemic of young people, and that the fatality was by far the greatest
among the comparatively small number of persons attacked at the higher
ages--a well-known law of typhus of which this Limerick demonstration was
perhaps the first numerically precise:

_Table of the Numbers admitted to Limerick Fever Hospital at stated ages
of five years, with the deaths, from 6 Jan. 1836 to 6 Jan. 1837._

                             Average
  Ages in                   mortality
   Years    Admitted  Died  per cent.

     1-5      81        2     2-1/4
     5-10    489       13     2-1/2
    10-15    762       18     2-1/4
    15-20    701       37     5-1/4
    20-25    362       22     6
    25-30    304       27     8-3/4
    30-35    100       12    12
    35-40    203       45    23-1/4
    40-45     70       13    18-1/2
    45-50     82       22    27
    50-55     23        5    21-1/2
    55-60     36       12    33-1/4
    60-65      2        1    50
    65-70     10        5    50
  Over 70      2        1    50
  ---------------------------------
  Total     3227      235     7-1/4

One-sixth of these Limerick hospital cases, to the number of 567, came
from the county, chiefly from the damp, boggy districts five to sixteen
miles from the city. The whole admissions were rather more than the same
hospital received in the famine year, 1817. But, although 1836 was not a
year of special scarcity, there must have been some cause at work to
raise the perennial typhus to the height of an epidemic, not only in
Limerick, but in Dublin, Cork, Waterford, Ennis, Belfast, and other towns.
In the country, an epidemic outburst during the months of March, April and
May, 1836, in the parish of Donoughmore, Donegal, is perhaps only a sample
of others unrecorded: it was remarkable in that nine-tenths of the cases
of fever had as a sequel large boils on various parts of the body, but
principally on the limbs[492].

In Dublin, the influenza of the first months of 1837 seemed to check the
prevalence of typhus for a time; but the latter increased greatly when the
influenza was over, so that the admissions to the Cork Street Hospital
until the end of 1838 nearly equalled those of the worst epidemics since
the hospital was opened in 1804[493]. Females in typhus were admitted
greatly in excess of males; a large proportion (1847 in two years) were
under fifteen years of age; the fever rarely relapsed, so that it was
mostly typhus, as in England and Scotland at the same time. In twelve
months of the same period (Oct. 1837 to Sept. 1838) there were 1786
admissions for fever at Cork, 1840 at Limerick, and 1706 at Belfast[494].

In Dublin, as in London, Edinburgh and Glasgow, the continued fevers of
the "thirties" were distinctively spotted typhus, which was a new
constitution. Graves, lecturing at Dublin in November, 1836, said: "We are
now at a point of time possessing no common interest for the reflection of
medical observers. It is now nearly two years since my attention was first
arrested by the appearance of maculated fever, of which the first examples
were observed in some hospital cases from the neighbourhood of Kingstown.
This form of fever has lasted ever since, prevailing universally, as if it
had banished all other forms of fever, and being almost the only type
noticed in our wards[495]."

This increase of fever in Ireland, as well as the change in its type,
corresponded closely to the great epidemic outburst in Scotland and
England. The census of Ireland, taken in June, 1841, for the ten years
preceding, gave a somewhat loose return of the causes of death in each
year of the decennial period[496].

The worst years for fever were 1837 and 1840, the best year 1841. The
deaths from fever in ten years were 112,072, being 1 in 10.59 of the
deaths from all causes. The counties with highest fever mortality were
Cavan, Mayo, Galway and Clare; the worst towns were Belfast, Kilkenny,
Dublin, Limerick and Carrickfergus. Of these deaths from typhus-like
fevers, 14,501 occurred in 86 fever-hospitals, which were open, or which
kept records, for more or less of the decennial period. The following
table shows the proportions of rural, urban and hospital fever-deaths in
each of the four provinces:

_Deaths from fever in ten years, 1831-41._

                         Leinster      Munster       Ulster   Connaught

  Rural fever-deaths       16,159       23,718       21,616    19,319
  Urban                     4,626        4,878        3,183     1,262
  Hospital                  9,030        5,465        2,439       386
                          ---------------------------------------------
                           29,815       34,061       27,238      20,958

  Rural population }
  in 1841          }    1,531,106    2,009,220    2,160,698   1,338,635

  Ratio of do. per }
  sq. mile         }          247          332          406         386

The following detailed table for the province of Leinster shows the
enormous preponderance of fever-deaths in the cottages or cabins[497].
Only Dublin and Kilkenny have most of the deaths in their fever hospitals
or public institutions; it was not until near the end of this decennial
period, the year 1839, that workhouses, with their infirmaries, began to
be provided for all the poor-law unions:

_Fever Mortality in Leinster, 1831-41._

                       Deaths from Fever      Deaths
                       in Hospitals and     from Fever
    Localities        Public Institutions     at home        Total

  Carlow County                 202            891            1093
  Drogheda Town                   1            238             239
  Dublin County                 111           1248            1359
  Dublin City                  6393           2369            8762
  Kildare County                276           1068            1284
  Kilkenny County               114           2378            2492
  Kilkenny City                 487            204             691
  King's County                 126           1754            1880
  Longford County                 3           1265            1268
  Louth County                    1           1201            1202
  Meath County                  294           2151            2445
  Queen's County                 84           1763            1847
  Westmeath County               54           1550            1604
  Wexford County                637           1736            2373
  Wicklow County                280           1002            1282
                             --------------------------------------
                               9063         20,758          29,821


The Great Famine and Epidemic Sicknesses of 1846-49.

The great epidemic of relapsing fever, typhus, dysentery, anasarca and
purpura, which arose in Ireland in the end of 1846 or spring of 1847 and
lasted until the beginning of 1849, had for its direct antecedents the
more or less complete loss of the potato-crop through blight in two
successive autumns, 1845 and 1846, while the state of distress and
sickness was prolonged by the potato disease in 1847 and 1848[498]. The
potato-blight, which caused so much alarm in Ireland for the first time in
September, 1845, had been seen in Germany several years before, in Belgium
in 1842, in Canada in 1844, and in England about the 19th of August, 1845.
Shortly after the last date, it attacked the Irish potato-fields, first in
Wexford, and before the end of the year it was estimated that one-third to
one-half of the yield, which was a fifth larger than usual from the
greater breadth planted and the abundant crop, was lost by absolute
rottenness or unfitness for food, the process of decay being of a kind to
make great progress after the tubers were pitted. The loss to Ireland was
estimated at about one pound sterling per head of the population. Sir
Robert Peel was keenly alive to the magnitude of the calamity which
threatened the Irish peasantry. His first step was to summon to his aid a
botanist, Dr Lindley, and a chemist, Dr Playfair; the latter went down to
Drayton Manor, and joined the prime minister in examining samples of the
diseased potatoes. The question was whether some chemical process could
not be found to arrest the decay of the tubers. Sir Robert Peel, in a much
talked-of address at the opening of the Tamworth Reading-Room in the
winter of 1840, had hailed the rising sun of science and useful knowledge.
It was only in reference to morals and religion that Peel's deliverance
called forth criticism, more particularly the memorable series of letters
to the _Times_ by John Henry Newman. But one of Newman's gibes was in a
manner prophetic of Peel's attitude in approaching the material distress
of Ireland: "Let us, in consistency, take chemists for our cooks, and
mineralogists for our masons." The two professors proceeded to Ireland,
but could only confirm the fact, already known, that one-third, or
one-half, of the potato-crop would be lost.

Botany and chemistry being powerless to stay the effects of the
potato-blight, the appeal was next to economics. Ireland produced not only
potatoes but also corn. But for the most part the cottiers and cottagers
tasted little of the oats or wheat which they grew; as soon as the harvest
was gathered, the corn was sold to pay the November rents, and was
exported. Ireland was still in the paradoxical condition which Bishop
Berkeley puzzled over a hundred years before: "whether our exports do not
consist of such necessaries as other countries cannot well be without?"
The industry and trade of Irish ports was largely that of corn-milling and
shipping of oatmeal, flour and other produce; thus Skibbereen in the
extreme south-west, where the horrors of famine were felt first, had
several flour-mills and a considerable export trade in corn, meal, flour
and provisions. The Irish corn harvest of 1845 had been abundant:
O'Connell cited the _Mark Lane Express_ for the fact that 16,000 quarters
of oats from Ireland had arrived in the Thames in a single week of
October; on the 23rd of the same month the parish priest of Kells saw
fifty dray-loads of oatmeal on the road to Drogheda for shipment. Ireland
paid its rent to absentee landlords in corn and butter, just as a century
before it had paid it largely in barrelled beef, keeping little for its
own use besides potatoes and milk. In the face of the potato famine, the
measure approved by the Irish leaders of all parties, O'Connell and Smith
O'Brien as well as ducal proprietors, was to keep some of the oatmeal at
home. A committee which sat at the Dublin Mansion House were of opinion,
on 19 November, 1845, that the quantity of oats already exported of that
harvest would have sufficed to feed the entire population of Ireland.
O'Connell's plan was to raise a million and a half on the annual revenue
of the Irish woods and forests (L74,000), and to impose a tax on
landlords, both absentee and resident, and with the moneys so obtained to
buy up what remained of the Irish corn harvest for use at home. In the
ensuing session of Parliament, both he and Smith O'Brien protested that
Ireland had no need of English doles, having resources of her own if the
landlords were compelled to do their duty.

About the same time Lord John Russell, leader of the Opposition, was led
by the danger of famine in Ireland to pronounce for the repeal of the Corn
Laws of 1815; and at the meetings of the Cabinet in December, Peel urged
the same policy upon his colleagues for the same reason. The political
history does not concern us beyond the fact that the threatened Irish
distress caused by the first partial potato-blight of 1845 was the
occasion of the Corn and Customs Act of June, 1846, by which the Corn Laws
were repealed, and that an Irish Coercion Bill, brought in on account of
outrages following an unusual number of evictions, was made the occasion
of turning out Peel's ministry at the moment of its Free Trade victory, by
a combination of Tory protectionists, Whigs and Irish patriots.

The direct effects of the potato-blight of 1845 were not so serious as had
been expected. The Government quietly bought Indian meal (maize flour) in
America without disturbing the market, and had it distributed from twenty
principal food-depots in Ireland, to the amount of 11,503 tons, along with
528 tons of oatmeal. This governmental action ceased on the 15th of
August, 1846, by which time L733,372 had been spent, L368,000 being loans
and the rest grants. The people were set to road-making, so as to pay by
labour for their food, the number employed reaching a maximum of 97,000 in
August. The Government, having been led by physicians in Dublin to expect
an epidemic of fever, passed a Fever Act in March, 1846, by which a Board
of Health was constituted. But no notable increase of sickness took place,
and the Board was dissolved. There was a small outbreak of dysentery and
diarrhoea at Kilkenny (and possibly elsewhere) in the spring of 1846,
which the physician to the workhouse set down to the use of the Indian
meal "and other substitutes for potatoes[499]."

It was the total loss of the potato crop in the summer and autumn
following, 1846, together with a failure of the harvest in England and in
other countries of Northern Europe, that brought the real Irish distress.
A large breadth of potatoes had been planted as usual, but doubtless with
a good deal of the seed tainted. An ordinary crop would have been worth,
according to one estimate, sixteen millions sterling, according to
another, twice as much. The crop was a total loss. The fields looked well
in the summer, but those who dug the early potatoes found them unusually
small. About the beginning of August the blight began suddenly and spread
swiftly. A letter of the celebrated Father Mathew, the temperance
reformer, brings this out:

    "On the 29th of last month (July) I passed from Cork to Dublin, and
    this doomed plant bloomed in all the luxuriance of an abundant
    harvest. Returning on the 3rd instant (August) I beheld with sorrow
    one wide waste of putrefying vegetation. In many places the wretched
    people were seated on the fences of the decaying gardens wringing
    their hands and wailing bitterly the destruction that had left them
    foodless[500]."

The relief-works and distribution of Indian meal, which had been estimated
by the Government to last only to August, 1846, at a cost of L476,000
(one-half of it being a free grant), were resumed under the pressure of
public opinion, in the winter of 1846 and spring of 1847, a cost of
L4,850,000, one-half of the sum being again a free grant. Before the
distress was over, other free grants and advances were made; so that, on
15 February, 1850, Lord John Russell summed up the famine-indebtedness of
Ireland to the Consolidated Fund at L3,350,000, (which was to be repaid
out of the rates in forty years from that date). Allowing an equal sum
freely gifted from the national exchequer, the whole public cost of the
famine would have been about seven millions sterling.

The short crops in Britain in 1846 were an excuse for not interfering with
the export of oats from Ireland. The imports of Indian meal were left to
the ordinary course of the market, and the distribution to retail traders.
The corn merchants of Cork, Limerick and other ports made fortunes out of
the American cargoes, and the dealers throughout the country made large
profits.

To encourage the influx of foreign food-supplies, and to lower freights,
the Navigation Laws were suspended for a few months, so that corn could be
carried in other than British bottoms. When Parliament met in January,
1847, the distress in Ireland occupied the greater part of the Queen's
Speech.

Lord George Bentinck proposed that sixteen millions should be advanced for
the construction of railroads, so as to give employment and wages to the
starving multitudes. The Government, however, objected that such relief
would operate at too great a distance, in most cases, from the homes of
the people; and it was urged by independent critics that a State loan for
railways would really be for the relief of the landlords more than of the
peasantry. The large sums actually voted were spent in road-making and in
procuring food and medical relief. A Board of Works directed the
relief-works. A Commissariat, with two thousand Relief Committees under
it, directed the distribution of food. A Board of Health provided
temporary fever-hospitals and additional physicians. It was not to be
expected that this machinery would work well, and, in fact, the public
relief was costly in its administration and often misdirected in its
objects. Private charities, especially that of the Society of Friends,
gave invaluable help, money being subscribed by all classes at home and
sent from distant countries, including a thousand pounds from the Sultan
of Turkey. On one day, the third of July, 1847, nearly three millions in
Ireland received food gratuitously from the hands of the relieving
officers. In March, 1847, the public works were employing 734,000. The
number relieved out of the poor rates at one time reached 800,000.
Workhouses were enlarged, and temporary fever-hospitals were built to the
number of 207, which in the two years 1847 and 1848, received 279,723
patients.

Emigration to the United States and Canada, which had averaged 61,242
persons per annum from the last half of 1841 to the end of 1845, rose
steadily all through the famine until it reached a total of 214,425 in the
year 1849, the passage money to the amount of millions sterling having
come largely from the savings of the Irish already settled in the New
World.

The grand effect of the famine upon the population of Ireland was revealed
by the census of 1851. The people in 1841 had numbered 8,175,124; in 1851
they numbered 6,515,794. The decrease was 28.6 per cent. in Connaught,
23.5 per cent. in Munster, 16 per cent. in Ulster, and 15.5 per cent. in
Leinster. In many remote parishes the number of inhabitants, and of
cabins, fell to nearly a half. The depopulation was wholly rural, so much
so that there was a positive increase of inhabitants not only in the large
county towns, but even in small towns such as Skull and Kanturk, situated
in Poor Law unions where the famine and epidemics had made the greatest
clearances all over[501]. Our business here is with the epidemical
maladies, which contributed to this depopulation; but a few words remain
to be said on the subject at large.

Malthus had been prophetic about this crisis in the history of Ireland.
Criticizing Arthur Young's project to encourage the use of potatoes and
milk as the staple food of the English labourer instead of wheat, so as to
escape the troubles of scarcity and high prices of corn, Malthus says:

    "When, from the increasing population, and diminishing sources of
    subsistence, the average growth of potatoes was not more than the
    average consumption, a scarcity of potatoes would be, in every
    respect, as probable as a scarcity of wheat at present; and when it
    did arrive it would be beyond all comparison more dreadful. When the
    common people of a country live principally upon the dearest grain, as
    they do in England on wheat, they have great resources in scarcity;
    and barley, oats, rice, cheap soups and potatoes, all present
    themselves as less expensive, yet at the same time wholesome means of
    nourishment; but when their habitual food is the lowest in this scale,
    they appear to be absolutely without resource, except in the bark of
    trees, like the poor Swedes; and a great portion of them must
    necessarily be starved[502]."

The forecast of Malthus was repeated in his own way by Cobbett, although
neither of them foresaw the potato-blight as the means.

    "The dirty weed," said Cobbett in a conversation in 1834, "will be the
    curse of Ireland. The potato will not last twenty years more. It will
    work itself out; and then you will see to what a state Ireland will be
    reduced.... You must return to the grain crops; and then Ireland,
    instead of being the most degraded, will become one of the finest
    countries in the world. You may live to see my words prove true; but I
    never shall[503]."

This is what has come to pass in a measure, and will come to pass more and
more. Only in some remote parts do the Irish cottiers now live upon
potatoes and milk. It has come to be quite common for them to grow an
Irish half acre of wheat, and, what is more to the purpose, to consume
what they thus produce instead of selling it to pay the rent. Doubtless
the enormous imports of American, Australian and Black Sea wheat have made
it easier for the Irish to have wheaten bread. But, whatever the reason,
they have at length adopted the ancient English staff of life, a staple or
standard which they were in a fair way to have achieved long ago, had not
their addiction to "lost causes and impossible loyalties" given an
unfavourable turn to the natural progress of the nation[504].

We come at length to the purely medical side of the great famine of
1846-47[505]. The distress in the latter part of the year 1846 was felt
first in the west and south-west--in the districts to which the famine of
1822 had been almost confined. It happened that the state of matters
around Skibbereen, the extreme south-western point of Ireland, was brought
most under public notice; but it is believed that there were parts of the
western sea-board counties of Mayo, Galway, Clare and Kerry from which
equally terrible scenes might have been reported at an equally early
period. It was in Clare that relief at the national charges was longest
needed.

Dr Popham, one of the visiting physicians to the Cork Workhouse, wrote as
follows:

    "The pressure from without upon the city began to be felt in October
    [1846], and in November and December the influx of paupers from all
    parts of this vast county was so overwhelming that, to prevent them
    from dying in the streets, the doors of the workhouse were thrown
    open, and in one week 500 persons were admitted, without any
    provision, either of space or clothing, to meet so fearful an
    emergency. All these were suffering from famine, and most of them from
    malignant dysentery or fever. The fever was in the first instance
    undoubtedly confined to persons badly fed or crowded into unwholesome
    habitations; and as it originated with the vast migratory hordes of
    labourers and their families congregated upon the public roads, it was
    commonly termed 'the road fever'[506]."

It was the same in the smaller towns of the county, such as Skibbereen; in
the month of December, 1846, there were one hundred and forty deaths in
the workhouse; on one day there were fifteen funerals waiting their turn
for the religious offices. Still farther afield, in the country parishes,
the state of matters was the same. The sea-board parish of Skull was a
typical poor district, populous with cabins along the numerous bays of the
Atlantic, but with few residential seats of the gentry. On the 2nd of
February, 1847, the parish clergyman, the Rev. Traill Hall (himself at
length a victim to the contagion), wrote as follows:

    "Frightful and fearful is the havock around me. Our medical friend, Dr
    Sweetman, a gentleman of unimpeachable veracity, informed me yesterday
    that if he stated the mortality of my parish at an average of
    thirty-five daily, he would be within the truth. The children in
    particular, he remarked, were disappearing with awful rapidity. And to
    this I may add the aged, who, with the young--neglected, perhaps,
    amidst the widespread destitution--are almost without exception
    swollen and ripening for the grave[507]."

They were "swollen" by the anasarca or general dropsy, which was reported
from nearly all parts of Ireland as being, along with dysentery and
diarrhoea, the prevalent kind of sickness before the epidemic fever became
general in the spring of 1847. The same had been remarked as the precursor
of the fever of 1817-18. In the end of March, Dr Jones Lamprey, sent by
the Board of Health, found the parish of Skull "in a frightful state of
famine, dysentery and fever." Dysentery had been by far more prevalent
than fever in this district, as in many others. "It was easily known,"
says Dr Lamprey, "if any of the inmates in the cabins of the poor were
suffering from this disease, as the ground in such places was usually
found marked with clots of blood." The malady was most inveterate and
often fatal. It must have had a contagious property, for the physician
himself went through an attack of it[508].

In the Skibbereen district the dead were sometimes buried near their
cabins; at the town itself many were carried out in a shell and laid
without coffins in a large pit[509]. Along the coast of Connemara for
thirty miles there was no town, but only small villages and hundreds of
detached cabins; this district is said to have been almost
depopulated[510].

Besides the dysentery and dropsy, which caused most of the mortality in
the winter of 1846-47, another early effect of the famine was scurvy, a
disease rarely seen in Ireland and unknown to most of the medical men. It
was by no means general, but undoubtedly true scurvy did occur in some
parts: thus in the Ballinrobe district, county Mayo[511], it was very
prevalent in 1846 for some months before the epidemic fever appeared,
being "evidenced by the purple hue of the gums, with ulceration along
their upper thin margin, bleeding on the slightest touch, and deep
sloughing ulcers of the inside of the fauces, with intolerable
foetor"--affecting men, women, and children. In some places, as at
Kilkenny early in 1846, there was much purpura[512]. These earlier effects
of the famine (dysentery and diarrhoea, dropsy, scurvy and purpura), were
seen in varying degrees before the end of 1846 in most parts of Ireland.
The counties least touched by them were in Leinster and Ulster, such as
Down, Derry, Tyrone, Fermanagh and some others, where the peasantry lived
upon oatmeal as well as on potatoes. But even these were invaded by the
ensuing epidemic of fever, the only place in all Ireland which is reported
to have escaped both the primary and the secondary effects of the famine
having been Rostrevor, on the coast of Down, a watering-place with a rich
population, which was also one of the very small number of localities that
escaped in 1817-18.

According to the following samples of admissions to the Fever Hospital of
Ennis in the several months, the summers were the season of greatest
sickness, a fact which was noted also in the epidemic of 1817-18:

  Year   Month    Patients

  1846  November      93
   "    December     224
  1847  June         757
  1848  February     210
   "    May          705
   "    November     400

The almost uniform report of medical men was that the epidemic of fever
began in 1847, in the spring months in most places, in the summer in
others. Relapsing fever was the common type. It was usually called the
famine fever for the reason that it was constantly seen to arise in
persons "recovering from famine," on receiving food from the Relief
Committees[513]. It was a mild or "short" fever, apt to leave weakness,
but rarely fatal. Dr Dillon, of Castlebar, reports that he would be told
by the head of a family: "We have been _three times down_ in the fever,
and have all, thank God, got through it." Dr Starkey, of Newry, "knew many
families, living in wretched poverty on the mountains near the town, who
were attacked with fever, and who without any medical attendance, and but
little attendance of any kind, passed through the fever without a single
death." The doctor of Bryansford and Castlewellan, county Down, (where
there was no famine), declared that the recoveries of the poor in their
own cottages destitute of almost every comfort, were astonishing. In the
Skibbereen district, Dr Lamprey was "often struck with the rarity of the
ordinary types of fever among the thousands suffering from starvation." In
some of the most famine-stricken places, such as the islands off the
coast of Mayo and Galway, and in Gweedore, Donegal, not more than one in
a hundred cases of relapsing fever proved fatal. In Limerick the mortality
was "very small." In many places it is given at three in the hundred
cases, in some places as high as six in the hundred. When deaths occurred,
they were often sudden and unexpected,--more probable in the relapse than
in the first onset. At Clonmel it was remarked that a certain blueness of
the nose presaged death; in Fermanagh it was called the Black Fever, from
the duskiness of the face. The report from Ballinrobe, Mayo, says that it
was attended by rheumatic pains, which caused the patients to cry out when
they stirred in bed[514]. It was mostly a fever of the first half of life,
and more of the female sex than of the male. One says that it was
commonest from five to fifteen years of age, another from ten to thirty
years.

Relapsing fever was the most common fever of the famine years, in the
cabins, workhouses and fever hospitals, in the country districts as well
as the towns and cities. Dr Henry Kennedy says of Dublin: "Cases of
genuine typhus were through the whole epidemic very rare, I mean
comparatively speaking." But everywhere there was a certain admixture of
typhus, and in some not unusual circumstances the typhus was peculiarly
malignant or fatal--many times more fatal than the relapsing fever. The
poor themselves do not appear to have suffered much from the more
malignant typhus, unless in the gaols and workhouses. When the doors of
the Cork workhouse were thrown open in December, 1846, five hundred were
admitted pell mell in one week; the deaths in that workhouse were 757 in
the month of March, 1847, and 3329 in the whole year. In the Ballinrobe
workhouse, county Mayo, "men, women and children were huddled together in
the same rooms (the probationary wards), eating, drinking, cooking, and
sleeping in the same apartment in their clothes, without even straw to lie
on or a blanket to cover them." Typhus at length appeared in that
workhouse, said to have been brought in by a strolling beggar, and the
physician, the master and the clerk died of it. Wherever the better-off
classes caught fever, it was not relapsing but typhus, and a very fatal
typhus. At Skibbereen the relapsing fever "was not propagated by
contagion; but in persons so affected, when brought in contact with the
more wealthy and better fed individuals, was capable of imparting fevers
of different types[515]." There were many opportunities for such
contact-in serving out food at the depots, in superintending the gangs
working on the roads, in attending the sessions, in visiting the sick. The
crowds suffering from starvation, famine-fever or dysentery exhaled the
most offensive smells, the smell of the relapsing fever and the anasarca
being peculiar or distinguishable[516]. There appeared to be a scale of
malignity in the fevers in an inverted order of the degree of misery. The
most wretched had the mildest fever, the artizan class or cottagers had
typhus fatal in the usual proportion, the classes living in comfort had
typhus of a very fatal kind. This experience, however strange it may seem,
was reported by medical observers everywhere with remarkable unanimity.
One says that six or seven of the rich died in every ten attacks, others
say one in three. Forty-eight medical men died in 1847 in Munster, most of
them from fever; in Cavan county, seven medical men died of fever in
twelve months, and three more had a narrow escape of death: two of the
three physicians sent by the Board of Health to the coast of Connemara
died of fever[517]. Many Catholic priests died as well as some of the
Established Church clergy; and there were numerous fatalities in the
families of the resident gentry, and among others who administered the
relief. Yet a case of fever in a good house did not become a focus of
contagion; the contagion came from direct contact with the crowds of
starving poor, their clothes ragged and filthy, their bodies unwashed, and
many of them suffering from dysentery. The greater fatality of fever among
the richer classes had been a commonplace in Ireland since the epidemic of
1799-1801, and is remarked by the best writers[518]. At Loughrea, in
Galway, Dr Lynch observed that "in the year 1840 the type of fever was
very bad indeed, and very many of the gentry were cut off by it." He
reckoned that ordinarily one in six cases of fever among the richer class
proved fatal, one in fifteen among the poor[519]. But in the great famine,
six years after, the fever of the poor assumed the still milder type of
relapsing, fatal perhaps to one in a hundred cases, or three in a hundred,
while the fever which contact with them gave to those at the other extreme
of well-being became a peculiarly malignant typhus, fatal to six or seven
in ten cases, as Dr Pemberton of Ballinrobe found, or to three or four in
ten cases, as many others found. Of course it was the peasantry who made
up by far the greater part of the mortality in the years of famine; but
they were cut off by various maladies, nondescript or definite, while the
richer classes died, in connexion with the famine, of contagious typhus
and here or there of contagious dysentery.

Even in the crowded workhouses and gaols, more deaths occurred from
dysentery than from fever. But in some of the gaols great epidemics arose
which cut off many of the poor by malignant infection. That was an old
experience of the gaols, studied best in England in the 18th century; the
worst fevers, or those most rapidly fatal, were caught by the prisoners
newly brought to mix with others long habituated to their miserable
condition. The gaols in Ireland during the famine were crowded to excess,
not so much because the people gave way to lawlessness--their patience and
obedience were matters of common complimentary remark--but because they
committed petty thefts, broke windows, or the like, in order to obtain the
shelter and rations of prisoners. The mortality in the gaols rose and fell
as follows[520]:

  Year    Deaths in gaol

  1846         130
  1847        1320
  1848        1292
  1849        1406
  1850         692
  1851         197

Most of the deaths in these larger totals came from two or three great
prison epidemics in each of the series of years--at Tralee,
Carrick-on-Shannon, Castlebar and Cork in 1847, at Galway in 1848, at
Clonmel, Limerick, Cork and Galway in 1849, the highest mortality being
485 deaths in Galway county gaol in 1848. Descriptions remain of the state
of the gaols at Tralee and Castlebar in 1847, from which it appears that
they were frightfully overcrowded and filthy. Dr Dillon, of Castlebar,
says that the county gaol there in March, 1847, had twice as many
prisoners as it was built for, "those committed being in a state of
nudity, filth and starvation." He expected an outbreak of typhus, and
applied to the magistrates to increase the accommodation, which they
declined to do. In due time, very bad maculated typhus broke out, of which
the chaplain, matron and others of the staff died. This contagious fever
is said to have proved fatal to forty per cent. of those attacked by it.
The deaths for the year are returned at 83 in Castlebar gaol, those in
Tralee gaol at 101, and in the gaol of Carrick-on-Shannon at 100.

No exact statistical details of the mortality in the great Irish famine of
1846-49 were kept. Ireland had then no systematic registration of deaths
and of the causes of death, such as had existed in England since 1837.
Information as to the mortality was got retrospectively once in ten years
by means of the census, heads of families being required to fill in all
the deaths, with causes, ages, years, seasons, &c., of the same, that had
occurred in their families within the previous decennial period. This was,
of course, a very untrustworthy method, more especially so for the famine
years, when many thousands of families emigrated, leaving hardly a trace
behind, many hamlets were wholly abandoned, and many parishes stripped of
nearly half their inhabited houses. When a certain day in the year 1851
came round for the census papers to be filled up, a fourth part of the
people were gone, and that fourth could have told more about the famine
and the deaths than an equal number of those that remained. However, the
Census Commissioners did their best with the defective, loose or erroneous
data at their service. Much of the interest of the Irish Census of 1851
centered, indeed, in the Great Famine; and the two volumes of specially
medical information compiled by Sir William Wilde, making Part V. of the
Census Report, are a store of facts, statistical and historical, of which
only a few can be given here[521].

_Table of Workhouses and Auxiliary Workhouses in Ireland during the
Famine._

          No. of     Numbers     Numbers   Ratio of deaths
  Year  Workhouses   relieved   that died     One in

  1846     129       250,822     14,662       17.11
  1847     130       332,140     66,890        6.92
  1848     131       610,463     45,482       13.4
  1849     131       932,284     64,440       14.47
  1850     163       805,702     46,721       17.74

During the ten years from 6 June, 1841, to 30 March, 1851, the deaths from
the principal infective or "zymotic" diseases in the workhouses were as
follows:

  Dysentery      50,019
  Diarrhoea      20,507
  Fevers         34,644
  Measles         8,943
  Cholera         6,716
  Smallpox        5,016

Besides the workhouses, there were during the famine 227 temporary fever
hospitals, which received 450,807 persons from the beginning of 1847 to
the end of 1850, of whom 47,302 died.

According to the Census returns, the deaths from the several causes
connected with the famine were as follows in the respective years:

                       Dysentery
  Year     Fever    (with Diarrhoea)  Starvation

  1845     7,249       ------           -----
  1846    17,145        5,492           2,041
  1847    57,095       25,757           6,058
  1848    45,948       25,694[522]      }
  1849    39,316       29,446[523]      } 9,395
  1850    23,545       19,224           -----

According to this table, fever caused more deaths than dysentery. But
there are reasons for thinking that the deaths from dysentery, anasarca
and other slow effects of famine and bad food really made up more of the
extra mortality of the famine-years than the sharp fever itself. In the
returns from the workhouses, dysentery is actually credited with about
one-half more deaths than fever. It is known that most of the mortality at
the beginning of the famine, the winter of 1846-47, was from dysentery and
allied chronic forms of sickness. Dysentery also followed the decline of
the relapsing-fever epidemic of 1847-48. Dillon, of Castlebar, says that
many, who had gone through the fever in the autumn of 1847, fell into
dysentery in 1848, during which year it was very prevalent. Mayne says
that dysentery often attacked those recovering from fever, and proved
fatal to them[524]. In the General Hospital of Belfast the fatality of
fever-cases was 1 in 8, "but this included dysentery." Probably the same
explanation should be given of the high rates of fatality in the Fever
Hospital of Ennis, the chief centre of relief for the greatly distressed
county of Clare: 1846, 1 in 12-1/2; 1847, 1 in 5-3/4; 1848, 1 in 5-1/2.

It will be noticed that some thousands of deaths were put down to
starvation in the Census returns. Perhaps a more technical nosological
term might have been found for a good many of these, such as anasarca or
general dropsy. But even if physicians had made the returns, instead of
the priests or relatives, they would have put many into a nondescript
class, for which starvation was a sufficiently correct generic name.
Scurvy was another disease of malnutrition which was far from rare during
the famine; the deaths actually set down to that cause were some hundreds
over the whole period.

The deaths from all causes in the decennial period covered by the Census
of 1851 were 985,366. But these returns were made, as we have seen, on a
population which had been reduced by a fourth part in the course of ten
years, so that they fall considerably short of the reality. If the
population of Ireland had multiplied at the same rate as that of England
and Wales from 1841 to 1851, namely, 1.0036 per cent. per annum, it should
have been 9,018,799 in the year 1851; but it was only 6,552,385.
Emigration beyond the United Kingdom had averaged 61,242 persons per annum
from the 30th of June, 1841, to the 31st December, 1845; next year, 1846,
it rose to 105,955, in 1847 it was "more than doubled," in 1848 it was
178,159, in 1849, 214,425, in 1850 it was 209,054, and in 1851 it touched
the maximum, 249,721. Nearly a million emigrated in the six years
preceding the date of the Census, and there was besides a considerable
migration to Liverpool, Glasgow, London and other towns of England and
Scotland. It is probable that emigration accounts for two-thirds of the
decrease of inhabitants revealed by the Census of 1851; but the extra
mortality of the famine years, or the deaths over and above the ordinary
deaths in Ireland during a decennial period, can hardly be estimated below
half a million.


Decrease of Typhus and Dysentery after 1849.

The potato famines of 1845-48 were a turning-point in the history of
Ireland. From that time the population has steadily declined and the
well-being of the people steadily improved. By the Census of 1871 the
population was 5,386,708, by that of 1881 it was 5,144,983, by that of
1891 it was 4,704,750. Registration of births and deaths, which began in
1864, shows the following samples:

  Year    Births    Deaths

  1867   144,318    98,911
  1871   151,665    88,720
  1880   128,010   102,955
  1888   109,557    85,892

The enormous amount of pauperism which followed the great famine was at
length brought within limits: from 1866 to the present time it has been
marked by a steady increase of out-door relief, and by some increase in
the numbers within the Union Workhouses; the out-door paupers have
increased from 10,163 on 1 Jan., 1866, to 53,638 on 1 Jan., 1881, the
absolute number of indoor paupers having remained, on an average of good
and bad years, somewhat steady in a declining population.

