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diff --git a/43671.txt b/43671.txt deleted file mode 100644 index d7fdfd4..0000000 --- a/43671.txt +++ /dev/null @@ -1,46149 +0,0 @@ -The Project Gutenberg eBook, A History of Epidemics in Britain, Volume II -(of 2), by Charles Creighton - - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - - - - -Title: A History of Epidemics in Britain, Volume II (of 2) - From the Extinction of Plague to the Present Time - - -Author: Charles Creighton - - - -Release Date: September 8, 2013 [eBook #43671] - -Language: English - -Character set encoding: ISO-646-US (US-ASCII) - - -***START OF THE PROJECT GUTENBERG EBOOK A HISTORY OF EPIDEMICS IN BRITAIN, -VOLUME II (OF 2)*** - - -E-text prepared by the Online Distributed Proofreading Team -(http://www.pgdp.net) from page images generously made available by -Internet Archive (http://archive.org) - - - -Note: Images of the original pages are available through - Internet Archive. See - http://archive.org/details/historyofepidemi02unse - - -Transcriber's Notes: - - Text enclosed by underscores is in italics (_italics_). - - Text enclosed by equal signs is in bold face (=bold=). - - The original text includes Greek characters that have - been replaced with transliterations in this text version. - - - - - -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 retard 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-coloured 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-coloured 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-coloured 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-coloured 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-coloured 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 coloured 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 coloured plates of the intestinal or mesenteric -lesion in some of them, the earliest coloured 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 Taff, 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-coloured 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 negroes[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 negroes as white men, for they infect one the other, and the -ship is then in a very deplorable condition unless they have an able man -to take care of them." But the original source of infection, he believed, -was the fogs that hung at nightfall over the estuaries of the rivers; and -he gives an experimental proof, remarkable but not quite incredible, of -the poisonous nature of the miasmata: - - "But to let you see the evil, malevolent, contagious, destructive - quality of those fogs that fall there in the night, and how far they - are inimical to human nature, I will tell you of an experiment of my - own. I made a lump of paste with oat-meal somewhat hard, and about the - bigness of a hen's egg, which was exposed to the fog from twilight to - twilight, i.e. from the dusk of the evening till daybreak in the - morning; after which I crumbled it, and gave it to fowls, which we had - on board, and soon after they had eaten it, they turned round and in a - kind of vertigo dropt down and expired." - -A great mortality in Guinea in 1754 or 1755 was ascribed by Lind, the -least credulous in such matters, to "a noxious stinking fog[779]." - -What the alternations of heat and chill, of moisture and drought, produce -ordinarily in the way of miasmata, the same, we may suppose, is produced -on the great scale, as a phenomenon at some particular time and place, by -one of those cataclysms which break the surface of the earth or the bed of -the sea, lower or raise the level of wells and springs, and fill the air -with particles of dust or vapour which may overhang the locality for -months and visibly disperse themselves to a great distance. Nothing -relating to miasmata in the air need be hard for belief after the -wonderful diffusion and permanence in the atmosphere of the whole globe, -for two years or more, of finely divided particles shot up by the -earthquakes and eruptions of Krakatoa in the Straits of Sunda on the 27th -and 28th of August, 1883[780]. - -A theory of influenza constructed from such generalities as those of -Boyle, Arbuthnot and Webster will have attractions for many over the -theory that influenza is always present in some remote country and becomes -dispersed now and then over the world by contagion from person to person: -it will have superior attractions, for the reason that influenza is a -phenomenal thing which needs a phenomenal cause to account for it. But if -anyone were to attempt to fit each historic wave of influenza with its -particular earthquake, or to find the precise locality where clouds of -infective matter had arisen, or the particular circumstances in which they -arose, he would certainly find his fragile structure of probabilities -pulled to pieces by the professed discouragers and depravers. I make no -such attempt; but I am not the less persuaded of the direction in which -the true theory of influenza lies. - - -Influenza at Sea. - -There is no point more essential to a correct theory of influenza than to -find out in what circumstances it has occurred among the crews of ships on -the high seas. If it be true that a ship may sail into an atmosphere of -influenza, just as she may sail into a fog, or an oceanic current, or the -track of a cyclone, then the possible hypotheses touching the nature, -source, and mode of diffusion of influenza become narrowed down within -definite limits. - - One of the first observations was made in the case of a Scotch vessel - in the influenza of 1732-33[781]. The epidemic was earlier in Scotland - than in England; it began suddenly in Edinburgh on 17 December, 1732, - the horses having been attacked with running of the nose towards the - end of October. About the time when the disease began among mankind, - in December, a vessel, the 'Anne and Agnes' sailed from Leith for - Holland. One sailor was sick on this voyage. She sailed on the return - voyage to Leith, with the other ten of her crew in perfect health. - Just as she made the English coast at Flamborough Head on the 15th of - January, 1733, six of the sailors fell ill together, two more the next - day, and one more on the day after that, so that when the vessel - anchored in Leith Roads there was only one man well, and he fell ill - on the day following the arrival. The symptoms were the common ones of - the reigning epidemic. The dates are not given more precisely or fully - than as above. Influenza was prevalent in Germany and Holland somewhat - earlier than in Scotland or England; the men may, of course, have - imbibed the infection when they were in the Dutch port, just as it is - almost certain that the crews of Drake's fleet in 1587 had received - during a ten days' stay upon the island of St Jago, of the Cape de - Verde group, the miasmatic infection of which they suddenly fell sick - in large numbers together in mid-Atlantic some six days after sailing - to the westward. - -This early case of the 'Anne and Agnes' in 1733 may pass as an ambiguous -one. The next occasion when influenza on board ship attracted much notice -was the epidemic of 1782. - - On the 6th of May, Admiral Kempenfelt sailed from Spithead with seven - ships of the line and a frigate, on a cruize to the westward; on the - 18th May, he came into Torbay, and sailed again soon after; on the - 30th May he came again into Torbay with eight sail of the line and - three frigates, and on 1 June sailed again to the westward. Sometime - before his squadron put into Torbay for the second time, influenza had - appeared among them at sea, it is said in the 'Goliath' on the 29th of - May[782]. A letter from Plymouth, of the 2nd June, after referring to - the violence of influenza in that town, at the Dock, and on board the - men-of-war lying there, says that the 'Fortitude' of 74 guns, and - 'Latona' frigate came in that afternoon with 250 sick men from the - fleet under Admiral Kempenfelt, mostly with fevers. Another Plymouth - letter two days later (4 June) says: "Kempenfelt is returning to - Torbay: he could keep the sea no longer, on account of the sickness - that rages on board his fleet. More than 400 men have been brought to - the hospital this morning. Our men drop down with it by scores at a - time. The 'Latona' frigate, that sailed the other day is returned, the - officers being the only hands that could work the ship[783]." - -This outbreak on board ships in the Channel was fully as early as the -great development of influenza in 1782 on shore, whether in London or -Plymouth; but there were almost certainly cases of it at the latter port -before the 'Latona' sailed to join Kempenfelt's squadron. Robertson, -however, who was surgeon on the 'Romney' in the Channel service at that -time, says that "hundreds in different ships, towns, and counties, which -had _no_ communication with one another, were seized nearly as suddenly -and so nigh the same instant as if they had been electrified.... The -companies of many of the ships were very well at bed-time, and in the -morning there were hardly enough able to do the common business of the -ship[784]." This is confirmed by McNair, surgeon of the 'Fortitude,' who -told Trotter that two hundred of her men, as she lay in Torbay, were -seized in one night and were unable to come on deck in the morning[785]. - -There was another English fleet in the North Sea at the same time, under -Lord Howe, watching the Dutch fleet or seeking to intercept the Dutch East -Indiamen. - - Howe sailed from St Helen's on the 9th May, with twelve ships of the - line. Towards the end of that month he had his fleet in the Texel; the - men were in excellent health, "when a cutter arrived from the - Admiralty, and the signal was given for an officer from each ship [to - come on board the admiral]. An officer was accordingly sent with a - boat's crew from every vessel, and returned with orders, carrying with - them also, however, the influenza"--which soon prostrated the crews to - the same extraordinary extent as in the ships under Kempenfelt at the - other end of the Channel. This was the oral account given to Professor - Gregory of Edinburgh, by a lieutenant on board a sixty-four gun - ship[786]. Another account says that the disorder first appeared in - Howe's fleet on the Dutch coast about the end of May, on board the - 'Ripon,' and in two days after in the 'Princess Amelia'; other ships - of the same fleet were affected with it at different periods, some - indeed, not until their return to Portsmouth about the second week of - June. "This fleet, also, had no communication with the shore until - their return to the Downs, on their way back to Portsmouth, towards - the 3d and 4th of June[787]." - -But, apart from the story of the Admiralty despatch-boat carrying the -influenza to Howe's squadron, it appears that both Kempenfelt and Howe -were joined from time to time by additional ships, which might have -carried an atmosphere of influenza with them[788]. Still, it was an -influenza atmosphere that they had carried, and not merely so many sick -persons. The doctrine of contagion from person to person would have to be -so widened as to become meaningless, if all those experiences of the fleet -in 1782 were to be brought within it. In the history both of sweating -sickness and of influenza, there are instances of the disease breaking out -suddenly in a place after someone's arrival; but the new arrival may not -have had the disease, it was enough that he came from a place where the -disease was[789]. That was, perhaps, the reason why Beddoes, in his -inquiry of 1803, framed one of his questions so as to elicit information -about the dispersal of influenza by _fomites_. - -It is not easy to prove that a ship may meet with an atmosphere of -influenza on the high seas; but many have believed that ships have done -so. Webster says: "The disease invades seamen on the ocean in the same -[western] hemisphere, when a hundred leagues from land, at the same time -that it invades people on shore. Of this I have certain evidence from the -testimony of American captains of vessels, who have been on their passage -from the continent to the West India Islands during the prevalence of this -disease[790]." There are several instances of this, authenticated with -times, places, and other data of credibility. - - The best known of these is the voyage of the East Indiaman 'Asia' in - September, 1780, through the China Sea from Malacca to Canton: "When - the ship left Malacca, there was no epidemic disease in the place; - when it arrived at Canton it was found that at the very time when they - had the _Influenza_ on board the Atlas (_sic_) in the China seas, it - had raged at Canton with as much violence as it did in London in June, - 1782, and with the very same symptoms[791]." - -In the present century, the cases nearly all come from the medical reports -of the navies of Great Britain, France, Germany and the Netherlands, and -they relate to ships on foreign service--in the East Indies, the Pacific, -Africa, or other foreign stations. In some of the instances influenza went -through a ship's company in port or in a roadstead, others are examples of -outbreaks at sea: - - 1837: "The ship's company of the 'Raleigh,' were attacked by epidemic - catarrh--influenza--first in March, while at sea between Singapore and - Manilla, and again, although less severely, in June and July while on - the coast of China.... Influenza also made its appearance amongst the - crew of the 'Zebra' in April while she lay at Penang; it was supposed - to have been contracted by infection from the people on shore, as they - were then suffering from it. No death occurred under this head[792]." - - 1838: In the 'Rattlesnake,' at Diamond Harbour, in the Hooghly River, - a large proportion of the men were suffering from epidemic catarrh. - Intermittent fever made its appearance; "the change from the catarrhal - to the febrile form was sudden and complete, the one entirely - superseding the other[793]." - - 1842: In the 'Agincourt' on a voyage from the Cape of Good Hope to - Hongkong in August and September, the greater part of 102 cases of - catarrh occurred; many of these were accompanied with inflammation of - tonsils and fauces, and in some there was deafness with discharge from - the ear. This is not claimed as an instance of epidemic influenza, but - as an aggregate of common colds, due to cold weather in the Southern - Ocean and to wet decks[794]. - - 1857: "Influenza broke out in the 'Monarch' while at sea, on the - passage from Payta [extreme north of Peru] to Valparaiso. She left the - former place on the 23d August, and arrived at the latter on the last - day of September. About the 12th of the month [twenty days out], the - wind suddenly changed to the south-west, when nearly every person in - the ship began to complain of cold, although the thermometer did not - show any marked change in the temperature. On the 12th and 13th seven - patients were placed on the sick list with catarrhal symptoms; and - during the following ten days, upwards of eighty more were added, but - by the end of the month the attacks ceased. [She carried 690 men, and - had 191 cases of "influenza and catarrh," in the year 1857.] Some of - the cases were severe, ending either in slight bronchitis or - pneumonia, accompanied with great prostration of the vital powers. On - the arrival of the ship at Valparaiso, the surgeon observes: 'We found - the place healthy, but in the course of a few days some cases of - influenza made their appearance, and very soon afterwards the disease - extended over the whole town. It was generally believed that we - imported it, and the authorities took the trouble to send on board a - medical officer to investigate the matter.' He further observes that - the whole coast, from Vancouver's Island southward to Valparaiso was - visited by the epidemic." It made its appearance on board the - 'Satellite' at Vancouver's Island in September, and among the - residents ashore, both on the island and mainland, at the same - time[795]. - - 1857: Catarrh "assumed the form of influenza in the 'Arachne' [149 - men, 114 cases] while the vessel was cruizing off the coast of Cuba, - with which, however, she had no communication. There was nothing in - the state of the atmosphere to attract special attention. A question - therefore arises whether it might not have been caused by infection - wafted from the shore." It was prevalent at the time at Havana[796]. - - 1857: "Australian Station:--An eruption of epidemic catarrh occurred - in the 'Juno' [200 men, 131 cases], but long after she left the - station[797]." - - Whilst the influenza was on the American Pacific coast in September, - 1857, it was on the coast of China three months earlier--on board the - 'Inflexible' at Hongkong on the 18th of May, and in the 'Amethyst' and - 'Niger' in a creek near Hongkong early in June[798]. But it had been - on the Pacific coast of South America the year before, according to - the following: - - "1856: Epidemic catarrh broke out in the 'President' when lying off - the island of San Lorenzo in the bay of Callao, first on the 20th - October, and the last cases were placed on the sick list on 1st - November,--the usual period which influenza takes to pass through a - frigate ship's company. About sixty required to be placed on the sick - list." It had occurred on board English ships of war at Rio de - Janeiro, on the other side of the continent, some two months before, - in August, 1856[799]. - - 1863: The following, in the experience of the French navy, has been - elaborately recorded[800]: The frigate 'Duguay-Trouin' left 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 coloured, suddenly fall into an illness, one symptom of -which is that they feel "intensely miserable." It lasts acutely for about -four days, and gradually declines. It resembles influenza in all respects, -and is known by the name of _murri-murri_, which is curiously like the old -English name of _mure_ or _murre_. "The mere appearance of murri-murri is -proof to the inhabitants, even at distant parts of the island, which is -thirty miles long, that a ship is in port, insomuch that, on no other -evidence, people have actually ridden off to Waitangi to fetch their -letters[804]." - -About equally distant in the Pacific from Brisbane, as Wharekauri from -Christchurch, lies Norfolk Island, originally colonized by the mutineers -of the 'Bounty.' A writer in a newspaper says: - - "During a seven years' residence in Norfolk Island, I had - opportunities of verifying the popular local tradition that the - arrival of a vessel was almost invariably accompanied by an epidemic - of influenza among the inhabitants of the island. In spite of the - apparent remoteness of cause and effect, the connexion had so strongly - impressed itself on the mind of the Norfolk Islanders that they were - in the habit of distinguishing the successive outbreaks by the name of - the vessel during whose visit it had occurred[805]." - -Something similar has long been known in connexion with the Danish trade -to Iceland, the first spring arrivals from the mother country bringing -with them an influenza which the crews did not suffer from during the -voyage, nor, in most cases, during the progress of the epidemic in -Reikjavik. The experience at Thorshaven, in the 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 negroes. - -The result is that sixteen in the hundred are marked more or less with -smallpox, four of them being black men or boys. One had "lately had the -smallpox," another had "newly recovered of the smallpox." One was a -cherry-cheeked boy of twelve, "somewhat disfigured with smallpox," who had -run away from Bradford school. Two are described as much disfigured, some -as a little disfigured, several others as "full of pock-holes." The