The public health has been undisturbed by great epidemics since the potato
famine, although the effects of that calamity did not wholly cease until
some years after. It is best estimated by the mean annual average of
deaths among a thousand inhabitants, a ratio which has been low for the
provinces of Connaught and Munster, and not excessive for the provinces of
Ulster and Leinster. The following tables are of the death rates in two
sample years, 1880 and 1889 respectively[525]:

              1880   1889

  Connaught   15.3   12.4
  Munster     19.5   15.1
  Ulster      20.0   16.8
  Leinster    23.3   18.3

_Four healthiest counties_:

       1880         |       1889
  Mayo       14.5   |  Galway    11.8
  Sligo      15.3   |  Kerry     12.1
  Galway     15.6   |  Leitrim   12.1
  Roscommon  15.8   |  Cavan     12.2

_Four unhealthiest counties_:

        1880           |        1889
  Dublin co.     31.7  |  Dublin co.  24.5
  Waterford co.  24.9  |  Antrim      21.2
  Louth          22.6  |  Down        18.6
  Antrim         21.9  |  Armagh      17.0

The higher death rates of some counties are chiefly owing to their greater
urban populations. The health of the cottier districts is remarkably good,
and is rarely if ever disturbed by any _morbus miseriae_. The cabins,
except in a few remote parts, are more comfortable than they used to be,
the diet is better, the clothing is better, the education of the children
is better. The present happier lot of the Irish peasantry can be measured
not unfairly by the statistics showing the decrease in the number of
cabins of the lowest class, and the increase of dwellings in the higher
classes.

The history of fever and dysentery in Ireland subsequently to the great
epidemics of 1846-49 has few salient points. Dysentery, the old "country
disease," has steadily declined to about a hundred deaths in the year,
while the considerable mortality from diarrhoea, nearly two thousand
deaths in a year, is nearly all from the cholera infantum or summer
diarrhoea of children in the large towns. The history of the continued
fevers is made complex by the modern identification of typhoid or enteric
fever. According to the testimonies of several, it played but a small part
in the epidemics of 1846-49, even in Dublin itself[526], and it can hardly
be doubted that its recent increase in that city is not apparent but real.
The following table from the year 1880 to the present time will show how
the deaths from continued fever are now divided in the registration
returns:

                  Simple
  Year  Typhus  continued  Enteric

  1880   934       1073     1087
  1881   859        774      813
  1882   744        657      844
  1883   810        593      853
  1884   628        572      693
  1885   505        443      716
  1886   394        380      772
  1887   405        385      740
  1888   362        330      741
  1889   359        250      968
  1890   391        231      855
  1891   266        183      859
  1892   268        210      714

This decline of typhus in a country where for many generations it seemed
to be a national malady is a remarkable testimony to the influence of the
changed conditions which have made typhus rare everywhere.

There are some interesting points in connexion with Irish typhus since
1849. After the subsidence of the great epidemic of relapsing and typhus
fevers (1847-49), says Dr Dennis O'Connor, of Cork, "intermittent fever
made its appearance, and, as long as it lasted, scarcely a case of
continued fever was seen. As soon as the last cases of intermittent
disappeared, the present epidemic broke out (1864-65), and still rages
with much severity. This alternation of continued and intermittent fever
is remarkable. Indeed it might have been observed that the fever of 1847
passed first into a remittent form, and gradually into the intermittent
which prevailed more or less for ten years subsequently[527]." The same
succession of relapsing fever by intermittent fever was observed after the
epidemic of 1826 by Dr John O'Brien, of Dublin[528]. The epidemic of fever
which Dr O'Connor describes for Cork in 1864-65, appeared in Dublin about
the same time--the latter half of 1864. It was of the nature of typhus in
both cities, cerebro-spinal in part, but probably not typhoid[529]. At
Cork it had some peculiarities--a croupous-like exudation on the tongue,
resembling thrush in the mouth, and a dark mottled rash (rubeola nigra),
or fiery red spots on a dark red ill-defined base. "The true typhoid rash
has been seen but seldom, and the petechiae of genuine typhus, so frequent
in former epidemics, have been equally rare. The latter I attribute to the
improved condition of our poor in good clothing and the ventilation of
their dwellings." The intellect was little disturbed in this fever, there
was usually a crisis about the fourteenth day, and there were no relapses.
The sequelae were peculiar--"great nervous debility, leading to a
semi-paralysed state of the limbs," congestion of the lungs, sometimes
solidification, or gangrene or suppuration of them. It occurred at a time
"when the food of the people is most abundant and of the best quality."
There had been three bad harvests in succession from 1860, but it may be
inferred from a Dublin article of August, 1863, that no epidemic of typhus
had arisen in Ireland down to that date, although there was much typhus in
England, especially in Lancashire owing to the "cotton famine." When the
epidemic did arise in Dublin, Cork, and doubtless elsewhere in Ireland, in
the latter part of 1864, to continue throughout 1865, it was not connected
with scarcity or distress among the common people. On the other hand, Dr
Grimshaw, of Dublin, found that it was subject to influences of the
weather, as if the infective principle had been a soil poison like that of
plague, yellow fever, cholera, or enteric fever. Taking the Cork Street
Fever Hospital for his study, he made out that there was a very close
correspondence, from the 29th of May to the 31st of December, 1864,
between the fluctuating pressure upon its accommodation and the periodic
rises in the atmospheric moisture and heat, the crowd of patients being
always greater when a high temperature coincided with a large
rainfall[530]. One would not have been surprised to find some such law as
that in enteric or typhoid fever, although a correspondence from day to
day is subject to many sources of fallacy; but, by all accounts, the
disease was typhus, the last of the considerable outbreaks of it in
Ireland hitherto, and an outbreak that seemed to require, both at Cork and
Dublin, the language of Sydenham's epidemic constitutions for its adequate
description. For a good many years, the continued fever of Dublin has been
chiefly enteric or typhoid. As late as 1862 a physician to the Fever
Hospital, unconvinced by the method of Sir William Jenner, believed that
he observed a transition from the old typhus into the new enteric: "The
change at first seemed to be to the gastric type; to which was shortly
added diarrhoea in nearly every instance; and this latter, again,
occurring in a large number of cases which presented all the characters of
typhus, including a dense crop of petechiae[531]." Assuming that there had
been a mixture of cases of enteric and typhus fevers, the latter must have
had diarrhoea among the symptoms, as they often had in special
circumstances (as well as tympanitis). Since that time the species of
typhus has greatly declined, and the species of typhoid has considerably
increased. The remodelling which Dublin has undergone, like all other old
cities, explains the one fact. The notorious Liberties have been in great
part rebuilt, and the conditions of typhus, as well as its actual fomites,
to that extent removed. On the other hand, something has happened to
encourage the soil poison of enteric fever. It is not easy to say what are
the conditions that have favoured the enteric poison in modern towns; but
there can be little doubt about the fact in general, or that Dublin and
Belfast are among the best fields for the study of the problem[532].




CHAPTER III.

INFLUENZAS AND EPIDEMIC AGUES.


Epidemic agues are joined in the same chapter with influenzas for the
reason that they can hardly be separated in the earlier part of the
history. Until 1743 the name influenza was not used at all in this
country. The thing itself can be identified clearly enough in certain
instances from the earliest times. But there are periods, such as 1657-59,
1678-79, and 1727-29 when short waves of epidemic catarrhs or catarrhal
fevers came in the midst of longer waves of epidemic agues, "hot agues,"
or intermittents, the whole being called by the people "the new disease,"
or "the new ague," while by physicians, such as Willis and Sydenham, they
were taken to be the distinguishable constituent parts of one and the same
epidemic constitution. The last period in which epidemic agues were so
recognised and named in England was from 1780 to 1785; and in the midst of
that also there occurred an epidemic catarrh--the "influenza" of the year
1782. It is possible that our own recent experience of a succession of
influenzas, or strange fevers, from 1889 to 1893, in some respects the
most remarkable in the whole history, would have seemed an equally
composite group if they had fallen in the 17th century and had been
described in the terminology of the time and according to the then
doctrines or nosological methods. Without prejudice to the distinctness
and unity of the influenza-type in all periods of the history, I am
unable, after trying the matter in various ways, to do otherwise than take
the epidemics of ague in chronological order along with the influenzas. As
the history will require the frequent use of the name "ague," and, in due
course, that of the name "influenza," it will be useful to examine at the
outset their respective etymologies and the meanings that usage has given
to them.

Originally the English name ague did not mean a paroxysmal or intermittent
fever, or a fever with a long cold fit followed by a hot fit, or the
malarial cachexia with sallowness, dropsy and enlarged spleen, or any
other state of health arising from the endemic conditions which are known
as malarial over so large a part of the globe in the tropical and
sub-tropical zones. It meant simply _acuta_, the adjective of _febris
acuta_ made into a substantive. Thus Higden's reference in the
_Polychronicon_ (which is exactly in the words of Giraldus Cambrensis a
century and a half before) to the _febris acuta_ of Ireland is translated
by Trevisa (14th cent.): "Men of that lond haue no feuere, but onliche the
feuere agu, and that wel silde whanne"; and by an anonymous translator:
"The dwellers of hit be not vexede with the axes excepte the scharpe axes,
and that is but selde[533]." Again in the MS. English translation of the
Latin essay on plague by the bishop of Aarhus, the acute fever which is
described as the attendant or variant of bubo-plague proper (well known
long after as the pestilential fever, a malignant form of typhus), is thus
rendered:

    "As we see a sege or prevy next to a chambre, or of any other
    particuler thyng which corrupteth the ayer in his substance and
    qualitee: whiche is a thing maye happe every daye. And therof cometh
    the ague of pestilence. And aboute the same many physicions be
    deceyved, not supposing this axes to be a pestilence.... And suche
    infirmite sometime is an axes, sometime a postume or a swellyng--and
    that ys in many thinges."

The same use of ague is continued in the first native English book on
fevers, Dr John Jones's 'Dyall of Agues,' which has chapters on plague as
well as on pestilential fever and on all other fevers including
intermittents. In Ireland the name of ague was applied until a
comparatively late period to the indigenous typhus of the country, as if
in literal translation of the _febris acuta_ first spoken of by Giraldus
in the 12th century. Ague in early English meant any sharp fever, and most
commonly a continued fever. The special limitation to intermittents
appears to have followed the revival of the study of the Graeco-Roman
writers on medicine, Galen above all, in the sixteenth century. But Jones,
who was freer than the more academical physicians of his time from
classical influences, is shrewd enough to see that it was a mistake to
transfer the experiences of Greece verbatim to England and to make them
our standard of authority: he is speaking, however, not of intermittents
but of the simple ephemeral fever, or inflammatory fever of one day:

    "Such as have the fever of heat or burning of the sun, sayeth Galen,
    theyr skin is drye and hot as that which is perched with the sun; of
    the which, in this orizon and countrye of oures, we have no great nede
    to entreate of, leaving it to the phisitions and inhabitantes that
    dwell nerer to the meridionall line and hoter regions, as Hispaine and
    Africke[534]."

At a later date, when the Hippocratic tradition had displaced the Galenic,
Rogers of Cork, perhaps the earliest writer on fevers whose observations
are essentially modern, has occasion thus to reflect upon the extreme
deference of Sydenham to his Greek model: "Again we learn from Hippocrates
that fevers in the warmer climates of Greece, at Naxos, Thasos or Paros,
ran their course in certain periods of time, which no ways answers in
regions removed at a farther distance from the sun,"--Rogers himself
having had no experience of intermittents among all the fevers and
dysenteries that he saw from 1708 to 1734, although Cork was surrounded by
marshes[535].

At the time of the Latin translations of Greek medical writings by Linacre
and Caius in the Tudor period, there were in this country actual
experiences of strange fevers, which were interpreted according to the
Greek teaching of quotidians, tertians and quartans, with their several
bastard or hybrid or larval forms. These, as I have said, were certainly
not the endemic fevers of malarious districts; they were, on the contrary,
widely prevalent all over the country during one or more seasons in
succession and more occasional for a few years longer; then there would be
a clear interval of years, and again an universal epidemic of "the new
fever," "the new acquaintance," "the new ague" or the like.

Sydenham, for example, has much to say of agues or intermittents prevalent
in town and country for a series of years, and then disappearing for as
long a period as thirteen years at a stretch. But he does not count these
as the agues of the marsh; his single reference to the latter is in his
essay on Hysteria, where he interpolates a remark that, if one spends two
or three days in a locality of marshes and lakes, the blood is in the
first instance impressed with a certain spirituous miasma, which produces
quartan ague, and that in turn is apt to be followed, especially in the
more aged, by a permanent cachectic state[536]. If Sydenham had intended
to bring all the intermittents of his experience into that class, he would
not have left the paludal origin of them to a casual interpolated remark.
On the other hand, he refers the epidemic agues, which occupy his pen so
much, to emanations from the bowels of the earth, according to a theory of
his friend Robert Boyle, applied by the latter to epidemical infections in
general and to epidemic colds or influenzas in particular. Sydenham and
his learned colleagues were not ignorant of the endemic agues of marshy
localities, but they made little account of them in comparison with the
aguish or intermittent fevers that came in epidemics all over England.

In admitting the reality of such agues, we must be careful not to ascribe
them to such conditions as Talbor, the ague-curer, found in one village in
Essex. We must be careful not to do so, because there are plausible
reasons for doing so. The ground is much better drained now than formerly;
there is less standing water, fewer marshes, a much smaller extent of
water-logged soil. But the malarious parts of England have been tolerably
well defined at all times; and at all times the greater part of the
country was as little malarious as it is now. It is the frequent reference
to agues in old medical writings that has led some modern authors to
construct a picture of a marshy or water-logged England, for which there
is no warrant. Cromwell died of a tertian ague which he caught at Hampton
Court; therefore "the country round London in Cromwell's time" must needs
have been "as marshy as the fens of Lincolnshire are now." The country
round London was much the same then as now, or as in John Stow's time, or
as in the medieval monk Fitzstephen's time, or as it has ever been since
the last geological change. The ague of which Cromwell died in the autumn
of 1658 was one of those which raged all over England from 1657 to
1659--so extensively that Morton, who was himself ill of the same for
three months, says the country was "one vast hospital." Whatever was the
cause of that great epidemic of "agues," and of others like it, we have no
warrant to assume that "the country round London," or wherever else the
epidemic malady prevailed, was then as marshy as the fens of
Lincolnshire[537].

The other name in the title of this chapter, influenza, appeared
comparatively late in the history. It is an Italian name, which is usually
taken to mean the influence of the stars. It may have got that sense by
popular usage, but the original etymology was probably different. As early
as the year 1554 the Venetian ambassador in London called the sweating
sickness of 1551 an _influsso_, which is the Italian form of _influxio_.
The latter is the correct classical term for a humour, catarrh, or
defluxion, the Latin _defluxio_ itself having a more special limited
meaning. It was not astrology, but humoral pathology, that brought in the
words _influxio_ and _influsso_; and I suspect that influenza grew out of
the latter, but not out of the notion of an influence rained down by the
heavenly bodies.

It was in 1743 that the Italian name of "influenza" first came to
England[538], the rumour of a great epidemic, so called, at Rome and
elsewhere in Italy having reached London a month or two before the disease
itself. The epidemic of 1743 was soon over and the Italian name forgotten;
so that when the same malady became common in 1762, some one with a good
memory or a turn for history remarked that it resembled "the disease
called influenza" nearly twenty years before. After the epidemic of 1782,
the Italian name came into more general use, and from the beginning of the
present century it became at once popular and vague. The great epidemics
of it in 1833 and 1847 fixed its associations so closely with catarrh that
an "influenza cold" became an admitted synonym for coryza or any common
cold attended with sharp fever. Lastly, the series of epidemics from 1889
to 1893 effectually broke the association with coryza or catarrh.

Before influenza became adopted as the common English name towards the end
of last century, what were the names popularly given to the malady in this
country? The earliest references to it are in the medieval Latin
chronicles under the name of _tussis_ or cough, or in some periphrasis. In
the fifteenth century the English name was "mure" or "murre," which
appears to be the same root as in murrain. Thus the St Albans Chronicle,
under the year 1427, enters a certain "infirmitas rheumigata," which in
English was called "mure"; and the obituary of the monks of Canterbury
abbey has two deaths from "empemata, id est, tussis et le murra[539]." In
the Tudor period there is no single distinctive name, unless it be "hot
ague": in 1558 the name is "the new burning ague," in 1562 "the new
acquaintance," in 1580 "the gentle correction," and at various times in
the 17th century "the new disease," "the new ague," "the strange fever,"
"the new delight," "the jolly rant." Robert Boyle called one sudden
outbreak "a great cold." Molyneux, of Dublin, mentions "a universal cold"
in one year (1688), and "a universal transient fever" in another (1693).
The earlier 18th century writers mostly use the word catarrh or catarrhal
fever, either in Latin or in English, the popular names probably
continuing fanciful as before, as for example Horace Walpole's "blue
plagues." That which stands out most clearly in the English naming from
the earliest times is the idea of something new or strange; but the
newness or strangeness pertained quite as much to the agues as to the
catarrhs. The notion of ague may be said to be uppermost in the 16th and
17th centuries, that of catarrh in the 18th and 19th; while our very
latest experiences have once more brought a suggestion of ague to the
front.


Retrospect of Influenzas and Epidemic Agues in the 16th and 17th
centuries.

In the former volume of this history I have dealt with the various
epidemics of "hot ague," "new disease" or the like down to the epidemic of
1657-59. It will be convenient to go over some of that ground again, with
a view to distinguish, if possible, the catarrhal types from the aguish,
and to illustrate the use of the word ague as applied to a universal
epidemic. Two of the epidemic seasons in the 16th century, 1510 and 1539,
are too vaguely recorded for our purpose; but I shall review briefly the
seasons from 1557-58 onwards.

    It is known from the general historians that there were two seasons of
    fever all over England in 1557 and 1558, of which the latter was the
    more deadly, the type according to Stow, being "quartan agues." In
    letters of the time the epidemic of 1557 is variously named: thus
    Margaret, Countess of Bedford, writes on 9 August from London to Sir
    W. Cecil that she "trusts the sickness that reigns here will not come
    to the camp [near St Quentin, where Francis, Earl of Bedford was]....
    As for the ague, I fear not my son." On the 18th of the same month,
    Sir Nicholas Bacon writes from Bedford to Cecil: "Your god-daughter,
    thanks be to God, is somewhat amended, her fits being more easy, but
    not delivered of any. It is a double tertian that holds her, and her
    nurse had a single, but it is gone clearly;" to which letter Lady
    Bacon adds a postscript about "little Nan, trusting for all this
    shrewd fever, to see her." On 21 September, it appears that the
    sickness had reached the English camp near St Quentin, for the Earl of
    Bedford writes: "Our general is sick of an ague, our pay very slack,
    and people grudge for want." As late as the 25th October the Countess
    of Bedford writes from London to Cecil that she "would not have him
    come yet without great occasions, as there reigns such sickness at
    London[540]."

    Next year, 1558, the epidemic sickness returned in the summer and
    autumn, in a worse form than before. Stow calls it "quartan agues,"
    which destroyed many old people and especially priests, so that a
    great number of parishes were unserved. Harrison, a canon of Windsor,
    says that a third part of the people did taste the general sickness.
    On the 6th September, sickness affected more than half the people in
    Southampton, Portsmouth, and the Isle of Wight. From the 20th October
    to the end of the year, no fewer than seven of the London aldermen
    died, a number hardly equalled in the first sweating sickness of 1485,
    and the queen (Mary) died of the lingering effects of an ague, which
    was doubtless the reigning sickness. On 17th October, the English
    commissioners being at Dunkirk to negotiate the surrender of Calais,
    one of them, Sir William Pickering, fell "very sore sick of this new
    burning ague: he has had four sore fits, and is brought very low, and
    in danger of his life if they continue as they have done." That year
    Dr Owen published _A Meet Diet for the New Ague_, and himself died of
    it in London on the 18th of October[541].

    Fuller quaintly describes the ague of 1558 as "a dainty-mouthed
    disease, which, passing by poor people, fed generally on principal
    persons of greatest wealth and estate[542]." Roger Ascham wrote in
    1562 to John Sturmius that, for four years past, or since 1558, "he
    was afflicted with continual agues, that no sooner had one left him
    but another presently followed; and that the state of his health was
    so impaired and broke by them that an hectic fever seized his whole
    body; and the physicians promised him some ease, but no solid
    remedy[543]." Thoresby, the Leeds antiquary of the end of the 17th
    century, found in the register of the parish of Rodwell, next to
    Leeds, a remarkable proof of the fatality of these agues, which fully
    bears out the general statements of Stow and Harrison. In 1557 the
    deaths in the register rose from 20 to 76, and in 1558, which the
    historians elsewhere say was the most fatal year, they rose to
    124[544]. This was as severe as the sweating sickness of 1551, for
    example in the adjoining parish of Swillington, or in the parish of
    Ulverston, in Lancashire[545].

The English names of the epidemic sickness in the summers and autumns of
1557 and 1558 are all in the class of agues--"this new burning ague," "a
strange fever," "divers strange and new sicknesses taking men and women in
their heads, as strange agues and fevers," "quartan agues." One medical
writer, Dr John Jones, says in a certain place that "quartans were
reigning everywhere," and in another place, still referring to 1558, that
he himself had the sickness near Southampton, that it was attended by a
great sweat, and that it was the same disease as the sweating sickness of
1551. There were certainly two seasons of these agues, 1557 and 1558, the
latter being the worst; and it is probable from Short's abstracts of a few
parish registers in town and country that there was a third season of them
in 1559. The year 1557 has been made an influenza year, perhaps because
the Italian writers have emphasized catarrhal symptoms here or there in
the epidemic of that year; while both the years 1557 and 1558 have been
received into the chronology of epidemic or pandemic agues or malarial
fevers[546]. There are perhaps a dozen English references in letters and
chronicles to the sicknesses of those years, either to particular cases or
to a general prevalence, but they do not enable us to distinguish a
catarrhal type in 1557 from the aguish type which they assert for both
1557 and 1558.

Four years after, another very characteristic influenza was prevalent in
Edinburgh.

    Randolph writes from Edinburgh to Cecil in the end of November, 1562:
    "Maye it please your Honer, immediately upon the Quene's (Mary's)
    arivall here, she fell acquainted with a new disease that is common in
    this towne, called here the newe acqayntance, which passed also
    throughe her whole courte, neither sparinge lordes, ladies nor
    damoysells, not so much as ether Frenche or English. It ys a plague in
    their heades that have yt, and a sorenes in their stomackes, with a
    great coughe, that remayneth with some longer, with others shorter
    tyme, as yt findeth apte bodies for the nature of the disease. The
    queen kept her bed six days. There was no appearance of danger, nor
    manie that die of the disease, excepte some olde folkes. My lord of
    Murraye is now presently in it, the lord of Lidingeton hathe had it,
    and I am ashamed to say that I have byne free of it, seinge it seketh
    acquayntance at all men's handes[547]."

It is not improbable that the interval between 1558 and 1562 may have been
occupied with milder revivals of the original great epidemic, the one at
Edinburgh counting in the series.

It appears from a Brabant almanack for the year 1561 that a sudden
catarrhal epidemic was quite on the cards in those years: the astronomer
foretells for the month of September, 1561: "Coughs innumerable, which
shall show such power of contagion as to leave few persons unaffected,
especially towards the end of the month[548]." There is an actual record
from more than one country (Italy, Barcelona, as well as Edinburgh) of
such universal catarrhs and coughs a year later than the one foretold. The
Italian writers assign the universal catarrhs and coughs to the autumn of
1562, the Barcelona writer to the winter solstice of that year, and the
letter from Edinburgh to "the laste of November."

The next undoubted influenza, that of 1580, was compared abroad to the
English sweat:

    "In some places," says Boekel, "the sick fell into sweats, flowing
    more copiously in some than in others, so that a suspicion arose in
    the minds of some physicians of that English sweat which laid waste
    the human race so horribly in 1529;" and again, "the bodies were
    wonderfully attenuated in a short time as if by a malignant sudden
    colliquation, which made an end of the more solid parts, and took away
    all strength[549]." The season of it was the summer.

    The outbreak attracted much attention from its universality, and was
    described by many abroad.

    Boekel says that it was of such fierceness "that in the space of six
    weeks it afflicted almost all the nations of Europe, of whom hardly
    the twentieth person was free of the disease, and anyone who was so
    became an object of wonder to others in the place.... Its sudden
    ending after a month, as if it had been prohibited, was as marvellous
    as its sudden onset." It came up, he says, from Hungary and Pannonia
    and extended to Britain. The principal English account of this
    epidemic comes from Ireland[550]. In the month of August, 1580, during
    the war against the Desmonds, an English force had advanced some way
    through Kerry for the seizing of Tralee and Dingle; "but suddenlie
    such a sicknes came among the soldiers, which tooke them in the head,
    that at one instant there were above three hundred of them sicke. And
    for three daies they laie as dead stockes, looking still when they
    should die; but yet such was the good will of God that few died; for
    they all recovered. This sicknesse not long after came into England
    and was called the gentle correction."

    This outbreak among the troops in Ireland is said to have been in
    August, before the sickness came to England. But it can be shown to
    have been at its height in London in the month of July. The year 1580
    was almost free from plague in London; the weekly deaths are at a
    uniform low level (a good deal below the births) from January to
    December, except for the abrupt rise shown in the following
    table,--the kind of rise which we shall see from many other instances
    to be the infallible criterion of an influenza[551]:

    _Weekly Deaths in London._

    1580.

                        Deaths by     Dead of
        Week ending     all causes    plague      Baptised

        June  23           55           2           59
         "    30           47           4           57
        July   7           77           4           65
         "    14          133           4           66
         "    21          146           3           61
         "    28           96           5           64
        Aug.   4           78           5           73
         "    11           51           4           53
         "    18           49           1           72

    As in 1557-58, the English references are to agues, both before and
    after the Gentle Correction of July-August, 1580. Cogan says that for
    a year or two after the Oxford gaol fever (1577) "the same kind of
    ague raged in a manner all over England and took away many of the
    strongest sort in their lustiest age, etc." And he seems to have the
    name "gentle correction" in mind when he says: "This kind of sickness
    is one of those rods, and the most common rod, wherewith it pleaseth
    God to brake his people for sin." Cogan's dates are indefinite. But
    there is a letter of the Earl of Arundel to Lord Burghley, 19th
    October, 1582, which shows that "hot ague" was epidemic as late as the
    second autumn after the influenza proper: "The air of my house in
    Sussex is so corrupt, even at this time of the year, as when I came
    away I left twenty-four sick of hot agues."

Two such epidemics in England as those of 1557-8 and 1580-82, of hot agues
or strange fevers, taking the forms of simple tertian or double tertian or
quartan or other of the classical types, would have made ague a familiar
disease, and its name a household word. For not only were there two or
more aguish seasons (usually the summer and autumn) in succession, but to
judge by later experience there would have been desultory cases in the
years following, and in many of the seizures acquired during the height of
the epidemic, relapses or recurrences would have happened from time to
time or lingering effects would have remained. Hence it is unnecessary to
assume that the agues that we hear casual mention of had been acquired by
residence in a malarious locality. They may have been, and most probably
were, the agues of some epidemic prevalent in all parts of the country.
These epidemics were the great opportunities of the ague-curers, as we
shall see more fully in the sequel. It is to the bargaining of such an
empiric with a patient that Clowes refers in 1579: "He did compound for
fifteen pound to rid him within three fits of his ague, and to make him as
whole as a fish of all diseases."

There were more sicknesses of that kind, perhaps not without a sweating
character, in the last ten years of the 16th century[552]. But they are
indefinitely given as compared with earlier and later epidemics, and I
shall pass to the next authentic instance.

    The autumn of 1612 was undoubtedly a season of epidemic ague or "new
    disease" in England[553]. When Prince Henry, eldest son of James I.,
    fell ill in November, in London, during the gaieties attending the
    betrothal of his sister the Princess Elizabeth to the Count Palatine
    of the Rhine, a letter-writer of the time said of his illness: "It is
    verily thought that the disease was no other than the ordinary ague
    that hath reigned and raged almost all over England since the latter
    end of summer[554]." The attack began in the end of October. The
    spirited and popular prince had been leading the gaieties in place of
    his father, who could not stand the fatigue, and was "seized by a
    fever that came upon him at first with a looseness, but hath continued
    a quotidian ever since Wednesday last [before the 4th of November],
    and with more violence than it began, so that on Saturday he was let
    blood by advice of most physicians, though Butler, of Cambridge, was
    loth to consent. The blood proved foul: and that afternoon he grew
    very sick.... I cannot learn that he had either speech or perfect
    memory after Wednesday night, but lay, as it were, drawing on till
    Friday between eight and nine of the evening that he departed. The
    greatest fault is laid on Turquet, who was so forward to give him a
    purge the day after he sickened, and so dispersed the disease, as
    Butler says, into all parts; whereas if he had tarried till three or
    four fits had been passed, they might the better have judged of the
    nature of it; or if, instead of purging, he had let him blood before
    it was so much corrupted, there had been more probability." At the
    dissection, the spleen was found "very black, the head full of clear
    water and all the veins of the head full of clotted blood. Butler had
    the advantage, who maintained that his head would be found full of
    water, and Turquet that his brains would be found overflown and as it
    were drowned in blood[555]." Butler, it appears, was "a drunken sot."
    When King James asked him what he thought of the prince's case, he
    replied "in his dudgeon manner" with a tag of verse from Virgil ending
    with "et plurima mortis imago." The Princess Elizabeth could not be
    admitted to see her brother "because his disease was doubted to be
    contagious[556]." It was at least epidemic, for in the same week
    alderman Sir Harry Row and Sir George Carey, master of the wards, died
    "of this new disease[557]." The earliest reference to it that I find
    is the death, previous to 11 September, of Sir Michael Hicks at his
    house Rackholt in Essex, "of a burning ague," which came, as was
    thought, by his often going into the water this last summer, he being
    a man of years[558]; but much more probably was a case of "the
    ordinary ague that hath reigned and raged almost all over England
    since the latter end of summer." The next year was still more
    unhealthy, to judge by samples of parish registers; agues are
    mentioned also in letters; thus, one going on 25 March, 1613, to visit
    Sir Henry Savile, found him "in a fit, an ague having caught hold of
    him[559]."

    The winter of 1613-14 was marked by most disastrous floods in Romney
    Marsh, in Lincolnshire, in the Isle of Ely, and about Wisbech, and
    most of all in Norfolk[560]; but the malarious conditions so brought
    about, being subsequent to, were not conceivably the cause of, the
    epidemics of ague in the autumn of 1612 and 1613, which made so great
    an excess of burials over christenings in the parish registers.

    A curious record remains of an aguish sickness in a child, which had
    begun about January, 1614. On 18 March, of that year, the dowager
    Countess of Arundel wrote from Sutton, near Guildford, to her son Earl
    Thomas, who was making the grand tour to Rome and elsewhere with his
    wife, and had left the children to the care of their grandmother:
    "Your two elder boys be very well and merry, but my swett Willm.
    continueth his tersion agu still. This day we expect his twelfth fitt.
    I assur myselfe teeth be the chefe cause. I look for so spedy ending
    of it, he is so well and merry on his good days, and so strong as I
    never saw old nor yonge bear it so well. I thank Jesu he hath not any
    touch of the infirmity of the head, but onely his choler and flushe
    apareth, but he is as lively as can be but in the time of his fits
    onely, which continueth some eight hours[561]."

    The epidemic of ague or "new disease," which began to rage all over
    England in the end of the summer, 1612, had probably recurred in the
    years following, down to 1616. There is not a trace of plague during
    those years in any known record; and yet they are among the most
    unhealthy years in Short's abstracts of town and country parish
    registers[562].

The first half of the 17th century is a period which is almost a blank in
the conventional annals of "influenza" in Europe. But that period, which
was the period of the Thirty Years' War, had many widespread sicknesses. I
do not wish to claim these as influenzas, or to contend that they were
infections equivalent thereto in diffusiveness. We may, however, find a
place for them in this context; for they were certainly as mysterious as
any epidemics admitted into the canon of influenzas. So far as concerns
Britain, the first was the epidemic ague, or "new disease," of 1612 and
1613, probably recurring until 1616. The second was the universal spotted
fever of 1623 and 1624, of which I have given an account in the chapter on
typhus. That was followed by the plague of 1625, and that again by a
harvest ague in the country in the end of the same year. The next epidemic
ague or "general sickness, called the new disease," fell mostly in England
upon the two years 1638 and 1639. It was in part a harvest ague, "a
malignant fever raging so fiercely about harvest that there appeared
scarce hands enough to take in the corn[563]"; but it was also a winter
disease. I pass over the war-typhus of 1643, to which the name of "new
disease" was also given, and the widespread fever of the year following.
In 1651 we hear again of a strange ague, which "first broke out by the
seaside in Cheshire, Lancashire and North Wales," eighty or a hundred
being sick of it at once in small villages. Whitmore, who saw this
epidemic in Cheshire, identified it with the Protean disease which he
described in 1657-58, and hazarded the theory that the former was a
diluted or "more remiss" infection carried by the wind from Ireland, where
the plague was then raging, in Dublin, Galway, Limerick and other places,
after their sieges or occupations by the army of the Commonwealth.

Thus in the first half of the 17th century we have more or less full
evidence of epidemics of "new disease" in 1612-13, 1623-24, 1625, 1638-9,
1643-4 and 1651, not one of which was an influenza as we understand the
term[564].

We come at length to the years 1657-59, in the course of which one
catarrhal epidemic, or perhaps two, did prevail for a few weeks. The hot
agues or "new disease" had been raging all over the country from the
summer of 1657; then in April, 1658, there came suddenly universal coughs
and catarrhs, "as if a blast from the stars"; they ceased, and the hot
agues dragged on through the summer and autumn. A letter from London, 26
October, 1658, says: "A world of sickness in all countries round about
London: London is now held to be the wholesomest place," and adds that
"there is a great death of coach-horses almost in every place, and it is
come into our fields[565]." It was after this, in the spring of 1659, if
Whitmore has made no mistake in his dates, that coughs and catarrhs
"universally infested London, scarce leaving a family where any store
were, without some being ill of this distemper." The details have been
given fully in the former volume[566]. I wish merely to remark here that
the two catarrhal epidemics, or influenzas proper, in two successive
springs, were sharply defined episodes in the midst of a period of
epidemic agues, and that the "new disease" as a whole, during the two or
three years that it lasted, had such an effect in the way of ill health
and mortality that it was afterwards viewed as a "little plague" worthy of
being set in comparison with the Great Plague of 1665.