same -mark of identity is occasionally mentioned in the advertisements beyond -the hundred tabulated, but not more frequently than before, the usual term -in the later period being "pock-broken." This proportion of pock-marked -persons among the London populace, sixteen in the hundred, or about twelve -in the hundred excluding negroes, does not err on the side of -under-statement, if it errs at all. Some such small ratio is what we might -have expected in the antecedent probabilities, arising out of the varying -degrees of severity of smallpox and the various textures of the human -skin. Pitting after smallpox has always been a special risk of a certain -texture of the skin, namely, a sufficient thickness of the vascular layer -to afford the pock a deep base. Such complexions are common enough even in -our own latitudes; and those are the faces that have always borne the most -obvious traces of smallpox. It was some of the confluent cases, or rather, -of such of them as recovered, that became pock-marked: the babe that -became a changeling was not likely to survive. Adults retained the marks -more than children, so that there must always have been a good many -pock-marked faces in a population where the incidence of the disease was -largely upon grown persons, as in the 17th century and in our own time. -When smallpox was something of a novelty at the end of the Elizabethan -period, a poet addressed a pathetic lyric to his mistress's pock-marked -face. A medical writer of the same period reproduces the old Arabian -prescription against pitting, to open the pocks on the face with a golden -pin, and adds: "I have heard of some, which, having not used anythinge at -all, but suffering them to drie up and fall of themselves, without picking -or scratching, have done very well, and not any pits remained after -it[850]." Whitaker, in 1661, dismisses the risk of pitting very briefly, -remarking that the means of prevention was "commonly the complement of -every experienced nurse[851]." Morton, in his sixty-six clinical cases and -in his commentary, makes but slight reference to pitting. In his 14th -case, a severe one, "no scars remained"; in his general remarks he treats -pitting as a bugbear: "women set the fairness of their faces above life -itself," which may mean, as in Beaumont and Fletcher's comedy, that they -would chill themselves at all risks by the cooling regimen so they might -drive the pocks in[852]. - - -The Epidemiology continued to the end of the 17th century. - -What little remains to be said of smallpox in England to the end of the -seventeenth century may be introduced by the following table of the deaths -in London. - -_Smallpox Deaths in London 1661 to 1700._ - - Total Smallpox - Year deaths deaths - - 1661 16,665 1246 - 1662 13,664 768 - 1663 12,741 411 - 1664 15,453 1233 - 1665 97,306 655 - 1666 12,738 38 - 1667 15,842 1196 - 1668 17,278 1987 - 1669 19,432 951 - 1670 20,198 1465 - 1671 15,729 696 - 1672 18,230 1116 - 1673 17,504 853 - 1674 21,201 2507 - 1675 17,244 997 - 1676 18,732 359 - 1677 19,067 1678 - 1678 20,678 1798 - 1679 21,730 1967 - 1680 21,053 689 - 1681 23,951 2982 - 1682 20,691 1408 - 1683 20,587 2096 - 1684 23,202 1560 - 1685 23,222 2496 - 1686 22,609 1062 - 1687 21,460 1551 - 1688 22,921 1318 - 1689 23,502 1389 - 1690 21,461 778 - 1691 22,691 1241 - 1692 20,874 1592 - 1693 20,959 1164 - 1694 24,100 1683 - 1695 19,047 784 - 1696 18,638 196 - 1697 20,972 634 - 1698 20,183 1813 - 1699 20,795 890 - 1700 19,443 1031 - -Sydenham's remarks throw some light on the smallpox of the several years. -While the epidemic of 1667-68 was of a regular and mild type, that of -1670-72, which has fewer deaths in the bills, was of the type of black -smallpox complicated with flux. The year 1674 has the highest figures yet -reached; the type of the disease was confluent, and so severe that it -"almost equalled the plague"; while the smallpox of the year 1681, with a -still higher total, was "confluent of the worst kind." - -It is not easy to make out what the differences of "type" described by -Sydenham depended on; but it may be hazarded that those who fell into -smallpox in an otherwise unhealthy season would die in larger numbers, -being weakened by antecedent disease, such as measles or epidemic -diarrhoea, influenza or typhus fever. An epidemic of measles in the first -six months of 1674 was most probably the reason of the great fatality of -smallpox in the second half of that year (see the chapter on Measles). The -high figures of smallpox mortality in 1681 followed two hot summers, -unhealthy with infantile diarrhoea, and coincided with a third season -unhealthy in the same way. The deaths by smallpox in the last week of -August, 1681, reached the very high figure of 168, the next highest cause -of death that week, and the highest the week after, being "griping in the -guts," or infantile diarrhoea. The smallpox of 1685 was more uniformly -distributed over the months of the year, which was one of malignant -typhus, the worst week for fever having 114 deaths (ending 29 Sept.), and -the worst week for smallpox 99 deaths (ending 18 Aug.). - -The deaths by smallpox in the London bills are the only 17th century -figures of the disease. According to later experience, a high mortality in -London in a certain year meant an epidemic general in England in that or -the following year; and the same appears to have held good for the period -following the Restoration. In the parish register of Taunton, a weaving -town, the smallpox deaths are many in 1658 ("all the year," which was one -of agues and influenza), in 1670, 1677, and 1684 ("very mortal," the year -being noted for a very hot summer and for fevers and dysenteries[853]). -The highest total of deaths in London to the end of the 17th century fell -in 1681, which is known to have been a year of very fatal smallpox at -Norwich[854] and at Halifax. Thoresby's friend Heywood lost three children -by it at the latter town in the epidemic of 1681, which does not appear to -have visited Leeds. In 1689 Thoresby himself lost his two children at -Leeds within a few days. In 1699 the epidemic returned, and he again lost -two of the four children that had been born to him in the interval[855]. -Similar calamities befell country houses, of which the following from the -correspondence of a titled family in Cumberland is an instance: - - "17th April, 1688,--Captaine Kirkby came hither, and told me that Mrs - Skelton, my god-daughter, of Braithwaite, dyed the last week, and her - two children, of the smallpockes[856]." - -Rumours of "smallpox and other infectious disease" at Cambridge in the -summer of 1674[857], and at Bath in the summer of 1675[858], threatened to -interfere with the studies of the one place and the gaieties of the other. - - -Smallpox in London in 1694: the death of the Queen. - -The epidemic of smallpox in London in 1694 was made memorable by the death -of the queen. On 22 November Evelyn notes, "a very sickly time, especially -the smallpox, of which divers considerable persons died"; on 29 December: -"the smallpox increased exceedingly, and was very mortal," the queen -having died of it the day before. Queen Mary came of a stock to which -smallpox had been peculiarly fatal, a brother and sister of her father, -James II., having died of it at Whitehall in 1660. Some of the particulars -of her illness and death come from bishop Burnet[859], who saw her in the -first days of the attack and was about the Court until the end of it; the -authentic medical details are by Dr Walter Harris, one of the physicians -in attendance, who published them, by leave of his superiors, in order to -meet the censures passed on the doctors "by learned men at a great -distance[860]." - - The symptoms of illness on the first day did not prevent the queen - from going abroad; but, as she was still out of sorts at bedtime, she - took a large dose of Venice treacle, a powerful diaphoretic which her - former physician, the famous physiologist Dr Lower, had recommended - her to take as often as she found herself inclined to a fever[861]. - Finding no sweat to appear as usual, she took next morning a double - quantity of it, but again without inducing the usual effect of - perspiration. Up to that time she had not asked advice of the - physicians. To this severe dosing with one of the most powerful - alexipharmac or heating medicines, the malignant type of the ensuing - smallpox was mainly ascribed by Harris, who was a follower of Sydenham - and a partizan of the cooling regimen. On the third day from the - initial symptoms the eruption appeared, with a very troublesome cough; - the eruption came out in such a manner that the physicians were very - doubtful whether it would prove to be smallpox or measles. On the - fourth day the smallpox showed itself in the face and the rest of the - body "under its proper and distinct form." But on the sixth day, in - the morning, the variolous pustules were changed all over her breast - into the large red spots "of the measles"; and the erysipelas, or - rose, swelled her whole face, the former pustules giving place to it. - That evening many livid round petechiae appeared on the forehead above - the eyebrows, and on the temples, which Harris says he had foretold in - the morning. One physician said these were not petechiae, but - sphacelated spots; but next morning a surgeon proved by his lancet - that they contained blood. During the night following the sixth day, - Dr Harris sat up with the patient, and observed that she had great - difficulty of breathing, followed soon after by a copious spitting of - blood. On the seventh day the spitting of blood was succeeded by blood - in the urine. On the eighth day the pustules on the limbs, which had - kept the normal variolous character longest, lost their fulness, and - changed into round spots of deep red or scarlet colour, smooth and - level with the skin, like the stigmata of the plague. Harris observed - about the region of the heart one large pustule filled with matter, - having a broad scarlet circle round it like a burning coal, under - which a great deal of extravasated blood was found when the body was - examined after death. Towards the end, the queen slumbered sometimes, - but said she was not refreshed thereby. At last she lay silent for - some hours; and some words that came from her shewed, says Burnet, - that her thoughts had begun to break. She died on the 28th of - December, at one in the morning, in the ninth day of her illness. - -The case of Queen Mary was one of discrete smallpox turning to the -haemorrhagic form; and it had from first to last the most striking -resemblance to that of her uncle, the Duke of Gloucester, in September, -1660[862]. The smallpox, says Burnet, came out, but the pustules "sunk so -that there was no hope of raising them"; and in sinking they turned to -livid spots or blotches. It is quite possible that the repeated doses of -Venice treacle at the outset, which failed in their usual effect of -inducing sweat, may have had something to do with the result, as Dr Harris -certainly believed and afterwards publicly said with the leave of his -superiors. But the queen, with eminent qualities of mind and heart, was -not physically of good constitution. She was one of those children of -James II. whom Willis had brusquely pronounced, some twenty-five years -before, to be affected with _mala stamina vitae_; and her father's -brother, the Duke of Gloucester, who was not treated in the same way, and, -by one account, not treated at all, died in exactly the same kind of -haemorrhagic smallpox[863]. - - -Circumstances of the great Epidemic in 1710. - -For fifteen years after the year of Queen Mary's death by haemorrhagic -smallpox, there was comparatively little of the disease in London. In -seven of the years the deaths were counted by hundreds, while the average -of the whole period from 1695 to 1710, which included the years of -Marlborough's campaigns, was unaccountably low. There was a corresponding -lull in the fever mortality in London; and as precisely the same kind of -lull took place both in fever and smallpox during the next great war with -France a century after, it may seem as if a state of war, instead of -spreading infectious disease as it did in the countries where the war -raged, had the effect in England of reducing it. The period of comparative -immunity came to an end, both for fever and smallpox, with the great -epidemic of each disease in 1710, in which year smallpox cut off 3138 in -London and "great numbers in Norwich[864]." In 1714 there was another -severe epidemic of smallpox in London, again in company with one of fever, -and thereafter a high average for many years. - -_Smallpox deaths in London, 1701-1720._ - - Deaths from Deaths from - Year smallpox all causes - - 1701 1099 20,471 - 1702 311 19,481 - 1703 398 20,720 - 1704 1501 22,684 - 1705 1095 22,097 - 1706 721 19,847 - 1707 1078 21,600 - 1708 1687 21,291 - 1709 1024 21,800 - 1710 3138 24,620 - 1711 915 19,833 - 1712 1943 21,198 - 1713 1614 21,057 - 1714 2810 26,589 - 1715 1057 22,232 - 1716 2427 24,436 - 1717 2211 23,446 - 1718 1884 26,523 - 1719 3229 28,347 - 1720 1442 25,454 - -The marked increase of smallpox deaths in 1710 and 1714, after an interval -of low or moderate annual mortalities, caused the same cry to be raised -as in the Restoration period, namely, that the medical treatment was to -blame. Lynn, writing in 1714, says that many complaints were made of the -destructiveness of smallpox in the epidemic four years before (1710), and -of "the great want of better help, care or advice therein[865]." Woodward -also ascribed the great increase of smallpox fatalities from 1710 onwards -to erroneous treatment[866]. All the lives that might have been saved by -better medical treatment or by more assiduous visiting of the sick would, -in the then circumstances of the London populace, have made little -difference to the bills of mortality. The causes that made fever so mortal -in the same years were in great part the causes that made smallpox mortal, -the former chiefly among those in the prime or maturity of life, the -latter chiefly among the children. London had nearly reached its maximum -of overcrowding; its population advanced but little for a good many years, -and its mortality from all causes was so great that the numbers were only -kept up by a constant recruit from the country. The necessity of doing -something for the health of the poorer classes was felt, but nothing -adequate was done or could be done[867]. So far as concerned the richer -classes, they incurred constant danger of smallpox infection. In one of -those fatal years, probably 1720, when there was smallpox among persons of -quality in London, the Duchess of Argyll wrote to the Countess of Bute, to -congratulate her on the birth of a daughter and on having two fine boys in -her family already, "and he that has had the smallpox as good as two, so -mortal as that distemper has been this year in town was never known[868]." - -The domestics also of great houses frequently caught smallpox and spread -it, a trouble which gave occasion at length, in 1746, to the first -Smallpox Hospital for the admission of such of them as brought -subscribers' letters. Before that it had been the practice of the rich to -send their domestics to private houses kept by nurses[869]. - -It was in these circumstances, and for the benefit of the upper classes -and their domestics, that a project of getting through smallpox on easy -terms was brought to the notice of London society in 1721. - - -Inoculation brought into England. - -The first that was heard in England of engrafting the smallpox was through -a communication by Dr Timoni, a Greek of Constantinople, to Dr Woodward, -Gresham professor of physic, who had the paper printed in the -_Philosophical Transactions_ of the Royal Society[870]. After a statement -that "the Circassians, Georgians and other Asiatics" had brought the -practice to Constantinople, and that it had been followed there for forty -years by "the Turks and others" (statements never confirmed but on inquiry -contradicted by those who knew), he proceeds to matters more within his -own competence. During these eight years past "thousands" of subjects have -been inoculated, and the value of the practice has now been put beyond all -suspicion and doubt. The practice is to take fluid smallpox matter from -the pustules of a discrete case of the natural disease, and convey it warm -in a stopped phial to the scene of inoculation. A few punctures with a -three-edged surgeon's needle are made in any of the fleshy parts (but -preferably over the muscles of the arm or forearm) until the blood comes; -a drop of the fluid matter of smallpox is then to be mixed with the blood, -and the inoculated part to be protected by a walnut shell bound over it. -The symptoms that follow are very slight, some being scarce sensible that -they are ill. The pocks that ensue are for the most part distinct, few, -and scattered; commonly ten or twenty break out; now and then the patient -may have only two or three; few have a hundred. The matter is hardly a -thick pus, as in the common sort, but a thinner kind of _sanies_. There -are some in whom no pustules appear except at the points of insertion, -where purulent tubercles arise; yet these have never had the smallpox -afterwards in their whole lives, though they have consorted with persons -having it. On one occasion fifty were inoculated together, and of these -four developed smallpox which was nearly confluent; but there was a -suspicion that they must have been already infected by contagion. Timoni -had never observed any mischievous accident from this incision hitherto; -reports of such had sometimes spread abroad among the vulgar, "yet having -gone on purpose to the houses whence such rumours have arisen I have found -the whole to be absolutely false." But, to keep nothing back, he will -mention two fatalities of children inoculated; both of them were cases of -hereditary _lues_ with marasmus, and it was about the fortieth day from -their inoculation that death ensued. The rest of Timoni's paper is printed -in the original Latin, being devoted to a theory of engrafting which -afterwards passed current:--one attack of smallpox secures from a second, -a mild attack serves as well as a severe, as also in the natural way, the -reason being that smallpox, in whatever degree, causes a fermentation of -the mass of the blood. - -A year after this, in 1715, there was published in London _An Essay on -External Remedies_, of which the 37th chapter was "Of the Variolae or -Small Pox, the manner of ingrafting or giving them, and of their Cure." -The author was Peter Kennedy, Chir. Med., a Scot of good but impoverished -family, who had spent several years in various parts of Europe visiting -the schools of medicine and surgery, and had found his way to -Constantinople[871]. His account of the engrafting of smallpox, which he -had seen or heard of there, differs somewhat from that of Timoni, whom he -just refers to: "Dr Timoni, a Grecian who resides there, had taken or -followed this same method with his two sisters a little before my arrival -at Constantinople." - -Kennedy says that engrafting the smallpox was practised in the -Peloponnesus or Morea, "and at this present time is very much used both in -Turkey and Persia, where they give it in order to prevent its more severe -effects by the early knowledge of its coming; as also probably to prevent -them being troubled with it a second time." In Persia, however, the -smallpox was taken internally in a dose of dried powder. In Constantinople -the matter was inserted at scarifications upon the forehead, wrists, and -ankles. After eight or ten days the smallpox came forward in a kindly -manner, and not nearly so numerous as if naturally taken. "The greatest -objection