Willis does not say that the epidemic agues lasted after 1658, perhaps
because his essay was printed early in 1659; but Whitmore, whose preface
is dated November, 1659, says, without distinguishing the hot ague from
the catarrhal fever but speaking of them both as one Protean malady: "it
now begins again, seizing on all sorts of people of different nature,
which shows that it is epidemic." Sydenham does not appear upon the scene
until 1661; but when his epidemic constitutions do begin, it is with
intermittents or agues, which lasted, according to him, until 1664.
Perhaps if Sydenham's experience had extended back to 1657 he would have
made his aguish constitution to begin with that year, and to go on
continuously until 1664. At all events it does not appear that the year
1660 was a clear interval between Willis's and Whitmore's period of
1657-59, Sydenham's period of 1661-64; for it so happens that John Evelyn
has left the following note of his own illness:

    "From 17 February to 5 April [1660] I was detained in bed with a kind
    of double tertian, the cruell effects of the spleene and other
    distempers, in that extremity that my physicians, Drs Wetherburn,
    Needham and Claude were in great doubts of my recovery." Towards the
    decline of his sickness he had a relapse, but on the 14th April "I was
    able to go into the country, which I did to my sweete and native aire
    at Wooton." On the 9th of May he was still so weak as to be unable to
    accompany Lord Berkeley to Breda with the address inviting Charles II.
    to assume the crown.

Sydenham makes the "constitution" which began for him in 1661 to decline
gradually, and to end definitely in 1664, after which he finds
intermittents wholly absent for thirteen years, or until 1677. This clear
interval will make a convenient break in the chronology, whereat we may
bring in the popular and professional notions of ague then current, and
the popular practice in that disease by empirics.


The Ague-Curers of the 17th Century.

It is to be observed that all the respectable writers of the profession
speak of agues or intermittents as epidemic over the country for a
definite period, and as disappearing thereafter for years together. At the
same time they say little or nothing of the endemic malarious fevers of
marshy localities. Further, it appears that the professed ague-curers,
although they would wish to represent ague as a perennial disease, are
really basing upon the same experiences of occasional epidemics which
Willis, Whitmore and Sydenham recorded as occasional. The best instance of
this is the 'Pyretologia' by Drage of Hitchin. It was published for
practice in 1665, being designed to show forth the author's skill as an
ague-curer[567]. When we examine its generalities closely, we find that
they all come from the sickly season of 1657, the first of those described
by Willis.

    The great autumnal epidemic of that year (and the following), which we
    know from other sources to have been reckoned a "little plague," he
    describes as "a malignant sickness," which was followed in the winter
    by quartans. He himself escaped the autumnal fever but he incurred the
    quartan later in the year. In his own case, while the original
    paroxysm of this ague was still going on, a new one arose towards
    evening, and again, on the following day, a new paroxysm gathered
    vigour and supplanted the old, becoming the substantive paroxysm. Many
    of those who died of the quartan in 1657 had either the paroxysms
    duplicated, or a total want of them, or, in another passage, "the
    quartan which followed the autumnal disease of heterogeneous quality
    in 1657, cut off divers old people, the fever being erratic,
    duplicated or triplicated." It was a bad sign when the quartan became
    doubled or trebled; regularity of the paroxysm was a sign of a good
    recovery. The symptoms of a quartan are various; but it is not easy to
    pronounce that these all are the symptoms of an intermittent fever, or
    the prodromal signs thereof, unless intermittent fevers be epidemic at
    the time. He gives the case of a civil and pious priest who had a
    tedious quartan from being struck with lightning; he was confined to
    bed for two years, with loss of hearing, but, strangely enough,
    retaining the use of his eyes; sometimes he was vexed with
    convulsions, sometimes with quartan fever. The "plebs medicorum" say
    that a quartan fever comes of melancholy, a tertian of choler, a
    quotidian of putrefied pituitous matter. The "plebs plebis" think that
    the cause is wind or flatus, and that they get rid of the ague by
    belching. In his own case he observed that if he drank more cold ale
    than usual, he was seized with distension in the loins and with
    palpitation, and belched up "flatus and crass vapours infected with
    the quality of a quartan." He knew a man who, in the fourth or fifth
    month of a quartan, drank wine too freely, so that the paroxysms came
    every day, and that violently; after a week he had an especially
    severe paroxysm, and then no more for three weeks, when the fever
    returned under the type of an exquisite quartan. One case, which he
    mentions twice, led him to doubt whether quartans were not catching:
    a certain girl suffering from a quartan asked her father, who was
    skilled in the art, to open a vein; her parent declared that during
    the blooding the morbid smell of the flowing blood reached his
    nostrils, so that he was seized of his daughter's fever at the proper
    time of her paroxysms, having three or four ague fits in due order;
    meanwhile the girl was free from the paroxysms for a whole week, but
    no longer. The singular nature of quartans is further brought out in
    the fact that papules, pustules and exanthems breaking out on the skin
    were quite common in the quartan fever which followed the malignant
    epidemic of the autumn of 1657. "In the fevers hardly any heat is
    perceived; and so the unskilled vulgar say 'This is an ague' (Hoc est
    anglice _Ague_), and 'This is fever and ague' (Et hoc est febris et
    anglice _Ague_) when cold and heat are mixed equally or combined
    regularly." Peruvian bark does not evacuate the morbific matter unless
    by chance it provokes vomiting; cases treated by it often relapse, and
    are not well in the intervals. Bark does not occur in his own
    prescriptions; but he had cured many with "pentaphyllum." He knew
    several physicians in the epidemic of quartans in 1657 who trusted to
    narcotics entirely.

Drage must have had a real experience of aguish distempers of one kind or
another during the sickly seasons of 1657-59. But it is clear from the
essays or advertisements of empirics that agues were discovered in many
forms of sickness that were neither intermittent fevers nor fevers of any
distinctive type. One of these practitioners in the time of Charles I.
claims to be "the king's majesty's servant in ordinary[568]"; which is not
incredible, as Sir Robert Talbor, whom Charles II. deigned to honour, was
an ague-curer of the same class.

    "An ague, which hitherto amongst all sorts hath been accounted the
    physitian's shame, both for definition and cure (thus farre hath
    ignorance prevailed), but that the contrary is manifest appeareth
    sufficiently by this following definition: and shall be cured whether
    tertian, quartern or quotidian, by me Aaron Streater, physitian of
    Arts in Oxford, approved by Authority, the King's Majesties servant in
    ordinary, and dwelling against the Temple, three houses up in
    Chancerie Lane, next house to the Golden Anchor." An ague, he goes on,
    "is either interpolate (intermittent) or continual; it is either
    engendered of a melancholic humour or it is a splenetic effect; the
    liver is obstructed by abundance of choler proceeding from a salt
    rheum that cometh from the brain" etc. Agues are to be dreaded most
    for their remote effects: "Say not therefore, 'It is but an ague, but
    a feaver; I shall wear it out.' Dally not with this disease;" and he
    adds a case to show what people may come to if they neglect an ague at
    the beginning: "Being carried downe from London to South-hampton by
    Master Thomas Mason,--September 1640, word was brought me of a Mayd
    dead, 16 years of age: and being requested to see what disease she
    dyed of, I took my chirurgion with me and went. And after section or
    search, I found as followeth: a gallon and a half of green water in
    the belly, that stunk worse than carrion; under the lyver an impostume
    as bigg as my fist, full of green black corrupted matter, and the
    lyver black and rot. The spleen and kidneys wholly decayed, and the
    place as black as soot; the bowels they were fretted, ulcerated and
    rotten. In the chesse was two great handfuls of black burnt blood in
    dust or powder; the heart was all sound, but not a drop of blood in
    it; nor one spoonfull in the whole body.

    Here was an Annatomy indeed, skinne and bone; and I verily beleeve
    that there was no braine left, but that she lived while that was
    moyst: the sent was so ill, and I not well, that I forbore to search
    it.

    God that knowes the secrets of all hearts knowes this is a truth, and
    nothing else here written. Arthur Fauset, chirurgion at Southampton,
    was the man I employed to cut her up, as many there can witness that
    were present.

    And what of all this, may some say? Why this. An eight weeks' ague in
    the neglect of it breeds all these diseases, and finally death."

Let us take next the advertisement of an apothecary a generation after,
who professed to cure Kentish agues,--"the description and cure of Kentish
and all other agues ... and humbly showing (in a measure) the author's
judgment why so many are not cured, with advice in relation thereunto,
whether it be Quotidian, Tertian or Quartan, simple, double or
triple[569]." Before the Fire of London he had practised in Mark Lane, but
after his house was destroyed he removed to Kent, attending Maidstone
market every Thursday, and residing at Rochester, a city which, "besides
being subject to diseases in common with others, hath two diseases more
epidemical, namely, the Scurvey for one but the Ague in special." The
symptoms of scurvy, as he gives them, cover perhaps the one moiety of
disease, and those of ague the other.

    Agues are of two sorts, curable and incurable; the curable are those
    that come in a common way of Providence, the incurable those that are
    sent more immediately from God in the way of special judgment, as
    instances adduced from Scripture show. What is an ague? Some think it
    is a strange thing, they know not what; the more ignorant think it is
    an evil spirit, but coming they know not whence. Agues have their seat
    in the humours either within the vessels or without them; those
    residing within are continual quotidians, continual tertians,
    continual quartans; those without are intermittent ditto. (This
    distinction of within and without the vessels is traditional, and is
    found in Jones's _Dyall of Agues_ as well as in Dutch medical books a
    century later.) The paroxysms of the intermittents are really the
    uprising of the Archaeus [of van Helmont], or spirit, to oppose the
    rottenness of the humours. A quartan is harder to cure than any other
    ague; part of its cure is an old 14th-century rule of letting blood in
    the plague; "let blood in the left hand in the vein between the ring
    finger and the little finger, which said thing to my knowledge was
    done about sixteen years ago [to say nothing of three hundred years
    ago] by the empiric Parker in this country, with very good success and
    to his great honour and worldly advancement." This ague-curer says
    little of Peruvian bark; his specific is the powder of Riverius, "the
    preparation of which, as well as some of the powder itself is lately
    and providentially come to my hands." Three doses cost not above five
    shillings, "and I never yet gave more in the most inveterate of these
    diseases.... My opinion is that he that will not freely part with a
    crown out of his pocket to be eased of such a disease in his body
    deserves to keep it."

The most celebrated ague-curer of the Restoration period was Sir Robert
Talbor, who thus describes the high motives that made him a
specialist[570]:

    "When I first began the study and practice of Physick, amongst other
    distempers incident to humane bodies I met with a quartan ague, a
    disease that seemed to me the _ne plus ultra_ of physic, being
    commonly called Ludibrium et Opprobrium Medicorum, folly and derision
    of my profession, did so exasperate my spirit that I was resolved to
    do what study or industry could perform to find out a certain method
    for the cure of this unruly distemper.... I considered there was no
    other way to satisfy my desire but by that good old way, observation
    and experiment. To this purpose I planted myself in Essex near to the
    seaside, in a place where agues are the epidemical diseases, where you
    will find but few persons but either are, or have been afflicted with
    a tedious quartan. In this place I lived some years, making the best
    use of my time I could for the improving my knowledge."

Talbor's first chapter is a fluent account of how agues are produced by
"obstructions" of the spleen. This was a matter of theoretical pathology
which an empiric could make a show with as well as another. But the
empiric betrays himself as soon as he comes to practice. The enlarged
spleen of repeated agues, or of the malarial cachexia, is commonly known
as the ague-cake. There is no doubt that much of the unhappiness of the
aguish habit resides in the ague-cake, and that one of the best pieces of
treatment is to apply counter-irritants or the actual cautery to the left
side, against which the enlarged spleen presses as a cake-like mass.
Talbor, however, desired to free the patient from his "ague-cake"
altogether:

    "I have observed these in four patients: two were cast out the stomach
    by nature, and the other two by emetic medicines. One of them was like
    a clotted piece of phlegm, about the bigness of a walnut, pliable like
    glue or wax, weighing about half an ounce; another about the bigness
    of the yolk of a pullet's egg, and like it in colour, but stiffer,
    weighing about five drachms; the other two of a dark colour, more
    tough, about the like bigness, and heavier. It is a general
    observation amongst them that their ague comes away when they see
    those ague-cakes[571]."

Having followed this "good old way of observation and experiment" for
several years among the residents of the Essex marshes, Talbor came to
London, and set up his sign next door to Gray's Inn Gate in Holborn. In
1672 (14th July) he issued a small work with a Greek title--the quacks
were fond of the Greek character on their title-pages--"[Greek:
Puretologia], a rational account of the cause and cure of agues, with
their signs: whereunto is added a short account of the cause and cure of
feavers." He made a bid also for practice in "scurvy," a disease of
landsmen in those times which was more a bogey than ague itself--"a
strange monster acting its part upon the stage of this little world in
various shapes, counterfeiting the guise of most other diseases ...
sometimes it is couchant, other times rampant, so alternately chronic and
acute."

Most of the agues which Talbor professed to have met with in London in
those years must have been equally factitious: for Sydenham, who makes
more of "intermittents" than other writers of repute, was of opinion that,
for thirteen years from 1664 to 1677, fevers of that type had not been
seen in London, except some sporadic cases or cases in which the attack
had begun in the country. But the air was then full of talk and
controversy about Peruvian bark, or Jesuits' powder (_pulvis patrum_), or
"the cortex," which was cried up as a specific in agues by some, and cried
down by others. Talbor had seized upon this specific, and claimed to have
an original way of administering it, whereby its success was assured. We
get a glimpse of his practice from Dr Philip Guide, a Frenchman who came
to London and practised for many years as a member of the College of
Physicians[572]. Talbor had cured the daughter of Lady Mordaunt of an
ague, and the cure had reached the ears of Charles II. One of the French
princesses having been long afflicted with a quartan ague,

    "The king commanded Mr Talbor to take a turn at Paris, and as a mark
    of distinction he honoured him with the title of knight. He succeeded
    wonderfully. But he could not cure Lady Mordaunt's daughter a second
    time, whom he had cured once before at London, by whom he gained most
    of his reputation." He tried for two months, but did not relieve the
    symptoms. Dr Guide was called in, and being asked to give his opinion
    of the ague that the young lady was afflicted with, "after some
    inquiry I found her distemper was complicated and quite different from
    the ague, which made me lay the thought of the ague aside, and apply
    myself wholly to the complicated disease, which I effectually cured in
    twelve days, together with her ague, without having any further need
    of the infallible specific of Sir Robert Talbor."


The Peruvian Bark Controversy.

It can hardly be doubted that the conflicting opinions as to the benefit
of Peruvian bark in ague, which have been often cited in disparagement of
medicine and as an example of its intolerance, arose from the
indiscriminate use of it in "agues" diagnosed as such by quacks and
pushing practitioners. The bark had been brought first to Spain in 1632
and had been tried medicinally in 1639[573]. It was under the powerful
patronage of the Jesuits, especially of Cardinal de Lugo, and most of it
at that time found its way to Rome, the centre of a malarious district. In
1652 it failed to cure a "double quartan" in an Austrian archduke, and
thereafter fell into some disrepute. A violent controversy on its specific
use in agues arose in the Netherlands; it had failed in every case at
Brussels, it had not failed in a single case at Delft. Meanwhile it
remained, very dear, sixty florins having been paid at Brussels in 1658
for as much as would make twenty doses, to be sent to Paris. The London
'Mercurius Politicus' of the week 9-16 December, 1658, contained an
advertisement[574] that a supply of it had been brought over by James
Thompson, merchant of Antwerp, and was to be had either at his own
lodgings at the Black Spotted Eagle in the Old Bailey or at Mr John
Crook's, bookseller, at the sign of the Ship in St Paul's Churchyard. The
London physicians such as Prujean and Brady countenanced it, and Willis,
in reprinting his essay on Fevers in 1660, spoke of it as coming into
daily use. Sydenham, whose publisher was the same Crook at the sign of the
Ship, made a brief reference to it in the first edition (1666) of his
_Observationes Medicae_, in the section upon the epidemic constitution of
intermittents during the years 1661-64. He admits that the bark could keep
down fermentation for the time being; but the _materies_ which the
fermentation would have dissipated if it had been allowed its way, will
remain in the system and quickly renew its power. He had known a quartan
continue for several years under the use of bark. It had even killed some
patients when given immediately before the paroxysm. Prudently and
cautiously given, in the decline of such fevers, it had been sometimes
useful and had stopped the paroxysms altogether, especially if the aguish
fits were occurring at a season when the malady was less epidemical. But
it is clear that Sydenham in 1666 inclined strongly to non-interference
with the natural depuratory action of the fever upon the _materies_ of the
disease. His teaching that the cortex, while it kept down the fermentation
of the blood for a time, left the dregs of the fever behind, was thus
popularly stated some years after by Roger North in relating the fatal
illness of his brother the Lord Keeper Guilford in the summer of
1685[575].

    The fever of Lord Guilford was not an intermittent at all, but a
    "burning acute fever without any notable remissions and no
    intermissions," a case of the epidemic typhus of that and the
    succeeding year, elsewhere described. The treatment was first in the
    hands of Dr Masters, pupil and successor of Dr Willis, whose cardinal
    doctrine of fevers was that they were a natural fermentation of the
    blood. He ordered phlebotomy. Next Dr Short, of another school, was
    sent for: "So to work with his cortex to take it off: and it was so
    done; but his lordship continued to have his headache and want of
    sleep. He gave him quieting potions, as they called them, which were
    opiates to make him sleep; but he ranted and renounced them as his
    greatest tormentors, saying 'that they thought all was well if he did
    not kick off the clothes and his servant had his natural rest; but all
    that while he had axes and hammers and fireworks in his head, which he
    could not bear.' All these were very bad signs; but yet he seemed to
    mend considerably; and no wonder, his fever being taken off by the
    cortex. And it is now found that, without there be an intermission of
    the fever, the cortex doth but ingraft the venom to shoot out again
    more perniciously." The Lord Keeper's illness dragged on, and at
    length the physicians "found he had a lent fever which was growing up
    out of the dregs which the cortex had left; and if it were not taken
    off, they knew he would soon perish. So they plied him with new doses
    of the same under the name of cordial powders, whereof the quantity he
    took is scarce credible; but they would not touch his fever any more
    than so much powder of port. And still he grew worse and worse. At
    length the doctors threw up[576]."

Sydenham having indicated in his edition of 1666 that bark was dangerous
when given immediately before a paroxysm, but that it was sometimes useful
in the decline of the fever, and that its benefits were greatest in those
desultory agues which appeared at, or continued into, a season when agues
had become less epidemical, he proceeded in his third edition of 1675 to
enlarge these indications for giving bark in ague. He begins, as Talbor
had begun in his essay of 1672, and as the empiric Streater had in his
advertisement of 1641, by calling quartans the _opprobrium medicorum_, and
he then lays down precisely how bark was to be given in those obstinate
fevers, as well as in tertians of the aged or feeble: namely, after the
fever had exhausted itself _suo Marte_, in the intervals between two
paroxysms, an ounce of bark (in two ounces of syrup of roses) to be taken
in the course of the two free days, a fourth part at a time morning and
evening. The dosage may have been borrowed from Talbor, as Sir George
Baker alleges[577]; it matters little for anyone's fame. Sydenham,
however, in a letter of October, 1677, thus claimed to have been
independent of Talbor so far as concerned the directions for giving bark
which he inserted in his edition of 1675:

    "I have had but few trials, but I am sure that an ounce of bark, given
    between the two fits, cures; which the physicians in London not being
    pleased to take notice of in my book, or not believing me, have given
    an opportunity to a fellow that was but an apothecary's man, to go
    away with all the practice on agues, by which he has gotten an estate
    in two months, and brought great reproach on the faculty[578]."

Talbor was patronised by Charles II., who caused him to be made one of his
physicians. On 2 May, 1678, a few months after the date of Sydenham's
letter, Lord Arlington wrote to the president of the College of
Physicians[579]: "His Majesty, having received great satisfaction in the
abilities and success of Dr Talbor for the cure of agues, has caused him
to be admitted and sworn one of his physicians." Next year, 1679, the king
had an attack of the reigning ague, and a recurrence of it in 1680. It is
probably to the occasion of one or other of these attacks that an undated
letter belongs from the Marquis of Worcester to the marchioness: "The
physicians came to the Council to acquaint them that they intend to give
the king the Jesuit's powder five or six times before he goes to
Newmarket, which they agreed to. He looks well, eats two meals of meat a
day, as he used to do[580]." Evelyn has preserved a story told him by the
Marquis of Normanby, which probably relates to the same aguish attack of
Charles II.[581]:

    "The physicians would not give the _quinquina_ to the king, at a time
    when, in a dangerous ague, it was the only thing that could cure him
    (out of envy, because it had been brought into vogue by Mr Tudor
    [Talbor] an apothecary), till Dr Short, to whom the king sent to know
    his opinion of it privately, sent word to the king that it was the
    only thing which could save his life, and then the king enjoined his
    physicians to give it to him, which they did, and he recovered. Being
    asked by this lord [Normanby] why they would not prescribe it, Dr
    Lower said it would spoil their practice, or some such expression."

What Dr Lower was most likely to have said was, that it went against his
principles to give bark in fevers. He was a physiologist, in the sense of
an anatomist, the pupil of Willis at Oxford and his successor in practice
in London. It was the teaching of Willis that blood was like the juice of
vegetables, particularly the juice of the grape, in respect of fermenting,
just as it was like milk in respect of curdling. Fever was a sudden access
of fermentation, apt to arise in spring and autumn, from internal or
constitutional occasions, as well as to come at any time by infection; by
this febrile ferment, ebullition or commotion, the blood was purged of
certain impurities, comparable to the lees of wine, which were removed
from the body in the sweat, the urine or other critical evacuation.
Jesuit's bark was believed to check fermentation, or, in the later phrase
of Pringle and others, it was antiseptic; and it was probably because he
thought it would check the natural defaecating action of the blood in an
ague that Lower refused to prescribe it. Sydenham was more tentative,
pliant, empirical. He cavilled at Willis's doctrine of the ebullition or
fermentation of the blood without actually rejecting it; for he held
practically the same view of the salutary or depuratory nature of fever,
which was indeed the Hippocratic view of it. Accordingly in his first
reference to bark, in 1666, he sustains the objection to it, that it
interfered with a natural depuratory action; and it was only in following
the lead of Talbor, a more empirical person than himself, that Sydenham
overcame his doctrinal scruples. Dr Short, to whom Charles II. sent
privately for advice, was of Sydenham's party; soon after that occasion,
the latter dedicated to Short his 'Tractate on Gout and Dropsy' (1683). It
was Short who "went to work with his cortex" upon the Lord Keeper in 1685,
after Dr Masters, of the school of Willis, had tried his hand with
phlebotomy. The king's experiences, a few months before the Lord Keeper's
death, had been just the same, and with the same result: the deathbed of
Charles II., it is well known, was the scene of ecclesiastical rivalries;
but the physicians at the bedside of the king had their rivalries too.

On Monday the 2nd of February, at eight in the morning, the king had a
seizure of some kind in his bed-chamber, which was currently said to have
been an "apoplectic fit[582]," although there is nothing said of
paralysis. A letter of the 3rd February[583] says the king "was seized in
his chair and bed-chamber with a surprising convulsion fit which lasted
three hours." Dr King, an expert operator who had assisted Lower in the
delicate operation before the Royal Society on 23 November, 1667, of
transfusing blood from one body to another, happened to be at hand, and,
at once drawing his lancet, bled the king. His promptitude in action,
which probably left him little time for diagnosis, was much applauded, and
the Privy Council voted him a reward of a thousand pounds, which Burnet
says he never received.

    "This rescued his Majesty for the instant," says Evelyn, (who came up
    from Wooton on hearing the news, and is probably correct in his
    narrative), "but it was only a short reprieve. He still complained,
    and was relapsing, often fainting, with sometimes epileptic symptoms,
    till Wednesday, for which he was cupp'd, let blood in both jugulars,
    had both vomit and purges, which so reliev'd him that on Thursday
    hopes of recovery were signified in the public Gazette; but that day,
    about noone, the physitians thought him feverish. This they seem'd
    glad of, as being more easily allay'd and methodically dealt with than
    his former fits; so as they prescribed the famous Jesuit's powder: but
    it made him worse, and some very able doctors who were present did not
    think it a fever, but the effect of his frequent bleeding and other
    sharp operations us'd by them about his head, so that probably the
    powder might stop the circulation, and renew his former fits, which
    now made him very weake. Thus he pass'd Thursday night with greate
    difficulty, when, complaining of a paine in his side, they drew 12
    ounces more of blood from him; this was by 6 in the morning on Friday,
    and it gave him reliefe; but it did not continue, for being now in
    much paine, and struggling for breath, he lay dozing, and after some
    conflicts, the physitians despairing of him, he gave up the ghost at
    halfe an houre after eleven in the morning, being 6 Feb. 1685, in the
    36th yeare of his reigne, and 54th of his age.... Thus died King
    Charles II. of a vigorous and robust constitution, and in all
    appearance promising a long life[584]."

Whether the bark would have saved him if the aguish nature of the
paroxysms (such as he had in 1679 and again in 1680) had been clear from
the first, may be doubted. But his chances of recovery were certainly made
worse by the halting and stumbling diagnosis, (according to Evelyn)--now
apoplexy, now epilepsy, now fever[585].

The true value of cinchona bark in medicine was not seen until much that
was vague in the use of the term "ague" had been swept away. In the last
great epidemic period of agues in this country, as we shall see, from 1780
to 1786, bark was found, for some reason, to be ineffective. It is not in
the treatment of epidemic agues, but of agues in malarious countries, that
the benefits of Jesuits' bark have been from first to last most obvious.

The practice in so-called agues was long in the hands of empirics, who,
like their class in general, made business out of ignorant or lax
diagnosis. I shall add here what remains to be said of specialist
ague-curers in later times. They are heard of in London in the Queen Anne
period, and as late as 1745.

    Swift writes in his Journal to Stella, 25 December, 1710, from Bury
    Street, St James's: "I tell you a good pun: a fellow hard by pretends
    to cure agues, and has set out a sign, and spells it _egoes_; a
    gentleman and I observing it, he said, 'How does that fellow pretend
    to cure agues?' I said, I did not know, but I was sure it was not by a
    _spell_. That is admirable." In 1745, Simon Mason, of Cambridge,
    published by subscription and dedicated to Dr Mead an essay, _The
    Nature of an Intermitting Fever and Ague considered_ (Lond. 1745), in
    which he has the following on "charm-doctors":--"When one of these
    poor wretches apply to a doctor of this stamp, he enquires how many
    fits they have had; he then chalks so many strokes upon a heater as
    they tell him they have had fits, and useth some other delusions to
    strengthen the conceit of the patient" (p. 167). Francis Fisher, who
    had been upper hostler in a livery stable in Crutched Friars near
    forty years, "told me he seldom missed a week without several ague
    patients applying to him, and he cured great numbers by a charm they
    wore in their bosoms" (p. 239). Another, who kept a public-house near
    St George's Fields, Southwark, sold "febrifuge ale" at a shilling a
    pint. It was a small ale brewed without hops, but with bark,
    serpentery, rhubarb and cochineal mixed in the brewing. The receipt
    was given him by an old doctor who was a prisoner in the King's Bench.
    His customers came in the morning fasting, and drank their shilling's
    worth after the publican had given them faith by a cordial grip of the
    hand. "By this means," he told Mason, "I got a good trade to my house,
    and a comfortable maintenance too."

We may now return to the actual history of the epidemic fevers upon which
the Peruvian bark was first tried on a large scale in England. The
"intermittent" constitution which began in 1677 and lasted year after year
until 1781 or even longer was a very remarkable one. It was called at the
time the new fever, or the new ague, and it had at least one short
interlude of influenza or epidemic catarrhal fever in the winter of 1679,
just as the last epidemic of the kind, in 1657-59, had at least one, and
probably two, short and swift epidemic catarrhs in spring. But before we
come to that epidemic of 1678-81, there falls to be noticed an epidemic in
the month of November, 1675, which has always been counted among the
influenzas proper. After giving the particulars of it from Sydenham and
from the London bills of mortality, I shall show from Sydenham and the
bills of mortality that there was an exactly similar epidemic in the month
of November, 1679, which has not been admitted into the conventional list
of influenzas. Thereafter I shall proceed to the epidemic constitution of
1678-81 as a whole, which has been reckoned among the epidemic agues or
malarious epidemics.


The Influenza of 1675.

The first that we hear of the universal cold of 1675 is an entry which
Evelyn makes in his diary under 15 October: "I got an extreme cold, such
as was afterwards so epidemical as not only to afflict us in this island,
but was rife over all Europe, like a plague. It was after an exceeding dry
summer and autumn." It was not until November that the epidemic cold made
an impression upon the death-rate in London; the deaths mounted up from
275 in the week ending 2 November, to 420 and 625 in the two weeks
following, and thereafter gradually declined to an ordinary level. Part of
the excess, but by no means the greater part of it, was set down under
fevers, as the following section from the weekly bills of the year will
show:

1675

                                Griping in
  Week Ending  Fever  Smallpox  the Guts    All causes

      Nov. 2    42        9        29          275
           9    60       12        42          420
          16   130       13        43          625
          23    99        2        28          413
          30    61        6        29          349
      Dec. 7    54        7        25          308
          14    43        5        12          266

This shows the characteristic rise and fall of an epidemic catarrh both
in the article of fever deaths and in the column of deaths from all
causes. The other excessive articles besides fever in the two worst weeks
are also characteristic of influenza mortality:

              Week ending   Week ending
               9 Nov.        16 Nov.

  Consumption    68            99
  Aged           40            67
  Tissick        10            35

Sydenham's account bears out the figures[586]. At the end of October, he
says, the mild, warm weather turned to cold, while catarrhs and coughs
became more frequent than at any time within his memory. They lasted until
the end of November, when they ceased suddenly. Afterwards he gives a
special chapter to the "Epidemic Coughs of the year 1675, with Pleurisies
and Pneumonias supervening." The epidemic spared, he says, hardly anyone
of whatever age or temperament; it went through whole families at once. A
fever which he calls _febris comatosa_ had been raging far and wide since
the beginning of July, with which in the autumn dysenteric and diarrhoeal
disorders were mingled (it was an exceedingly dry season). This
constitution held the mastery all the autumn, affecting now the head, now
the bowels, until the end of October, when catarrhs and coughs became
universal and continued for a month. Sydenham's view of the sequence of
events was his usual one, namely, that one constitution, by change of
season, passed by transition into another. Whatever the constitution of
"comatose" fevers may have been, which prevailed "far and near," it has
left no trace upon the bills of mortality in London, which are remarkably
low until the beginning of November. But as soon as the epidemic of coughs
begins, the weekly deaths mount up in an unmistakeable manner, so that for
two or three weeks in November, the mortality is nearly double that of the
weeks preceding or following.

The "severe cold and violent cough," of 1675, says Thoresby of Leeds[587],
who was then a boy, "too young or unobservant to make such remarks as
might be of use," was known in the north of England "profanely" by the
name of the "jolly rant." Thoresby well remembered that it affected all
manner of persons, and that so universally that it was impossible, owing
to the coughing, to hear distinctly an entire sentence of a sermon. He
gives December as the month of it in Leeds, and says that it affected
York, Hull, and Halifax, as well as the counties of Westmoreland, Durham,
and Northumberland. In Scotland also we find a trace of a strange epidemic
sickness. It was the time of the persecution of the Covenanters, whose
preachers moved hither and thither among the farm-houses. One of them,
John Blackadder, was at the Cow-hill in the parish of Livingstown in
August, 1675. He came in one evening from the fields very melancholy, and
in reply to questions, he said he was afraid of a very dangerous
infectious mist to go through the land that night. He desired the family
to close doors and windows, and keep them closed as long as they might,
and to take notice where the mist stood thickest and longest, for there
they would see the effects saddest. "And it remained longest upon that
town called the Craigs, being within their sight, and only a few families;
and within four months thereafter, thirty corpses went out of that
place[588]." The prophecy was fulfilled within four months, which would
bring us to the date of the influenza, although the mortality for a small
place is somewhat excessive.


The Influenza of 1679.

For the sake of comparison, I pass at once to an epidemic of coughs and
colds in the month of November, 1679, which Sydenham has chronicled, but
no one except Cullen[589] has thought of including among the influenzas.
It produced the characteristic effect of influenza on the London weekly
bills, and it came in the midst of epidemic agues, just as the epidemic
catarrhs of 1658 and 1659 had done. The following rise and fall are just
as distinctive of an influenza as on the last occasion in 1675:

1679

                                      Griping of
  Week ending    Fever    Smallpox    the Guts   All causes

  Nov. 11          50        18           34        328
       18          89        27           39        541
       25         126        21           55        764
  Dec.  2          82        27           38        457
        9          63        12           38        388

Sydenham's account[590] of this remarkable November outburst of sickness
in London, written within a few weeks of its occurrence, is almost exactly
a repetition of his language concerning the epidemic coughs of November,
1675. The prevailing intermittent fevers, he says, gave place to a new
epidemic depending upon a manifest crasis of the air. The new epidemic was
one of coughs, which were so much more general than at the same season in
other years that in nearly every family they affected nearly every person.
In some cases of the cough, the aid of a physician was hardly needed; but
in others the chest was so shaken by the violent convulsive cough as to
bring on vomiting, and the head was affected with vertigo. For the first
few days the cough was almost dry, and so purely paroxysmal as to remind
Sydenham of the whooping-cough of children. Everyone was surprised, he
says, at the frequency of these coughs in this season. His own suggestion
was that the rains of October[591] had filled the blood with crude and
watery particles, that the first access of cold had checked transpiration
through the skin, and that Nature had contrived to eliminate this serous
colluvies either by the branches of the "vena arteriosa" or (as some will
have it) by the glands of the trachea, and to explode it by the aid of a
cough. Phlebotomy and purging were the best cures; diaphoretics he
considered less safe, and he ascribed to their abuse the fever into which
some fell, and the pleurisies which were apt to attack patients with great
violence during the subsidence of the epidemic catarrh.


The Epidemic Agues of 1678-80.

The other English writer on the epidemic constitution of 1678-79 is Dr
Christopher Morley[592]. Like Sydenham, he is occupied almost exclusively
with the epidemic agues; but he also records the extraordinary rise of the
mortality in London for a few weeks in the last months of the year, and
the causes thereof, although it did not occur to him to count that as a
separate part of "the new disease," still less as the principal part,
which it really was in London so far as concerned the death-rate. Dating
his preface from London, the 31st of December, 1679, he says in the text:
"Within the very days of my present writing, it happens that as many as
four hundred deaths more than usual have taken place in a fortnight," the
excessive mortality having been due to "coryza, bronchitis, catarrh, cough
and fever," which were the effects of "most pernicious destillations."