commonly proposed is, whether or not it hinders the patient from -being infected a second time. But, in answer to this, it is advanced that -we do rarely or never find any to have been troubled with this distemper -twice in the same manner or the same fulness of malignity"--i.e. we rarely -find this in the natural way. - -Kennedy's object was, not to recommend the engrafting of smallpox in -England, but to show how easily distempers or contagions, "as well as -medicines," may be communicated to the blood from the surface of the body: -"and this is more confirmed by some of the country people in Italy, in the -more remote parts from towns, so also in some parts of the highlands of -Scotland, where they infect their children by rubbing them with a kindly -pock, as they term it." - -Meanwhile Timoni's essay in the _Philosophical Transactions_ had stirred -up Sir Hans Sloane to make farther inquiries[872]. He applied to the -British consul at Smyrna, Dr Sherrard, who was fortunately able to get -information at first hand from an old Smyrna colleague, Dr Pylarini, -consul for Venice, who had practised inoculation at Constantinople in the -first years of the century. Pylarini, who had retired to Venice, was -induced to draw up an account of what he knew of the beginnings and -original methods of engrafting, which was printed at Venice, with a -dedication to Sherrard, in 1715, and at once copied into the -_Philosophical Transactions_[873]. This, the most trustworthy account of -the Constantinople practice, ignores the earlier essay of Timoni -altogether. - -Pylarini carries the authentic history of the practice at Constantinople -back to the year 1701. Its history before that was obscure; but it is most -certain, he says, that it began in Greece, more particularly in Thessaly, -and crept gradually from place to place until it reached Constantinople, -where it attracted little notice for several years, being rarely practised -and only among the lower class. A noble Greek having spoken of it to him -in 1701, with a view to the protection of his children from the epidemic -then raging, Pylarini had to confess his entire ignorance of it, but being -at the Greek's house four days after he there met a Greek woman who -expounded the practice clearly in detail and gave him many instances of -persons who had gone through it safely. Pylarini inquired into some of -these cases and found them to be genuine; but in that great city he could -not search them all out. Soon after this interview, the woman came and -operated on the four children of the rich Greek, of whom the three younger -had a very mild disease, but the eldest a severe attack, which nearly cost -her life. Many other rich Greek families followed suit, so that, says -Pylarini in 1715, "every one wishes to have the advantage of -transplantation." He adds, however, that "the Turks have hitherto -neglected it." He confirms Timoni in saying that the pocks raised by -transplantation were nearly always of the distinct kind and few in -number--ten to twenty or thirty, rarely a hundred, very rarely two -hundred,--although he does not reach Timoni's minimum of "two or three," -or the pustules only at the punctured spots. - -These accounts from Constantinople, printed in London in 1714, 1715 and -1716 were regarded, says Douglass, "as virtuoso amusements[874]" until the -spring of 1721, when inoculation began to be tried tentatively in London, -and in a bold and confident way during the very same weeks at Boston, New -England. - -Dr Pitcairn, of Edinburgh, had received an account of inoculation from -Bellini, an Italian physician, who had read Pylarini's essay. Douglass -says that Pitcairn "was very fond of it, but could not persuade himself to -venture it in practice[875]." Sometime in March, 1721, one 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 negroes are known also to have carried with them to the -West Indies the practice of "buying the yaws," which is also a contagious -and inoculable disease of the skin. The earliest medical notices of buying -the smallpox come from Poland in 1671 and 1677. A case having been -published in the _Miscellanea Curiosa_ of the Imperial German Academy, in -which a quartan ague was alleged to have been got rid of by transferring -it to a brute animal, Dr Vollgnad, of Warsaw wrote: "There is a similar -superstition not uncommon among our nurses, who instruct the children -under their charge to buy for a few farthings a certain number of pocks -from one infected with the smallpox, in the belief that those who purchase -that disagreeable commodity will be affected with a more scanty eruption -and will be the sooner freed from the disease and with the less -risk[885]." Six years after, Dr Simon Schultz, of Thorn, physician to the -king of Poland, wrote that the same practice of buying the smallpox -obtained also in that part of Poland: "What I have first to remark," he -says, "is that, in most cases if not in all, those infants that buy of the -infected (whether in their proper persons or through others), while they -may have few pocks, yet fall into a more serious illness than otherwise -(_gravius reliquis decumbant_): which I remember to have happened to my -younger brother Johannes, to say nothing of others[886]." - -These early references to buying the smallpox were made _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 negroes, and -admitted the deaths of six of them, probably by inhaled infection[912]. -But Douglass says: - - "The precise number of those who dyed by inoculation in Boston, I am - afraid will never be known because of the crowd of the sick and dead - whilst inoculation prevailed most, the inoculator and relations - inviolably keeping the secret.... Some porters who at that time were - employed to carry the dead to their graves say that it was whispered, - in sundry houses where the dead were carried from, that the person had - been inoculated. I could name some who are suspected, but having only - hearsay and conjectural evidence, I forbear to affront the surviving - relations. I myself am certain of one more who died 'after - inoculation' as they express it." - -He then gives the case, which was clearly one of the natural contagion of -smallpox acquired at the same time as the inoculation. In the Charleston -inoculations of 1738, which were also done in the midst of an epidemic, -there is little doubt that the fatalities were mostly from natural -smallpox which the inoculated infection had failed to anticipate or -prevent. The inoculators were often in that dilemma with their fatal -cases: either the inoculation had killed the patient or it had been -powerless to keep off the contagion; sometimes they confess the former as -an untoward accident, at other times they plead the latter, which appears -to me to have been the more usual of the two in a time of epidemic -smallpox[913]. - -Douglass, for all his bitterness against his rival Boylston, and his -severity against the extravagant assertions and loose reasoning of the -first inoculators, was far from denying the merits of inoculation, whether -in theory or in practice. "We may confidently pronounce," he says, "that -those who have had a genuine smallpox by inoculation never can have the -smallpox again in a natural way, both by reason and experience; but there -are some who have had the usual feverish symptoms, a discharge by their -incisions, with a few _imperfect_ eruptions, that may be obnoxious to the -smallpox,"--of which he gives instances. In like manner Nettleton, in -Yorkshire, who took pains to make his smallpox a real thing, and succeeded -in doing so as well as any inoculator ever did succeed, was persuaded that -inoculated smallpox counted for a natural attack. He admitted only one -failure, a case at Halifax which had been inoculated without an eruption -ensuing and took smallpox by contagion a month after. Failures in England, -in that sense, were fewer than the deaths directly from inoculation. The -deaths were freely admitted, but any alleged failure of inoculation to -ward off the natural smallpox was challenged, investigated, and denied, so -that Mead, writing in 1747, declared that he knew of none. There were, -however, a few cases recorded, which appear to be authentic. One of the -six charity children inoculated at the instance of the Princess of Wales -had taken natural smallpox twelve weeks after. The child of one Degrave, a -surgeon, had a similar experience. Another familiar case was the son of a -person of distinction, inoculated on 7 May, 1724, by the Rev. Mr Johnson. - - On the 14th a rash came out, on the 15th there was fever, on the 16th, - very little eruption to be seen and the fever gone, and on the 18th he - was pronounced "secure." On that day (18th May), his sister was - inoculated in the same place, both children remaining together at the - inoculator's house until the 2nd of June, when the boy went home. For - a day or two before the 8th of June the boy was ill, and on the 9th he - began to have smallpox in the natural way, of a good sort, the disease - keeping its natural course. He was supposed to have caught it from his - sister, who was inoculated after his own protection was over, and was - "very full of smallpox" until the 27th of May, her brother being with - her[914]. - -Another case of failure, which must have been known to some at the time, -was not published until some ten years after, when Deering brought it to -light[915]: - - "I was an eyewitness of the inoculation of a little boy, the child of - Dr Craft, who is now a sugar-baker in the Savoy. He was inoculated by - one Ahlers under the direction of Dr Steigerthal, the late king's - physician in ordinary; and notwithstanding the great care there was - taken in the choice of the pus, had the confluent kind severely; and - twelve months after had them naturally, and though a favourable sort, - yet was very full." - -A boy aged three, the son of Mr Richards, M.P. for Bridport, was -inoculated in 1743, and had fifty to sixty pocks which maturated and -scabbed. About two years after ("one year ago") he had smallpox again, the -pustules numbering from 200 to 300; when the eruption came out the fever -declined and did not return. These facts are given in a letter to Dr Dod -from Dr Brodrepp, grandfather of the child, who attended him on both -occasions[916]. - -Such cases were not often heard of. As Mead said, "If such a thing -happened once, why do we not see it come to pass oftener?" There was, -however, little encouragement for anyone to come forward with adverse -evidence; witness the case of an unfortunate Welshman, one Jones, of -Oswestry, who had innocently mentioned, in writing to his son in London, -that natural smallpox had followed an inoculation done by him, on 9th -August, 1723, and was frightened out of his wits by the _apparatus -criticus_ which Jurin brought to bear upon him[917]. Another reason why so -few failures could be discovered was that the inoculated were not kept -long in sight. A child of Dr Timoni, the first writer on inoculation, was -inoculated at Constantinople in December, 1717, at the age of six months, -and had an average effect, namely ten small _boutons_. She died of -smallpox in 1741, at the age of twenty-four. This failure came to light by -the vigilance of the celebrated De 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 -negroes, who had all been born in Africa (and commonly have smallpox there -or in the voyage across), it was not easy, he admits, to find out whether -they had had smallpox before or not, the pits on their faces being less -obvious than in whites, and the marks of other distempers easily mistaken -for them. On the whole Kilpatrick was confident that inoculation in this -epidemic had saved many lives; and it was the rumour of its success, -together with corresponding reports from the plantations in the West -Indies relating the valuable lives of negroes saved, that gave a fresh -impulse to the practice in England. In 1743 Kilpatrick came to London, -where he republished his Charleston essay, with an historical appendix, -and soon got into the leading practice as an inoculator, having proceeded -to the degree of M.D. and changed the spelling of his name to Kirkpatrick. -Woodville says "he was esteemed the most scientific inoculator in -London." During the eleven years from his setting up in practice there -until the publication of his _Analysis of Inoculation_ (1754), he had -almost certainly been applying the arm-to-arm method which he learned from -Mowbray in Charleston, having briefly indicated it in his first essay and -avowed it more explicitly in his second. The establishment of Kirkpatrick -in London, to practise the Charleston method of inoculation, corresponds, -as nearly as one can trace it, with the revival of the practice in the -south of England, to the extent of some two thousand cases in the counties -of Kent, Surrey, Sussex, Hampshire and Dorset. We have a glimpse of that -practice in the essay on inoculation published in 1749 by Dr Frewen, of -Rye in Sussex[923], a physician of considerable learning (of the school of -Boerhaave), whose theories of the effects of inoculation are reflected in -Kirkpatrick's _Analysis_ of 1754. In 350 cases, Frewen had only one -fatality, the death of a child, aged four, from worm fever on the eighth -day of a discrete eruption. He still used the incision on the arm, but -less deep than Nettleton's, keeping the pledget of lint, moistened with -matter, bound upon it for twenty-four hours; also he encouraged the -rendering from the incision for some weeks, giving the same reason as -before, that "Nature by means of a continual drain is greatly aided in her -attempts to throw off the matter of the disease." In his general account -of the effects of inoculation, we seem to be reading of as real symptoms -and as many pocks as Nettleton described--the eruption, always of the -simple distinct kind, beginning on the 9th day, all out in three or four -days after, the pocks filling and turning yellow for the next four or five -days, then scabbing and falling, leaving temporary shallow marks. But it -is clear that he had other results than these from trying new ways of -procuring matter. "Experience," he says, "has convinced me that it is in -reality of no consequence from what kind of smallpox it [the matter] is -procured." If taken from the natural smallpox, it should be taken from -ripe pustules: "yet I have sometimes applied it sooner, while only a -limpid water." Oftentimes it happened that an inoculation produced too -"slight" pustules to furnish matter for the succeeding operations. The -question then arose whether the matter rendering from the incisions on the -arms in these cases was merely common pus or whether it had the property -of "variolosity." This abstract quality, as it were the essence or -quiddity of the pustular exanthem, was assumed to be present if the pus of -the rendering incision could be made to raise a pustule on another arm, -and if the person so infected could stand exposure to natural smallpox -with impunity. One person so inoculated did have an attack of smallpox by -contagion, so that Frewen concluded that the matter used for his -protection had "run off all its variolosity." But others inoculated with -the same, "in whom the symptoms were remarkably light, and in some few no -pustules at all," were equally exposed to contagion without catching it, -so that they were "judged to be secure from ever taking the smallpox -again." Frewen's general conclusion, if it be not very logical, is at -least modest: - - "However, it may be worth the attention to reflect seriously whether - it be not highly probable, from the success attending the numbers I - have been concerned for, that inoculation has been often times a - security against taking the most dangerous kinds of the natural - smallpox." - -Whether Frewen got the ideas of these novelties of method from -Kirkpatrick's first account of the South Carolina practice, or struck them -out for himself, it is clear that Kirkpatrick, in his next essay of 1754, -has adopted variolosity as an abstract doctrine to surmount certain -difficulties in the concrete reason. Many of his inoculated cases had only -a few bastard pustules of smallpox, some had none. Was their disease -smallpox? Did it warrant their future security? - - "As many of the inoculated have very few pustules, and they are - sometimes disposed to scab and wither away with very little - suppuration, it might be of service to discover that the matter from - the incisions would infect. But it would be certainly satisfactory to - find it would where there was no eruption from inoculation, as its - variolosity would greatly warrant the future security of the person it - was taken from. That it is variolous is now evinced by the fact that - it infected others to the like slight degree[924]." - -The movement towards attenuating the virus used for inoculation was -general in Europe. One of the mild methods, invented by Tronchin, of -Amsterdam and afterwards of Paris, was to raise a small blister on the arm -and to pass through the fluid a thread moistened with smallpox matter. -This became one of the most common continental methods and was in use -until the beginning of the 19th century. Kirkpatrick, who went to see the -practice of Tronchin, found the method by blister to produce as slight -effects in the way of eruption as he describes for his own method: - - "I attended and infected five poor children:--three, about seven years - old, by incision; and two, about five years old, by vesication. Of the - first three, one, a girl, had a pretty moderate but very kindly - sprinkling; the two boys very few. The two by blisters, a boy and a - girl, had rather less,--the boy Dudin, a very fair delicate little - child, not having above three or four, all which had not matter enough - to infect one patient[925]." - -Everywhere after the middle of the eighteenth century inoculation was -coming into fashion again. In France it was lauded by the _philosophes_, -while it was scouted by the medical faculty. La Condamine, a mathematician -who had acquired fame by his journey to the Amazon to measure the three -first degrees of the meridian, became interested in the subject by hearing -from a credulous Carmelite missionary at Para how he had saved half of his -Indian converts by inoculation after the other half had been destroyed by -the natural smallpox. The mathematical philosopher on his return became an -enthusiast for inoculation, and twice harangued the 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 negroes[980]. Watson, -with the epidemics in the Foundling fresh in his memory, estimated that -inoculation might have saved 23,000 out of the 23,308 who had died of -smallpox in London in ten years, 1758-68[981]. Haygarth[982] reckoned that -351 might have been saved by inoculation of the 378 children who died of -smallpox at Chester from 1772 to 1777. Woodville, who wrote the history of -inoculation down to the advent of Sutton, declared in 1796 that the art of -inoculation, originally a fortuitous discovery, "is capable of saving more -lives than the whole _materia medica_[983]." Arnot, the historian of -Edinburgh (1779), asserted inoculation to be "a remedy so compleat that we -hesitate not in the least to pronounce those parents, who will not -inoculate their children for the smallpox, accessory to their death[984]." -The College of Physicians, in a formal minute of 1754, pronounced it -"highly salutary to the human race." - -Despite all those academic pronouncements, inoculation was somehow not a -practical success. It cannot be maintained that it failed because the -people were averse to it; for it continued to be in popular request far -into the 19th century, until it was at length suppressed by statute. For -the present we may return to the proper subject of epidemic smallpox, -premising, on the ground of what has been said, that inoculation made but -little difference to the epidemiological history. - - -The Epidemiology continued from 1721. - -The ordinary course of smallpox in Britain was little touched by -inoculation. The inoculators were like the fly upon the wheel, with the -important difference that they did indeed raise the dust. The writers who -kept up the old Hippocratic or Sydenhamian habit of recording the -prevalent maladies of successive seasons, such as Huxham, Hillary[985], -and Barker, of Coleshill, while they dealt with epidemics impartially and -comprehensively, were as if by a common instinct adverse to the fuss made -about inoculation. Says Barker, in an essay against inoculation during the -Suttonian enthusiasm, "It is undoubtedly a great error that the smallpox -is now considered the only bugbear in the whole list of diseases, which, -if people can get but over, they think they are safe." This hits fairly -enough the disproportionate share given to inoculation in the medical -writings of the time, while it is made more pointed by the author's -suggestions for a scientific study of the conditions of smallpox -itself[986]. It is still possible, with much trouble, to bring together -the data for a scientific handling of the disease in the 18th century, -thanks most of all to the exact school of observers or statisticians which -began with Percival, of Manchester, and was continued to the end of the -century by Haygarth, Heysham, Ferriar, Aikin and others. The best of the -original English inoculators, Nettleton of Halifax, has also left a large -number of interesting statistics relating to epidemics in Yorkshire and -other northern counties in the years 1721-23; also, upon his suggestion, -the figures were procured from many more smallpox epidemics in other parts -of England down to 1727. It will be convenient to resume the history with -these, as they come next in order after the London epidemic of 1720, at -which point the interlude of inoculation came in. The following is a -complete table of the figures collected from various sources: it will be -observed that most parts of England are represented, the fullest -representation being of the northern counties. - -_Censuses of Smallpox Epidemics in England, 1721-30._ - - Percentage - Locality of the Deaths of - Epidemic Period Authority Cases Fatalities - - Halifax[987] winter of 1721 Nettleton, 276 43 15.9 - to April 1722 _Phil. Trans._ - XXXII. 