I shall now go back to the beginning of the epidemic constitution in the
midst of which this November interlude occurred, and I shall follow it
season after season to the end, so as to set forth in historical
prominence that which was regarded at the time as "the new disease." When
Sydenham returned to London in the autumn of 1677, after six months' rest
from practice, he was told by his professional friends that intermittents
were being seen here and there (after a clear interval of thirteen years),
being more frequent in the country than in the city. In the letter of
October, 1677, cited above, he speaks of Talbor having made a fortune in
two months by his cures of agues with bark.

    The first particular notice of the "new fever" occurs in a London
    letter of 23 February, 1677/78: "Lady Katherin Brudenhall has been in
    great danger of death by the new feaver[593]." A severe aguish illness
    of Roger North, fully described in his 'Autobiography,' was probably
    another instance of the reigning malady; it came upon him in the hot
    weather of 1678, while he was residing with his brother, Lord
    Guilford, at Hammersmith[594]. In the autumn of 1678, the "new fever"
    came more into notice. On the 8th of September, a letter was brought
    to Evelyn in church, from Mr Godolphin (afterwards celebrated as the
    minister of William III.), to say that his wife was exceedingly ill
    and to ask Evelyn's prayers and assistance. Evelyn and his wife took
    boat at once to Whitehall, and found the young and much-beloved Mrs
    Godolphin "attacqu'd with the new fever then reigning this excessive
    hot autumn, and which was so violent that it was not thought she could
    last many hours." She died next day, in her twenty-ninth year; but, as
    she had been brought to bed of a son six days before, her fever may
    have been more from puerperal causes than from "the new fever then
    reigning." Other known cases of ague the next season were those of Sir
    James Moore, his majesty's engineer, who, in August, 1679, coming from
    Portsmouth "was seized with an ague, and had two or three violent
    fits, which carried him off[595];" and of the king, Charles II., who
    was congratulated on his recovery by the lord mayor and aldermen, on
    15 September, and had a recurrence of the aguish attack ("two or three
    fits") on 15 May, 1680[596]. There are also references to the agues of
    1679 in the country, in the letters of Lady North[597].

Sydenham wrote his account of this epidemic of intermittents in compliance
with a request from Dr Brady, Master of Gonville and Caius College,
Cambridge, that he would continue the method of his 'Observationes
Medicae' into the years following, and in particular give an account of
his method of administering bark. He occupied most of his space with
treatment; but he gives here and there the following epidemiological
details. The agues were mostly tertians, or quotidians, or duplex forms of
these, whereas on a former occasion they had been mostly quartans; after
two or three intermissions they were apt to become continual fevers. The
agues, which had occurred in the spring of 1678, became more common in the
summer and autumn, when they raged so extensively that no other disease
deserved the name of epidemic so much. In winter smallpox took the lead;
but early in July, 1679, the agues began again, and so increased day by
day that in August they were raging excessively and destroying many. It
was in August that the king had his "great cold" at Windsor, which
afterwards changed to an ague. Sydenham then comes to the November
interlude of epidemic catarrhs, which was followed by "a fever without
cough" (_non penitus deleta, sed manente adhuc in sanguine, malae crasis
impressione_), lasting to the beginning of 1680. As that year wore on, the
intermittent fevers began again, and continued more or less until 1685,
becoming indeed less common in London, and less severe, than in the first
four years of the constitution, but in other places, now here, now there,
not less so than at first[598].

I have kept to the last the special account of this epidemic written by
Morley at the end of the second year of it, namely, in December, 1679. He
had been a witness of this fever, first at Leyden in the autumn of 1678,
and next in England in the autumn of 1679, and he made it the subject of a
treatise at the request of an eminent physician in London. It was not so
severe by half in England as in Holland, but the English made a great deal
more of it, calling it the New Disease, the New Ague, the New Fever, the
New Ague Fever, and, in Derbyshire sarcastically, the New Delight. In
Holland they called it neither new nor old, neither intermittent nor
continued, nor a conjunction of both, but simply _morbus epidemicus_, or
_febris epidemica_. His master at Leyden, Professor Lucas Schacht, taught
very decidedly that it was of a scorbutic nature, and as early as the
month of June, 1678, had prophesied the arrival of such an epidemic fever
because "tertians were becoming more and more scorbutic," just as they had
done before the great epidemic of fever in Holland in 1669. Morley claims,
however, that the fever of 1678 was in some respects different from that
of 1669, as well as from that of the year immediately preceding, 1677,
when "an incredible multitude of people all over Belgium, and in every
city and town, fell sick." The Dutch, it appears, called these occasional
outbreaks simply "the epidemic fever," neither intermittent nor continued;
and certainly that of 1669, which is sometimes counted among the epidemic
agues, was a very remarkable "ague." (See Chapter I. p. 19.)

The epidemic fever of 1678, wherever it may have been bred or engendered,
was prevalent in England at the same time as in Holland--in an exceedingly
hot and dry autumn. The most constant symptoms, says Morley (and he writes
both for Holland[599] in 1678 and for the country districts of England in
the autumn of the following year), were nausea, severe vomiting,
incredible tightness about the breast, weight in all the limbs, weariness,
giddiness, vigils, thirst, restless tossing, and languor remaining after
the disease was gone. Among the more remarkable symptoms were the
following: Many had aphthae of the mouth, some twice or thrice, some being
endangered by the severity and closeness of the patches of thrush. In some
there occurred bleeding from the nose, or from piles, stranguary, etc.
Round worms were observed, issuing both by the mouth and anus. In some few
there were spots on the skin, but hardly ever petechiae or tumours near
the ears. It affected all classes equally, all ages and both sexes. Some
said it was easier to children than to adults, but others denied this.
Some said it was more pernicious in the country than in the towns. In
Leyden, the deaths never exceeded 150 in the week, being about twenty in a
week above the ordinary level. More died from the coughs, anginas,
peripneumonies and pleurisies that followed, than from the disease itself.
Schacht says that the wind for nearly two years had been steadily from the
North, or veering to the East or West. The Leyden faculty, and the Dutch
generally, did not think the disease a malignant one; it was very freely
called so, however, in England, the chorus being led by empirics and
illiterate persons: "Ac indicio est," says Morley, "libellus perexiguus
nostra lingua ab Empirico conscriptus de hoc morbo." This seems to refer
to the tract by one Simpson, which I shall notice briefly[600].

    Simpson styles himself a Doctor of Physic, and denies that he is an
    empiric. One sign of his affinity to that order, however, is that he
    objects to the orthodox treatment--emetics, drenches, a too cooling
    regimen, and purges, while he thinks blood-letting of doubtful
    utility. The symptoms were chills at the outset, pains in the head and
    back (in some with shaking), then intense burning heat, thirst,
    profuse immoderate sweats and great debility, a general lassitude,
    dulness, and stupor which in many were followed by delirium and a
    comatose state. Sometimes the fever simulated a quotidian, sometimes a
    tertian. He calls it "this new fever so grassant in city and country"
    and says that in many it assumed "the guise of a morbus cholera, known
    by the much vomitings or often retchings to vomit; and in others under
    the livery of the gripes with looseness, or, in some, looseness
    without gripes." This choleraic tendency concurring with other usual
    causes from the late season of fruit-eating etc., had swelled the
    bills of mortality. The morbus cholera and the gripes were to the new
    fever "like the circumjoviales that move in the same sphere with (but
    at some distance from) their master-planet."

The meaning of all this is obvious on turning to the London weekly, bills
of mortality. In the months of August and September for three years in
succession, 1678-80, the deaths from "griping in the guts" and from
"convulsions" rose greatly. These were, indeed, three successive seasons
of fatal diarrhoea, mostly infantile, as I shall show in the chapter on
that disease.

The following extracts from the London weekly bills of mortality show how
"fevers," as well as other diseases, contributed to the great rise in the
autumns of 1678, 1679, and 1680.

_Autumnal London Mortality in 1678._

1678

                                    Griping
  Week ending    Fever   Smallpox   in Guts   All causes

      Aug. 20     77       31         87        459
           27     79       37        130        510
      Sept. 3     82       37        121        530
           10    103       27        164        621
           17     82       23        178        580
           24     83       20        152        528
       Oct. 1     82       25        117        485
            8     77       27        106        456

_Summer and Autumnal London Mortality in 1679._

1679

                                    Griping
  Week ending    Fever   Smallpox   in Guts   All causes

      July 22     42       55        101        442
           29     60       50        134        565
      Aug.  5     78       63        143        531
           12     62       43        161        579
           19     55       64        149        545
           26     68       53        112        514
      Sept. 2     96       40         97        466
            9     92       47         75        471
           16     85       50         87        462

(For the Influenza weeks, see former Table.)

_Autumnal London Mortality in 1680._

1680

                                    Griping
  Week ending    Fever   Smallpox   in Guts   All causes

      Aug. 10     70       17        108        427
           17     90        6        132        494
           24     98       17        127        552
           31    140       18        228        816
      Sept. 7    101       14        215        671
           14     94       13        173        635
           21    106        9        175        628
           28    130        9        159        615
       Oct. 5    125       16        138        597
           12    121       10         94        530
           19    109       14         68        488
           26     93        5         58        407
       Nov. 2     77       10         53        396

The last of the three autumnal seasons, 1680, is one of the few in the
bills with high deaths from fever along with high deaths from choleraic
disease; and that excess of fever mortality may have been due in part to
the ague epidemic, then in its third season.

The following extracts from Short's summation of parish registers show the
great excess of burials over baptisms in various parts of England during
the years of the aguish epidemic constitution.

_Country Parishes._

           Registers   Sickly    Baptisms   Burials
  Year     examined   parishes   in do.     in do.

  1678        136       17         312        527
  1679        137       44         800       1203
  1680        137       54        1093       1649
  1681        137       41         679       1156
  1682        140       30         632        975

_Market Towns._

           Registers   Sickly    Baptisms   Burials
  Year     examined   parishes   in do.     in do.

  1678         22        5         578        789
  1679         23        7         877       1371
  1680         24        7         946       1494
  1681         24        9         945       1333
  1682         25        9         795       1092
  1683         25        8        1109       1398
  1684         25        8         865       1243
  1685         25        4         741       1191


The Influenza of 1688.

The seasons continued, according to Sydenham, to produce epidemic agues
until 1685, when the constitution radically changed to one of pestilential
fevers, affecting many in all ranks of society and reaching a height in
1686. Sydenham records nothing beyond that date, having shortly after
fallen into ill health and ceased to write or even to practise. One would
wish to have known what he made of the "new distemper" in the summer of
1688, for it was a sudden universal fever, and yet not a catarrh or a
"great cold." It is thus referred to in a letter of the month of June,
from Belvoir, Rutlandshire[601]: "The man that dos the picturs in inemaled
is gon up to London for a weke.... I wish the man dos not get this new
distemper and die before he comes agane." On turning to the London weekly
bills of mortality we find in the first weeks of June the characteristic
rise of one of those sudden epidemic fevers or new diseases, of which the
earliest with recorded figures was the "gentle correction" of July, 1580.
The following are the weekly London figures corresponding to the "new
distemper" of 1688:

_Weekly London Mortalities._

1688

  Week ending   Fevers   All causes

  May 29          58        368
  June 5          76        518
      12         101        559
      19          65        435
      26          66        437

The contemporary London notice of this "influenza" comes from Dr Walter
Harris, who mentioned it in a book written the year after[602]:

    "From the middle of the month of May in the year 1688, for some weeks,
    a slight sort of fever became epidemical. It affected the joints of
    the patients with slight pains, and they complained of a pain in their
    heads, especially in the fore-part, and of a sort of giddiness. It was
    more rife than any that I ever observed before, from any cause
    whatsoever, or in any time of the year. A great many whole families
    were taken at once with this fever, so that hardly one out of a great
    number escaped this general storm. Now this so epidemical or febrile
    insult seemed plainly to me to depend upon the variety of the season
    of the year, the most intense heat of some days being suddenly changed
    to cold.... Never were so many people sick together: never did so few
    of them die. They recovered under almost any regimen,--almost everyone
    of them."

It will be seen, however, that the bills rose very considerably for four
weeks, and that, too, in the healthiest season of the year.

A somewhat fuller account of its symptoms is given by Molyneux for
Dublin[603]. He had been informed by a learned physician from London that
it had been as general there as in Dublin, which we know to have been the
case from Harris's account. Both Molyneux and Harris call it a slight
fever, without mentioning catarrhal symptoms. The spring months
immediately preceding had been remarkable for drought.

    At Dublin this "short sort of fever" was first observed about the
    beginning of July, or some six weeks later than in London. "It so
    universally seized all sorts of men whatever, that I then made an
    estimate not above one in fifteen escaped. It began, as generally
    fevers do, with a chilness and shivering all over, like that of an
    ague, but not so violent, which soon broke out into a dry burning
    heat, with great uneasiness that commonly confined them to their beds,
    where they passed the ensuing night very restless; they commonly
    complained likewise of giddiness, and a dull pain in their heads,
    chiefly about the eyes, with unsettled pains in their limbs, and about
    the small of their back, a soreness all over their flesh, a loss of
    appetite, with a nausea or aptness to vomit, an unusual ill taste in
    their mouths, yet little or no thirst. And though these symptoms were
    very violent for a time, yet they did not continue long: for after the
    second day of the distemper the patient, usually of himself, fell into
    a sweat (unless 'twas prevented by letting blood, which, however
    beneficial in other fevers, I found manifestly retarded the progress
    of this): and if the sweat was encouraged for five or six hours by
    laying on more cloaths, or taking some sudorifick medicine, most of
    the disorders before mentioned would entirely disappear or at least
    very much abate. The giddiness of their head and want of appetite
    would often continue some days afterwards, but with the use of the
    open fresh air they certainly in four or five days at farthest
    recovered these likewise and were perfectly well. So transient and
    favourable was this disease that it seldom required the help of a
    physician; and of a thousand that were seized with it, I believe
    scarce one dyed. By the middle of August following, it wholly
    disappeared, so that it had run its full course through all sorts of
    people in seven weeks time.... This fever spread itself all over
    England; whether it extended farther I did not learn."

This short fever of men was preceded by a slight but universal
horse-cold[604].


The Influenza of 1693.

Molyneux considered the strange transient fever of the summer of 1688 to
have been the most universal fever that perhaps had ever appeared, and he
thought the universal catarrh of five years' later date (1693) to have
been "the most universal cold." We have thus a means of contrasting in the
descriptions of the same author a universal slight fever and a universal
catarrh, which happened within five years of each other, and were neither
of them called at the time by the name of influenza,--a name not known in
Britain until half a century later. Before coming to Molyneux's
description, it should be said that the London bills of mortality bear no
decided trace of an influenza in the end of the year 1693, the following
being the highest weekly mortalities nearest to the date given for the
epidemic at Dublin[605]:

_London Weekly Mortalities._

1693

  Week ending   Fever    All causes

  October  10      43        353
           17      62        353
           24      53        384
           31      69        457
  November  7      68        455
           14      48        365

Molyneux's account of the flying epidemic of 1693 is as follows[606]:

    "The coughs and colds that lately so universally prevailed gave us a
    most extraordinary instance how liable at certain times our bodies
    are, however differing in constitution, age and way of living, to be
    affected much in the same manner by a spreading evil.... 'Twas about
    the beginning of November last, 1693, after a constant course of
    moderately warm weather for the season, upon some snow falling in the
    mountains and country about the town [Dublin], that of a sudden it
    grew extremely cold, and soon after succeeded some few days of very
    hard frost, whereupon rheums of all kinds, such as violent coughs that
    chiefly affected in the night, great defluxion of thin rheum at the
    nose and eyes, immoderate discharge of the saliva by spitting,
    hoarseness in the voice, sore throats, with some trouble in
    swallowing, whesings, stuffings and soreness in the breast, a dull
    heaviness and stoppage in the head, with such like disorders, the
    usual effects of cold, seized great numbers of all sorts of people in
    Dublin.

    "Some were more violently affected, so as to be confined awhile to
    their beds; those complained of feverish symptoms, as shiverings and
    chilness all over them, that made several returns, pains in many parts
    of their body, severe head-aches, chiefly about their foreheads, so as
    any noise was very troublesome: great weakness in their eyes, that the
    least light was offensive; a perfect decay of all appetite; foul
    turbid urine, with a brick- sediment at the bottom; great
    uneasiness and tossing in their beds at night. Yet these disorders,
    though they very much frightened both the sick and their friends,
    usually without help of remedy would abate of themselves, and
    terminate in universal sweats, that constantly relieved.... When the
    cold was moderate, it usually was over in eight or ten days; but with
    those in whom it rose to a greater height, it continued a fortnight,
    three weeks, and sometimes a month. One way or other it universally
    affected all kinds of men; those in the country as well as city; those
    that were much abroad in the open air, and those that stay'd much
    within doors, or even kept close in their chambers; those that were
    robust and hardy, as well as those that were weak and tender--men,
    women and children of all ranks and conditions.... Not one in thirty,
    I may safely say, escaped it. In the space of four or five weeks it
    had its rise, growth, and decay; and though from first to last it
    seized such incredible numbers of all sorts of men, I cannot learn
    that any one truly dyed of it, unless such whose strength was before
    spent by some tedious fit of sickness, or laboured under some heavier
    disease complicated with it.... It spread itself all over England in
    the same manner it did here, particularly it seized them at London and
    Oxford as universally and with the same symptoms as it seized us in
    Dublin; but with this observable difference that it appeared three or
    four weeks sooner in London, that is, about the beginning of
    October.... Nor was its progress, as I am credibly informed, bounded
    by these Islands for it spread still further and reached the
    Continent, where it infested the northern parts of France (as about
    Paris) Flanders, Holland, and the rest of the United Provinces with
    more violence and no less frequency than it did in these countries."

Yet no other writer, English or foreign, appears to have mentioned it. Its
existence rests on the authority of Molyneux alone, according to the above
very circumstantial narrative.


The Influenza of 1712.

There were so many fevers from 1693 to the end of the century that it is
not easy to distinguish epidemic agues or catarrhs among them. If we
follow the continental writers, it is not until 1709 and 1712 that there
is any concurrence of testimony for such widespread maladies. Evelyn,
however, says that in the remarkably dry and fine months of February and
March, 1705, "agues and smallpox prevail much in every place" (21st
February). The very general coughs and catarrhs of 1709 seem to have been
really caused by the severity of the memorable hard winter, the frost
having begun in October, 1708 and lasted until March, 1709. The evidences
of a truly epidemic infectious catarrh or influenza all over Europe in
1709 are scanty and ambiguous. It is probably to this "universal cold"
that Molyneux refers under the year 1708[607]; but English writers have
not otherwise mentioned an epidemic in 1709.

The next, in 1712, was a "new ague" of the kind without catarrhal
symptoms, like that of 1688. One German writer called it the
"Galanterie-Krankheit," another the "Mode-Krankheit," and it was about the
same time that the French name "la grippe" came into use. These names all
mean "the disease _a la mode_" or the reigning fashion[608]; they remind
one of the earlier "trousse galante" and "coqueluche" (a kind of bonnet),
and of the "grande gorre" of 1494. It appears to have made little or no
impression on the mortality, and would hardly have been noticed but for
its wide prevalence. In England it was the subject of a brief essay by Dr
John Turner under the title of "Febris Britannica Anni 1712[609]"--a
certain epidemic fever, of the milder kind, fatal to none, but prevalent
far and wide and leaving very few families untouched. It was marked by
aching and heaviness of the head, burning or lancinating pains in the
back, pains in the joints like those of rheumatism, loss of appetite,
vomiting, pains of the stomach and intestines. The venom though not sharp,
acted quickly. Turner ascribed it to malign vapours from the interior of
the earth (_malignos terrae matris halitus_). Its season in England, as in
Germany, was probably the summer or autumn. Turner begins his discourse
with a reference to the plague in the East of Europe, which, he says, had
been kept out of England by quarantine, to the murrain which was then
raging in Italy (and appeared in England in 1714), and to fevers of a bad
type which had traversed all France during the past spring, invading noble
houses and even the royal palace. Having begun his discourse thus, he ends
it by remarking that the slight British fever did not, in his opinion,
forebode a plague to follow. It may have been a recurrence of this
epidemic next year that Mead speaks of under the name of the "Dunkirk
rant" (supposed to have been brought over from Dunkirk by returning troops
after the Peace of Utrecht) in September, 1713; it was, he says, a mild
fever, which began with pains in the head and went off easily in large
sweats after a day's confinement[610]. The weekly bills of mortality in
London are no help to us to fix the date of the one or more slight fevers
or influenzas about 1712-13. The great fever-years of the period were 1710
and 1714; but the fever was typhus, probably mixed with relapsing fever,
according to the evidence in another chapter. Even compared with the
universal fever or influenza of 1688, that of 1712 must have been
unimportant; for the former sent up the London mortality considerably,
whereas there is no characteristic rise to be found in any month of 1712
or 1713.

Either to this period, or to the undoubted aguish years 1727-28, belongs a
curious statement as to "burning agues, fevers never before heard of to be
universal and mortal," in Scotland, the same having been a "sad stroke and
great distress upon many families and persons." The authority is Patrick
Walker, who traces these hitherto unheard of troubles to the Union of the
Crowns (1707)[611].

On other and perhaps better authority, it does appear that Scotland before
that period was reputed to be remarkably free from agues; and it is
probable that the universal and mortal burning agues some time between
1707 and 1728, had come in one of those strange epidemic visitations, just
as the agues of 1780-84 did. It would be erroneous to conclude from such
references to ague that Scotland had ever been a malarious country. Robert
Boyle refers in two places to the rarity of agues in Scotland in the time
of Charles II.; the Duke of York, he says[612], on his return out of
Scotland, 1680, mentioned that agues were very unfrequent in that country,
"which yet that year were very rife over almost all England"--to wit, the
epidemic of 1678-80. Again, agues, especially quartans, are rare in many
parts of Scotland, "insomuch that a learned physician answered me that in
divers years practice he met not with above three or four[613]." However,
Sir Robert Sibbald, while he admits the rarity of quartans, does allege
that quotidians, tertians and the anomalous forms occurred, that agues
might be epidemic in the spring, with different symptoms from year to
year, and that certain malignant fevers, not called agues, were wont to
rage in the autumn[614].


Epidemic Agues and Influenzas, 1727-29.

The contemporary annalist of epidemics in England is Wintringham, of York,
who enters remittents and intermittents almost every year from 1717 to the
end of his first series of annals in 1726; but none of his entries points
very clearly to an epidemic of ague[615]. It is not until the very
unwholesome years 1727-29 that we hear of intermittent fevers being
prevalent everywhere, with one or more true influenzas or epidemic
catarrhs interpolated among them. To show how unhealthy England was in
general, I give a table compiled from Short's abstracts of the parish
registers, showing the proportion of parishes, urban and rural, with
excess of burials over christenings:

_Country Parishes._

                      Registers
         Registers   showing high   Births     Deaths
  Year   examined     death-rate    in ditto   in ditto

  1727     180           55           1091      1368
  1728     180           80           1536      2429
  1729     178           62           1442      2015
  1730     176           39           1022      1302

_Market Towns._

                      Registers
         Registers   showing high   Births     Deaths
  Year   examined     death-rate    in ditto   in ditto

  1727      33           19           2441      3606
  1728      34           23           2355      4972
  1729      36           27           3494      6673
  1730      36           16           2529      3445

It is clear from the accounts by Huxham, Wintringham, Hillary, and Warren,
of Bury St Edmunds[616], that much of the excessive sickness in 1727-29
was aguish, although much of it, and probably the most fatal part of it,
was the low putrid fever so often mentioned after the first quarter of the
18th century. At Norwich, where the burials for three years, 1727-29, were
nearly double the registered baptisms, many were carried off, says
Blomefield, "by fevers and agues, and the contagion was general." In
Ireland also, a country rarely touched by true agues, Rutty enters
intermittent fever as very frequent in May, 1728; and again, in the spring
of 1729: "Intermittent fevers were epidemic in April; and some of the
petechial kind. Nor was this altogether peculiar to us; for at that same
time we were informed that intermittent and other fevers were frequent in
the neighbourhood of Gloucester and London; and very mortal in the country
places, but less in the cities."

       *       *       *       *       *

In the midst of this epidemic constitution of agues and other fevers there
occurred one or more horse-colds, and one or more epidemic catarrhs of
mankind. The most definitely marked or best recorded of these was the
influenza of 1729.

The universal cold or catarrh of 1729 fell upon London in October and
November, and upon York, Plymouth and Dublin about the same time. It
prevailed in various parts of Europe until March, 1730, its incidence upon
Italy being entirely after the New Year. The rise in the London deaths was
characteristic: the level was high when the epidemic began, but the
epidemic nearly doubled the already high mortality during the worst week
and trebled the deaths from "fever."

_London Weekly Mortalities._

1729

  Week ending    Fever   All causes

  October   21     88       564
            28    118       603
  November   4    213       908
            11    267       993
            18    166       783
            25    124       635

The high mortalities of the weeks following may be taken as due to the
sequelae of the epidemic (pneumonias, pleurisies, malignant fevers) and
are indeed so explained in one contemporary account:

  Week ending  Fever   All causes

  December 2     92       678
           9    132       779
          16    116       707
          23    123       710
          30    109       628

The influenza of October and November, 1729, was the occasion of a London
essay[617], which appears to treat solely of the epidemic catarrh and its
after-effects, and not of the two years' previous sicknesses, which are
the subject of another essay, by Strother, written before the influenza
began. London, says this author, as well as Bath, and foreign parts, have
been on a sudden seized universally with the disorders named in his title
(fevers, coughs, asthmas, rheumatisms, defluxions etc.). These had come in
the course of an unusually warm and wet, or relaxing, winter; "we have for
some time past dwelt in fogs, our air has been hazy, our streets loaden
with rain, and our bodies surrounded with water." So many different
symptoms attend the "New Disease" that a volume, he says, would not
suffice to describe them, but he thus summarizes them:

    Sudden pain in the head, heaviness or drowsiness, and anon their noses
    began to run; they coughed or wheezed, and grew hoarse; they felt an
    oppression and load on their breasts, and turned vapourish, either
    because they apprehended ill consequences, or because their spirits
    were oppressed with a load of humours. The victims of the epidemic, he
    says again, were very subject to vapours; they are, upon the least
    fatigue or emotion of mind, dispirited, and flag upon every emergency.
    Among other symptoms were, quick pulse, thirst, loss of appetite and
    vertigo: the mouth and jaws hot, rough and dry, the thrush raising
    blisters thereon; the throat hoarse; a fierce brutal cough, which
    weakens by bringing on profuse sweats; the urine, muddy and white, "if
    they who are seized have been old asthmaticks."

He speaks of cases that had proved suddenly fatal and says that all who
died of "epidemical catarrhs" had been found to have polypuses in their
hearts. If reference be made to the Table, it will be seen that the high
mortality continued in London for at least a month after the epidemic had
passed through its ordinary course of rise, maximum and decline; and it is
probably to that post-epidemic mortality that the author refers in the
following passages:

    "Numbers, as appears by our late bills, are taken with malignant
    fevers, or malignant pleurisies or with pleuritic fevers....
    Whosoever, then, would prevent a defluxion from turning into a fever,
    or from anything yet worse, if worse can be, must keep warm and
    observe a diluting regimen so long as till their water subsides and
    the symptoms are vanquished.... I am convinced by experience that many
    poor creatures have perished under these late epidemical fevers, from
    the fatal mistake of never retiring from their usual employments till
    they have rivetted a fever upon them, and till they have neglected
    twelve or fourteen days of their precious time." This was fully
    endorsed by Huxham for the influenza of 1733: "Morbus raro lethalis,
    quem tamen, multi, vel ob ipsam frequentiam, temeri spernentes, seras
    dedere poenas stultitiae, asthmatici, hectici, tabidi."

Hillary's account for Ripon is very brief[618]:

    "The season continuing very wet, and the wind generally in the
    southern points, about the middle of November [1729] an epidemical
    cough seized almost everybody, few escaping it, for it was
    universally felt over the kingdom; they had it in London and Newcastle
    two or three weeks before we had it about Ripon."

Wintringham, of York, says the epidemic in the early winter of 1729 was "a
febricula with slight rigors, lassitude, almost incessant cough, pain in
the head, hoarseness, difficulty in breathing, and attended with some
deaths among feeble persons, from pleuritic and pulmonary
affections[619]." There was a tradition at Exeter as late as 1775 that two
thousand were seized in one night in the epidemic of 1729. Huxham, of
Plymouth, says of the epidemic in November:

    "A cartarrhal febricula, with incessant cough, slight dyspepsia,
    anorexia, languor, and rheumatic pains, is raging everywhere. When it
    is more vehement than usual, it passes into bastard pleurisy or
    peripneumony; but for the most part it is easily got rid of by letting
    blood and by emetics." In December, the coughs and catarrhal fever
    continued, while mania was more frequent than usual, and in January,
    1730, the cartarrhal fever still infested some persons.

Rutty, of Dublin, merely says: "In November raged an universal epidemic
catarrh, scarce sparing any one family. It visited London before us[620]."

These references to the unusual catarrhal febricula in November, 1729, are
all that occur in the epidemiographic records kept by some four British
writers who recorded the weather and prevalent diseases of those years.
The epidemic catarrh made a slight impression upon them beside some other
epidemics, and hardly a greater impression than another of the same kind,
which seems to have occurred in the beginning of 1728. Thus, Rutty says,
under November, 1727: "In Staffordshire and Shropshire their horses were
suddenly seized with a cough and weakness. In December, it was in Dublin
and remote parts of Ireland; some bled at the nose." On December 25th, he
enters: "The horses growing better, a cough and sore throat seized mankind
in Dublin[621]." Huxham, for Devonshire, under Oct.-Nov. 1727 confirms
this: "a vehement cough in horses, which lasted to the end of December;
the greater number at length recovered from it." He does not say in that
context that an epidemic cough followed among men, as Rutty does say for
Dublin; but in a subsequent note upon horse-colds, he says: "In 1728 and
1733 it [the precedence of the horse-cold] was most manifest; in which
years a most severe cough seized almost all the horses, one or two months
earlier than men." From which it would appear that the influenza of
Nov.-Dec. 1729, was not the only one during the aguish years 1727-29.

In the weekly London bills the other series of mortalities that look most
like those of an influenza are in the month of February, 1728 (748, 889,
850 and 927 in four successive weeks, being more than double the average).


The Influenza of 1733.

The next influenza was three years after that of 1729--in January, 1733.
In London, it raised the weekly deaths for a couple of weeks to a far
greater height than the preceding had done. Also the purely catarrhal
symptoms of running from the eyes and nose are more prominent in the
accounts for 1733 than for the influenza of 1729. The first notice of it
comes from Edinburgh. The horses having been "attacked with running of the
nose and coughs towards the end of October and beginning of November," the
same symptoms began suddenly among men on the 17th December, 1732[622]. By
the 25th the epidemic was general in Edinburgh, very few escaping, and it
continued in that city until the middle of January, 1733. In a great many
it began with a running of lymph at the eyes and nose, which continued for
a day. Generally the patients were inclined to sweat, and some had profuse
sweats. It was noted as remarkable that the prisoners in the gaol escaped;
also the boys in Heriot's Hospital, as well as the inhabitants of houses
near to that charity. The Edinburgh deaths rose as in the following table;
the bulk of these extra burials are said to have been at the public
charges, the epidemic having swept away a great number of poor, old, and
consumptive people:

  Buried in November, 1732   89
    "    "  December, 1732  109
    "    "  January,  1733  214
    "    "  February, 1733  135

Hillary[623] fixes the date of its beginning at Leeds on 3 February, one
week later than at York, three weeks later than at Newcastle, or than in
London and the south of England generally. At Leeds in three days' time
about one-third part of the people were seized with chills, catarrh,
violent cough, sneezing and coryza; the epidemic lasted five or six weeks
in the town and country near. Dr John Arbuthnot, who was then living in
Dover Street, is clear that the outbreak in London was later than in
Edinburgh, which indeed appears also from the paragraph in the
_Gentleman's Magazine_, dated Wednesday the 11th January, and from a
comparison of the dates of highest mortalities in London (p. 349) and
Edinburgh. It was in Saxony from the 15th November to the 29th of that
month, and in Holland before it broke out in England. But it had begun in
New England in the middle of October, and had broken out soon after in
Barbados, Jamaica, Mexico and Peru. Its outbreak in Paris was at the
beginning of February, 1733, and at Naples in March. The symptoms, says
Arbuthnot, were uniform in every place--small rigors, pains in the back, a
thin defluxion occasioning sneezing, a cough with expectoration. In France
the fever ended after several days in miliary eruptions, in Holland often
in imposthumations of the throat. In some, the cough outlasted the fever
six weeks or two months. The horses were seized with the catarrh before
mankind[624].

    The account of the influenza of 1733 in London in the _Gentleman's
    Magazine_ is under the date of 11 January: "About this time coughs and
    colds began to grow so rife that scarce a family escaped them, which
    carried off a good many, both old and young. The distemper discovered
    itself by a shivering in the limbs, a pain in the head, and a
    difficulty of breathing. The remedies prescribed were various, but
    especially bleeding, drinking cold water, small broths, and such thin
    liquids as dilute the blood[625]."

Huxham says that it was in Cornwall and the west of Devon in February,
1733, and that at Plymouth, on the 10th of that month, some were suddenly
seized: "the day after they fell down in multitudes, and on the 18th or
20th of March, scarce anyone had escaped it."

    It began with slight shivering, followed by transient erratic heats,
    headache, violent sneezing, flying pains in the back and chest,
    violent cough, a running of thin sharp mucus from the nose and mouth.
    A slight fever followed, with the pulse quick, but not hard or tense.
    The urine was thick and whitish, the sediment yellowish-white, seldom
    red. Several had racking pain in the head, many had singing in the
    ears and pain in the meatus auditorius, where sometimes an abscess
    formed: exulcerations and swelling of the fauces were likewise very
    common. The sick were in general much given to sweating, which, when
    it broke out of its own accord and was very plentiful, continuing
    without striking in again, did often in the space of two or three days
    carry off the fever. The disorder in other cases terminated with a
    discharge of bilious matter by stool, and sometimes by the breaking
    forth of fiery pimples. It was rarely fatal, and then mostly to
    infants and old worn out people. Generally it went off about the
    fourth day, leaving a troublesome cough often of long duration, "and
    such dejection of strength as one would hardly have suspected from the
    shortness of the time." The cough in all was very vehement, hardly to
    be subdued by anodynes: and it was so protracted in some as to throw
    them into consumption, which carried them off within a month or
    two[626].

Huxham is unusually full on the coughs and anginas of horses for several
months before the influenza of men. In August, 1732, coughs were troubling
some horses; in September, a coughing angina (called "the strangles")
everywhere among horses which almost suffocates most of them; in October
the disease of horses is raging at its worst; and in December it is still
among them.


The Influenza of 1737.

After several years, unhealthy in other ways, the influenza came again in
the autumn of 1737. In Devonshire, according to Huxham, the horses began
to suffer from cough and angina, and some of them to die, as early as
January, 1737, the epizootic being mentioned again in February, but not
subsequently. The same observer says the influenza began at Plymouth in
November and lasted to the end of December, 1737, seizing almost everyone,
and proving much more severe than the epidemic catarrhal febricula of
1733[627]. In London it must have begun in the end of August, to judge by
the characteristic rise in the weekly bills, and in the item of "fevers"
more especially; and although the deaths kept high for a longer period
than in 1733, yet no single week of 1737 had much more than half the
highest weekly mortality of the preceding influenza season.

_London Weekly Mortalities._

1733

  Week ending  Fevers  All causes

  January  16    69      531
           23    83      783
           30   243     1588
  February  6   170     1166
           13   110      628
           20    66      591

1737

  Week ending  Fevers  All causes

  August    30   117      611
  September  6   161      720
            13   201      837
            20   229      861
            27   167      770
  October    4   143      687
            11   114      551

In Dublin the worst week's mortality in 1737, in the month of October, was
144, whereas in the influenza of 1733 the highest weekly bill had been
only 98[628]. Hardly any particulars of the influenza of 1737 remain,
although it appears to have been widely diffused, being recorded for
Barbados and New England. The only source of English information is Huxham
of Plymouth, who mentions some symptoms which should serve to characterize
this outbreak, namely: violent swelling of the face, the parotids and
maxillary glands, followed by an immense discharge of an exceedingly acrid
pituita from the mouth and nose; toothache and, in some, hemicrania; "in
multitudes," wandering rheumatic pains; in others violent sciatics; in
some griping of the bowels. Huxham makes one interesting statement: "This
catarrhal fever has prevailed more or less for several winters past;" or,
in other words, the interval between the severe influenza of 1733 and the
milder influenza of 1737 was not altogether clear of the disease. He adds
that it put on various forms, according to the different constitutions of
those it attacked.


The Influenza of 1743.

Six years after, in 1743, came another influenza, which presents some
interesting points. A writer in the _Gentleman's Magazine_ for May, 1743,
says that the epidemic began in September last in Saxony, that it
progressed to Milan, Genoa, and Venice, and to Florence and Rome, where it
was called the Influenza; in February last (1743) no fewer than 80,000
were sick of it [? in Rome] and 500 buried in one day. At Messina it was
suspected to be the forerunner of a plague--which did, indeed, ensue. It
is now (May) in Spain, depopulating whole villages. The outbreak in Italy
is authenticated by many notices collected by Corradi, Brescia having had
the epidemic in October, 1742, Milan and Venice in November, Bologna in
December, Rome, Pisa, Leghorn, Florence and Genoa in January, 1743, Naples
and the Sicilian towns in February. The English troops, in cantonments
near Brussels, were little touched by it when it reached that capital
about the end of February, but, strangely enough, "many who in the
preceding autumn had been seized with intermittents then relapsed[629]."

In London the epidemic appears to have begun in the end of March, and had
trebled the deaths in the week ending 12th April; by the beginning of May
it was practically over.

_London Weekly Mortalities._

1743

  Week ending  Fevers  All causes

  March 29       94      579
  April  5      189     1013
        12      300     1448
        19      223     1026
        26      115      629
  May    3       82      537

The familiar view of the influenza in London is given in a letter by
Horace Walpole from Arlington Street, 25 March, 1743[630]:

    "We have had loads of sunshine all the winter: and within these ten
    days nothing but snows, north-east winds and _blue plagues_. The last
    ships have brought over all your epidemic distempers; not a family in
    London has scaped under five or six ill; many people have been forced
    to hire new labourers. Guernier, the apothecary, took two new
    apprentices, and yet could not drug all his patients. It is a cold and
    fever. I had one of the worst, and was blooded on Saturday and Sunday,
    but it is quite gone; my father was blooded last night; his is but
    slight. The physicians say there has been nothing like it since the
    year thirty-three, and then not so bad [the bill of mortality almost
    the same]; in short our army abroad would shudder to see what streams
    of blood have been let out! Nobody has died of it [as yet, but later
    some 1000 in a week above the usual bill] but old Mr Eyres of Chelsea,
    through obstinacy of not bleeding; and his ancient Grace of York;
    Wilcox of Rochester succeeds him, who is fit for nothing in the world
    but to die of this cold too."

The account in the _Gentleman's Magazine_ confirms the vast shedding of
blood: "In the last two months it visited almost every family in the city;
so that the surgeons and all the phlebotomists had full employment.
Bleeding, sweating and blistering were the remedies usually prescribed.
All over the island it cut off old people. At Greenwich upwards of twenty
hospital men and boys were buried in a night[631]." In Edinburgh, as in
London, the weekly burials were trebled. On Sunday, May 6th, fifty sick
persons were prayed for in the Edinburgh churches, and in the preceding
week there had been seventy burials in the Greyfriars, being three times
the usual number[632]. It reached Dublin in May, proving milder and less
fatal than in London (perhaps that is why the writer in the _Gentleman's
Magazine_ says it did not visit Ireland at all); it visited, also, the
remote parts of Ulster and Munster, scarce sparing a family[633].

It had reached Plymouth in the end of April. Huxham, who is again the
chief witness to its symptoms, says that it was much less severe there
than in the south of Europe or even than in London.

    Innumerable persons were seized at once with a wandering kind of
    shiver and heaviness in the head; presently also came on a pain
    therein, as well as in the joints and back; several, however, were
    troubled with a universal lassitude. Immediately there ensued a very
    great and acrid defluxion from the eyes, nostrils and fauces, and very
    often falling upon the lungs, which occasioned almost perpetual
    sneezings, and commonly a violent cough. The tongue looked as if
    rubbed with cream. The eyes were slightly inflamed; and, being
    violently painful in the bottom of the orbit, shunned the light. The
    greater part of the sick had easy, equal and kindly sweats the second
    or third day, which, with the large spitting, gave relief. Great loss
    of strength, however, remained. Frequently towards the end of this
    "feveret," several red angry pustules broke out: often, likewise, a
    sudden, nay a profuse, diarrhoea with violent griping. In many cases
    Huxham was astonished at the vast sediment (yellowish white), which
    the urine threw down, "than which there could not be a more favourable
    symptom[634]." One remarkable feature of the epidemic of 1743 was
    recalled by W. Watson in a letter to Huxham on the epidemic of 1762:
    "In the disorder of 1743 the skin was very frequently inflamed when
    the fever ran high; and it afterwards peeled off in most parts of the
    body[635]."


Some Localized Influenzas and Horse-colds.

For the space of nineteen years, from 1743 to 1762, there occurred no
universal cold common to all the countries of Europe; the convergence of
positive testimony, which is so remarkable on many occasions from the 16th
century onwards, is found on no occasion during that interval. And yet the
period is not wanting in instructive notices of epidemic catarrh, which I
shall take from English writings only. British troops occupied Minorca
during some of those years, and the epidemics of the island were carefully
noted by Cleghorn. Under the year 1748 he writes:

    "About the 20th April there appeared suddenly a catarrhal fever, which
    for three weeks raged so universally that almost everybody in the
    island was seized with it. This disease exactly resembled that which
    was so epidemical in the year 1733. For in most part of the sick the
    feverish symptoms went off with a plentiful sweat in two or three
    days; while the cough and expectoration continued sometime longer. In
    a few athletic persons, who were not blooded in time, it terminated in
    a fatal pleurisy or phrensy[636]."

Another English epidemiographist, Hillary, who had begun his records at
Ripon, was in those years resident in Barbados; and in that island, as in
Minorca, we hear of unmistakeable universal colds, although none of them
at the same time as the one recorded by Cleghorn. The Barbados annalist
records a general catarrhous fever in September, 1752[637], and a
recurrence of the same in the end of December, lasting until February 1753
(catarrh and coryza, cough, hoarseness, a great defluxion of rheum, some
having fever with it). As it ceased in February, 1753, a slow nervous
fever began, and continued epidemic for eighteen months, until September,
1784, when it totally disappeared, and was not seen again so long as
Hillary remained in the island (1758). In 1755 there was another epidemic
catarrhal fever, first in February and again in the end of the year. In
the earlier outbreak, few escaped having more or less of it, the symptoms
being cold ague for a few hours, followed by a hot fever with great pain
in the head, or pains in the back and all over the body, which lasted two
or three days, or longer, and then went off in some by a critical sweat.
In the October outbreak it affected children mostly. Once more, in 1757,
the same catarrhous fever returned, with almost the same
circumstances[638]. That year there was a universal catarrh in North
America.

Not less remarkable than the epidemic catarrhal fever in Minorca in 1748,
or those in Barbados in 1752-3, 1755 and 1757, was the epidemic of 1758 in
Scotland[639]. It was first noticed with east winds from the 16th to 20th
September, several children having taken fever like a cold. In the last
week of September thirty out of sixty boys at the Grammar School of
Dalkeith were seized with it in two or three days. In October it became
more general, among old and young, and increased till about the 24th, when
it began to abate. In Edinburgh not one in six or seven escaped. It was in
most parts of Scotland in October--Kirkaldy, St Andrews, Perthshire (where
many died of it), Ayrshire, Glasgow, Aberdeenshire, Rossshire (end of
October). A gentleman told Dr Whytt that in the Carse of Gowrie, in
September, "before this disease was perceived, the horses were observed to
be more than usually affected with a cold and a cough."

The symptoms in Scotland were of the Protean kind of "influenza": there
might be fever with no cold; or a coryzal attack with little or no fever;
or some had bleeding at the nose for several days, which might be profuse;
or the soreness and pains in the bones might be in all parts of the body,
or confined to the cheekbones, teeth and sides of the head. Others had a
fever without any distinctive concomitant, but a cough when the fever
subsided[640]. One of Whytt's patients, a lady aged thirty, had been
feverish for four days, when a scarlet rash appeared, but did not come
fully out; the fall of the pulse and fever coincided with the beginning of
a troublesome tickling cough, "so that the cough might be said to have
been truly critical." Those who exposed themselves too soon frequently
relapsed. Few died of the disease, except some old people. "In some parts
of the country, when the disease was not taken care of in the beginning,
as being attended with no alarming symptoms, it assumed the form of a slow
fever, which sometimes proved mortal."

The year after the localised influenza of Scotland there was an epidemic
of the same kind in Peru and Bolivia, that year, 1759, being one in which
no universal fever or catarrh is reported from any other country. It
extended from south to north, along the coast as well as over the high
table-lands of Bolivia and the sierra region of Peru, invading, among
others, the populous towns of Chuquisaca, Potosi, La Paz, Cuzco and Lima.
In five or six days hardly one inhabitant of a place had escaped it,
although some had it very slightly. As it was swift in its attack, so it
was soon over, lasting about a month in each place. Its symptoms were
great dizziness and heaviness of the head (vertigo and gravedo),
feebleness of all the senses, deafness, strong pains over all the body,
moderate fever, weariness, great prostration, complete loss of appetite,
bleeding from the mouth and nostrils (this had been noted in Scotland the
year before), and a long convalescence. Dogs shared the disorder, and
might have been seen lying stretched out in the streets, unable to stand.
It will be observed that the symptoms given do not include catarrh[641].

Before we come to the next general influenza in Britain, that of 1762,
there are some facts to be mentioned as to agues and horse-colds in the
interval since 1743. In Rutty's Dublin chronology, agues are entered as
prevalent in 1745. In 1750, about the middle or end of December, the most
epidemic and universally spreading disease among horses that anyone living
remembered made its appearance in Dublin, and in Ulster and Munster almost
as soon. It had been in England in November, and was like that which
preceded the universal catarrhs of mankind in 1737 and 1743. In 1751,
irregular agues were frequent in March, as were also tumours of the face,
jaws and throat. Agues also continued to be frequent in April, both in
Dublin and in several parts of the country. In December, 1751, and
January, 1752, there was another horse-cold, the same as a twelvemonth
before. In 1754 the spring agues were frequent in Kilkenny and Carlow,
though rare in Dublin. In 1757, "intermittent fevers, which had not
appeared since April, 1746," came in the end of February. In 1760, a great
catarrh among horses became general in Dublin in April. Coughs and tumours
about the fauces and throat, with a slight fever, often occurred in March;
and regular intermittents, tertians or quotidians, were more frequent than
for some years past. These, according to Sims, of Tyrone, abated after
1762, so that he had not seen an intermittent since 1764 until the date of
his writing, 1773.

The horse-cold of 1760 was observed in London in January. The _Annual
Register_ says under date 27 Jan.: "A distemper which rages amongst horses
makes great havock in and about town. Near a hundred died in one week." In
a letter a day later (28 Jan.) Horace Walpole writes: "All the horses in
town are laid up with sore throats and colds, and are so hoarse you cannot
hear them speak.... 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[642]." This same horse-cold is reported from the Cleveland district
of Yorkshire: "In February, [1760] horses were invaded by the most
epidemic cold or catarrh that has ever happened in the remembrance of the
oldest men living[643]." The same authority for Cleveland says that
intermittents were frequent and obstinate in the spring of 1760.

Among these miscellanies of the history may be mentioned an outbreak of
"violent pleuritic fever or peripneumene" in the spring of 1747, which was
fatal to a comparatively large number in the parish of George Ham, North
Devon. Thirteen died of it from the 20th to the 31st March, four in April,
four in May, and one in June, "most of them in four or five days after the
first seizure." The same family names recur in the list[644].


The Influenza of 1762.

The universal slight fever or catarrhal fever of 1762 was, in London, much
less mortal than those of 1733 and 1743.

_London Weekly Mortalities._

1762

  Week ending  Fevers  All causes

  May   4         72       467
       11        104       626
       18        159       750
       25        162       659
  June  1        121       516
        8         85       504

It began in London about the 4th of April, and by the 24th of that month
"pervaded the whole city far and wide, scarcely sparing anyone." It was in
Edinburgh by the beginning of May, and in Dublin about the same time, but
did not reach some parts of Cumberland until the end of June. Short, who
was then living at Rotherham, says that it "continued most of the
summer[645]." It had the usual variety of symptoms in the individual
cases, of which only a few need be again particularized. Where the fever
was sharp, it usually remitted during the day, having its exacerbation in
the night. Sometimes it proved periodical, and of the tertian type: "it
usually returned every night with an aggravation of the feverish symptoms"
(Rutty). Perspiration was a constant symptom; the tongue was as if covered
with cream (Baker repeats this figure of Huxham's in 1743). "Depression of
mind and failure of strength were in all cases much greater than was
proportionate to the amount of disease. A great number of those affected
were very slowly restored to health, languishing for months, and some even
for a whole year with cough and feverishness--relics of the disease which
it was difficult to shake off. Some, after struggling long with impaired
health, fell victims to pulmonary consumption. In some there were pains in
all the joints and in the head, with lassitude and vehement fever, but
with little signs of catarrh." Rutty, of Dublin, says that in some a
measly efflorescence or a red rash was seen, attended by violent
itching[646]. Among labourers in the country, the pestilence was so
violent as to destroy many within four days, from complications of
pneumonia, pleurisy and angina. Sometimes it took the form of a slow
fever, "and approximated to that form of malady which the ancients
denominated 'cardiac'[647]."

The mortality is said to have varied much. White, of Manchester, declared
that fewer died there than in ordinary while the epidemic lasted. On the
other hand Offley, of Norwich, said there were more victims there than by
the epidemic of 1733 "or by the more severe visitation called influenza in
1743"--the two visitations which were incomparably the worst in the whole
history, according to the London bills. Baker says that it infested cities
and the larger towns crowded with inhabitants earlier than the surrounding
villages, and is inclined to think that it was mostly brought by persons
coming from London[648].

The progress of this epidemic over Europe had been peculiar. It was seen
in the end of February, 1762, at Breslau, where the deaths rose from 30 or
40 in a week to 150. It was in Vienna at the end of March, and in North
Germany about the same time as in England--April and May. There were at
that time British troops in Bremen, among whom the epidemic appeared
shortly after the 10th April[649].

    "It looked at first as if they were going to have agues, but soon they
    were attacked with a cough and a difficulty of breathing and pain of
    the breast, with a headache, and pains all over the body, especially
    in the limbs. The first nights they commonly had profuse sweats. In
    several it had the appearance of a remitting fever for the two or
    three first days." The cough in many was convulsive. The epidemic
    seized most of the people in the town of Bremen: very few of the
    British escaped, but none of them died, except one or two, from a
    complication of drunkenness and pneumonia.

It is said to have been nowhere in France except in Strasburg and the rest
of Alsace, in June. Baker says, "Whilst it raged everywhere else, it did
not reach Paris or its vicinity, a fact which I learned from trustworthy
persons." On board British ships of war in the Mediterranean it occurred
in July. Its severity appears to have varied greatly in different cities
of the same country. Rutty, for Ireland, agrees with Baker, for England,
that it was more fatal in the country than in the towns.


The Influenza of 1767.

The next influenza, that of 1767, was so unimportant that its existence in
England would hardly have been known but for Dr Heberden's paper, "The
Epidemical Cold in June and July 1767[650]." Those few who were affected
by a cold in London early in June observed that it differed from a common
cold, and resembled the epidemical cold of the year 1762, on account of
the great languor, feverishness, and loss of appetite. It became more
common, was at its height in the last week of June or beginning of July,
and before the end of July had entirely ceased. It was less epidemical and
far less dangerous than the cold of 1762, so much so that the London bills
of mortality hardly witness at all to its existence. The attack began with
several chills; then came a troublesome and almost unceasing cough, very
acute pains in the head, back, and abdomen under the left ribs,
occasioning want of sleep. Many of the symptoms hung upon several for at
least a week, and sometimes lasted a month. The fever might be great
enough to bring on deliriousness, yet had plain remissions and
intermissions. The same disorder was reported to be common about the same
time in many other parts of England, and more fatal than it was in London.
Heberden did not anticipate from it the lingering effects in the
individual, for months or years, which marked so many of the cases in
1762[651].


The Influenza of 1775.

Heberden invited physicians in the provinces to send in accounts of the
epidemic of June and July, 1767, but no one seems to have responded.
However, the next epidemic catarrh, of November and December, 1775, was
made the subject of many communications from all parts of Britain, in
response to a circular drawn up by Dr John Fothergill. This was a
distinctly catarrhal epidemic, running of the nose and eyes, cough and
(or) diarrhoea, being commonly noted.

At Northampton some had "a severe pain in one side of the face, affecting
the teeth and ears, and returning periodically at certain hours in the
evening, or about midnight, attended with vertigo, delirium and limpid
urine during the exacerbation. Some whose cases were complicated with the
above symptoms had a general rash, but without its proving critical....
Many of those who escaped the catarrh have been more or less sensible of
giddiness, or pains in the head or face," with limpid urine, etc., as if
they had a full attack[652]. The epidemic began in London about the 20th
October, and made a slight impression upon the bills of mortality in some
weeks of November and December[653]. Grant says that it lasted nearly five
months in London, having been attended by the same "comatose" fever which
Sydenham associated with the epidemic catarrh of 1675. The fatalities in
Grant's practice occurred late in the epidemic:

    "On the 23rd December [1775] I had lost one patient, and soon after
    two others; all died comatous, owing, as I then imagined, to the
    remains of the comatose fever of Sydenham, which had raged all the
    autumn, was complicated with the catarrhous fever, and continued by
    the wet, warm uncommon weather for the season of the year; and I still
    [1782] am of opinion that this complication is the reason why the
    epidemic catarrh of 1775 proved much more fatal than it did in 1782--a
    fact known to all of us[654]."

A Liverpool writer also says that the catarrh of 1782 "distinguished by
the same title," was a much slighter complaint than the "influenza" of
1775. The latter, however, was a summer epidemic, and was naturally less
complicated with pneumonia and bronchitis, whatever the "comatose" fever
of 1775 may have been. Grant's statement that the influenza of 1775 lasted
five months in London is borne out by the Foundling Hospital records: on
11 November, there were 16 in the Infirmary with "epidemic fever and
cough," next week 22 with "fevers, coughs and colds," and so on week by
week under the same names until the 9th of March, 1776[655]. At Dorchester
it was general after 10th November; about the same time it was in Exeter,
where within a week it seized all the inmates, but two children, in the
Devon and Exeter Hospital, to the number of 173 persons. The middle of
November is also the date of its decided outbreak at Birmingham, at
Worcester, and at Chester, where Howard found the prisoners suffering from
it. At York in the north, as at Blandford in the south, it is claimed to
have begun earlier than in London. At Lancaster it was not seen until
three weeks after the accounts of its prevalence in London began to come
in, but only three days after it was first heard of in Liverpool. At
Aberdeen it was fully a month later than in London. It did not visit
Fraserburgh, though there was a putrid fever there very fatal at that
time[656].

In many cases the disease assumed the type of an intermittent towards its
decline, but bark was not useful (Fothergill, Ash, while Baker says that
bark did good when the fever was spent). All the observers agree both as
to its slight fatality and its universality. At Chester it attacked 73 out
of 97 affluent persons, neighbours in the Abbey Square; at the Cross,
inhabited by people in trade, 109 had the disease out of 144; in the
House of Industry, not one escaped out of 175; it attacked people in the
country rather later than in the town, and less generally, but it was in
villages and even in solitary houses.

The unusual prevalence of catarrh among horses (and dogs) is asserted by
John Fothergill ("during this time"), Cuming ("after the middle of August
very generally in Yorkshire"), Glass (in September), Haygarth (in North
Wales, about August and September), Pulteney ("before we heard of it among
the human race"). The fullest statement is by Dr Anthony Fothergill, of
Northampton:

    "This distemper prevailed some time among horses before it attacked
    the human species. The cough harassed them severely and rendered them
    unfit for work, though few died. About the same time also it infested
    the canine species and with great fatality, especially hounds. An
    experienced huntsman informed me that it ran through whole packs in
    many parts of England and that several dogs died[657]."

The progress of influenza from other countries towards Britain was so much
a matter of rumour or vague statement in the earlier periods that it has
not seemed worth while to make a point of it under each epidemic. It
happens, however, that there is good evidence of the line of progress of
the epidemic of 1775. The afterwards celebrated Professor Gregory, of
Edinburgh, encountered it in Italy in the autumn, and followed it all the
way home to Scotland. He saw it successively in Genoa, in the south of
France, in the north of France, in London, and last of all in Edinburgh,
where he himself at length fell ill with it, several of his travelling
companions having taken it in Italy two or three months before. In his
lectures long after (as reported by Christison, who heard them about 1817)
he traced the influenza of 1775 from south to north: "It appears to have
broken out somewhere on the north and west coast of Africa, whence it
spread not only north into Europe, but likewise eastward to Arabia, Egypt,
Syria, Palestine, Asia Minor, Hindostan, China, and was ascertained to
have spread over the whole immense empire of the Chinese. From China it
returned westward by a northern route through the extensive dominions of
Russia and from that country it was sent again over Europe in 1782[658]."


The Influenza of 1782.

Seven years after, in the early summer of 1782, there came another swift
and brief wave of catarrhal fevers over England, Scotland and Ireland, in
the midst of a great "constitution" of epidemic agues which continued for
several years. This was the occasion when the Italian name of "influenza"
was formally adopted by the College of Physicians. Perhaps the first
appearance of the name in English was in an account of the epidemic in
Italy in 1729, given by a London periodical devoted to political news from
foreign countries, and called, "The Political State of Great
Britain[659]." In 1743 the news of the Italian epidemic under its native
name reached London before the infection itself, the Italian name being
frequently given to it while it lasted that season in England. When the
next epidemic came, in 1762, it was not called the influenza as a matter
of course, but was compared to the disease in 1743 "called the influenza."
In the epidemic of 1775, "influenza" came more into use, and in 1782 it
was the name usually given to the epidemic malady. The adoption of this
name put an end at length to the ambiguity between epidemic agues and
influenzas, leaving the curious correspondences between them in time and
place, or the nosological affinities between them, as interesting as ever.

As late as the very fatal aguish years 1727-29, there was no clear
separation of the epidemic agues from the influenzas, of which latter
there were two or more, the one in the end of 1729 being easy to identify.
In the great aguish constitution of 1678-81, Sydenham distinguished the
epidemic coughs and catarrhs in Nov. 1679; but Morley made no such
distinction, describing the whole series of agues for two seasons (and he
might have done so for two seasons more) as the "new fever," "new ague,"
or "new delight," as in Derbyshire, without a suspicion that the universal
coughs, catarrhs and fevers in November, 1679, were something
nosologically distinct, which the future would identify as "influenza." In
like manner Whitmore, in the great aguish period immediately preceding,
that of 1658-59, had described the "new disease" as one single Proteus. In
the still earlier epidemic seasons of 1557-58 and 1580-82, everything was
"ague," although we now discover influenza mixed therewith. I do not say
that this inclusive naming was the better scientifically; nor do I uphold
Willis and Sydenham in their teaching that the intermittent constitution
passed into the catarrhal, in 1658 and 1679 respectively. But it is
necessary to bear in mind the matter of fact, namely, that those agues,
amidst which the "great colds" occurred, were epidemic agues, and not the
endemic fevers of malarious places; and I have now to show that the
"influenza" of 1782 was in like manner a brief episode in the midst of
several successive seasons of agues, which were as much "new" or "strange"
as any of those in the earlier history. Whether the epidemic agues of
1780-85 were the last of the kind in Britain had better be left an open
question until our most recent and most strange experiences in 1890-93 are
read in the light of history.

The influenza of 1782 was a very definite incident of a few weeks--_teres
atque rotundus_. It is easily discoverable in the weekly bills of
mortality in London to have fallen in the month of June:

_London Weekly Mortalities._

1782

  Week ending   Fevers   All causes

  May   21        45        336
        28        49        390
  June   4        57        385
        11       121        560
        18       110        473
        25        89        434
  July   2        49        296

The sudden rise and fall of the deaths and the height reached are much the
same as in other such epidemics in the summer--the "gentle correction" of
1580, the "transient slight fever" of 1688, and the epidemic catarrh of
1762. On the other hand the epidemics of autumn, winter or spring in 1729,
1733, 1737 and 1743 were far more severe, while the winter epidemics of
1675 and 1679 had figures almost the same as the summer epidemics.

The influenza of 1782 was not remarkable, whether in its fatality or in
its characters; but it received far more attention than any that had
preceded it. Two collective inquiries were held upon it, one by a Society
for promoting Medical Knowledge[660], the other by a committee of the
College of Physicians of London[661], many physicians all over England,
Scotland and Ireland contributing to one or other. There were also three
or more separate essays[662].

The epidemic appeared in 1782 at Newcastle in the end of April, and raged
there all May and part of June. In London it appeared between the 12th and
18th of May, in the Eastern Counties about the middle of May, in Surrey
and at Portsmouth, Oxford and Edinburgh, also about the third week of May,
but not in Musselburgh until the 9th or 10th of June. It was at Chester on
the 26th of May, at Plymouth on the 30th, at Ipswich, Yarmouth, York,
Liverpool and Glasgow in the first week of June. In Northumberland it was
raging in July, and did not cease until the third week of August. In
Scotland it was at a height in July, during the haymaking[663]. The most
curious fact in its incidence comes from North Devon; it was prevalent in
Barnstaple at the usual time, the month of June; but the neighbouring town
of Torrington was not then affected by it, having previously gone through
the epidemic, it is said, from a date as early as the 24th of March[664].
In all places it spread quickly, affecting from three-fourths to
four-fifths of the adult inhabitants, but children not so much. At
Christ's Hospital, London, only fourteen out of seven hundred boys had it.
Wherever it attacked children, it did so mildly. It lasted under six weeks
in each place that it came to. There were some strange attacks of it in
London in September, "two months after the late epidemical catarrh had
entirely disappeared from England." The king's ships 'Convert' and
'Lizard' arrived in the Thames from the West Indies in September. Their
crews were perfectly healthy till they reached Gravesend, where they took
on board three custom-house officers; and in a very few hours after that
the influenza began to make its appearance. Hardly a man in either ship
escaped it; and many both of the officers and common seamen had it in a
severe degree[665]. Others who came to London from the West Indies in
merchantmen in the end of September were attacked by influenza in their
lodgings in the beginning of October[666]. To this epidemic belong also
the strange experiences of the Channel Fleet in its two divisions under
Howe and Kempenfelt; but I postpone for the present the whole question of
influenza at sea.

Gray thus sums up the great variety of symptoms as related by his numerous
correspondents:

    Chilliness and shivering, sometimes succeeded by a hot fit, the
    alternation continuing for some hours; languor and lassitude,
    sneezing, discharge from the nose and eyes, pain in the head
    (particularly between or over the eyes), cough, sometimes dry,
    sometimes accompanied with expectoration, inflammation in one or both
    eyes, oppression and tightness about the praecordia, difficulty of
    breathing, pain in the breast or side, pain in the loins, neck,
    shoulders or limbs, sense of heat or soreness in the throat and
    trachea, hoarseness, bleeding from the nose, spitting of blood and
    loss of smell and taste, nausea, flatulence. Also watery blisters
    about the upper parts of the body, and swellings in the face and other
    parts, attended with considerable soreness, apparently erysipelatous.
    In some the catarrhal symptoms were very slight, or entirely wanting,
    the disorder in those cases being like a common fever.

The committee of the College of Physicians said that "the universal and
almost pathognomonic symptom was a distressing pain and sense of
constriction in the forehead, temples, and sometimes in the whole face,
accompanied with a sense of soreness about the cheek-bones under the
muscles," reminding one of the _fierro chuto_ or "iron cap" of the South
American epidemic in 1719. Sometimes no catarrhous affection followed
these strange head pains. The languor of body and depression of spirits
were thought to be more protracted than in 1762, but the fatalities at the
time were fewer than in the earlier epidemic, and there were fewer
consumptions following. Sweating, also, was said by some to be less
remarkable than in 1762; but Carmichael Smyth said: "The late influenza
[1782] might very properly have been named the sweating sickness, as
sweating was the natural and spontaneous solution of it[667]." One
distinctive thing in the epidemic of 1762 was missed by most in 1782,
namely, the peculiar constriction of the breast, with heat and soreness of
the trachea, as if excoriated; but Hamilton describes that very thing for
1782 in Bedfordshire[668]. As in other epidemics of the kind, especially
those which have been least catarrhal, there were hardly two cases quite
the same.


The Epidemic Agues of 1780-85.

Let us now take up the strange history of epidemic agues for two or three
years preceding and following the influenza of June, 1782. Sir George
Baker begins his account of them thus[669]: "The predominance of certain
diseases observable in some years, and the total or partial disappearance
of the same in other years, constitute a subject worthy of our
contemplation."

    These agues were first noticed in London in the spring and autumn of
    1780, but they infested various parts of England a little earlier. In
    the more inland counties the agues were "often attended with
    peculiarities extraordinary and alarming. For the cold fit was
    accompanied by spasm and stiffness of the whole body, the jaws being
    fixed, the eyes staring and the pulse very small and weak." When the
    hot fit came on the spasms abated, and ceased in the sweating stage;
    but sometimes the spasm was accompanied by delirium, both lasting to
    the very end of the paroxysm. Even in the intermissions a convulsive
    twitching of the extremities continued to such a degree that it was
    not possible to distinguish the motion of the artery at the wrist.
    "This fever had every kind of variety, and whether at its first
    accession it were a quotidian, a tertian or a quartan, it was very apt
    to change from one type to another. Sometimes it returned two days
    successively, and missed the third day; and sometimes it became
    continual. I am not informed that any died of this fever whilst it
    intermitted. It is, however, certain that many country people whose
    illness had at its beginning put on the appearance of intermission,
    becoming delirious, sank under it in four or five days."

Reynolds, another London physician, in a letter to Sir George Baker
confirms all that the latter says of these singular epidemic agues: "No
two cases resembled each other except in very few circumstances[670]"--the
remark commonly made about the influenza itself. If these descriptions of
the epidemic ague had not been given by physicians living as late as 1782,
and altogether modern in their methods, we might have supposed that they
were confusing influenzas with agues, or using the latter term inexactly.
"The ague with a hundred names" is the striking phrase of Abraham Holland,
in his poem on the plague of 1625. Whitmore, describing the fatal epidemic
ague (with an episode of influenza) in 1658-59, does not say that it had a
hundred names, but that it assumed a hundred shapes, "which render it such
a hocus-pocus to the amazed and perplexed people, they being held after
most strange and diverse ways with it.... So prodigious in its alterations
that it seems to outvie even Proteus himself[671]."

As farther showing the anomalous character of these epidemic agues, or
their difference from the endemic, Baker adds:--

    "It is a remarkable fact, and well attested, that in many places,
    whilst the inhabitants of the high grounds were harassed by this
    fever, in its worst form, those of the subjacent valleys were not
    affected by it. The people of Boston and of the neighbouring villages
    in the midst of the Fens were in general healthy at a time when fever
    was epidemic in the more elevated situations of Lincolnshire." Women
    were nearly exempt, but few male labourers in the fields escaped it.

Baker heard from all parts that the same constitution continued through
1781 and 1782; and that since that time, though it seemingly abated,
yet agues had been much more prevalent than usual, and had even been
frequent in places where before that period they were uncommon. They
were very noticeable in London from 1781 to 1785, not least so during
the very severe cold of the winter and spring of 1783-84. We hear of
great numbers attacked at Hampstead with common intermittents in
February and the following months of 1781, during which time even
the measles, in the greater number of cases, "ended in very troublesome
intermittents[672]"--just as they were apt to end often in troublesome
coughs.

The annals of Barker, of Coleshill, are full of references to agues, among
other fevers, from 1780 onwards. Under 1781 he writes:--

    "This spring that very peculiar, irregular, dangerous and obstinate
    disease, the burning, or as the people in Kent properly enough called
    it, the Plague-ague, made its appearance, became very epidemical in
    the eastern part of the kingdom, and raged in Leicestershire, the
    lower part of Northamptonshire, Bedfordshire, and in the fens
    throughout the year.... This strongly pestilential disease had such
    an effect upon them that the complexion of their faces continued for a
    time as white as paper, and they went abroad more like walking corpses
    than living subjects."

As many as five persons in an evening were buried from it in some large
towns in Northamptonshire; and about Boston it was so general and grievous
that out of forty labourers hired for work in harvest, half of them, it
was said, would be laid up in three days[673]. In 1783 the "pestilential
agues" were as bad in Northamptonshire and eastern parts as the year
before. A Liverpool writer says:

    "In the autumn of 1782 the quartan ague was very prevalent on the
    opposite shore of the river in Cheshire: it was universal in the
    neighbourhood of Hoylake, where many died of it. Yet it was scarcely
    heard of in Liverpool, although from the uncommon wetness of the
    season it prevailed throughout the kingdom[674]."