51 - Rochdale[988] " " 177 38 21.4 - Leeds[989] " " 792 189 23.8 - Halifax parish 1722 _Ibid._ p. 221 297 59 19.9 - towards Bradford - Halifax parish, " " 268 28 10.4 - another part - Bradford " " 129 36 27.9 - Wakefield " " 418 57 13.6 - Ashton under Lyne[990] " " 279 56 20.0 - Macclesfield " " 302 37 12.2 - Stockport " " 287 73 25.4 - Hatherfield " " 180 20 11.1 - Chichester[991] 1722 Whitaker, 994 168 16.9 - (to 15 Oct.) _Ibid._ p. 223 - Haverfordwest 1722 Perrot Williams, 227 52 22.9 - _Ibid._ - Barstand, Ripponden, " Nettleton, in 230 38 16.5 - Sorby, and part of Jurin's _Acct._ - Halifax parish for 1723, p. 7 - 4 miles from the - town - Bolton 1723? Jurin's _Acct._ 406 89 21.6 - for 1723, p. 8 - Ware " " 612 72 11.7 - Salisbury " " 1244 165 13.2 - Rumsey, Hants " " 913 143 15.6 - Havant " " 264 61 23.1 - Bedford " " 786 147 18.4 - Shaftesbury 1724? _Ibid._ for 660 100 15.1 - 1724, p. 12 - Dedham, near " " 339 106 31.3 - Colchester - Plymouth " " 188 32 17.2 - Aynho, near 27 Sept. 1723 Rev. Mr Wasse, 133 25 18.8 - Banbury to 29 Dec. 1724 rector, _Ibid._ - for 1725, p. 55 - Stratford on Avon " Dr Letherland, 562 89 15.8 - _Ibid._ - Bolton le Moors " Dr Dixon, _Ibid._ 341 64 18.8 - Cobham " Sir Hans Sloane, 105 20 19.0 - _Ibid._ - Dover 29 Sept. 1725 Dr Lynch of 503 61 12.1 - to 25 Dec. 1726 Canterbury, in - Jurin's _Acct._ - for 1726, p. 17 - Deal 25 Dec. 1725 " 362 33 9.1 - to 29 Nov. 1726 - Kemsey, " Dr Beard, in 73 15 20.5 - near Jurin, _Ibid._ - Worcester - Uxbridge[992] 1727 Dr Thorold, in 140 51 36.4 - Scheuchzer's - _Acct._ for - 1727 and 1728 - Hastings 1729-30 Dr Frewen, 705 97 13.7 - _Phil. Trans._ - XXXVII. 108 - -The years 1722 and 1723, to which most of these epidemics belong, were one -of the greater smallpox periods in England. In Short's abstracts of the -parish registers those years stand out very prominently by reason of the -excess of deaths over births in a large proportion of country parishes -(see above, p. 66); and, according to Wintringham's annals, it was not -fever that made them fatal years, but smallpox, along with autumnal -dysenteries and diarrhoeas. Of one epidemic centre in the winter of -1721-22, which is not in the table, the district of Hertford, we obtain a -glimpse from Maitland, who repaired thither from London to practise -inoculation. - - "I own that it seem'd probable that the six persons in Mr Batt's - family might have catched the smallpox of the girl that was - inoculated; but it is well-known that the smallpox were rife, not only - at Hertford but in several villages round it, many months before any - person was inoculated there: witness Mr Dobb's house in Christ's - Hospital buildings, where he himself died of the worst sort with - purples, and his children had it; some other families there, and - particularly Mr Moss's, (where the above-named Elizabeth Harrison, - inoculated in Newgate, attended several persons under it to prove - whether she would catch the distemper by infection); both Latin - boarding-schools, Mr Stout's and Mr Lloyd's families, Mr John - Dimsdale's coachman and his wife, and Mr Santoon's maid-servant, who - was brought to the same house and died of the confluent kind of the - smallpox[993]." - -Here we have the same indication of adults attacked as well as children, -which we find in Dover's practice in London in 1720 and in all the 17th -century and early 18th century references to smallpox. The most detailed -account is that given for the epidemic of 1724-25 at Plymouth by Huxham, -who was not an inoculator but purely an epidemiologist and practitioner in -the old manner. - - The epidemic was a very severe one and of an anomalous type. Adults, - according to his particular references and his general statement, must - have been freely attacked. The major part of the adult cases, he says, - proved fatal, including one of an old gentlewoman of 72,--"a very - uncommon exit for a person of her years"! When the disease raged most - severely, some children had it very favourably and required no other - physic than to be purged at the end of the attack. The pustules were - apt to be small and to remain unfilled. In some there were miliary - vesicles, dark red or filled with limpid serum, in the interstices - between the smallpox pustules. Some had abundance of purple petechiae - among the pocks, the latter also being livid. Only one person survived - of all who had that haemorrhagic type. Swelling of the face and throat - was also seldom recovered from; in such cases that did well, the - maxillary and parotid glands would remain swollen for some time. "It - was a remarkable instance of the extraordinary virulence of these - smallpox that the women (tho' they had had the smallpox before and - some very severely too) who constantly attended those ill of the - confluent kind, whether children or grown persons, had generally - several pustules broke out on their face, hands and breast.... I knew - one woman that had more than forty on one side of her face and breast, - the child she attended frequently leaning on those parts on that - side." - - Huxham appears to have adopted the whole Sydenhamian practice of - blooding, blistering, purging, and salivating. For the last he used - calomel: "Two adults and some children in the confluent sort never - salivated. Some very young children drivelled exceedingly through the - course of the distemper. A diarrhoea very seldom happened to - children[994]." - -Corresponding very nearly in time to Huxham's malignant and anomalous -constitution of smallpox at Plymouth, and agreeing exactly with his -generalities as to children and adults, there is an interesting table of -the ages and fatalities of those who were attacked at Aynho, in -Northamptonshire, six miles from Banbury. It was then a small market town, -and its smallpox for some fifteen months of 1723-24, as recorded by the -rector of the parish, may be taken as a fair instance of what happened at -intervals (usually long ones) in the rural districts in the earlier years -of the 18th century[995]: - - above - Ages 0-1 -2 -3 -4 -5 -10 -15 -20 -25 -30 -40 -50 -60 -70 70 Total - - Cases 0 0 3 4 6 15 33 14 16 9 12 10 4 4 2 132 - Deaths 0 0 2 1 0 1 3 1 3 3 3 4 1 2 1 25 - -The small fatality of the disease between the ages of five years and -twenty is according to the experience of all times. But the considerable -proportion of attacks at the higher ages would hardly have been found -anywhere in England, not even in a country parish, a generation or two -later, although it is consistent with all that is known of smallpox in the -17th century and in the first years of the 18th[996]. - -Another glimpse of a prolonged smallpox epidemic of the same period in a -town is given in Frewen's census of Hastings, with a population of 1636 -(males 782, females 854). The disease was prevalent for about a year and a -half, and had ceased previous to 28 January, 1732[997]. The table accounts -for the whole population: - - The number of those that recovered of the smallpox - (including four that were inoculated) 608 - Died of it 97 - Escaped it 206 - Died of other diseases since the smallpox raged there 50 - The whole number of inhabitants in that town are 1636 - -Leaving out the fifty who died of other diseases as persons who may or may -not have had smallpox, it appears that 725 of the inhabitants of Hastings -had been through the smallpox in previous epidemics, that 705 were -attacked in this epidemic, and that 206 had hitherto escaped, some of them -to be attacked, doubtless, in the future. The proportion of attacks above -the age of childhood in the epidemic of 1730-31 would have depended on the -length of time since the last great epidemic; the interval was probably a -long one, by the large number of susceptible persons in the town, just as -at Boston, Massachusetts, in 1721 and 1752, and at Charleston, Carolina, -in 1738[998]; and, as the fact is known for these places, so it is -probable that the epidemic at Hastings had included many adolescents and -adults. - -On the other hand, where smallpox came in epidemics at short intervals, or -where it was always present, the incidence, even in the first half of the -18th century, was much more exclusively upon childhood. Thus at Nottingham -there was always some smallpox, with a great outburst perhaps once in five -years. The year 1736 was one of those fatal periods of smallpox, the -victims being "mostly children." From the end of May to the beginning of -September, great numbers were swept away; the burials in St Mary's -churchyard were 104 in May; the burials from all causes for the whole year -exceeded the baptisms by 380; there had been no such mortality since -thirty years. Such excessive incidence of smallpox upon the earliest years -of life happened in places where the infant mortality was high from all -causes. Nottingham was one of those places. Leaving out the great smallpox -year, 1736, the other seven years of the period 1732-39 had a total of -2590 baptisms to 2226 burials, of which burials no fewer than 1072 were of -"infants," meaning probably children under five years, although the work -of Harris on the Acute Diseases of Infants, which was current at that -time, defines the infantine age as under four years[999]. - -The years of distress and typhus fever in England, Scotland, and Ireland -from 1740 to 1742 were another great period of smallpox epidemics -throughout the country. The mortality from that cause is known to have -been excessive in Norwich, Blandford, Edinburgh and Kilmarnock, which may -be taken as samples of a larger number of epidemics in the same years. The -association of much smallpox of a fatal type with much typhus fever, which -can be traced in the London bills from an early period, is at length seen -to be the rule for the country at large. After 1740-42, the next instances -of it were in 1756 and 1766: it is most definitely indicated again in -1798-1800, very clearly in 1817-19, and in 1837-39. In all the later -instances smallpox was the peculiar scourge of the infants and children in -times of distress, while the contagious fever was as distinctively fatal -to the higher ages. There is some reason to think that the law of -incidence was the same in populous cities in 1740-42. - -Thus at Edinburgh there died in the two worst years of the distress -(population in 1732 estimated at 32,000)[1000]: - -_Edinburgh Mortalities._ - - 1740 1741 - - Under two years 439 562 - From two to five 198 269 - From five to ten 53 93 - Above ten 547 687 - ---- ---- - 1237 1611 - - Fever 161 304 - Flux 3 36 - Consumption 278 349 - Aged 102 156 - Suddenly 56 62 - {Smallpox 274 206 - {Measles 100 112 - {Chincough 26 101 - {Convulsions 22 16 - {Teething 111 141 - {Stillborn 29 50 - Other diseases 77 78 - -More than half the deaths were under five years, and among those deaths it -will be necessary to include most of the smallpox mortality. That disease -in the two exceptional years made 17 per cent. of all deaths, or one in -six. But in its somewhat steady prevalence among children in Edinburgh -from year to year, smallpox accounted for one death in about ten, as in -the following[1001]: - -_Deaths by Smallpox and all causes in Edinburgh, including St Cuthbert's -parish, 1744-63._ - - All Dead of - Year Burials Smallpox - - 1744 1345 167 - 1745 1463 141 - 1746 1712 128 - 1747 1200 71 - 1748 1286 167 - 1749 1132 192 - 1750 1038 64 - 1751 1241 109 - 1752 1187 147 - 1753 1105 70 - ----- ---- - 12709 1256 - or 1 in 9.6 - - 1754 1215 104 - 1755 1187 89 - 1756 1316 126 - 1757 1267 113 - 1758 1001 52 - 1759 1136 232 - 1760 1123 66 - 1761 903 6 - 1762 1305 274 - 1763 1160 123 - ----- ---- - 11613 1185 - or 1 in 9.8 - -As in other epidemics, it was not until its second year that the smallpox -reached Norwich. The mortality had been enormous in 1741, owing to the -distress and the fever, 1456 burials to 851 baptisms; but in 1742 the -burials were 1953 (to 825 baptisms), the excess over the previous year -being ascribed, in general terms, to the smallpox[1002]. It is probable -that the enormous excess of burials over baptisms at Newcastle in 1741 was -due in great part to the same disease among the children; but the -statistics do not show it. - -Northampton is an instance of a town with very moderate mortality for the -18th century; for that and other reasons its bills were used by Price as -the basis of a table of the expectation of life. It had certainly shared -in the fever epidemic of 1741 and 1742, for in the latter of those years -the annual bill shows the very high fever-mortality of 37 in 130 deaths -from all causes in All Saints' parish, which had fully one-half of the -population. But in that year there are no smallpox deaths recorded, and -only nine in the next four years. The great periodic outburst of smallpox -came in 1747[1003]: - -_Smallpox in Northampton, 1747._ - - Percentage - Parish Cases Deaths of Fatalities - - All Saints 485 76 15.6 - St Sepulchre 175 21 12.0 - St Giles 131 23 17.5 - St Peter 30 6 20.0 - ----- ---- ---- - 821 126 15.3 or 1 in 6.5 - -Of the 76 deaths in All Saints' parish only 58 were buried there. The -deaths from all causes in that parish were 189, of which 103, or 54 per -cent., were under five years of age, and 10 between five and ten years. -Next year, when things had improved much, although the mortality was still -high, All Saints' parish had 119 burials, of which 47, or 40 per cent., -were under five years, and 4 from five to ten, only three of the deaths -being from smallpox. Only a few smallpox deaths appear in the bills of All -Saints' parish until 1756 and 1757, when an epidemic occurred, part of it -in each year, which produced in that greatest of the four parishes 85 -burials, or half as many again as in the epidemic of ten years before. It -is singular that the deaths under and over five are in a very different -ratio in the two successive years of the epidemic: - -_All Saints' Parish, Northampton._ - - 1756 1757 - - All deaths 140 135 - Smallpox deaths 31 54 - All deaths under 2 54 24 - " " 2-5 12 18 - " " 5-10 7 21 - " " 10-20 5 6 - " " 20-30 13 18 - " " 30-40 7 12 - " " 40-50 4 5 - " " above 50 38 31 - -This looks as if a good many more had died of smallpox at the higher ages -in the second year of its prevalence than in the first; but the great -difference between the deaths under two in 1756 and 1757 is explained -chiefly by the article "convulsions," which is 28 in the former year and -only 10 in the latter. - -In Boston, Lincolnshire, a town almost as healthy as Northampton, the -intervals between epidemics of smallpox were almost as long, and the -effect in raising the mortality for the year nearly the same. The -population in the last year but one of the table was 3470. The deaths -averaged 104 in a year, the smallpox deaths 9.45, or one in eleven[1004]. - -_Smallpox in Boston, Lincolnshire, 1749-68._ - - Died by - Year Baptised Buried Smallpox - - 1749 68 120 48 - 1750 80 93 -- - 1751 55 59 -- - 1752 88 85 -- - 1753 79 73 -- - 1754 88 111 1 - 1755 74 102 19 - 1756 66 110 34 - 1757 93 86 4 - 1758 83 88 4 - 1759 102 91 -- - 1760 106 84 2 - 1761 80 94 -- - 1762 95 134 3 - 1763 92 206 69 - 1764 130 102 5 - 1765 112 113 -- - 1766 144 117 -- - 1767 129 95 -- - 1768 131 117 -- - -This was a favourable instance of urban smallpox in the 18th century, -Boston having "no circumstances of narrow streets, crowded houses, -manufactories or want of medical assistance." We may compare with it an -industrial town only a little larger, the weaving town of Kilmarnock, -Ayrshire, the smallpox epidemics of which came as follows[1005]: - -_Smallpox in Kilmarnock, 1728-63._ - - Died by - Year Baptised Buried Smallpox - - 1728 111 162 66 - 1729 -- -- -- - 1730 -- -- -- - 1731 -- -- -- - 1732 -- -- -- - 1733 -- -- 45 - 1734 -- -- -- - 1735 -- -- -- - 1736 135 147 66 - 1737 -- -- -- - 1738 -- -- -- - 1739 -- -- -- - 1740 95 164 66 - 1741 -- -- -- - 1742 -- -- -- - 1743 -- -- -- - 1744 -- -- -- - 1745 116 102 74 - 1746 -- -- 8 - 1747 -- -- -- - 1748 -- -- 2 - 1749 134 149 79 - 1750 -- -- 5 - 1751 -- -- 1 - 1752 -- -- -- - 1753 -- -- 1 - 1754 146 203 95 - 1755 -- -- -- - 1756 -- -- -- - 1757 125 132 37 - 1758 -- -- 9 - 1759 -- -- -- - 1760 -- -- -- - 1761 -- -- -- - 1762 132 173 66 - 1763 -- -- 2 - -Although Kilmarnock had an average annual excess of baptisms over burials -(134 to 107), which was more than that of Boston, its smallpox mortality -was higher than that of the Lincolnshire market town. On an annual -average, one death in eleven from all causes was by smallpox at Boston, -one in six at Kilmarnock. In the former the epidemics came at intervals of -about five years, in the latter at intervals of three or four. The oftener -the epidemic came, the earlier in life it attacked children; and in all -subsequent experience it has been found that smallpox is far more mortal -to the ages below five than to the ages from five to ten or fifteen. More -generally, the conditions were worse for young children in a weaving town -than in a market town of nearly the same size. In the populous weaving -parish of Dunse, 130 children are said to have died of smallpox in 1733, -during a space of three months[1006]. - -The ages at which deaths from smallpox occurred in Kilmarnock from 1728 to -1763 are strikingly different from those already given for the small -market town or village of Aynho, near Banbury, in 1723-24; at the latter -the