On October 25, 1783, a correspondent of the _Gentleman's Magazine_ offered
an explanation of the "present epidemic disorder, which has so long
ravaged this country, and that in the most healthy situations of it,"
namely, "the putrescent air caused by the number of enclosures, and the
many inland cuts made for navigation[675]." Next year, 1784, appears to
have been the principal season of epidemic agues on both sides of the
Severn valley, one practitioner at Bridgenorth making them the subject of
a special essay[676].

It was at this time that Fowler brought into use his solution of arsenic
as a substitute for bark in agues, the latter having notably failed in the
epidemics since 1780.

Baker says: "The distinguishing character of this fever was its obstinate
resistance to the Peruvian bark; nor, indeed, was the prevalence of the
disease more observable than the inefficacy of the remedy:" in that
respect the epidemic agues had belied the experience with bark in ordinary
agues. Again, it is singular that bark had failed most, and arsenic been
especially useful in those parts of England where ordinary malarious agues
were never seen. One practitioner in Dorset laid in a large stock of
arsenic, wherewith he "hardly ever failed to stop the fits soon[677]."
Another, at Painswick, in Gloucestershire, used it successfully in two
hundred cases of epidemic agues from 1784 onwards. He gives the following
account of these unusual agues at Painswick:

    "This town, which is situated on the side of a hill, and is remarkable
    for the purity of its air, is very populous. In the year 1784 the
    epidemic ague, that prevailed in many parts of the kingdom, made its
    appearance in this place, and has continued till the present time
    [Nov. 1787], although previously to that period the disease was hardly
    ever seen here, unless a stranger came with it for the recovery of his
    health, on account of the healthy situation of the place. It affected
    whole families, and appeared to be most violent in spring and autumn.
    In the summer of 1786 it was followed by a fever of the kind called
    typhus, or low nervous fever, which not unfrequently degenerated into
    a putrid fever and proved very fatal[678]." In May, 1785, at a general
    inoculation of smallpox, "many had been afflicted with intermittents
    of several months' duration attended with anasarcous swellings[679]."

It will be seen from the following table of cases treated at the Newcastle
Dispensary, under the direction of Dr John Clark, during twelve years from
1 October, 1777, to 1 September, 1789, that influenza makes the smallest
show among them, being far surpassed by the intermittent fevers and
dysenteries, while all three together are greatly exceeded by the
perennial typhus fever:

                                       Cases treated

  Putrid fever                            1920
  Intermitting fever                       313
  Epidemic dysentery in 1783 and 1785      329
  Influenza of 1782                         53

In Scotland, also, agues became epidemic about the year 1780. There is no
reason to suppose that their prevalence in these years was less
exceptional there than in England and Ireland. It will be seen, indeed,
from the following table compiled from the books of the Kelso Dispensary
that the only years of their considerable prevalence were the same as the
years of epidemic ague in England.

_Kelso Dispensary_[680].

             All    Cases
  Year      Cases  of Ague

  1777       302      17
  1778       306      33
  1779       460      70
  1780       675     161
  1781       510     103
  1782       440      61
  1783       510      73
  1784       459      40
  1785       573      62
  1786       563      48
  1787       525      24
  1788       577      25
  1789       546      48
  1790       640      18
  1791       715      13
  1792       570      16
  1793       666      19
  1794       447       9
  1795       513      23
  1796       355      12
  1797       318       9
  1798       415       7
  1799       558       2
  1800       665       4
  1801       433       9
  1802       377       5
  1803       308       2
  1804       422       5
  1805       469       0
  1806       318       1

It was doubtless the recollection of these epidemic agues that led the
parish ministers who wrote in the 'Statistical Account of Scotland' from
1791 to 1799 to remark upon a supposed progressive decline of endemic
ague, which they set down to drainage of the land[681]. It is probable,
however, that each tradition of ague in Scotland dated from one of its
epidemic periods; it has been shown, indeed, in the foregoing that
Scotland in the end of the 17th century was reputed tolerably free from
ague, and that the severe agues previous to 1728, which belonged to the
epidemical kind, were thought to be something new.


The Influenza of 1788.

According to Barker, of Coleshill, who kept systematic notes of the
epidemic maladies from year to year, there were several recurrences of the
influenza of 1782[682]. But there is only one of these seasons, the
summer of 1788, that other English writers have singled out as a time of
influenza. It was undoubtedly of a very mild type, producing hardly any
effect upon the bills of mortality; but it attracted the notice of
several. Dr Simmons, the editor of the _London Medical Journal_, became
the recorder of it, collecting reports from various parts, as others had
done in 1782. He himself treated 160 cases at the Westminster General
Dispensary, and 65 more elsewhere. It was most prevalent in London from
the second to the fourth week of July, but the mortalities for those weeks
show no abrupt rise. It was at Chatham, Dover, Plymouth and Bath about the
same time, at Manchester in the beginning of August, in Cornwall in the
middle of August, and at Montrose about the end of August, or perhaps most
certainly in October. On 5 August, a physician at York wrote: "We have not
had the slightest appearance of a catarrh in our city or neighbourhood
during the year." The epidemic was undoubtedly a partial one in Britain,
and so slight as to have made little impression where it did occur. It is
said to have been very general at Warsaw in April or May, at Vienna in
April (20,000 cases before the 20th), at Munich in June, at Paris in the
end of August and still continuing on the 24th October, at Geneva on the
10th October. Its most constant symptom in England was pain in the
fore-part of the head, with vertigo; next most constant was a pain at the
pit of the stomach and along the breast-bone; cough was wanting in perhaps
a third of the cases and was always slight, diarrhoea was somewhat
general, running from the eyes exceptional, sore-throat in perhaps
one-sixth of the cases[683]. At Plymouth where it was seen earliest and
clearest among the regiment of artillery and in the guardships, the
symptoms were pain in the head and limbs, soreness of the throat, pain in
the breast, a feeling of coldness all over the skin, and these followed by
cough, a great discharge from the nose and eyes, and slight nausea. It was
much less noticeable among the townspeople than among the troops and
sailors[684]. It occurred chiefly among soldiers or sailors also at Dover
and Chatham. At Bath it was marked by chills, headache, swelling of the
throat, difficult swallowing, quick pulse, hot, dry skin (but not pungent
as in malignant fever), ending in a sweat; no delirium, but broken sleep
or vigil; the eyes scarcely affected, cough in some, but not vehement; in
some, sublingual swellings which suppurated[685]. At Manchester it looked
as if it had been brought in by travellers who had acquired it in
London[686].

At Portsmouth a singular thing happened two or three months after the
epidemic had passed. The frigate 'Rose' arrived on 4 November from
Newfoundland; within a short time all the dogs on board were seized with
cough and catarrh, and soon after the whole ship's company were affected
in the same way[687]. Simmons says of the epidemic of 1788 in general:
"During the progress of the influenza, a complaint which was evidently an
inflammatory affection of the mucous membrane of the fauces, etc. was
frequently observed among horses and other cattle, and was generally as
violent among them as it was mild among their rational neighbours"--many
dying after four or six days.

The very slight and partial influenza of July and August, 1788, happened
at a time when there was much fever of a more serious kind in the country.
The history of the latter belongs to another chapter; but there was in
Cornwall, in the same season as the influenza, an epidemic fever which
might in former times have been described as a part, and the most fatal
part, of the "new disease," and may be taken in this context rather than
in the chapter on typhus. The same physician, Dr William May, of Truro,
gave an account of the influenza first[688] and of the other fever
afterwards[689].

    The latter began at Truro in the end of April, 1788, and was also at
    St Ives and other small towns in various parts of the county. A
    malignant fever had for near two years before been exceedingly rife
    among the poor (owing to distress from loss of pilchard fishing), and
    had carried off a great number of them; but this was something new.
    Yet it was "truly a fever of the typhus type," one of its symptoms
    being constant wakefulness. It passed through whole families,
    affecting all ages and constitutions. It ended on the 17th day,
    whereas the influenza (says May in his other paper) ended with a sweat
    on the fourth or fifth day. In one small neighbourhood this epidemic
    fever affected chiefly the aged, who were blooded owing to dyspnoea:
    out of ten or eleven so affected, not one recovered, an experience
    that reminded May of what Willis said of the village elders being
    swept off by the "new fever" of 1658. Surgeons at St Austel, East Looe
    and Falmouth are cited as having seen much of the same fever. In like
    manner the Manchester chronicler of the influenza of 1788 says:
    "Fevers of different kinds, but chiefly of the type now distinguished
    by the appellation of typhus, were exceedingly prevalent after the
    epidemic catarrh had in great measure ceased to be general; but from
    which, by tracing the symptoms, the fever might usually be found to
    have originated[690]."

For a good many years after the period last dealt with, nothing is heard
in Britain either of epidemic agues or of influenza[691]. Writing in 1800,
Willan said that intermittents had not, to his knowledge, been epidemic in
London at any time within twenty years. He explains this by "the practice
of draining, and the improved modes of cultivating land in Essex, Kent,
and some other adjoining counties, from which either agues were formerly
imported, or the effluvia causing them were conveyed by particular
winds"--the latter being the doctrine of Lancisi for the country round
Rome. But he forgets that their appearance nearly twenty years before was
a strange phenomenon to the practitioners of that generation, and that
Sydenham, whom he cites to prove agues in London in former times, had also
remarked their absence, except in occasional cases, for as long a period
as thirteen years. Of such occasional agues acquired in London, Willan
and Bateman had each one or two examples in the autumn of 1794, and the
spring of 1805.

As in the case of epidemic agues, so also in the case of influenzas, there
was immunity in Britain for a good many years after 1788; and, as the
slight epidemic catarrh of 1788 was something less than universal, the
clear interval may almost be reckoned from the summer of 1782, a space of
over twenty years. Willan's monthly reports of the weather and diseases in
London from March, 1796, to December, 1800, twice mention epidemic
catarrhs,--in February and March, 1797, and in February, 1800, the latter
chiefly among children. But to neither of them will he concede the name of
"influenza," as the complaint was merely epidemical from a particular
state of the atmosphere, and not propagated by contagion, nor quite
general.

    The symptoms, however, were headache, sometimes attended with vertigo,
    a thin acrid discharge from the nostrils, slight inflammation of the
    throat, a sense of constriction in the chest, with a frequent dry
    cough, pains in the limbs, a white tongue, a quick and small pulse,
    with a sensation of languor and general debility. These symptoms,
    fairly complete for influenza of the correct type, lasted about eight
    days and ended in a gentle sweat or in a diarrhoea. Coughs had been
    remarkably severe and obstinate; they were frequently attended with
    painful stitches and spitting of blood[692].


The Influenza of 1803.

The number of the _Medical and Physical Journal_ for March, 1803,
announced that "a cold attended by symptoms of a very alarming nature has
been general in the city of Paris for some time"; but it said nothing of
the alarming disorder being in London. It is in the next number, under the
date of Soho Square, March 11th, that a correspondent identifies the Paris
epidemic with "the complaint now general in this metropolis, and called by
some the Influenza." In a report upon the diseases "in an Eastern District
of London from February 20 to March 20, 1803," the "catarrhal fever" is
thus described:

    "This disease has been so general as to claim the title of the
    reigning epidemic, and is very similar to one which prevailed a few
    years ago, and was denominated Influenza. It has generally been
    introduced by chilliness and shivering, which have been succeeded by
    violent pains in the head, with some discharge from the eyes and
    nostrils, as in a common catarrh, together with hoarseness and cough.
    The pains in the head have in some cases been the first symptoms and
    have been succeeded by giddiness, sickness and vomiting" &c. There
    were also rheumatic pains in the limbs, intercostals &c.

Meanwhile the information from various sources showed that the old
influenza was once more really in this country. Two collective inquiries
were made on the influenza of 1803: one by Dr Beddoes of Bristol, who
issued a circular of five queries, and received answers to them (with
other information) from one hundred and twenty-four correspondents[693];
the other by the Medical Society of London[694]. The _Medical and Physical
Journal_ and Duncan's _Annals_ each received a few independent papers on
it; and several pamphlets were issued, mostly devoted to treatment--two in
London[695], one at Edinburgh[696], one at Bath[697], and one at
Bristol[698].

In these abundant data there is little novelty and not much variety.

    The attack began with chills and severe pain in the head, along with
    slight running of the eyes and nose, as typhus fever might have begun.
    After the slightly catarrhal onset the malady was mostly a fever, with
    dry cough, dry and hot skin, pain in the forehead and about the
    eyeballs, pains in the limbs, "spontaneous" weariness and extreme
    prostration--a group of symptoms which led Hooper to find a rheumatic
    character in the malady. Among other symptoms were vertigo, nausea,
    vomiting and diarrhoea. Much sweating is not reported; but there was
    often a gentle sweat in recovering after about a week, less or more.
    There was the usual range from mildness to severity. Pneumonia and
    pleurisy were not rare, and were commonly the cause of fatalities.

The deaths were for the most part among the phthisical, the asthmatic and
the aged; but these were not many, certainly not so many as in 1729, 1733
and 1743, and probably in about the same proportion as in 1762, 1775 and
1782. In the London bills the weekly deaths rose in March, to an average
of 537 from an average of 429 in February, and of 375 in January, falling
to an average of 417 in April. In Ireland the epidemic is said to have
been seen among the troops in garrisons as early as December, 1802; it
became universal in spring and summer. In Edinburgh the rise in the
burials at Greyfriars churchyard was in the weeks ending 5th and 12th
April, making them about a half more than usual for the brief period. When
the wave of influenza was past, the public health in nearly all places
became unusually good, as had happened immediately after the influenza of
1782.

The question most to the front in the influenza of 1803 was its manner of
spreading. Beddoes, who believed in personal contagion, had this in view
in his five queries:

    1. When did the influenza appear and disappear with you?

    2. Was its date different in remote places within your reach?

    3. After being general, did it occur for some time in single
    instances?

    4. Did it ever seem to pass from person to person?

    5. If so, is it likely that clothes or fomites conveyed it in any
    case?

The dates of commencement were earlier or later according to no rule of
direction or of distance from London. In some large towns of Yorkshire it
appeared to be unusually late, in Chester unusually early; Edinburgh,
certainly, was as long behind London as London was behind Paris. Haygarth,
who took the most narrow view of contagion, made out the incidence thus:
London first, then the towns which have the greatest intercourse with
London, such as Bath and Chester, then smaller towns, and last of all the
villages around each of the more populous centres. Several towns had the
brunt of the epidemic in the same weeks (of March) as London; in very few
was it later than the first weeks of April. In some towns it attracted
little notice. In North Devon, it was said to have been at Hartland and
Clovelly a fortnight before it was seen in Bideford; the first of it seen
by one of the doctors of that town was in a solitary potter's house four
miles to the eastward, on a peninsula made by the confluence of a small
stream with the Torridge, all the inmates of the house being attacked; in
the town itself from first to last he saw but few cases, whereas there
were many in the adjacent country[699].

The general rule seems to have been that the more sparse populations had
it later, the nearer they were to the extremities of the kingdom, as in
Cornwall, the north of Scotland, and in Ireland. Opinion was divided as to
the part played by persons in carrying contagion from place to place, some
holding that the facts of diffusion could be explained on no other
hypothesis, while most held that the influenza was in the air. Beddoes got
as many answers favouring the doctrine of personal contagion as made a
respectable show for it; but when these had all been set forth to the best
advantage, a practitioner wrote to say that, after all, nine-tenths of
professional opinion was against the contagiousness of influenza. The
practical question for Haygarth, Beddoes, and other contagionists was
whether influenza was not a disease, like smallpox or scarlet fever, which
could be kept from spreading by means of isolation, disinfection (with the
fumes of mineral acids) and other precautions.

Some curious facts came out, showing the effect of influenza upon other
epidemic diseases, or the effect of other epidemic diseases upon
influenza. One writer applied to influenza what used to be said of the
plague or pestilential fever, that these Leviathan constitutions swallowed
up all other reigning epidemics. Holywell, a town in Flintshire, with a
large cotton-weaving industry, had not been free from a bad kind of typhus
for two years. "On the appearance of the influenza the typhus entirely
ceased, and only one case of fever has occurred since. I have not for many
years known this country so healthy as since the influenza
disappeared[700]." The influenza was said also to have superseded typhus
fever at Navan, in Meath[701]. At St Neots typhus was peculiarly prevalent
for three months before the influenza, but ceased thereafter[702]. Another
relation to typhus was seen at Clifton: "In the low, confined, and
ill-ventilated houses in the Hot Well road, where typhus often abounds,
the influenza was very unfrequent; while in the exposed high-lying
buildings on Clifton Hill it was almost universal[703]." As to ague, which
had often before stood in a remarkable relation to epidemics of catarrhal
fever, there is one possibly relevant fact related from the Lincolnshire
fens. A Wisbech physician writes:

    "The influenza which ceased here about the middle of April made its
    appearance again in May; the leading symptoms were the same as in the
    first attack. About the same time also a most malignant fever, having
    some symptoms in common with the influenza, began to rage in that part
    of Lincolnshire contiguous to us, which has proved fatal to
    hundreds[704]."

From 1803 to 1831, nothing is heard in England of a universal influenza,
although there was one such in the end of 1805 and beginning of 1806 in
Russia, Germany, France and Italy; and there were four great influenzas
in the Western Hemisphere (1807, 1815-16, 1824-25, and 1826). Catarrhs
were perhaps commoner than usual in England and Scotland in the winter of
1807-8, but they cannot be reckoned an epidemic of influenza[705]. The
summer following (1808) was unusually hot and agues became more epidemic
in the fens than at any time since the great aguish period of 1780 and
following years[706]. Agues were again unusually rife in England in 1826,
1827 and 1828, at the same time as the remarkable epidemics of them, from
inundations and subsequent drought, in Holland and along the German coast
of the North Sea. Dr John Elliotson, of London, met with cases of agues in
his practice in those years in the following scale:

  Year  Cases

  1823    8
  1824   14
  1825   15
  1826   44
  1827   53
  1828   27
  1829    8

They had increased, he says, throughout the country as well as in London,
owing, as he thought, in agreement with Macmichael, to the higher mean
temperature of the respective years; and he would apply the same law of
increase to the epidemic periods of ague in Britain in former times[707].
Christison saw his first case of ague at Edinburgh in the autumn of 1827,
in a labourer who had caught it working at the harvest in the fen-country
of Lincolnshire.


The Influenza of 1831.

The next influenza in Britain fell in the early summer of 1831. It was a
mild epidemic of the catarrhal type, which attracted hardly any notice in
England. In one of the London medical journals there is no other notice of
it but this, dated 2 July, 1831[708]: "In consequence of the sudden
variations of temperature which have prevailed since the last fortnight of
May an epidemic bronchitis has shown itself in Paris." Another London
journal[709], on the very same day, wrote: "Influenza in a severe form is
at present prevailing in London and some of the provincial towns. It
commences like a common cold, but is soon discovered to be more serious,
&c." The physician to the public dispensary in Chancery Lane found that
more than half of the seventy applicants on 23 June came with the symptoms
of influenza--severe, harsh, dry cough, in paroxysms, pain behind the
sternum, a fixed pain in one side, congested state of the throat, nose and
eyes, heaviness of the head, languor, debility, hot skin, foul tongue,
impaired sense of taste. The symptoms went off after three or four days
with a sweat in the night and a discharge from the nostrils[710].

This epidemic hardly affected the London bills of mortality, according to
the following figures:

  Four weeks, 25 May to 21 June, 1579 births, 1430 deaths.
  Five weeks, 22 June to 26 July, 2153 births, 2010 deaths.
  Four weeks, 27 July to 23 Aug., 1997 births, 1652 deaths.

The rise in the last four weeks was due to summer diarrhoea, or choleraic
diarrhoea, which was unusually common in 1831. This slight influenza was
also reported from Plymouth by a surgeon who had seen the disease, and
suffered from it, at Manilla in September, 1830[711], and by a Plymouth
practitioner, who wrote, on 14 July, that it had been extensively
prevalent there and in the neighbouring towns and villages[712]. It is
recorded also from the Isle of Man, Glasgow[713], and Ayr[714], and it is
supposed to have been in Aberdeen[715]. But, while there are many
accounts of this epidemic in Germany in May and June, and undoubted
evidence of it in France and Italy, as well as in Sweden, and in Poland
and Russia earlier in the year, the accounts of it in Britain are so
meagre and casual as to make one doubt whether it really was an influenza
worth reckoning.


The Influenza of 1833.

The next year, 1832, which was the first great season of Asiatic cholera
in Britain, is absolutely free from records of influenza in all Europe. It
was in the spring of the year following, 1833, that the really serious
influenza came. The continental literature of the epidemic of 1833 is
immense, the English literature of it is all but non-existent: and yet it
was a very severe influenza with us, just as with other European peoples.
There was no collective inquiry in Britain on this occasion, such as had
been made first by Fothergill in 1775, by the College of Physicians and
another Society in 1782, by Simmons in 1788, and by Beddoes and the
Medical Society of London in 1803, or such as was made in the next
influenza, that of 1837, by a committee of the Provincial Medical
Association. But enough is known of it to place it among the severer
influenzas. In London the bills of mortality, which relate only to a part
of London, showed the characteristic sudden rise and fall:

                                   Baptisms Burials

  Four weeks, 20 Feb. to 16 March   2310     2352
  Five   "    17 March to 23 April  1955     2105
  Four   "    24 April to 21 May    2016     3350
  Four   "    22 May to 18 June     2070     1685

For a whole month the burials in London were nearly doubled, and for the
two worst weeks they were nearly quadrupled. This mortality, by all
accounts, fell most on the richer classes, to whom it was a much more
serious calamity than the Asiatic cholera of the year before. The
president of the Medical Society said, on the 22nd April, that he had
"heard of nine lords or ladies who had been carried off by it or by its
indirect agency, in the course of last week[716]." Its type in the month
of May was worse than in April[717]. When it was first seen it was a
somewhat short catarrhal attack, ending in a sweat after two, three or
four days, with the usual head-pains, soreness of the ribs and limbs,
languor and prostration. Later, it became a more "adynamic" illness,
beginning indeed with slight catarrhal symptoms, but soon passing into
subacute nervous fever which might last for three weeks, involving much
risk to life[718]. Hence arose the warnings, just as in 1890-92, that the
influenza was a much more serious thing than it had been thought when the
epidemic began, and hence the delay, as it were, in the bills of mortality
to show the effects of the epidemic until it had been two or three weeks
prevalent. It is to the month of April, before the highest death-rate was
reached in London, that the following, in the _Gentleman's Magazine_,
applies[719]:

    "During the month a severe form of catarrhal epidemic, generally
    termed influenza, has been extremely prevalent in London. It has laid
    up at once all the members of many large households, and has attacked
    great numbers in several public offices, particularly the Bank of
    England and some divisions of the new police. The performers at the
    theatres have much suffered, and their houses have been closed for
    several nights. It commences suddenly with headache and feeling of
    general discomfort, attended or soon followed by cough, hoarseness, or
    loss of voice; oppression, and sometimes severe pain in the chest,
    tenderness about the ribs, and sense of having been bruised about the
    limbs or muscles.... The disease is generally attributed to the
    constant north-east winds; but by some of the learned is regarded as
    the epidemic influenza which has lately prevailed in the eastern parts
    of Europe, and that is travelling, like many of its predecessors, to
    the west."

It would have been in this earlier stage of the epidemic, when it was
laying up whole households, thinning workshops and closing theatres, that
a practitioner was heard to say (as reported by the _Lancet_): "Best thing
I ever had! Quite a godsend! Everybody ill, nobody dying!" The seriousness
of the disease was, however, at length recognized, so that the members of
the Medical Society debated the subject at three successive meetings. One
of the questions was, whether the malady called for blooding--a question
that had divided opinion as long ago as 1658[720]. On 13 May, the
following passed at the Medical Society:

    Mr Williams remembered the similar influenza of 1803, and said that
    depletion was then regarded as an injurious plan of treatment.

    Mr Proctor:--Yes, but the Brunonian doctrines were then in full fling,
    and practitioners had not learned the full use of the lancet.

Graves states very fairly the reasons that induced them to take blood in
the influenza of 1833, as well as the results of the practice[721]:

    "The sudden manner in which the disease came on, the great heat of
    skin, acceleration of pulse, and the intolerable violence of the
    headache,--together with the oppression of the chest, cough, and
    wheezing--all encouraged us to the employment of the most active modes
    of depletion; and yet the result was but little answerable to our
    expectations; for these means were found to induce an awful
    prostration of strength, with little or no alleviation of the
    symptoms."

The prostration, be it said, was probably as great and as frequent in the
epidemics of 1890-93, when bleeding had gone out altogether; still it was
not understood that all these signs of sthenic action in the attack were
really paradoxical, as Whitmore, in the passage cited in the note, saw
clearly two centuries before.

The epidemic became rapidly prevalent all over England, Scotland and
Ireland in April and May, following no very definite order of progression.
The Liverpool newspapers asserted that ten thousand were down with it in
that town in one week. A doctor at Lincoln wrote, on 13 May, that few
families there had escaped it[722]. Other towns in which it is said to
have been "more or less" prevalent were Portsmouth, Sheffield, Birmingham,
Leeds, York, Halifax, Glasgow, Edinburgh[723], Dublin and Armagh; so that
we may fairly assume, although we are without the detailed evidence
available for earlier epidemics, that it was ubiquitous in town and
country.

At Birmingham[724], among the outpatients of the Infirmary, the cases of
influenza were as follows, the 25th and 26th April being the days when
cases came first in rapid succession, while the middle of May was
practically the limit:

          Cases of
          Influenza    Males    Females

  April      151         52        99
  May        464        159       305
  June        28          9        19
             ---        ---       ---
             643        220       423

The great excess of females is remarkable, but was probably due to some
local circumstances. Of the 643 cases, 122 were under ten years of age. Of
the females, 9 died, of the males 3. But the deaths in Birmingham caused
by the epidemic directly or indirectly were many; the burial registers of
four churches and chapels showed a marked increase of burials above those
of the corresponding months of 1832:

           1832      1833

  April     205       245
  May       211       434
  June      193       230
            ---       ---
            609       909

Medical opinion in 1833 was decidedly adverse to the contagiousness of
influenza. The common remark was that it was just as little contagious as
the cholera of the year before had proved to be. As in 1837 and 1847, when
the doctrine of contagiousness was equally out of favour, the disease was
observed to spread rapidly, in no very definite line, affecting most parts
of the country in the same two or three weeks, affecting the population
within a considerable radius almost at once, and the inmates of houses all
together. These, it was said, are not the marks of a disease that persons
hand on one to another, _quasi cursores_.


The Influenza of 1837.

Between the influenza of April-May, 1833, and that of January-February,
1837, it seems probable that there were minor catarrhal outbreaks,
distinguishable from ordinary colds. One writer on the influenza of 1837
refers to those "who had it in 1834 or in the intervening period between
the two epidemics." The table of diseases of the outpatients at the
Birmingham Infirmary for the year 1836 contains a large total of catarrhs,
and, in another line, 24 cases of "epidemic catarrh" in the summer months.
The _Gentleman's Magazine_ begins its notice of the epidemic of 1837 by
calling it "an influenza of a peculiar character," which shows that
influenza of the ordinary kind was a familiar thing. Probably the name was
a good deal misapplied in the years following every great epidemic from
1782 onwards: thus in 'St Ronan's Well,' which was written in 1823, or
twenty years from the last general influenza, a tradesman's widow in easy
circumstances and given to good living comes to the Spa on account of a
supposed malady which she calls the _influenzy_. But our recent
experiences of four great influenza seasons in succession from 1889-90 to
1893, although it is without precedent in the history, will incline us the
more to credit what is recorded of influenza cases in the intervals
between the years of great historical epidemics[725]. However that may be
for the years following 1833, the influenza of January, 1837, was sudden,
simultaneous, universal.

The first cases, which Watson compares to the first drops of a
thunder-shower, were seen earlier in some places than in others; but from
all parts of England it was reported that the influenza was at its height
from the middle of January to the end of the first week of February.
Possibly it was a few days earlier in London than in most other towns,
inasmuch as the great increase of the deaths that is shown in the
following table, in the second and third weeks of January, would imply a
prevalence of the epidemic for at least a fortnight before.

_Weekly Mortalities in London (by the old Bills)._

1837

  Week ending   Influenza   All causes

  Jan.  10         0          284
        17        13          477
        24       106          871
        31        99          860
  Feb.   7        63          589
        14        35          558
        21        20          350
        28         8          321
  March  7         4          262

This sudden rise in the deaths from all causes is a characteristic
influenza bill, comparable with those already given from 1580 onwards.
But the bill is far from showing the whole of the mortality in London in
1837. The London bills of mortality compiled by the Parish Clerks' Company
had fallen into the last stage of inadequacy, and were on the eve of being
superseded by the general system of registration for all England and
Wales[726].

The London bills, so long as they existed, never took in the great
parishes of St Pancras, Marylebone, Kensington and Chelsea. The area
"within the bills of mortality" was that of London about the middle of the
18th century. But, instead of becoming more and more crowded as time went
on, it had actually become much less populous, especially in the old City
and Liberties, owing to the erection of warehouses, workshops,
counting-houses and other non-residential buildings where dwelling houses
used to be; so that the decrease of mortality "within the bills" in the
19th century is in part due to the decrease of population within the same
area. This has to be kept in mind when the above table is compared with
one of those for former influenzas, such as that of 1737, exactly a
hundred years before.

It was thought that the 1837 influenza in London was worse than that of
1833, but the figures show the contrary as regards the number of deaths
from all causes[727]. Both of them, however, were in the first rank of
severity, finding their nearest parallels in the three great influenzas of
the 18th century, in 1733, 1737 and 1743, when the deaths from all causes
during the influenza rose, indeed, to a much larger total within the
bills, but rose from a much higher mean level.

In Dublin the great increase of burials from the influenza of 1837 fell
at the same time as in London, according to the following comparison with
the year before for Glasnevin Cemetery[728]:

1835-36

  Dec. 1835     355
  Jan. 1836     392
  Feb.   "      362
  Mar.   "      392
               ----
               1501

1836-37

  Dec. 1836     413
  Jan. 1837     821
  Feb.   "      537
  Mar.   "      477
               ----
               2248

At Glasgow the deaths from influenza were as follows[729]:

1837

              Males   Females   Total

  January      111      118      229
  February      37       62       99
  March          9       20       29
               ---      ---      ---
               157      200      357

But the heading of "influenza" did not nearly show the full effects of the
epidemic upon the mortality, which was enormous in Glasgow in January, as
compared with the same month of 1836:

  ---------------------------------------------------------------
            || All causes||Catarrh| Aged| Asthma| Fever| Decline
  ----------||-----------||-------|-----|-------|------|---------
  Jan. 1836 ||    790    ||    4  |  73 |   31  |   45 |   124
  Jan. 1837 ||   1972    ||  229  | 274 |  185  |  201 |   247

There was also a great increase in the deaths of infants by bowel
complaint. The only period of life which did not show a great rise of
mortality was from five to twenty; the greatest rise was between the ages
of forty and seventy, corresponding to the London experience in the
epidemic of 1847.

At Bolton, Lancashire, the great rise in the deaths, as compared with the
average of five years before, was in February:

              Average of
              five years
               1831-36     1837

  January       111.2       115
  February       79.0       205
  March          97.8       100
                -----       ---
                288.0       420

At Exeter, the burials in the two chief graveyards were 227 in January
and February, 1837, as compared with 125 in the same months of 1836. These
mortalities, although large, were but a small ratio of the attacks. In
2347 cases enumerated in the collective inquiry, there were 54 deaths, a
ratio of two deaths in a hundred cases being considered a full average.
The attacks were mostly in middle life, and the deaths nearly all among
the asthmatic, the consumptive and the aged. The ages of one hundred
persons attacked at Birmingham were as follows[730]:

  Ages   1-   5-   10-   20-   30-   40-   50-   60-   70-   80-90

  Cases   3    2    12    23    21    19    12     7     0      1

At Evesham only five out of 93 were under five years. At Leamington, in a
list of 170 cases, there were 26 under fourteen years, 119 from fourteen
to sixty-five years, and 25 above the age of sixty-five[731]. In some
places males seemed to be most attacked, just as at Birmingham in 1833
there was a great excess of female cases; but the collective inquiry
showed that the sexes shared about equally all over. The type of the
malady was on the whole catarrhal, as in 1833. Nearly all the cases had
symptoms of sneezing, coughing, and defluxions; many cases had nothing
more than the symptoms of a severe feverish cold; the more dangerous cases
had dyspnoea, pneumonia and the like; while all had the languor,
weariness, and soreness in the bones which mark every influenza, whether
it incline more to the moist type of catarrhal fever or to the dry type of
the old "hot ague."

The influenza of 1837 having been remarkably simultaneous, sudden and
brief, the doctrine of personal contagiousness found little favour, just
as in 1833. The 12th query sent out by the committee of the Provincial
Medical Association was: "Are you in possession of any proof of its having
been communicated from one person to another?" The answers are said to
have been nearly all negative; namely, that there was "no proof of the
existence of any contagious principles by which it was propagated from one
individual to another." Shapter, a learned physician at Exeter, inclined
to a certain modified doctrine of contagion by persons. Blakiston, of
Birmingham, an exact mathematician, declared that the question as
ordinarily stated did not admit of an answer.

At Liverpool there was an interesting observation made, exactly parallel
with those made at Gravesend in 1782 and Portsmouth in 1788. The influenza
of 1837 was practically over by the first or second week of March; but
"that the atmosphere of Liverpool was still contaminated by the epidemic
influence up to the middle and latter end of April was apparent from the
fact that many of the officers and men of the American ships, and
generally the most robust, were violently attacked shortly after their
arrival in port,"--the same being the case also with black sailors on
ships arriving from the Brazils and the West Coast of Africa[732]. At the
naval stations of Sheerness, Portsmouth, Plymouth and Falmouth, every one
of the ships of war had been attacked in January, the ships cruising on
the south coast of Spain, or lying at Barcelona, in February, the ships at
Gibraltar in April, and those at Malta in May. The 'Thunderer,' on the
passage from Malta to Plymouth, had the first cases of influenza at sea on
the 3rd of January, four days before reaching Plymouth[733], as if she had
sailed into an atmosphere of it somewhere near the coast of Brittany.