greater part of the fatalities, although not of the attacks, happened -to persons between twenty and fifty; at the former nine-tenths of the -deaths were of infants and young children, as in the following: - -_Ages at Death from Smallpox, Kilmarnock, 1728-63._ - - Deaths - at all Under One to Two to Three to Four to Five to Above Age not - ages One Two Three Four Five Six Six stated - - 622 118 146 136 101 62 23 27 9 - -This almost exclusive incidence of fatal smallpox upon infants and young -children in a weaving town during the middle third of the 18th century we -shall find abundantly confirmed for English manufacturing and other -populous towns in the last third of the 18th century, and thereafter until -the middle of the 19th century. On the other hand, the less populous towns -and the country districts continued in the 18th century to furnish a fair -share of adult cases, for the reason that epidemics came to them at longer -intervals, wherein many had passed from infancy to childhood, and even -from childhood to youth or maturity, without once encountering the risk of -epidemic contagion. - -Of such less populous places we have an instance in Blandford, Dorset. -Particulars of its smallpox have been given in connexion with general -inoculations; here let us note that in this typical market town of 2110 -inhabitants (in 1773), the known epidemics were in 1731, 1741, 1753 and -1766--at intervals of ten or a dozen years. In the villages the intervals -were longer. Haygarth gives the instance of three parishes in Kent with -only ten deaths from smallpox in twenty years, and of Seaford, in Sussex, -with one death "eleven years ago[1007]." An authentic instance is the -parish of Ackworth, Yorkshire, whose register of burials contains only one -smallpox death in the ten years 1747-57, while there are thirteen such -deaths in it in the next ten-years period, clearly the effects of an -epidemic, perhaps in 1766[1008]. This parish, judged by the excess of -births, was not so healthy as many[1009], while its mortality by "fevers" -was considerable. The following somewhat general statements are made for -the parish of Kirkmaiden, Wigtonshire[1010]: - - 1717. "Nearly thirty-seven died of the smallpox." - 1721. Forty-eight died, "mostly of fevers." - 1725. Forty-three died, "mostly of the smallpox." - -By means of this law of periodic return, at short intervals in the -populous industrial towns, at longer intervals in the market towns, and at -very long intervals in the villages, we may realize in a measure what -smallpox was at its worst. It was the great infective scourge of infancy -and childhood, admitting but few or feeble rivals or competitors, as we -shall see in the historical accounts of measles, whooping-cough and -scarlatina. The table of epidemics from 1721 to 1727, given at p. 518, is -of a kind that might have been furnished by any series of years in the -18th century; they were so much of a commonplace that hardly anyone -thought of chronicling them unless for a special statistical purpose, such -as the inoculation controversy. Thus, the Salisbury epidemic of 1723, with -1244 cases and 165 deaths, must have been only one of a series at -intervals, which may or may not have become more frequent, or of -different age-incidence, or of more fatal type, as the century proceeded. -We have a glimpse of one of them in 1752-3. Lord Folkestone having given a -hundred pounds to the poor of Salisbury, it was ordered on 15 December, -1752, "that five shillings be given to every inhabitant who hath had the -smallpox in the natural way since 1 September, or that shall have it -hereafter." The epidemic went on for months; it was not until the end of -1753 that the mayor advertised the city free of smallpox. In September of -that year ten guineas were voted to Mr Hall, the apothecary, for his -trouble during the smallpox, and a like sum to Mr Dennis, the -surgeon[1011]. - -The year 1753 was also the time of one of the periodical Blandford -outbreaks. For a year or two before there had been much smallpox at -Plymouth, the account of which by Huxham will serve as a sample of his -numerous references to the disease there from the beginning of his annals -in 1728. - - In May, 1751, smallpox was brought in by Conway's regiment; it spread - in July and August, becoming worse in type in the autumn as it became - more common. In January 1752 it was still prevalent, the pustules - often crude, crystalline, undigested to the end; sometimes very - confluent, small and sessile; sometimes black and bloody, attended now - and then with petechiae. In March the type grew more mild; in April - the malady was still up and down, some cases being of a bad sort. It - became more frequent again in June, and was epidemic all the summer, - the eruption often confluent, small, sometimes black, with - haemorrhages from the nose, especially in children. In August it was - epidemic everywhere, and more fatal, becoming milder in September and - October. In December, "the crusts of the black confluent kind many - times remained for at least thirty days after the eruption." It - declined from January, 1753, and entirely ceased in May, having had a - prevalence of two years[1012]. - - -Smallpox in London in the middle of the 18th century. - -There is hardly any epidemic malady in London of which so few particular -records remain as of smallpox, except in the bills of mortality. The -monthly notes in the _Gentleman's Magazine_ from 1751 to 1755 by Dr -Fothergill, who practised at that time in White Hart Court, Lombard Street -(having afterwards removed westward to Harpur Street, Red Lion Square), -contain the following references to it: - - 1751, May. Smallpox uncommonly mild in general, few dying of it in - comparison of what happens in most years. - - 1751, December. Smallpox began to make their appearance more - frequently than they had done of late, and became epidemical in this - month. They were in general of a benign kind, tolerably distinct, - though often very numerous. Many had them so favourably as to require - very little medical assistance, and perhaps a greater number have got - through them safely than has of late years been known. - - 1752, January. A distinct benign kind of smallpox continued to be the - epidemic of this month.... A few confluent cases, but rarely. - February--Children and young persons, unless the constitution is very - unfavourable, get through it very well, and the height to which the - weekly bills are swelled ought to be considered in the present case as - an argument of the frequency, not fatality, of this distemper. - - 1752, April. Smallpox continued to be the principal epidemic, as in - the preceding months; during which time it attacked most of those who - had not hitherto had the distemper, and it is now spread into the - suburbs and the neighbouring villages, but still in a favourable way - in general. Some have the confluent, a few the bleeding kind, but - these are not very common. - - 1752, June. Smallpox still continues, not many escaping who have not - had it before. - - 1752, July. Smallpox inclined to become malignant, but the - constitution on the whole remarkably mild. Children from one to three - years old have, I believe, suffered more from the distemper during - this constitution than those of any other ages; at least it has so - fallen out under the writer's observation. - - 1753, December. Smallpox of a bad type. - - 1754, August. Smallpox frequent in many parts of the City, and eastern - suburbs especially. In general the kind was mild, distinct and - favourable. Out of sixteen who had the disease in a certain district, - of different ages, one only died. In some it was very virulent, with - livid petechiae. - - 1754, December. Smallpox not unfrequent. Many had the worst kind seen - for years. - - 1755, January. Smallpox more favourable. - -Fothergill, who pointed out the defects of the London bills of mortality -and made a serious attempt to get them reformed[1013], was disposed to -take their figures of smallpox deaths as on the whole trustworthy: "The -smallpox, of all diseases mentioned in the weekly bills, is perhaps the -only one of which we have any tolerably exact account, it being a disease -which the most ignorant cannot easily mistake for another." Reserving this -opinion for some critical remarks in the sequel, we may now resume the -London statistics from the year last given. - -_Smallpox Mortality in London, 1721-60._ - - Deaths Deaths - from from - Year smallpox all causes - - 1721 2,375 26,142 - 1722 2,167 25,750 - 1723 3,271 29,197 - 1724 1,227 25,952 - 1725 3,188 25,523 - 1726 1,569 29,647 - 1727 2,379 28,418 - 1728 2,105 27,810 - 1729 2,849 29,722 - 1730 1,914 26,761 - 1731 2,640 25,262 - 1732 1,197 23,358 - 1733 1,370 29,233 - 1734 2,688 26,062 - 1735 1,594 23,538 - 1736 3,014 27,581 - 1737 2,084 27,823 - 1738 1,590 25,825 - 1739 1,690 25,432 - 1740 2,725 30,811 - 1741 1,977 32,169 - 1742 1,429 27,483 - 1743 2,029 25,200 - 1744 1,633 20,606 - 1745 1,206 21,296 - 1746 3,236 28,157 - 1747 1,380 25,494 - 1748 1,789 23,069 - 1749 2,625 25,516 - 1750 1,229 23,727 - 1751 998 21,028 - 1752 3,538 20,485 - 1753 774 19,276 - 1754 2,359 22,696 - 1755 1,988 21,917 - 1756 1,608 20,872 - 1757 3,296 21,313 - 1758 1,273 17,576 - 1759 2,596 19,604 - 1760 2,181 19,830 - -The year 1752, to which Fothergill refers most fully in the notes cited, -had the highest total of deaths from smallpox in the period 1721-60, -namely, 3538, and was exceeded by only two years in the latter part of the -century, 1772, with 3992 deaths and 1796 with 3548. Fothergill says twice -that the disease in 1752 was on the whole mild, but so universal that not -many escaped it who had not had it before; and that children from one to -three years suffered most from it. As the year was not an unhealthy one -in general, this epidemic of smallpox may be chosen to show its effect -upon the weekly mortalities, of children in particular. - -_London Weekly Mortalities: Smallpox Epidemic of 1752._ - - Under Two Five Convulsions - Week All two to to Smallpox deaths - Ending deaths years five ten deaths - - March 3 438 162 54 19 64 113 - 10 441 165 40 16 63 116 - 17 477 177 56 15 76 110 - 24 456 161 61 19 87 111 - 31 471 169 62 8 96 117 - April 7 500 185 58 14 87 129 - 14 431 144 52 27 76 99 - 21 397 145 37 18 77 106 - 28 458 161 47 25 94 98 - May 5 421 133 52 17 81 85 - 12 414 140 62 24 93 101 - 19 461 235 52 20 119 104 - 26 456 157 66 24 120 92 - June 2 452 159 65 28 125 98 - 9 415 172 51 17 113 87 - 16 421 165 56 20 120 98 - 23 380 160 57 15 102 82 - 30 353 127 52 19 92 74 - July 7 390 142 68 19 107 87 - 14 339 142 44 12 79 98 - 21 351 144 38 23 73 97 - 28 368 168 53 14 92 93 - Aug. 4 316 141 37 13 72 90 - 11 350 155 44 13 58 99 - 18 297 145 26 9 43 98 - 25 371 168 46 12 57 109 - -The weeks with highest smallpox mortalities have not always the highest -deaths from all causes; but they correspond to a marked rise of the deaths -from two to five years. If the table were continued to the end of the -year, to show the decline of smallpox to a fourth or fifth of its highest -weekly figures, the decline in the deaths from two to five, as well as -from five to ten, would be seen to correspond more strikingly[1014]. The -other notable suggestion of the figures is that the article "convulsions," -which included at that time nearly the whole of infantile diarrhoea, is -not so high as usual when the article smallpox rises most. The highest -weekly deaths from convulsions are in the first months of the year, when -the smallpox epidemic was beginning, and in September and October, the -season of infantile diarrhoea, when the smallpox epidemic was nearly -spent. - -The ages at which persons died in the several diseases were not given in -the Bills, although they were recorded in the books of Parish Clerks' -Hall; so that the incidence of smallpox mortality upon infants and young -children cannot be proved for the capital as it can for other great towns -in the 18th century. Not only can it not be proved, but it was not the -fact that the disease was so exclusively an affair of childhood as it was -in the populous provincial centres. The London population was peculiar in -receiving a constant recruit direct from the country. Many of them came -from parishes where, as Lettsom says, "the smallpox seldom appears"; they -must often have passed their childhood without meeting with it, to -encounter the risk when they came to London[1015]. Many of the class of -domestic servants were in that position; and it was especially for them -that the London Smallpox Hospital existed, the admission to it being by -subscribers' letters, as in the voluntarily supported hospitals at -present. - -Its small accommodation was given up to some extent also to persons in -exceptionally distressed circumstances[1016]. From its opening on 26 -September, 1746, to 24 March, 1759, it had admitted 3946 cases, of which -1030 had died; these are stated in the annual reports to have been "mostly -adults, in many cases admitted after great irregularities and when there -was little hope of a cure"; so that the practice of this hospital alone -may be taken as evidence of several hundreds of adult cases of smallpox in -the year in London (the whole annual cases averaging perhaps twelve -thousand). - -The exact statistics which we shall come to in a later period of the -century, for Manchester, Chester, Warrington and Carlisle, show that -nearly all the deaths by smallpox were under five years; and it can -hardly be doubted that the bulk of them in London also, with all its -influx of country people, were at the same age-period. "Most born in -London," said Lettsom, "have smallpox before they are seven." It is -singular, therefore, that smallpox should have caused a much smaller -proportion of the deaths from all causes in London than in the populous -provincial cities. The annual average for London was one smallpox death to -about ten or twelve other deaths; in other large towns it was one in about -six or seven. Lettsom held that the proportion in London would have come -out nearly the same if the classification of deaths in the London bills -had been correct, the generic article "convulsions" having swallowed up, -in his opinion, a large number of the smallpox deaths of infants. An -assertion such as that is more easily made than refuted. Everyone agreed -that there was no difficulty in recognising smallpox[1017]. Whoever had -seen confluent smallpox all over an infant's body was not likely to have -set down its death under any other name, for there is hardly anything more -distinctive or more loathsome. It is possible, however, that many infants -with mild smallpox had died of complications, such as autumnal diarrhoea. -Sydenham, indeed, says as much under the year 1667, blaming the nurses for -killing the infants by trying to check the diarrhoea. The truly incredible -sacrifice of infant life in London in the 17th and 18th centuries by -summer diarrhoea, as shown in another chapter, may have caused a certain -number of deaths of infants to be classed under "griping in the guts" in -the earlier period, and under "convulsions" in the later, which were -primarily cases of smallpox. But the true probability of the matter--and -it is wholly for us a question of probability--is that London's smaller -ratio of smallpox deaths and greater ratio of infantile deaths from other -causes, was not artificially made by transferring deaths from the one to -the other, but was actual, owing to a really greater liability of the -London infants to die of other more or less nondescript maladies before -smallpox could catch them[1018]. - - -The Epidemiology continued to the end of the 18th century. - -The London bills, which are the only continuous series of figures, show -the following annual mortalities by smallpox from 1761 to the end of the -century: - -_Smallpox Mortality in London, 1761-1800._ - - Smallpox All - Year deaths deaths - - 1761 1,525 21,063 - 1762 2,743 26,326 - 1763 3,582 26,148 - 1764 2,382 23,202 - 1765 2,498 23,230 - 1766 2,334 23,911 - 1767 2,188 22,612 - 1768 3,028 23,639 - 1769 1,968 21,847 - 1770 1,986 22,434 - 1771 1,660 21,780 - 1772 3,992 26,053 - 1773 1,039 21,656 - 1774 2,479 20,884 - 1775 2,669 20,514 - 1776 1,728 19,048 - 1777 2,567 23,334 - 1778 1,425 20,399 - 1779 2,493 20,420 - 1780 871 20,517 - 1781 3,500 20,709 - 1782 636 17,918 - 1783 1,550 19,029 - 1784 1,759 17,828 - 1785 1,999 18,919 - 1786 1,210 20,454 - 1787 2,418 19,349 - 1788 1,101 19,697 - 1789 2,077 20,749 - 1790 1,617 18,038 - 1791 1,747 18,760 - 1792 1,568 20,213 - 1793 2,382 21,749 - 1794 1,913 19,241 - 1795 1,040 21,179 - 1796 3,548 19,288 - 1797 522 17,014 - 1798 2,237 18,155 - 1799 1,111 18,134 - 1800 2,409 23,068 - -The last twenty years of the century show a decrease in the annual -averages of smallpox deaths, along with a decrease of deaths from all -causes. The health of the capital had undoubtedly improved since the reign -of George II., especially in the saving of infant life. But it is not -worth while instituting a statistical comparison, for the reason that some -large parishes, containing poor and unwholesome quarters, had become -populous in the latter part of the century, but were not included in the -bills, while some of the old parishes, including those of the City, were -probably become less populous owing to the conversion of dwelling-houses -into business premises of various kinds. The decrease of fever-deaths in -the bills is closely parallel with the decrease of smallpox, and it is -probable that both were real; but as there is an element of uncertainty in -the data it would be unprofitable to abstract statistical ratios from -them, or to aim at demonstrating numerically what can only be in a measure -probable. Perhaps the safest generality from these London figures is that -smallpox once more fluctuates a good deal from year to year, seldom, -indeed, falling below a thousand deaths, but showing a considerable drop -for several years after some greater epidemic, as in the earlier history. -This becomes most obvious by exhibiting the mortality in a graphic -tracing. - -Manchester, which was a healthier place than the capital, having an excess -of births over deaths, had a smallpox mortality for six successive years, -1769-1774, as follows, the population, exclusive of Salford, having been -22,481 by a careful survey in 1773[1019]: - -_Smallpox Deaths in Manchester._ - - Year All deaths Smallpox deaths - - 1769 549 74 - 1770 689 41 - 1771 678 182 - 1772 608 66 - 1773 648 139 - 1774 635 87 - ----- ---- - 3,807 589 - -Between a seventh and a sixth part of all the deaths in Manchester (15.3 -per cent.) were from smallpox. All but one were under the age of ten -years: - - All deaths Under One to Two to Three to Five to Ten to - by smallpox One year Two Three Five Ten Twenty - - 589 140 216 110 93 29 1 - -Manchester was one of the towns that had smallpox continuously from year -to year at this period. It had a rapidly growing population, and an excess -of births over deaths which was in great part due to the very large number -of new families settling in it. It was probably this rapid increase of -children that explained the great height of the smallpox mortality in -1781, namely, 344, rising from three deaths in January and falling to -thirteen in December, the maximum being in the third quarter of the -year[1020]. - -Liverpool, like Manchester, had smallpox among its infants and children -steadily from year to year, and a higher rate of fatality from that cause -than Manchester. With a population half as great again as that of -Manchester, namely, 34,407 in 1773, it had the following deaths from -smallpox, according to the figures taken from the registers by Dobson and -supplied to Haygarth[1021]: - -_Smallpox Deaths in Liverpool._ - - Dead of - Year Baptisms Burials smallpox - - 1772 1160 1085 219 - 1773 1192 1129 200 - 1774 1207 1420 243 - -The smallpox deaths were 1 in 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 negro who proved recalcitrant against the bishop of Cloyne's panacea -died of the disease[1040]. The somewhat low fatality of the Boston -epidemic of 1752 (569 deaths in 5545 attacks not including the attacks -among inoculated persons) was thought possibly due to the use of tar-water -by many[1041]. - -Sometimes a run of highly favourable cases was followed by a succession of -fatalities, or _vice versa_. Dr Mapletoft, to whom Sydenham dedicated a -book, was originally in good physician's practice and Gresham professor of -physic; but he gave up these emoluments to enter the Church, and it is -related by one who conversed with him in his extreme old age that he gave -a singular reason for changing his profession, namely that, having treated -smallpox cases for years without losing one (his treatment being to do -nothing at all), he thereafter found that two or three died under his -hands[1042]. - -Fothergill's sixteen cases, in a certain locality of London in 1752, with -only one death, are an instance of a run of mild cases. At the Whitehaven -Dispensary in 1796 there was a good instance of how an average is made up; -of the first seven cases attended from the dispensary three died, and then -followed a run of thirty-four cases with only two of them fatal. Again, a -high or low degree of fatality might seem to pertain to a particular spot. -Bateman gives an instance in 1807 of 28 deaths within a month in a single -court off Shoe Lane; also in 1812, "in one small court in Shoe Lane, -seventeen individuals have lately been cut off by this variolous -plague[1043]." One can understand that of the old Shoe Lane; but why -should Nantwich have been reputed never to have its smallpox mortal? Worse -things are told of country smallpox in Scotland than in England. In 1758, -it is said, 8 died out of 28 near Cupar Fife, and in some parts of -Teviotdale "three or four died for one that recovered[1044]." Similar -unparalleled mortalities are reported by some parish ministers in the -'Statistical Account.' - -Cleghorn stationed with British troops in Minorca had a good opportunity -of comparing two epidemics of smallpox, one in 1742 and the other in 1746. -There had been no smallpox since 1725, so that when it did come in March, -1742, it found many susceptible of it: "every house was a hospital"; but -"in proportion to the numbers, not many died; and what mortality there was -happened chiefly among children at the breast and the common soldiers. -About the end of July the disease suddenly disappeared, most of those who -were susceptible of it having by that time undergone it." Four and a half -years after, in December, 1745, the infection was brought in by one of H. -M. ships from Constantinople, and produced in many cases attacks of a bad -type; which leads Cleghorn to remark that "it is a matter of chance -whether the best or the worst kind is got in the natural way[1045]." -Barbados had its epidemic maladies noted from season to season for several -years by Hillary, who enters smallpox once: "May, 1752, smallpox epidemic: -in general of the distinct kind; and in those few who had the confluent -sort, they were generally of a good kind[1046]." Foreign observers were -sometimes struck by the same mildness of a whole epidemic[1047]. - -The often cited remark of Wagstaffe in 1722, that there were cases which a -physician could not save and cases which a nurse could not lose, had many -illustrations. The cases of Queen Mary, in 1694, with the best physicians -at her bed-side, and of the Duke of Gloucester in 1660, show the one -event; the following from the _Gentleman's Magazine_, shows the other: - - In the parish of Whittington, Derbyshire, seventeen patients in all - had the smallpox in the year 1752; the first was seized June 7, and - the last August 12. They were all children, of various ages, and all - did well. An apothecary was called to one only of them[1048]. - -A note added says: - - "William Cave, a tradesman of Rugby, had twelve children, who, with - three nephews, were seized with the smallpox; some of them had it - severely, but all did well through the care of their mothers, without - the intervention of an apothecary." - -Or there might be the average fatality in village epidemics left to -domestic treatment only. At Kelsall and Ashton, two small Cheshire -villages, sixty-nine persons had smallpox during seven months of 1773, of -whom twelve died. "No medical practitioner visited any of the patients -during the whole disease[1049]." - -To find a single principle of cleavage through the smallpox of the 18th -century, dividing it into good and bad, is impossible. The determining -things were manifold, and they are to us obscure. Things proper to the -individual constitution or temperament, hidden in what has been called -"the abysmal deeps of personality," cover a good deal in our reactions -towards smallpox as in more important relationships. Generalizing such -facts to the utmost, we do not get beyond the notion that the greater or -lesser degree of proclivity runs in families. Morton could recall no case -of smallpox fatal in his own family, nor, curiously enough, among his -wife's relations. On the other hand he introduces a case, his 53rd, as if -to illustrate the contrary--a fair and elegant young lady, sprung of a -distinguished stock, but one to which this disease was wont to prove -calamitous as if by hereditary right[1050]. The royal family of Stuart had -a peculiar fatality in smallpox; and so, it appears, had the family of the -earl of Huntingdon, who wrote to Thomas Coke on 18 June, 1701: "I am -informed Lord Kilmorey [married to his sister] is ill of a fever, and that -some think it may prove the smallpox. For the love of God, send for my -sister to your house. She never has had them and they have proved fatal in -our family[1051]." A similar fatality in the family of John Evelyn can be -traced in the pages of his diary. - -Next to the individual constitution, we may take the epidemic -constitution, in the Hippocratic sense. No one keeping before him the -strange diversities of type in whole epidemics of scarlatina and measles -will say that the Hippocratic doctrine of varying constitutions is not -requisite to cover a certain element of mystery. But we should rationalize -it wherever we can; and there are some obvious considerations that may be -used to explain why smallpox, throughout a whole epidemic, had so high an -average fatality in some years or in some localities. Rutty, who noted the -fevers and other prevalent maladies in Dublin and elsewhere in Ireland -from year to year, and the associations of the same with famine or the -like, says that some had dysentery in 1757, "promoted perhaps by the -badness of their bread, as it was a time of great scarcity," that a low, -putrid, petechial fever followed in the winter, fatal to not a few of the -young and strong both in Dublin and in the country, and that as the cases -of petechial fever increased much beyond the usual number in January, -1758, "it was observable that the smallpox kept pace in malignity with -the fevers[1052]." That was the same year, 1758, for which Whytt records, -along with the fatal smallpox of Fifeshire and Teviotdale, a dysentery and -pestilential fever a month or two before, disastrous in Argyllshire, less -mortal in Haddington and Newcastle, as well as an influenza all over -Scotland[1053]. Again, in the country town and parish of Painswick, -Gloucestershire, there was an epidemic of smallpox in the summer of 1785 -so fatal that nearly one in three of the infected died. "This fatality," -says J. C. Jenner, "may in some measure perhaps be attributed to a -contagious fever and epidemic ague which prevailed at the same time, and -to the heat of the atmosphere"--many being dropsical from the agues that -had afflicted them for months, and many reduced by the typhus fever[1054]. -A striking instance of the fatality of smallpox among children in a poor -state of health owing to previous disease is given by Sir William Watson: - -At the Foundling Hospital of London, containing upwards of 300 children, -there were 60 cases of smallpox during the last six months of the year -1762, of which only 4 died, or 1 in 15. In April and May of next year -(1763) measles of a bad type broke out among the 312 inmates, attacking -180, of whom 19 died (over 1 in 10), while many who recovered were greatly -weakened, having ulcerations of the lips and mouth for some time after. In -May and June, when the children were recovering from measles, the smallpox -attacked many in the hospital, including 18 who had lately gone through -the measles. No fewer than 11 of those 18 died of smallpox. A -corresponding fatality of smallpox was observed shortly before among -children at the Foundling who were recovering from or had lately passed -through the dysentery or "dysenteric fever[1055]." - -It happens that we can compare a mild or average smallpox with an -unusually fatal one, and the conditions on which they respectively -depended, in the two neighbouring towns of Warrington and Chester in the -two successive years 1773 and 1774. Chester in 1774 had the average kind -of epidemic--1385 cases with 202 deaths (1 in 6.85), all in children. The -Chester populace, as described by Haygarth, lived for the most part in -poor houses of the newer suburbs; they were filthy in their persons and -their houses were often visited by typhus fever (supra, p. 41). But the -occupations of the men were not unhealthy, and the women would seem to -have been left to their domestic duties in the usual way. At Warrington -the circumstances were different. A seat of the sailcloth weaving from the -Elizabethan period (as early as 1586 the "poledavies" of Warrington are -mentioned), it had retained its repute and extended its industry as -sailcloth came more into demand[1056]. The American War, and the earlier -war with the French in Canada, caused an immense number of ships to be -commissioned for the royal navy, and the Warrington looms are said to have -furnished half of all the sailcloth that the fleets needed[1057]. Its -manufacturers made their fortunes, new looms were added, population was -drawn to the town from the country, marriages multiplied and were -unusually prolific, and the swarms of children were hardly into their -teens before they were set to earn wages along with their fathers and -their mothers. We have vital statistics from the parish register by -Aikin[1058], and an account of the industries by Arthur Young, as he saw -them in 1769[1059]. During the twenty years from 1702 to 1722, each -marriage, according to the register, produced only 2.9 children; from 1752 -to 1772, the marriages averaged 73 in a year, and the baptisms 237, being -3.25 children to each marriage[1060]. But in the last three years of that -period, 1770-72, the marriages had risen rapidly to an annual average of -95, and the baptisms to 331, being about 3.5 children to each marriage. -From 1773 to 1781 the marriages averaged 85 and the fecundity reached 4.5 -children to each. Arthur Young found the whole of this community, men, -women, and children, engaged in sailcloth or sacking manufacture, -boot-making, and pin-making. - - "At Warrington the manufactures of sailcloth and sacking are very - considerable. The first is spun by women and girls, who earn about - 2_d._ a day. It is then bleached, which is done by men, who earn - 10_s._ a week; after bleaching, it is wound by women, whose earnings - are 2_s._ 6_d._ a week; next it is warped by men, who earn 7_s._ a - week; and then starched, the earnings 10_s._ 6_d._ a week. The last - operation is the weaving in which the men earn 9_s._, the women 5_s._, - the boys 3_s._ 6_d._ a week. The spinners (women) in the sacking - branch earn 6_s._ a week. Then it is wound on bobbins by women and - children, whose earnings are 4_d._ a day.... The sailcloth employs - about 300 weavers, and the sacking 150; and they reckon 20 spinners - and 2 or 3 other hands to every weaver." - -On that basis of reckoning, Young estimated that the Warrington -manufactures employed about eleven thousand hands; but as Aikin, in 1781, -counted the whole inhabitants of the borough and three adjoining hamlets -at 9501, it is clear that a good many spinners of the flax and hemp who -lived in the country near Warrington must be allowed for in the eleven -thousand. At all events Warrington was an early and an extreme instance of -that hurry and scramble of wage-earning, by fathers, mothers and children, -which the growth of manufactures in the latter part of the 18th century -gave rise to, and of which many particulars came to light long after -during the discussions that preceded the passing of the Factory Act. The -mothers were workers, and all the while breeders at a somewhat high rate. -It is difficult to imagine how the household duties were got through, and -the infants reared, in such an industrial hive. Nor was there much -attention given, during those great days of the sailcloth industry, to the -scavenging and lighting of the town, and probably little to the -overcrowded state of its old-fashioned streets and lanes. It was in -January and February, 1775, fully a year after the great smallpox epidemic -had ceased, that Mr Blackburne, who had become lord of the manor in 1764, -"promoted the design of establishing a court of requests at Warrington, -cleansing and lighting the town, and removing the butchers' stalls." These -proposals, we are told, gave rise to a paper war[1061]. - -Ferriar has described what was apt to happen when country people migrated -to manufacturing towns, got married, and had children born to them: - - "A young couple live very happily, till the woman is confined by her - first lying-in. The cessation of her employment then produces a - deficiency in their income, at a time when expenses unavoidably - increase. She therefore wants many comforts, and even the indulgences - necessary to her situation: she becomes sickly, droops, and at last is - laid up by a fever or a pneumonic complaint; the child dwindles, and - frequently dies; the husband, unable to hire a nurse, gives up most of - his time to attendance on his wife and child; his wages are reduced to - a trifle; vexation and want render him diseased, and the whole family - sometimes perishes, from the want of a small timely supply which their - future industry would have amply repaid to the public[1062]." - -What Ferriar saw so often some years after at Manchester must have been a -not uncommon case at Warrington during the bustling time that Arthur Young -describes. Its infantile mortality was certainly excessive, according to -the following comparison with that of Chester, from the figures supplied -to Price by Aikin from the Warrington burial registers of nine years, -1773-81, and by Haygarth from the Chester bills for ten years, -1772-81[1063]. The deaths are reduced to annual averages, and those of -Warrington are raised, in the third column, to the ratio of the population -of Chester by making them half as much again. - -_Annual average of deaths from all causes under five years._ - - Warrington. Chester. Warrington - Pop. 9,501 Pop. 14,173 raised to the - Ages at death in 1781 in 1774 ratio of Chester - - Under one year 72.7 80.6 109.0 - One to two 43.5 36.1 65.2 - Two to three 20.1 23.4 30.1 - Three to four 11.5 14.4 17.2 - Four to five 7.0 8.7 10.5 - -It was among infants and young children born and brought up with such -comparatively poor chances of surviving, that smallpox broke out at -Warrington in January, 1773, reaching its climax in May and ending about -October, with a mortality of 209 or 211. Aikin says: - - "Its victims were chiefly young children, whom it attacked with such - instant fury that the best-directed means for relief were of little - avail. In general the sick were kept sufficiently cool, and were - properly supplied with diluting and acidulous drinks; yet where they - recovered, it seemed rather owing to a less degree of malignity in the - disease or greater strength to struggle with it, than any peculiar - management. When it ended fatally, it was usually before the pustules - came to maturation; and, indeed, in many they showed no disposition to - advance after the complete eruption, but remained quite flat and - pale"--a sure sign of poor _stamina vitae_. "In one neighbourhood I - found that out of 29 who had the disease, 12 died, or about 2 in 5; in - others the mortality was still greater, and I have reason to believe - it was not less on the whole." - -The monthly progress of the mortality at Warrington and Chester -respectively was as follows[1064]: - - Deaths. Deaths. - Warrington, Chester, - 1773 1774 - - Jan. 4 0 - Feb. 4 1 - March 13 0 - April 23 0 - May 63 3 - June 49 3 - July 33 11 - Aug. 11 26 - Sept. 7 28 - Oct. 3 46 - Nov. 0 44 - Dec. 1 40[1065] - --- --- - 211 202 - -The following are the ages at which the children died of smallpox, and of -all causes, in each town during the epidemic year[1066]: - - Warrington Chester - (pop. in 1781, 9501) (pop. in 1774, 14,713) - Ages Smallpox Other deaths Smallpox Other deaths - - Under one month 0 18 0 17 - One to three months 4 9 3 19 - Three to six months 4 9 4 10 - Six to twelve months 39 15 44 8 - One to two years 84 24 38 14 - Two to three years 33 5 42 3 - Three to five years 33 14 49 13 - Five to ten years 12 15 22 8 - Above ten years 0 -- 0 -- - --------------------------------------------- - 209 -- 202 -- - -Comparing the ages at death in the two epidemics, we see at a glance that -the second year was most fatal to children at Warrington, whereas at -Chester the deaths fell more at the higher ages, although in ratio of its -population it was only on a par with Warrington even at these ages. - -If the great smallpox year at each town be left out, 1773 at Warrington, -1774 at Chester, the mortality of infants in their second year from all -causes is found to be one-third more at Warrington than at Chester on an -annual average of eight (or nine) years. Some such difference Haygarth -says was well known between the smallpox of great and small towns, -namely, that it "attacks children at an earlier age, and consequently is -fatal to a larger proportion of people, in great than in small -towns[1067]." Although Warrington was the smaller town, infants died -earlier there than at Chester (from smallpox and from all causes), or the -probability of life was less;--a statistical fact which Price made out, -but was unable to explain. The explanation is the poor stamina of the -Warrington children, which was due most of all to the circumstance that -the married women were at once wage-earners and prolific breeders. - -In the smallpox year at Warrington, the deaths from all causes under five -years of age were 62.5 of the whole mortality, (in infants under two years -they were 43.5 per cent. of all deaths) smallpox having caused them in the -ratio of 199 to 291. Although Aikin's estimate of two deaths in five cases -is improbable for the whole epidemic, we may admit a rate of one death in -four, which would give Warrington in 1773 about as many cases in -proportion to its numbers as Chester had in 1774--844 in a population of -some 9000, as compared with 1385 in a population of 14,713. - -The epidemics of smallpox at Carlisle in 1779 and Leeds in 1781 were -unusually mortal, for reasons analogous to those assigned in the case of -Warrington. Both towns had increased fast in numbers, owing to the growth -of the weaving and spinning industries, both were overcrowded, ill -ventilated, and filthy, and both had high mortalities from typhus fever -among the adults, as described in another chapter. At Carlisle, the great -epidemic of smallpox, which was the children's special scourge, came in -1779, two years before the typhus fever reached a height. The smallpox -caused 90 deaths, while "a species of scarlet fever" at the same time -caused 39 deaths. Heysham estimated somewhat vaguely that these 90 deaths -occurred in 300 cases, or one case fatal in 3.3, which is double the -average[1068]. Lucas gives the proportion at Leeds more exactly--462 -cases, in six months, with 130 fatalities, or 1 in 3.5. The epidemic at -Leeds in 1721-22, which Nettleton described as "more than usually mortal," -caused 189 deaths in 792 attacks, or 1 in 4.2. There were fewer attacks in -the much larger population (17,117) of 1781, perhaps because there were -fewer persons who had not had the disease already, and these almost -exclusively the infants born and the young children who had grown up since -the last epidemic[1069]. In those circumstances it is hardly surprising -that the Leeds smallpox of 1781 should have been a degree more mortal than -that of 1721-22, which was itself "more than usually mortal." - - * * * * * - -A complete survey of smallpox in its great period, the eighteenth century, -in all places and continuously from year to year, is impossible even if it -were to be desired. Had it not been for the exact diligence of a few, -especially in the North of England, we should have been left in doubt on -some of the main epidemiological generalities. A system of registration -such as was applied for the first time in the epidemic of 1837-39 would -have saved much research and would have made it possible to bring the -facts within a smaller compass. By comparison and classification of many -scattered particulars we may still acquire a tolerably clear notion of -what smallpox was in the 18th century. It was chiefly a disease of infancy -and early childhood. It was always present in one part or another of the -capital and of the larger towns, rising at intervals to the height of a -great and general epidemic[1070]. At its worst, as in Glasgow, it took -about a third part of the lives under the age of five, and perhaps a sixth -part of the lives at all ages. It came in epidemics at somewhat regular -intervals in the smaller towns, and at longer intervals in the country -parishes. The village epidemics were apt to be very searching when they -did come. Haygarth gives the instance of Christleton, a small village two -miles from Chester, in 1778: "The distemper began in March and continued -till October. At the commencement of the epidemic, 107 poor children had -never been exposed to the variolous infection; of these 100 had the -distemper, probably all who were capable of receiving the smallpox." In -all places, with the possible exception of London where the risks from -infantile diarrhoea and "convulsions" were peculiar, it cut off the -infants and young children more than any other single disease, infectious -or other; and indeed it had few rivals among infectious diseases until -towards the close of the century, being for a time the grand epidemic -scourge of the first years of life just as the plague was once the unique -scourge of youth and mature age. It was more mortal in some seasons than -in others, and at certain places. Towards the end of the 18th century, -much more is heard of it in the northern industrial towns than in England -south of the Trent. If the statistics of Boston, Lincolnshire, are at all -representative, smallpox certainly declined much in market towns in the -last twenty years of the century. It appears to have declined also in the -capital during the same period. In the parishes of Scotland, by the almost -unanimous testimony of the articles which refer to it in the 'Statistical -Account,' it had become much less frequent and less dangerous for some -years previous to the publication of that work (1792-98). In Glasgow, with -the worst statistics of children's deaths in the whole kingdom, the -maximum had been reached, and passed, in the period between the close of -the American war and the first years of the great war with France. As the -French war proceeded, and vast sums of public money were poured out (the -bill being left to Prince Posterity to pay), the effects of this abundance -were seen in the remarkable decline, and almost total disappearance, of -fevers all over England, Scotland and Ireland. Corresponding with the lull -in fevers there was a lull in smallpox, not so marked as the former, but -very significantly covering the same period and lasting until the great -depression of trade in 1816 which followed the Peace. This will appear in -continuing the chronology of epidemics; but before we come to that, it -remains to make clear the scientific or pathological nature of a new kind -of inoculation which became at this juncture the rival of the old. The -extent to which each of the rival methods was practised will become a -subject of inquiry after the epidemic of 1817-19 has been dealt with. - - -Cowpox. - -Much has been said, in previous sections of this chapter, as to the -efforts of inoculators to reduce the effects of inoculated virus "to as -low a degree as we could wish." What kind of matter do you use? one -inoculator would ask of another. The comparative trials of Watson had -shown that serous or watery matter from an unripe pustule of smallpox, -preferably from the unripe pustule of a previous inoculation on the arm, -was most "successful," the success being measured by the slightness of the -effect produced at the time. The comparative trials of Mudge had confirmed -that, but had gone a little farther in showing that these slight effects -of crude or unripe matter left the constitution still open to the same -effects by the same means, or to more severe effects by more severe means. -What kind of matter to use was, accordingly, still an open question, which -offered some scope for originality and ingenuity. Among other sources of -crude or watery matter with bland properties was the glassy or watery -variety of eruption called swinepox, which, like its congener chickenpox, -was peculiar to man; and among those who tried that source of non-purulent -matter for inoculation was Jenner, of Berkeley. It was in 1789 that he -inoculated his child, aged eighteen months, with matter from the so-called -swinepox of man. There was still another pox bearing the name of a brute -animal, which was, however, a true affection of brutes--the cowpox or -pap-pox. A farmer at Yetminster, Dorset, named Benjamin Jesty, had used -matter from that source for the inoculation of his wife and two young -children in 1774, with the result that the arm of the former was much -inflamed and had to be treated by a surgeon. There seemed to be no good -reason for preferring matter of such dangerous tendency, and the -experiment was not repeated. A few years after, an apothecary of Lyme, in -Dorset, is said to have heard of another case of the domestic use of -cowpox matter for inoculation by the mistress of a farm house, and to have -pressed this fact upon the attention of Sir George Baker; who, although a -supporter of the mild or Suttonian inoculations with crude lymph, and by -his own avowal a friend of experiments, did not favour the trial of matter -from the pap-pox of cows, probably for the reason that he should have been -departing from the ground-principle of inoculating for the smallpox if he -were to go outside the class of variolous disease for his matter. The true -virtuoso, however, has no antecedent objection to experimenting with -anything. Sometime after Jenner had used the swinepox matter, he began to -talk among his medical neighbours of using cowpox matter. But it was known -that cowpox matter had properties and effects of its own, and that it -would be a radical innovation to use it, a departure _toto coelo_ from -every modification hitherto tried in the inoculation procedure. Although -it was also a pox by name, and although cowpox to the apprehension of a -man of words or notions might seem to be in the same class as swinepox, -glasspox, hornpox, waterpox or chickenpox, yet those who had ever seen it -on the chapped hands of milkers would hardly admit that matter from such a -source could serve for inoculation purposes unless upon wholly independent -and original proof of efficacy. Jenner's colleagues are reported to have -denied that cowpoxed milkers escaped natural smallpox any more than their -fellows[1071]. About the year 1794 Jenner began to press the subject upon -the attention of his friends. His clerical neighbour, Worthington, -mentioned it in one of his letters to Haygarth, of Chester, who replied, -on 15 April, 1794: - - "Your account of the cowpox is indeed very marvellous, being so - strange a history, and so contradictory to all past observations on - this subject, very clear and full evidence will be required to render - it credible. You say that this whole rare phenomenon is soon to be - published, but do not mention whether by yourself or some other - medical friend. In either case I trust that no reliance will be placed - upon vulgar stories. The author should admit nothing but what he has - proved by his own personal observation, both in the brute and human - species. It would be useless to specify the doubts that must be - satisfied upon this subject before rational belief can be obtained. If - a physician should adopt such a doctrine, and much more if he should - publish it upon inadequate evidence, his character would materially - suffer in the public opinion of his knowledge and discernment[1072]." - -It is clear that Haygarth, who was well acquainted with epidemic smallpox -and with inoculation, saw in this Gloucestershire idea something quite new -as well as antecedently improbable. What the real novelty was will appear -from the next historical reference to cowpox in an original work upon -Morbid Poisons by Joseph Adams, a writer of the Hunterian school. All that -Adams knew of the nature of cowpox previous to March, 1795, came from -Cline, surgeon to St Thomas's Hospital, who had been a fellow student of -Jenner's five and twenty years before, and kept up some correspondence -with him. Adams is writing on the peculiar danger of ulceration and -sloughing, or phagedaena, from transferring animal matters from one body -to another, his last illustration having been the notorious phagedaenic -ulceration of the gums, with rashes of the skin and constitutional effects -so severe as to be fatal, which followed the transplantation of fresh -teeth from one person to another in a number of cases about the year 1790 -and led to the speedy abandonment of that unnatural practice[1073]. He -proceeds to say, "Thus far we have only traced the poisonous effects of -matter applied from one animal to another of the same class," and then he -brings in the illustration of cowpox to finish the chapter: - - "The cowpox is a disease well known to the dairy-farmers in - Gloucestershire. The only appearance on the animal is a phagedaenic - ulcer on the teat, with apparent inflammation. When communicated to - the human subject, it produces, besides ulceration on the hand, a - considerable tumour of the arm, with symptomatic fever, both which - gradually subside. What is still more extraordinary, as far as facts - have been hitherto ascertained, the person who has been infected is - rendered insensible to the variolous poison[1074]." - -Jenner's own essay on the cowpox, when it appeared at length in 1798, -confirmed these statements as to the phagedaenic or corroding ulcerous -character of the milkers' sores, in his brief accounts of several cases, -of which it will suffice to mention these two: William Stinchcomb, farm -servant, had his left hand severely affected with several corroding -ulcers, and a tumour of considerable size appeared in the axilla of that -side; his right hand had only one small sore. A poor girl, unnamed, -"produced an ulceration on her lip by frequently holding her finger to her -mouth to cool the raging of a cowpox sore by blowing upon it[1075]." -Inquiries made by Dr George Pearson in various other dairy counties of -England brought out the same character of cowpox in milkers: the painful -sores might be as large as a sixpenny piece, and might last a month or -two, causing the milker to give up his work[1076]. - -As to the pap-pox itself, or cowpox in the cow, the most circumstantial -account was obtained, a few months after Jenner's first essay, by -interrogating a veterinary surgeon or cow-doctor, one Clayton, who -attended at most of the farms within ten miles of Gloucester: - - "That the chief diseases of the cow are the lough, swellings of the - udder, and cowpox; that the two former are the most common, the latter - being rarely seen except in spring and summer. - - That cowpox begins with white specks upon the cow's teats, which, in - process of time, ulcerate; and, if not stopped, extend over the whole - surface of the teats, giving the cow excruciating pain. - - That, if this disease is suffered to continue for some time, it - degenerates into ulcers, exuding a malignant and highly corrosive - matter; but this generally arises from neglect in the incipient stage - of the disease, or from some other cause he cannot explain. - - That this disease may arise from any cause irritating or excoriating - the teats; but that the teats are often chapped without the cowpox - succeeding. In chaps of the teats, they generally swell; but in the - cowpox, the teats seldom swell at all, but are gradually destroyed by - ulceration. - - That this disease first breaks out upon one cow, and is communicated - by the milker to the whole herd; but if one person was confined to - strip the cow having this disease, it would go no farther. - - That the cowpox is a local disease, and is invariably cured by local - remedies. - - That he never knew this disease extend itself in the highest degree to - the udder, unless mortification had ensued; and that he can at all - times cure the cowpox in eight or nine days[1077]." - -No account of cowpox in the cow has ever been given which differs -materially from that of this experienced Gloucester cow-doctor in -1798[1078]. Cowpox is not only a local disease, but it is peculiar to -certain individuals of the species, namely cows in milk; in them it occurs -on the teats, so that it was correctly known in Norfolk by the name of -pap-pox. The common observation has been that one cow starts it, and that -an infection is rubbed into the teats of others by the fingers of the -milkers. The cow which develops this ulceration of the paps is usually -either a heifer in her first milk, from which the calf has been taken -away, or a cow in milk which has been bought in a market, with the udder -"overstocked" or left distended for appearance sake, but as yet with no -blemish of the paps. The cause of cowpox is the rough handling of a highly -sensitive part, which was originally adapted only for the lips and tongue -of the calf. Ceely, a correct observer in the Vale of Aylesbury, uses no -exaggerated phrase when he speaks of "the merciless manipulations of the -milkers." Men milkers are well known to lack the delicate tact of women; -and cowpox has been most common in the great dairying districts where -men-milkers are employed. But in some animals cowpox may be produced even -under gentler handling or with slighter provocation, of which I give a -recent case from my notebook, taken during a visit to the country: - - 27 April, 1891. Case of cowpox. A maid in the service of Mr J. R. has - on the ulnar side of the fore finger of the right hand, over the joint - of the first and second phalanges, a collapsed bleb the size of a - sixpenny piece, pearly white round the margin, bluish towards the - centre, which is brown. The forefinger, as well as the wrist and hand - generally, bears traces of recent inflammation, and was said to have - been greatly swollen and painful, the pain extending up the arm. There - is a symmetrical rash of bright red papules on both arms as high as - the elbows, more copious and bright on the right arm but abundant on - the left also. The papules are elevated and pointed, with a small zone - of bright redness of the skin round the base of each. The history is - as follows: A cow was bought four or five weeks ago to supplement the - supply of milk from the three ordinarily kept. The new comer proved - "tough" to milk, so that the maid was obliged, contrary to usual - practice, to take the paps in the cleft of the fore and middle - fingers; under this mode of "stripping," the animal would hardly stand - quiet to be milked. After a time it was found that one of the paps had - a black crust upon it, which might have covered originally a chap of - the skin. The crust would have been displaced in the milking, and - would have grown again; the sore beneath soon healed. Only one pap was - affected. None of the other cows was infected. The "tough" cow was at - length sold as an unsatisfactory milker, and had been sent to a - distance on the morning of the day on which these notes were made. The - maid's finger began to be affected after two or three weeks of milking - the cow, the beginning of the large and tumid bluish-white vaccine - vesicle having been like a small wart. - -Jenner's opinion that cowpox was a specific disease "coeval with the brute -creation," and that it had been the parent of the great historical -smallpox of mankind, is not now received as correct. His other opinion, -that cowpox was derived from the hocks of horses affected with "grease," -which held a central place in his original essay, especially in connexion -with his doctrine of "true" and "spurious" cowpox, was rejected by most of -his contemporaries, and is perhaps unsupported by anyone at the present -time[1079]. - -In the title-page of his first essay, Dr Jenner called this singular -malady of the cow's paps by a new name--_variolae vaccinae_, or smallpox -of the cow. Pearson, the earliest and most ardent of Jenner's original -supporters, and for several years thereafter a convinced vaccinist, at -once took exception to the name _variolae vaccinae_ "for the sake of -precision of language and justness in thinking." It is a palpable -catachresis, says he, to designate what is called the cowpox by the -denomination variolae vaccinae, because the cowpox is a specifically -different distemper from the smallpox in essential particulars, namely, in -the nature of its morbific poison and in its symptoms[1080]. - -That the term _variolae vaccinae_ in Jenner's title-page is used -tropically can hardly be doubted; but it is not so easy to say which of -the great classical tropes it is. It may be objected that "catachresis" is -too general for the misuse of a word when that word is a scientific one -and occurs in the leading title of a scientific book. Here we have the -somewhat specific and purposeful use of a word in an unwonted sense, -which, if it fall under any of the scholastic figures of speech, ought to -be a figure more specifically defined than mere catachresis. In a matter -so important as this one should find the exact figure if possible; but at -the outset a difficulty arises, namely whether we should look for it in -the usage of the rhetors, as Isocrates teaches, or in the usage of the -logicians, as Aristotle lays down the definitions of tropes. If among the -former class, the nearest is perhaps the hypocorisma, or attractive, -agreeable name for something that is not so nice in itself. If among the -latter, we shall hardly find a better than the metalepsis, which is a -change more of mood than of meaning, namely the transition without proof -from a supposition to an assertion. But in truth no single figure of the -ancient teachers suits this modern instance. We require at least two. -Metalepsis carries us so far, but synecdoche must supplement it. The term -_variolae vaccinae_ is a synecdoche in that it names the cause from the -effect; it is a metalepsis in that