       *       *       *       *       *

For fully ten years, from March or April 1837 to November 1847, there was
no great and universal influenza in England. But there were several
undoubted minor, and perhaps localized, outbreaks of an epidemic malady
which was in each case judged to be truly the influenza, and not a common
cold. The earliest of these was in the spring of 1841. It was recognized
by the Registrar-General to have been in London from 20 February to 24
April, the mortality having been little affected by it. It was also
recognized in Dublin in March, and remarked upon by two physicians to the
Cork Street Fever Hospital; it was characterized by the usual languor,
weariness, and pains in the head, by defluxions of the eyes, nose and
throat, but not by any affection of the lungs, and was in all respects
mild[734]. Exactly a year after, in March, 1842, influenza was described
as epidemic at York[735]: it was noted also in London in March[736], and
is mentioned as having been again in Ireland in 1842[737]. The next
undoubted influenza is reported from a rural part of Cheshire (Holme
Chapel) in January, 1844, in the wake of an epidemic of scarlatina; it
continued in all kinds of weather until June, and had a remarkable
intercurrent episode, for some weeks from the middle of March, in the form
of an epidemic of pneumonia among young children, which passed into mild
bronchitis in the cases last attacked[738]. Coincidently with the
influenza in Cheshire, there is a report of a series of catarrhal cases in
Dublin about the beginning of January, 1844, in which the sense of
constriction and suffocation under the sternum and the paroxysmal
character of the attacks seemed to point to influenza[739]. Two years
after, a Dublin physician in extensive practice among the rich wrote, at
the request of a medical editor, an account of an epidemic of influenza in
January and February, 1847; he had sixty cases among children under
fourteen in his private practice, usually several children in one house,
and sometimes the adults in the house[740]. This was in the midst of the
great epidemic of relapsing fever in Dublin and all over Ireland, due to
the potato famine. The same prevalence of influenza to a slight extent is
recorded also for London at the end of 1846 and beginning of 1847[741]. It
is easy to object that these "influenzas" between 1837 and 1847 were but
the ordinary catarrhal maladies of the seasons. But the physicians who
took the trouble to record them--probably more might have done so--were,
of course, aware of the distinction that had to be made between many
common feverish colds concurring in the ordinary way, and a truly epidemic
influenza, however slight.


The Influenza of 1847-48.

The great influenza of 1847 began in London about the 16th or 18th of
November, was at its height from the 22nd to the 30th, had "ceased to be
very prevalent" by the 6th or 8th of December, but affected the bills of
mortality for some time longer, as in the following table:

_Weekly Mortalities in London._

1847

  Week ending All causes Influenza  Pneumonia Bronchitis  Asthma  Typhus

  Nov. 20      1086          4         95         61        12      86
       27      1677         36        170        196        77      87
  Dec.  4      2454        198        306        343        86     132
       11      2416        374        294        299        78     136
       18      1946        270        189        234        52     131
       25      1247        142        131        107        14      83
  Jan.  1      1599        127        148        138        26      74

In the thirteen weeks of the first quarter of 1848 the influenza deaths
declined as follows: 102, 102, 89, 56, 59, 47, 27, 33, 18, 11, 10, 16, 8.

This was the first great epidemic of influenza under the new system of
registration. According to the Superintendent of Statistics, it caused an
excess of 5000 deaths during the six weeks that it lasted, of which about
a fourth part only were set down to influenza, and the rest to pneumonia,
bronchitis, asthma, etc. During the three worst weeks it raised the deaths
in the age of childhood 83 per cent., in the age of manhood 104 per cent.,
in old age 247 per cent., whereas the deaths between fifteen years and
twenty-five were but little raised by it, and those between ten and
fifteen hardly at all. It raised the deaths during six weeks in St
George's-in-the East to a rate per annum of 73 per 1000 living: in some
other parishes it increased the death-rate very little. But it had the
usual effect of lengthening enormously the obituary columns of the
newspapers, which shows that it fell, as usual, to a large extent upon the
richer classes. It went all over England in a short time, the month of
December being the time of excessive mortality in the towns, according to
the following sample totals of deaths from all causes:

1847

             Manchester   Sheffield     York      Places in
             (Ancoats)     (West)    (Walmgate)   Scotland

  October       169          27          61          521
  November      135          27          52          728
  December      270          85          99         1001

In some parts of England, as in Kendal, a district of Anglesea and in the
Isle of Wight, the mortality of the last quarter of 1847 was actually
lower than that of the year before. From St Albans the sub-registrar
reported that there had been "no epidemic." In most parts of the country,
including the medium-sized towns, the mortality directly or indirectly due
to influenza was lower than in London. The principal returns did not come
in from the country until after the new year, the effects of the epidemic
having been, as usual, later in rural districts. Hence, while London had
1253 deaths put down to "influenza" in 1847 (nearly all in December), and
659 in 1848 (nearly all in the first quarter), the rest of England had
4881 influenza deaths before the New Year, and 7963 after it[742]. This
influenza in the mid-winter of 1847-8 made a great impression
everywhere[743]. As regards its range and its fatality, it was like those
of 1833 and 1837; and it had once more so much of the catarrhal type, that
the name of influenza became still more firmly joined to the idea of a
feverish cold or defluxion.

       *       *       *       *       *

By the year 1847, agues had almost ceased to be written of in England,
although they still occurred in the Fens. But Peacock begins his account
of the influenza of that winter with an enumeration of prevailing
diseases, which reads somewhat like an old "constitution" by Sydenham or
Huxham. The summers and autumns of 1846 and 1847, he says, were both
highly choleraic, and dysentery (as well as enteric fever) was unusually
common in the former year. Fatal cases of "ague and remittent fever" were
also more numerous than usual. Then came much enteric fever, "not
unfrequently complicated with catarrhal symptoms." Throughout the spring
and early summer of the influenza year, 1847, "intermittent fevers were
common, and in March, April and May, purpura was frequently met with,
either as a primary or secondary disease. Scurvy also, owing to the
deficiency of fresh vegetables, and from the general failure of the
potato crop in the previous year was occasionally seen." Then follows much
concerning a fever called remittent, which reads more like relapsing fever
than anything else[744]. "The remittent form of fever was frequent in the
course of the epidemic [of influenza], though seldom registered as the
cause of death." Peacock says truly that the rather unusual concurrence of
so many sicknesses was "not peculiar to the recent influenza alone;" and
he can "scarcely refrain from acknowledging that these several affections
are not merely coetaneous but correlative, and types and modifications of
one disease, with which they have a common origin. Assuming this inference
to be admitted, we may advance to the solution of the further question of
what is the essential nature or proximate cause of the disease." But the
inquiry led him to no result: the precise cause he leaves "involved in the
obscurity that veils the origin of epidemics generally"--which are surely
not all equally obscure[745].

       *       *       *       *       *

Influenza having continued epidemic for a few weeks in the beginning of
1848, ceased thereafter to attract popular notice in Britain during a
period of more than forty years. But a certain number of "influenza"
deaths continued to appear steadily year after year in the registration
tables. In 1851 this number was nearly doubled, in 1855 it was more than
trebled; and those two years were undoubtedly seasons (about January and
February) of real influenza epidemics in Europe, recorded by several but
not by English writers. A slight epidemic was described for Scotland in
1857, and one for Norfolk in 1878, neither of which seems to have
influenced the registration returns in an obvious degree. After the
undoubted influenza of 1855, the annual total of deaths in England set
down to that cause steadily declined from four figures, to three figures,
and then to two figures, standing at 55 in the bill of mortality for 1889.
It is improbable that those small annual totals of deaths in all England
and Wales were caused by the real influenza; the name at that time was
synonymous with a feverish cold, and would have been given here or there
to fatalities from some such ordinary cause. An epidemic ague was reported
from Somerset in 1858[746].


The Influenzas of 1889-94.

More than a generation had passed with little or no word of epidemic
influenza in this country, when in the early winter of 1889 the newspapers
began to publish long telegrams on the influenza in Moscow, St Petersburg,
Berlin, Paris, Madrid and other foreign capitals. This epidemic wave, like
those immediately preceding it in the Eastern hemisphere, in 1833, 1837
and 1847, and like one or more, but by no means all, of the earlier
influenzas, had an obvious course from Asiatic and European Russia towards
Western Europe[747]. In due time it reached London, and produced a decided
effect upon the bills of mortality for the first and second weeks of
January, 1890, but a moderate effect compared with that of 1847, which was
the first to be recorded under the same system of registration. It spread
all over England, Scotland and Ireland in the months of January and
February, 1890, proving itself everywhere a short and sharp influenza of
the old kind, but with catarrhal symptoms on the whole a less constant
feature than in the epidemics of most recent memory. At the end of
February it looked as if Great Britain and Ireland had got off lightly
from the visitation which had caused high mortalities in many countries of
Continental Europe. But this epidemic in the beginning of 1890 was only
the first of four, and less severe than the second and third. It returned
in the spring and early summer of 1891, in the first weeks of 1892, and in
the winter of 1893-94. To understand this influenza prevalence as a whole,
its four great seasons should be compared. The following tables show its
incidence upon London on each occasion:

_Four epidemics of Influenza in London, 1890-94._

1890

             Annual
           death-rate   Deaths
  Week      per 1000   from all
  ending     living     causes    Influenza    Bronchitis    Pneumonia

  Jan.  4     28.0       2371          4           530          215
       11     32.4       2747         67           715          253
       18     32.1       2720        127           630          281
       25     26.3       2227        105           468          193
  Feb.  1     21.8       1849         75           339          145
        8     20.6       1749         38           369          117

1891

             Annual
           death-rate   Deaths
  Week      per 1000   from all
  ending     living     causes    Influenza    Bronchitis    Pneumonia

  April 25    21.0       1809         10           240          179
  May    2    23.3       2006         37           280          241
         9    25.6       2069        148           302          230
        16    27.7       2245        266           352          207
        23    27.6       2235        319           337          219
        30    28.9       2337        310           353          189
  June   6    27.0       2189        303           320          176
        13    23.3       1886        249           255          166
        20    23.0       1865        182           248          159
        27    19.0       1538        117           151          113
  July   4    16.8       1363         56           108          103

1891-92

             Annual
           death-rate   Deaths
  Week      per 1000   from all
  ending     living     causes    Influenza    Bronchitis    Pneumonia

  Dec. 26     21.9       1771         19           355          131
  Jan.  2     42.0       3399         37           927          256
        9     32.8       2679         95           740          246
       16     40.0       3271        271           867          285
       23     46.0       3761        506          1035          317
       30     41.0       3355        436           844          255
  Feb.  6     30.6       2500        314           492          215
       13     24.6       2010        183           368          140
       20     20.7       1693         79           259          137

1893-94

             Annual
           death-rate   Deaths
  Week      per 1000   from all
  ending     living     causes    Influenza    Bronchitis    Pneumonia

  Nov.  4     20.2       1695          8           191          125
       11     21.4       1679         20           220          137
       18     24.4       2016         22           318          228
       25     26.5       2190         36           384          215
  Dec.  2     27.1       2235         74           426          248
        9     31.0       2556        127           491          266
       16     29.1       2401        164           421          232
       23     26.3       2170        147           387          203
       30     23.3       1920        108           306          157
  Jan.  6     24.5       2040         87           342          169
       13     29.5       2462         75           490          211
       20     23.7       1975         69           320          172
       27     19.8       1655         41           232          152

It will be seen that the third epidemic, that of Jan.-Feb. 1892, had the
highest maximum weekly mortality from influenza (506) as well as the
highest maxima from bronchitis and pneumonia not specially associated in
the certificates with influenza; that the second epidemic, of 1891, had
the next highest maxima, and that the first and last of the four outbreaks
were both milder than the two intermediate ones. All but the second, which
fell in early summer, are strictly comparable as regards season
(mid-winter). But although the second, in 1891, had the advantage of
falling in some of the healthiest weeks of the year, it was more
protracted than the original outbreak, much more fatal than it in the
article influenza, more fatal also in the article pneumonia, and less
fatal only in the article bronchitis. The third outbreak was not only more
protracted than the first, in the same season of the year, but much more
fatal in all the associated articles. As to the deaths referred to
influenza (whether as primary or secondary cause), the numbers are not
strictly comparable in all the outbreaks; they are probably too few in the
first table, more nearly exact in the second, third, and fourth, the
diagnosis having at length become familiar and the fashion of nomenclature
established. It is undoubted that many of the deaths from bronchitis and
pneumonia in January, 1890, were due to the epidemic; for, "while the
ordinary rise of mortality in cold seasons is mainly among the very aged,
the increased mortality in this fatal month was mainly among persons
between 20 and 60 years" (Ogle).

While the first epidemic of the series was universal and of short duration
all over the kingdom, the second and third were more partial in their
incidence and more desultory or prolonged. The second, which began in Hull
(and at the same time on the borders of Wales), produced the following
highest weekly death-rates per annum from all causes among 1000 persons
living:

_Highest Weekly Death-rates in the Second Influenza._

1891

                        Annual death-rate
                            from all
                Week       causes per
               ending     1000 living

  Hull        Apr. 11        42.5
  Sheffield     May 2        70.5
  Halifax        "  2        42.1
  Leeds          "  9        48.5
  Manchester     "  9        43.6
  Bradford       " 16        56.7
  Huddersfield   " 16        54.5
  Leicester      " 16        44.6
  Oldham         " 23        50.4
  London         " 30        28.9
  Salford        " 30        45.9
  Blackburn    June 6        48.5

The third was heard of first in the west of Cornwall and in the east of
Scotland, in the last quarter of 1891. It was in the following English
towns that it produced the maximum weekly death-rates per annum from all
causes:

_Highest Weekly Death-rates in the Third Influenza._

1892

                             Annual death-rate
                  Week        from all causes
  Town           ending       per 1000 living

  Portsmouth    Jan. 16           57.0
  London         "   23           46.0
  Norwich        "   23           44.7
  Brighton       "   23           60.9
  Croydon        "   30           47.2

These highest death-rates in the third successive season of influenza were
all in the southern or eastern counties; in the latter, Colchester also
had a maximum death-rate during one week of about 80 per 1000 per annum.
Liverpool, among the northern great towns, appears to have had most of the
third influenza. The fourth outbreak, in the end of 1893, was noticed
first in the Midlands (Birmingham especially), and was afterwards heard of
in the mining and manufacturing districts of Staffordshire, South Wales,
Lancashire, Yorkshire and Durham, as well as in Scotland and Ireland,
London, as in the table, having a share of it. The tables given of the
London mortality in each of the four outbreaks, from influenza and the
chest-complaints which were its most usual secondary effects, are a fair
index both of the period and of the severity of the disease all over the
kingdom in each of its successive appearances[748]. Everywhere the first
and the fourth were the mildest, the second and third the most fatal.
Deaths from "influenza" were reported from all the counties of England and
Wales in the first and second epidemics, the highest rates of mortality
per 1000 inhabitants in the corresponding calendar years having been in
the following counties, while in all the counties the greater fatality of
the second epidemic is equally marked:

1890

  Cumberland          .35
  North Wales         .28
  Herefordshire       .28
  Salop               .28
  Wilts               .28
  Somerset            .26
  Dorset              .25
  Bucks               .25

1891

  Rutland            1.36
  Lincolnshire       1.19
  North Wales        1.09
  Westmoreland       1.02
  Monmouth           1.00
  E. Riding Yorks     .98
  Herefordshire       .98
  Northamptonshire    .95

In London the entry of influenza is in the weekly bills of mortality
throughout the whole period, with the exception of a few weeks; but the
deaths were often reduced to unity, and there was perhaps only one
occasion, besides the four great outbursts, namely the months of March and
April, 1893, when cases were so numerous or so close together in
households or neighbourhoods as to constitute a minor epidemic.

The type of the influenza of 1890-93 was not quite the same as on the last
historical occasions. When it was announced as approaching from the
Continent, everyone looked for "influenza colds"; but the catarrhal
symptoms, although not wanting, were soon found to be unimportant beside
the nameless misery, prostration and ensuing weakness. Some, indeed,
contended that the disease was not influenza but dengue, so pronounced
were the symptoms of break-bone fever[749]. Many cases had a decided
aguish or intermittent character. The name of ague itself was once more
heard in newspaper paragraphs, and more freely used in private talk; but,
as we have long ceased to write of epidemic agues, equally as of marsh
intermittents, in this country, it is not probable that there will remain
any record of agues in Britain accompanying the influenzas of the years
1890-94. On the other hand the complications and after-effects of our
latest influenza, more especially as affecting the nervous system, have
been very fully studied[750].

That which chiefly distinguishes the influenza of the end of the 19th
century from all other invasions of the disease is the revival of the
epidemic in three successive seasons, the first recurrence having been
more fatal than the original outbreak, and the second recurrence more
fatal (in London at least) than the first. The closest scrutiny of the old
records, including the series of weekly bills of mortality issued by the
Parish Clerks of London for nearly two hundred years, discovers no such
recurrences of influenza on the great scale in successive seasons. It is
true that several of the old influenzas came in the midst of sickly
periods of two or more years' duration, such as the years 1557-58,
1580-82, 1657-59, 1678-80, 1727-29 and 1780-85. But in those periods the
bulk of the sickness was aguish, the somewhat definite episodes of
catarrhal fever having been distinguished from the epidemic agues by
Willis in 1658, by Sydenham in 1679, by several in 1729, and by Baker,
among others, in 1782. It is probable, indeed, that there were two
strictly catarrhal epidemics in successive years in the periods 1657-59
and 1727-29, just as we know that, in New England, there was a catarrhal
epidemic in the autumn of 1789 and an equally severe influenza, less
catarrhal in type, in the spring of 1790[751]. But history does not appear
to supply a parallel case to the four successive influenzas in the period
1889-94, unless we count the seasonal epidemic agues of former
"constitutions" as equivalent to influenzas for the purpose of making out
a series.


The Theory of Influenza.

Influenza is not an infection which lends itself to a simple theory of its
nature or a neat formula of its cause. All that one can do is to indicate
the direction in which the truth lies. Something broad, comprehensive,
steady from age to age, telluric if not cosmic, must be sought for. Some
have thought that the legendary or representative universal sickness at
the siege of Troy was influenza, because it began upon the horses and
dogs, as so many historical influenzas have done. But it will be
sufficient to show that influenza was the same in the Middle Ages as now;
for what circumstances make a broader contrast than medieval and modern?
The first writer in England to mention influenza--of course not under that
name--was a dean of St Paul's in the reign of Henry II., Radulphus de
Diceto[752]. He is narrating the journey to Rome of the archbishop-elect
of Canterbury: his election in England was in June, 1173, he had got as
far as Placentia by Christmas, whence he turned aside to Genoa, and at
length reached Rome, to have his election confirmed by the pope in the
nones of April, 1174. It is in the midst of this account of the
archbishop's journey, that reference is made to an influenza, otherwise
known, from German and Italian chronicles, to have happened in December,
1173: "In those days the whole world was infected by a nebulous corruption
of the air, causing catarrh of the stomach and a general cough, to the
detriment of all and the death of many"--_universus orbis infectus ex
aeris nebulosa corruptione_. What kind of infection can that be which has
befallen men on both sides of the Alps within the same short time in the
12th century as in the 19th? And what kind of infection is it which has
outlived so many changes in the great pestilences of mankind, has seen the
extinction of plague and the rise of cholera, and all other variations,
most of them for the better, in the reigning types of epidemic sickness?
To have lasted unchanged through so many mutations of things, from
medieval to modern, and from modern to ultra-modern, and to have become
more inveterate or protracted at the end of the 19th century than it had
ever been, is unique in this history. Influenza appears to correspond with
something broadly the same in human life at all times. Or is it rather a
thing telluric, of the crust of the earth or the bowels of the earth? Or
is it perhaps cosmic, affecting men as the vintage is affected by a comet,
or as if it came from the upper spheres? My belief is that we need not
transcend the globe to look for its source, and that, upon the earth, we
need not go deeper than the surface, nor beyond the inhabited spots. I
shall come back to this from giving the history of English opinion upon
it.

The best known influenzas of the 16th century all came in summer, as some
of the later ones have done, so that no one thought of them as exaggerated
common colds. But it happened that the influenzas observed by Willis in
1658, and by Sydenham in 1675 and 1679, came in spring or winter and in
such weather as to suggest to each of those physicians that the catarrhal
symptoms corresponded to the season. Robert Boyle, their great
philosophical contemporary, was also a witness of one or more of these
influenzas, and it appeared to him that there was more than season and
weather in them.

    "I have known a great cold," he says, "in a day or two invade
    multitudes in the same city with violent, and as to many persons,
    fatal symptoms; when I could not judge (as others also did not), that
    the bare coldness of the air could so suddenly produce a disease so
    epidemical and hurtful; and it appeared the more probable that the
    cause came from under ground, by reason that it began with a very
    troublesome fog[753]."

I am unable to say whether Boyle was the first to apply the doctrine of
telluric or subterranean emanations to influenza; he was certainly not the
first to apply it to pestilences in general, for it is found in Seneca
among the ancients[754], and it is clearly stated in Ambroise Pare's essay
"Sur les Venins," having been probably a familiar notion of the sixteenth
century, although a mystical and undefined one. Sydenham also, who must
have discussed these questions with Boyle, referred all the more obscure
or "stationary" epidemic constitutions to effluvia discharged into the air
from "the bowels of the earth": those hypothetical miasmata were for him
the [Greek: to theion] of Hippocrates, the mysterious something which had
to be assumed so as to explain plague, pestilential fever, intermittent
and remittent fevers, the "new fever" of 1685-6, and all other epidemic
constitutions which were not caused by obvious changes of season and
weather. But it does not appear, and it is not probable, that he ascribed
to that mysterious cause the two transient waves of influenza which fell
within his own experience, those of November, 1675, and of November, 1679.
On the other hand, Boyle certainly did so; he included influenza in his
hypothesis explicitly; and if one examines its general terms, it will
appear as if it had been made specially for influenza.

Boyle's general expression, for both endemial and epidemic maladies, is
that they are due to subterranean effluvia sent up into the air. As a
chemist, and as dealing with the new knowledge then most in vogue, he
assumed the sources of these miasmata to be for the most part mineral
deposits in the crust of the globe, especially "orpimental and other
mischievous fossiles"; but later in his writing he says:

    "To speak candidly I do not think that these minerals are the causes
    of even all those pestilences whose efficients may come from under
    ground"; there were many mischievous fossils of which physicians and
    even chymists had no knowledge, and "the various associations of
    these, which nature may, by fire and menstruums, make under ground and
    perhaps in the air itself, may very much increase the number and
    variety of hurtful matters."

He makes provision, also, for the hurtful matters multiplying in their
underground seats, according to a principle which we know now to be true
for organic, instead of mineral matters, and to be true for them above
ground, or in the air, as well as under ground:

    "I think it possible that divers subterraneal bodies that emit
    effluvia may have in them a kind of propagative or self-multiplying
    power. I will not here examine whether this proceeds from some seminal
    principle, which many chymists and others ascribe to metals and even
    to stones; or (which is perhaps more likely) to something analogous to
    a ferment, such as, in vegetables, enables a little sour dough to
    extend itself through the whole mass, or such as, when an apple or
    pear is bruised in one part, makes the putrefied part by degrees to
    transmute the sound into its own likeness; or else some maturative
    power ... as ananas in the Indies, and medlars ... after they are
    gathered, acquire (as it were spontaneously) in process of time a
    consistence and sweetness and sometimes colour and odour, and, in
    short, such a state as by one word we call maturity or ripeness."

Other of Boyle's fruitful principles (I am separating them out from amidst
much other matter not specially related to influenza) are these:

    "It is possible that these effluvia may be, in their own nature,
    either innocent enough, or at least not considerably hurtful, and yet
    may become very noxious if they chance to find the air already imbued
    with certain corpuscles fit to associate with them."

    Again, the effluvia sent up into the air may pass by certain places
    without causing an epidemic, because these "are not inhabited enough
    to make their ill qualities taken notice of; but, more frequently,
    because by being diffused through a greater tract of air, they are
    more and more dispersed in their passage, and thereby so diluted (if I
    may so speak) and weakened as not to be able to do any notorious
    mischief."

    Again, the effluvia may not produce epidemic disease at the part of
    the globe where they had emerged from under ground; an illustration of
    which may be intended in the case of the Black Death, which, as he
    says, came from China, yet plague is little heard of in that country,
    a Jesuit, Alexander de Rhodes, who spent thirty years in those parts,
    testifying that the plague is not so much as spoken of there. Again,
    why are some epidemics of so short duration at a given place? Either,
    he answers, because the morbific expiration from under ground had
    ascended almost at once, and been easily spent; or the subterraneal
    commotion which sends up the miasmata "may pass from one place to
    another and so cease to afford the air incumbent on the first place
    the supplies necessary to keep it impregnated with noxious exhalation;
    and it agrees well with this conjecture that sometimes we may observe
    certain epidemical diseases to have, as it were, a progressive motion,
    and leaving one town free, pass on to another"--as notably in the case
    of sweating sickness and influenza.

    Lastly there are ever new forms of epidemic disease appearing, not to
    count every variation of an autumnal ague "which the vulgar call a New
    Disease." Of the really new types Boyle offers the following
    explanation: "Some among the emergent variety of exotick and hurtful
    steams may be found capable to disaffect human bodies after a very
    uncommon way, and thereby to produce new diseases, whose duration may
    be greater or smaller according to the lastingness of those
    subterraneal causes that produce them. On which account it need be no
    wonder that some new diseases have but a short duration, and vanish
    not long after their appearing, the sources or fumes being soon
    destroyed or spent; whereas some others may continue longer upon the
    stage, as having under ground more settled and durable causes to
    maintain them."

As a chemist, Boyle sought for the source of the pestilential emanations
in underground minerals, in the new combinations of these under the action
of "fire and menstruums," in their self-multiplying power as if by
subterraneous fermentation ("which many chymists and others ascribe to
metals and even to stones"), and in their meeting with suitable
"corpuscles" in the air of an inhabited spot wherewith to combine for
their morbific effects. He assumed, also, their discharge into the air at
particular spots of the globe (where they might not be directly morbific
in their effects), or in a series of localities from the wave-like
progress of the underground commotion; in which assumption he seems to be
applying the very old idea of classical times that earthquakes and
volcanic eruptions were a cause or antecedent of epidemics. Sometimes his
mineral fossils were deep in the crust of the globe, touched only by the
greater cataclysms; and then we might expect novelties in the forms of
epidemic disease. But he does not exclude emanations from the earth's
surface proceeding more gently or insensibly.

It would be a mistake to set aside Boyle's hypothesis of epidemical
miasmata as made altogether void by his choosing strange minerals to be
the source of them, and by his assuming a kind of fermentation in these
inorganic matters so as to explain the continuance and spreading of the
infections. Substitute organic matters in the soil for minerals in the
crust of the earth, and read a modern meaning into the doctrine of
underground or aerial fermentation or leavening, and we shall find Boyle's
hypothesis, especially as applied to influenza, far from obsolete. Some
such adaptation of the doctrine of miasmata was made two generations later
by Dr John Arbuthnot in his 'Essay concerning the Effects of Air upon
Human Bodies,' the immediate occasion of which was the London influenza of
1733. There is nothing to note between Boyle and Arbuthnot; for Willis
and Sydenham, using the Hippocratic language of "constitutions,"
explained, as we have seen, the epidemic catarrhs of the spring or winter
as the reigning febrile constitution modified to suit the season and
weather.

Arbuthnot's essay makes more modern reading than Boyle's. He assumes
emanations from the ground, but they are no longer from the bowels of the
earth, or from deposits of strange minerals requiring earthquakes to set
them free, or "fire and menstruums" to give potency to them. Of all the
things that pass into the atmosphere, he makes most of the various steams
and other volatile decomposing matters of men and animals; and when he
brings in the earth, it is as the storehouse or receptacle of such
matters, in a surface stratum no deeper than the effects of drought and
rainfall could reach. While he accepts the Hippocratic doctrine of
epidemic constitutions, and recognizes the air with its various organic
contents as the [Greek: to theion], the _quid divinum_ or mysterious
something of epidemical causation, he does not forget that the earth is
inhabited by creatures, human and other, who befoul the atmosphere by
"their own steams"; again, he lays stress upon alternations of drought and
moisture in the soil and subsoil as a cause of morbific emanations, not,
indeed, stating the matters of fact in the very terms of Pettenkofer's
law, but assuming the presence of special organic matters in the soil as
much as that does. Although Arbuthnot was hardly a serious epidemiologist,
any more than Boyle, yet in the growth of opinion on the subject of
morbific matters in the air, he may be said to have shifted the interest
from inorganic or mineral substances and gases, to organic matters chiefly
of human or animal origin, and from the deeper regions of the globe, such
as only earthquakes reach, to the surface stratum of soil and subsoil
which is affected by every rise and fall of the ground-water. I shall now
give a few extracts, to bear out the above summary, from Arbuthnot's
essay.

    "Air," he says, "is the [Greek: to theion] in diseases, which
    Hippocrates takes notice of. Air is what he means by the powers of the
    universe, which, he says, human nature cannot overcome; and he lays it
    down as a maxim 'that whoever intends to be master of the art of
    physick must observe the constitution of the year; that the powers and
    influence of the seasons (what are seldom uniform) produce great
    changes in human bodies.'" He then pays a compliment to Sydenham as
    "endowed with the genius of Hippocrates," and passes on to his own
    analytic method. "Many great effects must follow, and many sudden
    changes may happen in human bodies by absorbing outward air with all
    its qualities and contents. Nothing accounts more clearly for
    epidemical diseases seizing human creatures inhabiting the same tract
    of earth, who have nothing in common that affects them except air:
    such as that epidemical catarrhous fever of 1728 and of this present
    year [1733].... It seems to be occasioned by effluvia, uncommon either
    in quantity or quality, infecting the air.... It is likewise evident
    that these effluvia were not of any particular or mineral nature,
    because they were of a substance that was common to every part of the
    surface of the earth: and therefore one may conclude that they were
    watery exhalations, or, at least, such mixed with other exhalable
    substances that are common to every spot of ground."

    In his account of the qualities and contents of the air, he enumerates
    them, not so much as detected in the air on analysis, but as having of
    necessity passed into it, and in some instances been deposited again
    from it, as in strange dews. One class of substances that pass into
    the air are the oils, salts, seeds and insensible abrasions of
    vegetables. Also all excrements and all the carcases of animals vanish
    into air. Another ingredient of the air is the perspirable matters of
    animals, the amount of which for human beings he works out by a
    curious calculation of a column of their own steams raised so many
    feet high in so many days. Perhaps there are insects in the air
    invisible to human eyes: one may observe, in that part of a room which
    is illuminated with the rays of the sun, flies sometimes darting like
    hawks as if it were upon a prey. Some have imagined the plague to
    proceed from invisible insects: this system agrees with many of the
    appearances in the progress or manner of propagation of that disease,
    but is altogether inconsistent with others. Air replete with the
    steams of animals, especially such as are rotting, has often produced
    pestilential fevers in that place: of which there are many instances.

    But why should certain years or seasons have a pestilential
    atmosphere, for example the season of the catarrhous fever of 1733?
    There had been, he says, an unusual drought for these two years past,
    the best estimate of the dryness of the surface of the earth being
    taken from the falling of the springs, "the consequence of which has
    been unusual diseases amongst several animals, and a great mortality
    amongst mankind. It is true, this did not happen during the dry
    weather.... The previous great drought must have been particularly
    hurtful to mankind. Great droughts exert their effects after the
    surface of the earth is again opened by moisture, and the perspiration
    of the ground, which was long suppressed, is suddenly restored. It is
    probable that the earth then emits several new effluvia hurtful to
    human bodies: this appeared to be the case by the thick and stinking
    fogs which succeeded the rain that had fallen before."

Arbuthnot knew the progress of the influenza of 1732-33. Its worst week in
London was from the 23rd to the 30th January, 1733; but he tells us that
it had been at a height in Saxony from the 15th to the 29th November,
1732, had been earlier in Holland than in England, earlier in Edinburgh
than in London, in New England before Great Britain. Again, it appeared in
Paris in February, somewhat later than in London, and in Naples in March.
This progress, he says, was often against the wind. Nor does he assume a
progressive infection of regions of atmosphere. The effluvia, he says,
were of a substance that was common to every part of the surface of the
earth; they were exhalable substances that were common to every spot of
ground; the excessive drought of two years, followed by heavy rains in the
end of 1732, is also assumed to have been common, for, in Germany and
France, especially in November, 1732, the air was filled with frequent
fogs. It is clear that Arbuthnot traced the universality of influenza, the
uniform symptoms of which he recognized, to certain conditions of soil and
atmosphere common to all the countries visited by the epidemic.

Throughout the rest of the 18th century there were numerous and varied
experiences of influenza, in summer and winter, spring and autumn, coming
up from the south as if from Africa, or from the east as if from Central
Asia, or appearing in America sooner than in Europe--experiences which
made a theory of the disease difficult. Some inclined to Arbuthnot's view
of unusual seasons and weather producing the same effects everywhere;
others favoured the hypothesis of contagion from a remote source, which
might be China or might be some other territory. Geach, a surgeon at
Plymouth who was a Fellow of the Royal Society, actually went back to the
astrological cause, pointing out that Jupiter and Saturn were in a certain
conjunction during the influenza of 1775. The only elaborate theory of the
strange disease that calls for notice, besides those of Boyle and
Arbuthnot, is that of Noah Webster, the famous lexicographer of Hartford,
Connecticut.

While Webster was a journalist in New York about the years 1794-6, the
subject of yellow fever, which was then of great practical moment, set him
reading and speculating about pestilences in general. Writing to
Priestley, he said that in the course of his inquiries he found the
American libraries ill supplied with books[755]; but he certainly made
diligent and skilful use of his literary materials, and produced in his
'Brief History of Epidemic and Pestilential Diseases,' a work which was
better than any before it in the chronological part, and remains to the
present time unique in its philosophical part for the boldness of its
generalities[756]. He saw that influenza was the crux of epidemiology, and
paid special attention to it.

In looking for the antecedents of influenza, he kept in view the greater
telluric changes and convulsions, such as earthquakes and volcanic
eruptions. He did not regard these as the cause of influenza, but as the
index of some hidden cause to which both they and the universal catarrh
were due.

    "It is probable to me," he says, "that neither seasons, earthquakes,
    nor volcanic eruptions are the causes of the principal derangements we
    behold in animal and vegetable life, but are themselves the _effects_
    of those motions and invisible operations which affect mankind. Hence
    catarrh and other epidemics often appear _before_ the visible
    phenomena of eruptions and earthquakes[757]." As to influenza, he
    found "reason to conclude the disease to be the effect of some access
    of stimulant powers to the atmosphere by means of the electrical
    principle. No other principle in creation, which has yet come under
    the cognizance of the human mind, seems adequate to the same effects."

    And again: "It is more probable that it is to be ascribed to an
    insensible action of atmospheric fire, which is more general and
    violent about the time of eruptions, and which fire is probably
    agitated in all parts of the globe, although it produces visible
    effects in explosions in some particular places only." It is due to
    Webster to give his reason for preferring a physical force to an
    organic poison: "If a deleterious vapour were the cause, I should
    suppose its effects would be speedy, and its force soon expended, the
    atmosphere being speedily purified by the winds. But if stimulus is
    the cause, it may exist for a long time in the atmosphere, and the
    human body not yield to its force in many weeks or months. This would
    better accord with facts. For, although diseases appear soon after an
    earthquake, yet the worst effects are often many months or years
    after[758]."

Dr Blagden also saw a difficulty in "the prodigious quantity of matter
required in the air to infect the space not only of the Chinese land, but
to a hundred leagues of the coast, or, as in this instance [1782] all
Europe and the circumjacent sea," and was accordingly driven to
Arbuthnot's view of an origin in the unusual weather of each locality.

Webster drew up a chronological table of influenzas in either Hemisphere,
with the volcanic eruptions, earthquakes, comets, etc., to suit[759]. A
few instances from near the beginning may serve as samples:

    1647. First catarrh mentioned in American annals, in the same year
    with violent earthquakes in South America, and a comet.

    1655. Influenza in America, in the same year with violent earthquakes
    in South America and an eruption of Vesuvius. It began about the end
    of June.

    1658. Influenza in Europe after a severe winter: the summer cool.

    1675. Influenza in Europe while Etna was still in a state of
    explosion: the winter mild.

    1679-80. Influenza in Europe during or just after the eruption of
    Etna: the season wet: a comet.

    1688. Influenza in Europe in the same year with an eruption of
    Vesuvius, after a severe winter, and earthquakes: it began in a hot
    summer.

    1693. Influenza in Europe in the same year with an eruption in Iceland
    and great earthquakes: the season cool.

    1697-98. Influenza in America after a great earthquake in Peru: a
    comet the same year: the winter severe.

In most instances the region of the earthquake is not specified in the
table; but it is sometimes named in the text of the annals under the
respective years. Volcanoes are on the whole made more of than
earthquakes, Webster's object being to find evidence of "electrical
stimulus," and not of material miasmata discharged into the air. Etna and
Hecla are much in request. Any earthquake suits, as if "earthquake" and
"volcano" were like algebraic symbols, always _a_ and _b_, and never
anything but _a_ and _b_, "influenza" being always _x_. One begins to
realize the difficulties of the volcano or earthquake theory of influenza
on turning to Mallet's Catalogue of Earthquakes[760]. Here, indeed, is an
embarrassing choice between China and Peru, Asia Minor and North Africa,
Portugal and Sicily or Calabria, Iceland and Jamaica, the Azores and the
Philippines, Caracas or Acapulco and Valparaiso, Hungary and Savoy,
Kamtschatka and Amboina; between earthquakes great and small; between
earthquakes and volcanoes. Any influenza year might be suited with one or
more earthquakes, perhaps in either Hemisphere; but there are some long
clear intervals between the greater influenzas in Europe, for example the
interval from 1803 to 1831, which seem to occupy as many pages of the
catalogue of earthquakes as the years wherein influenzas came thickest,
for example from 1729 to 1743, or from 1831 to 1847.

None the less, Webster, like Boyle, obeyed a true impulse when he looked
for the cause of influenzas in something telluric, occasional, phenomenal.
A wave of influenza comes up unexpectedly from a particular point of the
compass, passes quickly over many degrees of latitude and longitude,
lasting a few weeks at any given place, disappears in the distance, and
does not return again perhaps for a whole generation. Influenza has the
qualities of suddenness, swiftness, transitoriness; it has a certain
sameness in its symptoms; it can be identified as certainly in the brief
phrases of medieval chronicles as in elaborate modern descriptions; it has
had no season for its own, as plague and cholera have had the summer and
autumn, but has reached a height in Europe sometimes in midsummer,
sometimes in midwinter. No other epidemic malady can compare with it in
these respects; all the rest seem to have been provoked more or less by
the turns and changes in human affairs, some being of a medieval colour,
others of a modern, each in its own way admitting of explanation from
unwholesome living, or from famine, or from over-population, or from
something more recondite but still within the sphere of things insanitary
in an intelligible sense. Other plagues besides influenza were, it is
true, once reckoned mysterious, or associated in the popular mind with
earthquakes and comets. But several such plagues have disappeared from
among us, while their alleged causes, the earthquakes or comets, continue
as before. Influenza alone returns at intervals as of old, untouched by
civilization, by sanitation, by the immense differences between medieval
and modern, making the same impression upon England in the year 1890 as it
did in 1173, or 1427, or 1580, or, if changed at all, then changed for the
worse inasmuch as the epidemic came back more severely in 1891, and still
more severely in 1892. It is not surprising that for such a disease
something telluric or even cosmic should have been assigned as the cause,
something as occasional as itself, phenomenal, if not cataclysmic. It may
be proper, therefore, that we should try over again the philosophic
generalities of Boyle, Arbuthnot and Webster, peradventure a combination
of them may yield a true theory. From Boyle we may take the great
principle of a progressive infection through regions of air (or leagues of
ground), which was expressed once for all by Lucretius in the sixth book
of the 'De Rerum Natura':

        ... atque aer inimicus serpere coepit;
  Ut nebula ac nubes paulatim repit, et omne
  Qua graditur, conturbat et immutare coactat;
  Fit quoque ut in nostrum quum venit denique coelum
  Corrumpat reddatque sui simile atque alienum.

From Arbuthnot we may take the organic source and nature of the influenzal
miasmata, and the association with changes in the level of the water in
the soil. From Webster we may take the idea that the historic influenzas,
having been sudden, occasional or phenomenal, must have had phenomenal
causes somewhere in either Hemisphere. Instead of sketching a theory in
the abstract, and safeguarding it by following all its ramifications, I
shall proceed by the way of instances, choosing them so as to bring out
particular points in order.

The only generality which may be indicated at starting is one that has
presented itself time after time in the foregoing history, namely that
there is something more than accident in the association between epidemics
of influenza and epidemics of ague. So close was this association in
former times that both the influenza and the widely prevalent ague were
included together under such names as "the new ague," "the new fever,"
"the new distemper." As late as 1679, Morley did not distinguish the
epidemic of influenza from the epidemic agues in the midst of which it was
set, although the distinction was real, and was actually made by Sydenham
on that occasion, as it had been made by Willis and in a manner by
Whitmore on the occasion immediately preceding, and as it was made by
everyone on the last great occasion when an influenza made an interlude
among epidemic agues in the year 1782. It has often been suspected that
influenza was related to some other infection: at one time it was taken
for a volatile emanation of plague, in our own time it has been regarded
as a volatile emanation of Asiatic cholera. In a wider historical view the
question may arise, whether the real relation is not rather to those
remarkable agues which have been epidemic in company with influenza when
there was no plague and no cholera.

I come now to certain influenzas, as illustrating particular points of
theory, in order.


I.

It is probable that Webster's theory of influenza as related to
earthquakes and volcanoes, first published in 1799, was suggested to him
by a communication to the Royal Society on the volcanic waves seen at
Barbados on the 31st of March, 1761, and on the epidemic of influenza
thereafter ensuing all over the island. At Bridgetown, in the afternoon of
the 31st of March, 1761, the water in the bay and harbour ebbed and flowed
to the extent of eighteen inches or two feet at intervals of eight
minutes, and continued to do so for the space of three hours, the
oscillation regularly decreasing till night when it was no more
observable. These tidal waves were due to volcanic upheavals somewhere;
and it was found that the centre of disturbance had been in the Atlantic
near the coast of Portugal, and the time some hours earlier than the waves
were felt at Bridgetown. The Barbados chronicler proceeds:

    "It is very remarkable that since that time the island has been in a
    very deplorable condition, having suffered under the severest colds
    that have been ever known. The distress has been so general that I may
    venture to assert (with confidence) that nineteen twentieths of the
    inhabitants of the island have felt the effects of the contagion; and
    to some it has been repeated several times. It has puzzled all the
    adepts in pharmacy to find out the cause and cure of it. One
    favourable circumstance has attended it, viz. few have died with it.
    The Leeward Islands have not escaped, it having raged there more
    violently and more fatal. His Majesty's ships have severely felt the
    effects of it, some of them not being capable of keeping the seas for
    want of men fit for service. This happening at a season of the year
    remarkably the healthiest, makes it the more surprising[761]."

This is as good an instance as we shall find, of explaining something
sudden, swift, and phenomenal, by something else sudden, swift, and
phenomenal, in a purely empirical way and without pausing to ask whether
the latter could have been a _vera causa_ of the former. That the
influenza came to Barbados in the wake, as it were, of the volcanic waves,
had been a common subject of talk among the residents; and that common
opinion of the colony had found expression in the paper sent to the Royal
Society. The influenza was not only in Barbados, in the Leeward Islands,
and in the ships on the West Indian Station, but also in New England and
"over the whole country" of the North American Colonies. Dr Tufts, of
Weymouth, New England, wrote to Webster that "it began in April, and in
May ran into a malignant fever which proved fatal to aged persons. It
spread over the whole country and the West India Islands[762]." It was not
until some nine months after that influenza appeared in Europe, at first
in the east of that continent,--Hungary, Vienna, Breslau, Copenhagen--in
February and March, 1762, in central Germany and Scotland in April, in
London about the first of May and all over England and Ireland thereafter,
but not in France until June and July.

Precisely the same order was followed by the influenza twenty years after:
it began in North America in March, 1781, and, says Webster, spread over
that continent; it appeared in the East Indies in October and November,
1781, and on the eastern confines of Europe in January, 1782, having been
traced from Tobolsk, made a slow progress westwards, and was at its height
in London about the end of May or beginning of June. Assuming, says
Webster, that the American influenza of 1781 had been continuous with the
European of 1782, it must have "passed the Pacific in high northern
latitudes," traversed Siberia and Tartary, and so reached Russia in
Europe. In like manner, if the European influenza of 1762 were continuous
with the American of 1761, it must have made the circuit of the globe in
the same order, as if it were following the first impulse of the volcanic
waves across the Atlantic from the coast of Portugal westwards, and so
round the earth until it came back to Europe on its eastern frontier. So
much may be fairly advanced on the ground of a particular set of facts.
But then there were many other facts, both in 1761-62, and in 1781-82.
Meanwhile let us take another instance of volcanic waves felt at Barbados
six years before, on the same afternoon as the great earthquake of Lisbon.


II.

At Bridgetown, on the 1st November, 1755, Dr Hillary saw the peculiar flux
and reflux of the water in the harbour from 2.20 p.m. to 9 p.m. and
pronounced that there must have been an earthquake somewhere. The waves
came at first at intervals of five minutes, and at last at intervals of
twenty minutes. The day was calm, and the ships in the bay were not
touched; but small craft lying in the channel over the bar were driven to
and fro with great violence. There was no motion of the earth, and no
noise. The distance from Lisbon was 3400 miles, the vibrations having
taken seven and a half hours to reach Barbados. The one notable effect in
the harbour of Bridgetown was that the water flowed in and out with such a
force that it tore up the black mud in the bottom of the channel, so that
a great stench was sent forth and the fishes caused to float on the
surface, many of them being driven a considerable distance on to the dry
land where they were taken up by the <DW64>s[763].

It so happened that there was an epidemic catarrh prevalent at that very
time all over the island of Barbados, chiefly among children, few or none
of whom, white or black, escaped it. It had begun in October, says
Hillary[764] (who chronicled the epidemiology very exactly), and continued
into November, so that it both preceded and followed the great convulsion
in the bed of the Atlantic, which destroyed Lisbon and tore up the mud in
the harbour of Bridgetown, disengaging a great stench therefrom and
poisoning the fish. Webster's theory of a relation between earthquakes and
influenzas provides for such discrepancies in the dates of each: it is
probable, he says, that seasons, earthquakes and volcanic eruptions are
themselves the effects of those motions and invisible operations which
affect mankind, so that catarrh and other epidemics often appear _before_
the visible phenomena of eruptions and earthquakes. In like manner, the
chronicler of the earthquake of Lisbon in the _Philosophical Transactions_
drew attention to the fact that there had been a remarkable drought for
several years before, and that some of the springs near Lisbon were
actually dried up at the time. That droughts precede earthquakes is
perhaps the most instructive generality that has yet been reached as to
the cause of the latter.

Let us see, then, whether any such remote antecedents, in a possible
relation to the influenza epidemics, hold good for the island of Barbados.
Hillary's chronicle is sufficiently full to let us answer the question.

    Following the seasons and prevalent maladies backwards from the
    influenza of children in October-November, 1755, we find a catarrhal
    fever all over Barbados in February of the same year, which "few
    escaped having more or less of." The immediate precursor of that
    influenza had been a very definite constitution, eighteen months long,
    of a "slow nervous fever," from February, 1753 to September, 1754,
    which corresponds in every respect to the "remittent" fever of nearly
    the same period in England and Ireland, described by Fothergill,
    Rutty, Huxham and Johnstone, and to the famous Rouen fever described
    by Le Cat. Hillary is clear that the "slow nervous fever" was not seen
    again so long as he remained in the colony (1758). Just before it
    began, there had been an influenza so general in December, 1752, and
    January, 1753, "that few people, either white or black, escaped having
    it," and that, in turn, was preceded by a season of agues, which, says
    Hillary, "are never seen in Barbados now [1758], unless brought hither
    from some place of the Leeward Islands."

So many influenzas in Barbados, and so many things possibly relevant to
them among their antecedents. So also in New England, the influenza which
seemed to follow the earthquake along the coast of Portugal on the 31st
of March, 1761, had the same remittent and intermittent fevers among its
antecedents.

    In the winter and spring of 1760-61 there had been much fever in New
    England, which was believed to be malarious. Webster, however, says:
    "There is no necessity of resorting to marsh exhalations for the
    source of this malady. The same species of fever [as at Bethlem]
    prevailed in that winter and the spring following in many other parts
    of Connecticut where no marsh existed. In Hartford it carried off a
    number of robust men, in two or three days from the attack.... In
    North Haven it attacked few persons, but everyone of them died. In
    East Haven died about forty-five men in the prime of life, mostly
    heads of families. The same disease prevailed in New Haven among the
    inhabitants and students in college." In Bethlem the sickness began in
    November, 1760, and carried off about forty of the inhabitants in the
    winter following. This was the fever, generally reckoned malarious,
    which preceded the influenza of April and May, 1761[765].


III.

The next great influenza, twenty years after, which was in America in the
spring of 1781 and in Europe in the winter and spring following, will
repay the same kind of scrutiny. There had been influenza here or there in
Europe since the beginning of 1780, but no great epidemic of it; and in
England, as elsewhere, there had been epidemic agues and dysenteries since
that year, or the autumn before. The epidemic agues became worse in
England in 1783, 1784, and 1785, appearing in places which had never been
thought malarious. The whole period from 1780 to 1784 was remarkable for
hot and dry summers and great earthquakes. Italy and Sicily were troubled
by earthquakes to an unusual extent in 1780, 1781, 1782, and 1783; they
were so frequent in 1781 that the pope ordered public prayers. The great
earthquake of the period was in Calabria at half an hour after noon of the
5th of February, 1783, about six months after the great influenza of the
period was over. Sir William Hamilton, the British ambassador at Naples,
visited the numerous scenes of the earthquake in Calabria and Sicily in
the first fortnight of May, 1783, and sent to the Royal Society an account
of what he saw. At several places he found fever epidemic, part of it from
the overcrowding and filth of the temporary barracks in which the people
were living, part of it malarious from the damming of water by changes in
the river beds. At Palmi the spilt oil mixed with the corn of the
overthrown granaries, and the corrupted bodies, had a sensible effect on
the air, which threatened an epidemic; at the village of Torre del
Pezzolo an epidemical disorder had already manifested itself[766].

But the most striking effect of the earthquake was that a dry fog began in
Calabria in February, and overspread until autumn the greater part of
Europe, extending even to the Azores. This fog, though not consisting
apparently of moisture, was so dense that the sky was quite obscured,
appearing a light grey colour instead of blue, while the sun became a
blood-red disc. In Calabria the darkness was so great that lights were
needed in the houses, and ships came into collision at sea. There was a
most disagreeable odour[767]. The fog spreading over all Europe from
Calabria was not at all mythical, as we are apt to suppose that similar
recorded phenomena of the wonder-loving Middle Ages may have been. The
phenomenon was independently reproduced in Iceland the same year, from the
1st to the 11th of June, causing the same darkness at sea, the same
atmospheric effects at a distance, but not to so great a distance, and
some amount of sickness, but seemingly not aguish or febrile, among the
population[768].

Those two great convulsions of the year 1783, each of them the cause of a
widely spreading dry fog, may have been conceivably the cause of
pestiferous miasmata in the air, such as the corresponding hypothesis of
influenza requires; but how little comparable or equivalent were the
miasmata--in the one case from the ancient and well-peopled soil of
Southern Italy, in the other from the inhospitable Danish colony just
without the Arctic Circle! In any case, the earthquakes of 1783 were both
too late for the great influenza of the period. The antecedent common
alike to the influenza and the earthquakes was the extraordinary droughts,
which caused famine and famine-fever in Iceland, and, according to old
experience, was probably related to the epidemic prevalence of agues in
Britain and on the continent of Europe.


IV.

What kind or kinds of epidemic sickness earthquakes may produce as an
effect immediate and at the place, will appear from other instances. One
of the most remarkable of earthquakes was that which destroyed Port Royal
and nearly all the planters' houses and sugar-works throughout the island
of Jamaica on the 7th of June, 1692. Jamaica had been an English colony
for little more than thirty years, during which time it had passed from
its state of lethargy under the Spaniards into an emporium of commerce
with a rapidly growing population of slaves and whites. The business
capital was at Port Royal, wholly built since the British occupation. The
site of it was a sandy key or shoal which was said to have risen
perceptibly within the memory of original settlers; a writer in September,
1667, said of it: "wherever you dig five or six feet, water will appear
which ebbs and flows as the tide. It is not salt, but brackish[769]." A
quay had been built along this spit of land, at which vessels of 700 tons
could lie afloat. It was here that the havoc of the earthquake was most
complete.

Sloane, who had visited Jamaica a few years before, said that the
inhabitants expect an earthquake every year, and that some of them were of
opinion that they follow their great rains[770]. The year 1692 began in
Jamaica with very dry and hot weather which continued until May: then came
gales and heavy rains until the end of the month, and from that time until
the day of the earthquake, the 7th of June, the weather was excessively
hot, calm and dry. The shakes began at 11.40 a.m., and at the third shake,
the ground of nearly all Port Royal fell in suddenly, so that in the
course of a minute or two most of the houses were under water and the
whole wharf was covered by the sea to the depth of several fathoms. The
loss of life was, of course, greatest where population was densest; but in
the interior of the island the effects on the soil were greater than at
the shore: in the north a thousand acres of land sank and thirteen people
with it; mountains on either side of a narrow gorge came together and
blocked the way; wide chasms appeared in the ground, and on one mountain
side there were some dozen openings from which brackish water spouted
forth. The first effect in the streets of Port Royal was that men and
women seemed all at once to be floundering up to the neck in the wet
shifting sand, and were speedily drowned or floated away by the inrushing
water. The shakes ceased for days at a time, and then began again, five or
six perhaps in twenty-four hours; so that those who had escaped to ships
in the bay remained on board for two months, being afraid to come ashore.
The weather was hotter after the earthquake than before, and mosquitoes
swarmed in unheard of numbers.

During the upheavals or subsidences in Port Royal, and the rushing of
water into or from the gapings in the ground, "ill stenches and offensive
smells" arose, so that "by means of the openings and the vapours at that
time belcht forth from the earth into the air, the sky, which before was
clear and blue, was in a minute's time become dull and reddish looking (as
I have heard it compared often) like a red-hot oven." A very great
mortality followed among those who had escaped the earthquake. Some of
them settled at Leguanea, others at the place on the bay which became the
Kingston of later history, enduring many hardships in their hastily built
shelters, from the heavy rains that followed the earthquake, and from want
of clothes, food and comforts.

    One writes: "Our people settled a town at Leguanea side; and there is
    about five hundred graves already [20th September, 1692], and people
    every day is dying still. I went about once to see it, and I had like
    to have tipt off." Another says: "Almost half the people that escaped
    upon Port Royal are since dead of a malignant fever": and another,
    referring to the hasty settlement on the bay at Kingston, says "they
    died miserably in heaps." But the most interesting information is his
    next sentence: "Indeed there was a general sickness (supposed to
    proceed from the hurtful vapours belched from the many openings of the
    earth) all over the island, so general that few escaped being sick:
    and 'tis thought it swept away in all parts of the island three
    thousand souls, the greatest part from Kingstown, only yet an
    unhealthy place[771]."

That great mortality from a malignant fever after the earthquake of 7th
June, 1692, is usually counted an epidemic of the yellow fever which
became established at Kingston and Port Royal from that time for at least
a century and a half. I have not found any contemporary medical account of
it, but all the later writers on yellow fever at Kingston and Port Royal
have accepted the tradition that it was yellow fever. But there was one
peculiarity, which marks it off from all subsequent epidemics of yellow
fever--the sickness was all over the island, so general that few escaped
being sick, and was supposed to proceed from the hurtful vapours belched
from the many openings of the ground in and near Port Royal. In all
subsequent experience yellow fever has been almost confined to the shore
or to the ships in the bay[772]. Certainly it has never been all over the
island as in 1692, "so general that few escaped being sick": that is
rather in the manner of influenza, although there is nothing to show that
the sickness of the interior was so different from that of the shore as to
be counted an influenza, or that the mortality of the sick was other than
that of a "malignant fever."

The earthquake at Port Royal in 1692 produced "ill stenches and offensive
smells." The tidal waves, or the subterranean vibrations which caused
them, in tearing up the mud at the bottom of the channel at Bridgetown,
Barbados, in 1755, had in like manner sent forth a great stench which
poisoned the fish. Such offensive vapours were supposed in former times to
come, as in a figure, from "the bowels of the earth"; and undoubtedly the
sulphurous fumes which have overhung the region of Sicilian earthquakes
must have had a source as deep as the strange minerals or "fossils" of
Boyle's hypothesis. But, while the commotion of an earthquake is deep, it
is also superficial; whatever miasmata issue from the ground in the
ordinary alternations of wet and drought, would be discharged into the
atmosphere in unusual quantity and with unusual force in such disturbances
of soil as sunk Port Royal in 1692 or were felt at Barbados across the
whole width of the Atlantic in 1755. Nor is that effect upon miasmata
instantaneous or quickly past; in Jamaica the rumblings and shakes lasted
for nearly two months, during which time the pressure upon the gases in
the subsoil must have been such as to make them pass into the atmosphere
in stronger ascending currents than the mere alternations of moisture and
drought would have done. And just as the ordinary seasonal changes in the
level of the ground-water are of little or no account for
miasmatic-infective disease unless the soil in which they occur be full of
organic impurities from human occupancy, so one may reason that the great
cataclysmic changes of the earth's crust are, in this hypothesis of
influenza, of most account as touching the stratum of soil wherein lie
organic impurities, and as touching those areas of the surface,--the sites
of cities, the populous plains, the shores of bays, the bottoms of
harbours or any other definite spots--in which the products of organic
decomposition are present in largest amount and, perhaps, of somewhat
special kind. Such impurities of the soil are indeed a _vera causa_ of
infective disease, known to be capable of the effect which has to be
accounted for; and, as discharged into the air in great volume and with
great force by some upheaval, they would make a local beginning of that
"aer inimicus" which the Roman poet figures as creeping like a mist from
one region of the heavens to another so that it corrupts each successive
tract of air with its own baleful qualities, "reddatque sui simile atque
alienum."

But, as soon as we begin to apply this formula to particular historic
cases, difficulties and ambiguities arise[773]. To come back to the
instance of Jamaica in 1692, did the general sickness of the island,
manifestly miasmatic as it was, and due to disturbances of soil, become an
influenza for other regions of the globe? About fifteen months after there
was, indeed, a universal catarrh in Britain and Ireland, of no great
fatality, which is said by Molyneux, of Dublin, to have prevailed also in
the northern parts of France, Flanders, and Holland, but is not reported
in the usual way from Europe generally nor from America. Let us suppose a
miasmatic cloud formed over the island of Jamaica in June, July, August
and September, a cloud of infective particles which might produce
influenza at a distance from its place of origin, whatever disease the
miasmata after the earthquake may have produced in Jamaica itself. Let
this invisible cloud, or emanation, get into the warm atmosphere over the
great oceanic current that sets out from the Gulf of Mexico. The vehicle
lies ready to hand,--to receive the miasmata not far from their place of
origin, to carry them far into the Atlantic, and to bring them, perhaps,
to the shores of Britain. This may seem a sufficiently plausible source of
the influenza of October and November, 1693, which appears to have been
felt only in the British Isles and on the opposite shores of the North
Sea. But Webster's own choice is the volcanic eruption in Iceland in the
same year as the influenza; and if we prefer, in this hypothesis, an
earthquake to an active volcano, there is a rival source for the British
influenza of 1693, nearer both in place and time than that of Jamaica in
1692, and not less important in respect of miasmatic disease in its own
locality. This was the disastrous series of earthquakes in Calabria and
Sicily, culminating on the 9th of January, 1693. The following extracts
from the account sent to the Royal Society will show how great was the
commotion of soil, of underground water, and of atmosphere, and how close
the connexion of these with the sickness ensuing[774]:

    "In the plain of Catania, an open place, it is reported that from one
    of the clefts in the ground, narrow but very long and about four miles
    off the sea, the water was thrown forth altogether as salt as that of
    the sea, [as in Jamaica the year before]. In Syracuse and other places
    near the sea, the waters in many wells, which at first were salt, are
    become fresh again.... The fountain Arethusa for the space of some
    months was so brackish that the Syracusans could make no use of it,
    and now that it is grown sweeter the spring is increased to near
    double. In the city of Termini all the running waters are dried up....
    It was contrary with the hot-baths, which were augmented by a third
    part.

    Darkness and obscurity of the air has always been over us, but still
    inferior to that on the 10th and 11th of January; and often these
    clouds have been thin and light, and of a great extent, such as the
    authors call _rarae nubeculae_. The sun often and the moon always
    obscured at the rising and setting, and the horizon all day long
    dusky....

    The effects it has had on humane bodies (although I do not believe
    they have all immediately been caused by the earthquake) have (yet)
    been various: such as foolishness (but not to any great degree),
    madness, dulness, sottishness, and stolidity everywhere:
    hypochondriack, melancholick and cholerick distempers. Every-day
    fevers have been common, with many continual and tertian: malignant,
    mortal and dangerous ones in a great number, with deliria and
    lethargies. Where there has been any infection caused by the natural
    malignity of the air, infinite mortality has followed. The smallpox
    has made great destruction among children."

Thus we find in Sicily a great disturbance of soil followed, as in
Jamaica, by a great increase of local sickness, and by an atmosphere
visibly charged with products of the earthquake for months after. This is
a nearer source than the Jamaican for the British influenza of Oct.-Nov.
1693,--nearer in time, if that be any advantage for the theory, nearer
also in place. There are, however, no intermediate stages to connect the
influenza on the northern edge of the European continent with the
disturbance of soil and the miasmata arising therefrom in Sicily and
Calabria. If there had been any such dry fog as spread all over Europe
from the Calabrian earthquake of January, 1783, it would have been a help
at least to the imagination in bridging over a gulf of space and time.

As to the interval of time, it should at all events be kept in mind that
the same difficulty has to be reckoned with in any hypothesis of influenza
and in every great historic instance. In the instance still before us, the
infection began in England, according to Molyneux, in October, 1693, and
was in Dublin a month later. But we must assume it to have been in the air
for some time before it became effective upon mankind. Influenza has been
observed, with curious uniformity, to attack the horses, say of London, of
Plymouth, of Edinburgh, or of Dublin (as on the occasion before this,
1688) two months or more in advance of the inhabitants of the respective
places; and if it had waited, so to speak, for two months before it showed
its effects upon men, it may have waited equally long, or longer, before
it showed its effects upon horses. That would give at least four months;
and then we know, from such an influenza as that of 1743, that there may
be weeks, perhaps months, between its prevalence in Naples, Rome or Milan,
and its prevalence in London or Edinburgh, and, from the influenza of 1693
itself, that it was a month later in Dublin than in London. An earthquake
in Sicily on the 9th of January, 1693, with effects there for months after
upon the water, the air, and the prevalent diseases, is not excluded by
lapse of time from being a _vera causa_ of an influenza in England in
October of the same year, and in Ireland in November. The sort of proof
which most men desire, a proof such as we rarely get, and one that is
suspiciously neat when we do get it, would be to find an influenza in
Sicily and Calabria following the earthquake, and to trace the same step
by step over Europe. But the miasmatic sickness in the countries of the
earthquakes was not influenza, so far as is known; and there was no
epidemic catarrh, so far as is known, in any other part of Europe but the
British Isles and the neighbouring shores of the North Sea.


V.

Molyneux, who recorded with a good deal of circumstance the influenza of
1693, is the principal authority, along with Dr Walter Harris, of London,
for another influenza in 1688, seemingly peculiar to the British Isles.
Its effects can be discovered with the utmost certainty in the London
bills of mortality for two or three weeks at the end of May and beginning
of June, and it is mentioned as "the new distemper" in letters of the
time. Is it possible to find an earthquake for it? Webster's note is: "in
the same year with an eruption of Vesuvius, after a severe winter and
earthquakes"--which is somewhat general. Turning to Evelyn's diary, where
these matters are often recorded, we find, in the very weeks when the
influenza was at a height in London, this entry: "News arrived of the most
prodigious earthquake that was almost ever heard of, subverting the city
of Lima and country in Peru, with a dreadfull inundation following it"--as
if the influenza and the news of the earthquake had reached London at the
same time. This was the earthquake of 20th October, 1687, which destroyed
Lima, Callao and an immense district along the coast of Peru. The rocking
of the earth was most violent, the sea retreated like a sudden immense ebb
and filled again like a sudden immense flood, the effect of the commotion
being felt on board ships a hundred and fifty leagues out in the Pacific.
It was remarked that wheat and barley would not thrive in Peru after that
earthquake[775]. Here was undoubtedly a great disturbance of soil and of
subsoil, almost certainly attended with the discharge of effluvia or
miasmata into the air, as in other great earthquakes. But the universal
slight fever of the British Isles in the months of June and July, 1688, is
remote from the earthquake of Lima in place; and, if it be a question of
earthquakes at all, there are others nearer to it both in place and time,
such as that in the Basilicata province of Naples in January, 1688, and
the Jamaica earthquake, felt through all the island, on the 1st of March,
1688. The greatest of them all, that of Smyrna, on the 10th of July, was a
few weeks too late for the hypothesis.


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 <DW64>s 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 Goree,
    Senegambia, for Brest, in February. There were no cases of influenza
    in Goree 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 Goree, 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 deg. 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 , 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 Faroe 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
[Greek: apatheis], 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 <DW64>s.

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 <DW64>s, 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 a 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 a 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 <DW64>s 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 _a 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 <DW64>s, 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 Haen, 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
<DW64>s, 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 <DW64>s 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 Academie 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 L6300. 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 <DW64>s[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 5-1/2 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 <DW64> 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 L10,000 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 L20,000 was voted to him; and on 8 June, 1808, a National
Vaccine Establishment was appointed, at an annual cost of about L5,000.


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
L10,000[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 _a 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 Mueller, 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
Wuertemberg. 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, Wuertemberg, 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 (1/2)    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 "_anglice_ 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
    "maxime 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 <DW44> 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  4th    1st   2nd   3rd  4th   (four quarters)
            Qr.  Qr.    Qr.   Qr.   Qr.  Qr.

  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
<DW26>s 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- 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 deg. 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 foetid
    matter.... The nostrils are glandered.... From the absorption of the
    foetid 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-
    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-,
    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 foetid 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- 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- 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- 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
Ferriere 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 [Greek: diphthera], 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               All
  Week ending   the guts  Convulsions  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 deg. 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 creches 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 caute 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 deg. 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 fere, 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 [Greek: rheumatismos]--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 L8000 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 L8536. 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 L300,000 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 <DW72> 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 <DW75> valley,
    on the <DW72>s 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 <DW72> 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 2-1/2 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 Haj 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 L4,200,000. 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 deg., 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


  Faroe 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 _fievre 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. Sec. 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 Fievre Typhoide chez les Enfants_, These, 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 praecise
determinari potest."

[13] Haeser 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._ Sec. 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 [Greek: to theion] 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._ Secs. 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." Secs. 2, 3.

[34] _Ibid._ Sec. 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_, Sec. 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, _Archaeologia_, 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 proxime elapso, per Gallias passim ingravescere coeperunt febres
mali moris in nobiles domos, et regiam praecipue infestae; quo 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 _regime_ 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 L362. 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
_Oeconomical 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
                              L _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
                            -----------
                             L1   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 Bronte'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
deg. &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  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 Bronte. 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 Bronte. 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 Pitie 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- 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 oeffentlichen 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 Pare), 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 L28 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._ Sec. 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 Haeser'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, praecipue 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, [Greek: Synopsis] _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, Luebeck, 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] [Greek: Puretologia] _sive Gulielmi Dragei Hitchensis_ [Greek:
Iatrou kai Philosophou] _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] [Greek: Puretologia]. _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_, Sec. 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._ Sec. 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 <DW72> 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] Chaumeziere, _Fievre catarrhals epidemique, observee a 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 [Greek: Peri hydroposias], 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 Verole
sur la Mortalite a 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 _Bibliotheque 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, _a 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-verole," 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, _Mem. par la
Societe Econom. de Berne_, 1766.

[893] _Dissertationes in Inoculationem Variolarum_, a J. a 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 <DW64>s), 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, _Memoires pour servir a
l'Histoire de l'Inoculation_. 2me Memoire. 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, Sec. 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, _Memoires pour servir, &c._ (Deuxieme 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" (Sec. 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" _qua_
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 <DW64>s 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, _Mem. par la Societe Economique de Berne_, 1766. "Population
dans le pays de Vaud": p. 102, "J'ai vu a Veney, la petite verole etre
generale dans toute la ville, des centaines d'enfans attaques de cette
maladie, et qu'a 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 mea 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
 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  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. Sec. 8; _Epist. Respons._ I.
Sec. 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_, Tuebingen, 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 _Frieselbraeune_, or
miliary diphtheria, a somewhat rare and sporadic malady; in the account by
Bard, he finds _haeutige Brandbraeune_, or membranous angina maligna; while
he finds in an account by Chalmers for Charleston, S. Carolina, in 1770, a
third variety, _Friesel-Scharlachbraeune_, 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. Haeser 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 Jahrbuecher_, 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. Haeser, _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." _Oeconomia 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, Sec. 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 Franzoesischen und Englischen Autoren
zusammengestellt," Originalabhandlung in _Schmidt's Jahrbuecher_, 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 speciales du tissu muqueux et en
particulier de la Diphtherite_, Paris, 1826, with supplement in 1827.

[1368] Id. _Arch. gen. de med._, 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 Beitraege, &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, Sec. 2.

[1390] _Ibid._ III. cap. 2, Sec. 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, Sec. 7: "haud aliter ac si in aere
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 _a 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 a 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' 'eat and th' ile. Me
an' my mates wor speakin' o't last neet, an' we o' on us thowt th' saam
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 medicale 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.



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