it passes abruptly from the -hypothetical mood to the categorical; and in respect that it does both at -a stroke it is probably unique, and without precedent among the examples -known to the ancients. Or again, leaving the graver figures, and -translating the Latin name of Jenner's title-page, one may try the -figurative conversion of cowpox into smallpox by the standard of pure and -legitimate paronomasia, of which there is a familiar English example in -the conversion of a plant into an animal by the verbal play of -horse-chestnut and chestnut horse in the minor premiss. - -Some in more recent times, mistaking the figurative or rhetorical -intention of Jenner, have understood his Latin name of cowpox as if there -really were a smallpox of the cow (although not of the bull, nor of the -steer, the maiden heifer or the calf of either sex). Not being able to -find a smallpox of the cow in the natural way, they have thought to -satisfy the legitimate requirements of proof by manufacturing it. Certain -Germans of the Lower Rhine, where the cows ordinarily wear blankets, have -wrapped the blankets taken from smallpox beds round the bodies of cows, -after clipping the hair close; nothing was found to ensue in these -interesting experiments except an occasional pimple which had probably -been caused by the shears in the preliminary clipping. Others in England, -France, America and India, have succeeded in raising a smallpox pustule at -the point of puncture in the epidermis of the cow or in the more delicate -transitional epithelium, the matter from which has produced smallpox in -its turn[1081]. But these are academic exercises. The natural cowpox of -the cow has been likened by none to the natural smallpox of man in a -sustained comparison of all the anatomical and epidemiological particulars -of each; nor, I am persuaded, will anyone ever attempt to draw out such a -comparison. _Variolae vaccinae_ as a name for cowpox was a figure of -speech, and it is to misunderstand its original use to treat it as -anything else. - -The proof that cowpox had some power over smallpox consisted in trying to -inoculate with the latter those who had been previously inoculated with -the former. The accepted mode of testing the power of inoculated smallpox -itself was to inoculate it again; at first the test for cowpox was to -inoculate with smallpox, but after a few years the testing inoculation was -done with cowpox itself. The effects of Suttonian inoculation with -smallpox, as we have seen, were nearly always slight, and sometimes -invisible (as in Watson's practice at the Foundling Hospital). A previous -inoculation with cowpox made them slighter still; but even with cowpox in -the system, the pustules of smallpox rose where the matter had been -inserted on the arm. It may be thought that there were only fine shades of -difference between the effects of inoculation after cowpoxing and the -effects of the same in a virgin soil; but some difference must have been -perceived, for it was upon that, and upon nothing else, that the authority -in favour of cowpox as a substitute for smallpox in inoculation was -promptly established. The relationship between cowpox and smallpox was -admitted by all to be in the nature of things "extraordinary," as Jenner -said, or a mystery, as others said; but as an empirical fact many believed -it to be true, because the cowpoxed had less to show for the effects of -inoculation with smallpox than if they had not been cowpoxed. Jenner -himself is known to have made only two variolous tests. He used crude or -watery matter from the local pustule of inoculated smallpox, and advised -all his readers to do the same. In one of his two trials, a child Mary -James had nearly the same effects from inoculation after cowpox that her -mother and another child had from it without having been cowpoxed, namely -the pustule or confluent group of pustules at the place of puncture, and -the eruptive fever at the ninth day[1082]. - -In the earliest tests made independently of Jenner, five at -Stonehouse[1083], near Stroud, and five at Stroud[1084], in the first -months of 1799, the cowpoxed received smallpox afterwards by inoculation -"in the usual slight manner." In the practice at the Smallpox and -Inoculation Hospital, London, in the spring and summer of 1799, many of -the cowpoxed took smallpox by contagion from the atmosphere of the -hospital, so that Woodville, after a period of perplexity, at length -concluded that cowpox, while it was still active upon the arm, did not -shut out the action of the smallpox virus in the constitution[1085]. - -The antecedent objections to cowpox, arising out of its non-variolous -nature, were met by appealing to the results of experiments. The authority -in favour of cowpox was speedily established on that ground, and has been -continuous to the present time. The experimenters had to decide very nice -points both in the way of observation and of reasoning. They had to -appraise the margin of difference between the effects of Suttonian -inoculation where cowpox had preceded and where it had not preceded. They -had to allow for the first virus causing a swelling in the absorbent -glands, which would obstruct the entrance of the second testing virus into -the blood. They had to average the varying effects of Suttonian -inoculation for its own sake, and the equally varying effects of it as the -variolous test, and to find a broad difference between the two averages. -Having decided that preceding cowpox infection did make a real and -appreciable difference to the number of pustules resulting, at the spot or -elsewhere, from the insertion of inoculated smallpox matter, or to the -amount of fever, they had next to consider whether that degree of -resistance by a cowpoxed person to inoculation were a good measure of his -power to resist contagion reaching his vitals in the natural way. Their -diligence and acumen may or may not have been equal to these things--it -was a slack tide in medical science. Also they received little or no help -from Dr Jenner himself, whose inventive genius was of the kind that is apt -to leave the practical value, and even the theoretical probability, of the -project to be tried by others. The inventor made interest with great -personages--with the king, the duke of York, and the aristocracy of his -county. His priority, and the merits of his project, were referred in 1802 -to a Committee of the House of Commons, with Admiral Berkeley as -chairman, which entered on its labours with a strong recommendation from -the king, endorsed by Addington, the prime minister. They decided in -favour of Dr Jenner's claim for remuneration on all the issues, and on 2 -June, 1802, the Committee of the whole House unanimously voted: "That it -is the opinion of the Committee that a sum not exceeding 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 retard population as the plague had done. The -saving of life by the extinction of plague was in great part balanced by -the loss from smallpox, which fell, however, more and more upon the -earliest years of life until at length it was almost confined to them. The -first great decline of smallpox itself corresponded to a great decline of -typhus fever during the second half of the French war; but while there was -no great infectious disease in those years to thin the ranks of the -adults, measles took the place of the more loathsome smallpox in cutting -off a certain number of young lives. While the older types of infection -have disappeared, the incidence has shifted from mature lives to children, -so much so that at the present time enteric fever, and occasional choleras -and influenzas, are almost the only infections that correspond to the old -plague and to typhus fever in their age-incidence. - -The other remark is that the greater prevalence or fatality of measles, as -if in lieu of smallpox, meant a good deal more for the bills of mortality -than actually appeared under the name of measles. Smallpox was not an -infection that did much constitutional damage to those that came through -it, although it sometimes destroyed the vision and spoiled the beauty of -the face. On the contrary, it was held by many that the general health was -better after an attack of smallpox than before; and, if personal -experience can justify an opinion, that ought to be my own view of the -matter[1221]. But measles is an infection peculiarly apt to leave mischief -behind. The bronchial catarrh, which is an integral part of the malady, -and is often the cause of death in the second stage of the attack, may so -affect weakly children that the respiratory organs are permanently -damaged. Tuberculosis of the lungs is apt to follow measles. Some -children, again, fall into mesenteric disease after measles, and die -tabid, the intestinal catarrh being as dangerous in one way as the -bronchial is in another. Another large proportion of the subjects of -measles take whooping-cough[1222]. While smallpox did its work summarily, -the full effects of measles were longer in being realized. This may in -part explain the fact brought out by Watt, that while fewer children died -under two years of age, measles being the dominant epidemic disease, there -was an increase in the ratio of deaths from all causes between the years -of two and five and from five to ten. - - -Measles in the Period of Statistics. - -The history of measles for nearly a generation after the great epidemics -of 1808 and 1811-12 is little known. No one in Glasgow continued Watt's -laborious tabulation of the causes of deaths in the numerous burial -registers[1223]; nor was any regular account kept elsewhere except by the -Parish Clerks of London. The following deaths by measles in their bills -from 1813 to 1837, when the modern registration began, were probably no -more than from a third to a half of the deaths in all London: - - Measles - Year deaths - - 1813 550 - 1814 817 - 1815 711 - 1816 1106 - 1817 725 - 1818 728 - 1819 695 - 1820 720 - 1821 547 - 1822 712 - 1823 573 - 1824 966 - 1825 743 - 1826 774 - 1827 525 - 1828 736 - 1829 578 - 1830 479 - 1831 750 - 1832 675 - 1833 524 - 1834 528 - 1835 734 - 1836 404 - 1837 577 - -The inadequacy of these figures to the whole of London will appear from -the fact that the registration returns under the new Act gave for the last -six months of 1837 the measles deaths at 1354, while the bills of the -Parish Clerks gave them at 577 for the whole year. But the old bills -enable us to compare the deaths from different diseases within the same -area and under the same system of collection, and to compare the deaths -"within the bills" in a series of years since the last of the new parishes -were taken in about the middle of the 18th century. Using the bills so far -legitimately, we find that measles at length came to be of equal -importance with smallpox itself as a cause of death in childhood, and that -it had become a larger and steadier total from year to year. - -So far as concerns Glasgow, the high mortality from 1807 to 1812, making -10.76 on an annual average of the deaths from all causes, was not -maintained. When the tabulation of the causes of death was resumed from -1835, the annual average of measles for the five years ending 1839 was -found to be only 6 per cent. of the deaths from all causes, the average of -smallpox having come back to 5.3 per cent. During that unwholesome period, -in which there was much distress among the working class and a great -epidemic of typhus, measles and smallpox were dividing the infectious -mortality of childhood somewhat equally, the age-incidence of measles -being only a little lower than that of smallpox: - -_Ages of the Fatal Cases of Measles in Glasgow, 1835-39_[1224]. - - Under one 1-2 2-5 5-10 10-20 20-30 30-40 40-50 Total - - 1835 116 141 121 34 10 4 - - 426 - 1836 86 209 183 38 1 1 - - 518 - 1837 77 133 122 16 2 1 350 - 1838 76 124 161 39 3 1 1 405 - 1839 165 259 275 73 7 2 1 783 - -------------------------------------------------------- - 520 866 863 200 23 9 1 1 2482 - -In Limerick, which may stand for a typically unhealthy Irish city in the -worst period of over-population, there were many more deaths from smallpox -among children than from measles, the age-incidence being nearly the same, -according to the following dispensary statistics for a number of years -before 1840[1225]: - -_Limerick Dispensary Deaths._ - - Age 0-5 5-10 10-15 15-20 Total - - Smallpox 333 55 5 0 393 - Measles 187 32 6 1 226 - Scarlatina 8 2 10 - -Although it is impossible to prove it, yet the indications all point to -measles having kept for a whole generation after 1808 the leading place -among infantile causes of death which it then for the first time -definitely took[1226]. Almost the only direct references to the subject -were made by way of controverting the doctrine of Watt; but these are too -meagre, or too general in their terms, to be of any use[1227]. The -epidemics of measles seem to have travelled then, as they do now, from -county to county in successive years. Thus in 1818, while most parts of -England were or had recently been suffering from smallpox, the Eastern -counties were suffering from measles "very frequent and fatal." Smallpox -at length reached Norwich in 1819, and became the reigning epidemic in the -place of measles, which was "hardly met with" so long as the enormous -mortality of the other disease proceeded[1228]. At Exeter in the spring of -1824 measles became epidemic after a long interval; many susceptible -children had accumulated, and of these few escaped. The mortality was very -great, and was caused by severe pulmonary inflammation, the catarrhal -symptoms being mild. In one day seventeen children were buried in one of -the five parish churchyards of the city; but that high mortality, -according to the parochial surgeon, did not on an average stand for more -than four deaths in one hundred cases[1229]. - -When the curtain rises, in the summer of 1837, upon the prevalence and -distribution of diseases in England, as ascertained by the new system of -registration of the causes of death, measles is found in the first place -among the infectious maladies of childhood, thereafter yielding its place -to smallpox for a year or more, and taking the lead again until it was -passed by scarlatina. - -_Deaths by Measles and Smallpox in London, 1837-39._ - - 1837 1838 1839 - 3rd 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 -Lesbos for measuring uneven stones; it took account of gradations, -modifications, affinities, being careless of symmetry, of definitions or -clean-cut nosological ideas, or the dividing lines of a classification. -Sydenham was the great English exponent of this method; but, in one of his -more discursive passages, he sketched out another method of describing -diseases as if they were species or natural kinds[1247]. He did no more -than indicate this analogy, at the same time declining to put it in -practice; so that Sauvages correctly described his great Nosology of 1763 -as being constructed "juxta Sydenhami mentem et Botanicorum ordinem." The -identification of scarlatina in its modern sense, including scarlatina -simplex and scarlatina anginosa, falls really in the time of the -nosologies in the generation following the work of Sauvages, although both -the name and definition in the modern sense were used in England as early -as 1749. On the other hand, the name and definition of diphtheria were -little known until about the years 1856-59, when the form of -throat-distemper which is now quite definitely joined to that name became -suddenly common, having been almost unheard of for at least two -generations before. The only English writer who has attempted to unravel -the accounts of the 18th century epidemics of throat-disease was Dr Willan -in his unfinished work on Cutaneous Diseases, 1808; he swept the whole of -those epidemic types into the species of scarlatina, to which also he -reduced the great Spanish epidemics of "garrotillo" in the 16th and 17th -centuries. Whether he would have used so summary a method if he had seen -the sudden return of diphtheria in 1856, may well be doubted; at all -events the German writers who brought their erudition to bear upon the -question of identity some thirty years ago have discovered true diphtheria -among the 18th century throat-distempers, although no two of them agree as -to which of these should be called diphtheria and which scarlatina -anginosa. It is one advantage of a historical method that the complexities -of things may be stated just as they are, with due criticism, naturally, -of the matters of fact and of the relative credit of observers. The result -is more an impression than a logical conclusion,--an impression which will -take a colour from the pre-existing views or theoretical preferences of -individual readers on such points as fixity of type or the incompetence of -the earlier observers. An author who has puzzled over these difficulties -in detail can hardly help having a tolerably definite impression of the -real state of the case; and I do not seek to conceal mine, namely, that -scarlatina anginosa and diphtheria were not in nature so sharply -differentiated in the 18th century as they have been since 1856. - -The significant name of _pestis gutturuosa_ or plague of the throat is -given by the St Albans chronicler to the great pestilence, or some part of -it, in 1315-16, during one of the worst periods of famine and murrain in -the whole English history. But those two words being all that we have to -base upon, there is no use speculating whether the disease was scarlatina -anginosa, or diphtheria, or something different from either. This is -perhaps the only reference to an epidemic throat-distemper in England for -several centuries in which bubo-plague was the grand infection. In the -popular medical handbooks of the Tudor period one naturally looks for -scarlatina among the diseases of children. In Elyot's _Castel of Health_ -(1541), "the purpyles" is mentioned among children's maladies in company -with smallpox and measles, and the same name is in the London bills of -mortality from their beginning in 1629, although it does not appear -whether the deaths assigned to it were of children or adults. Perhaps the -most common use of purples in the 17th and 18th centuries was for a form -of childbed fever often attended with discoloured miliary vesicles. In -Scotland, according to Sibbald (1684), "the fevers called purple" were any -fevers, even measles or smallpox, in which livid or dark spots occurred as -an occasional thing. Unless a few scarlatinal deaths are included under -"purples" in the London bills (they could not have been many in any case), -there is no other evidence of their existence until 1703, when the entry -of scarlet fever appears for the first time, with seven deaths to it in -the year. The heading remains in the bills until 1730 (the deaths never -more than one figure), after which it is merged with fevers in general. -The same indications of the insignificance of scarlatina among the causes -of death in the 17th century may be got from the medical writers in -London. - -Sydenham introduced into the third edition (1675) of his _Observationes -Medicae_ a short chapter entitled "Febris Scarlatina[1248]." It was a -disease that might occur at any time of the year, but occurred mostly in -the end of summer, sometimes infesting whole families, the children more -than the elders. It began with a rigor, as other fevers did, the malaise -being but slight. Then the whole skin became interspersed with small red -spots, more numerous, broader, redder and less uniform than in measles; -they persisted for two or three days and then vanished, and, as the -cuticle returned to its natural state, there were successive desquamations -of fine branny scales, which he compares elsewhere to those following the -measles of 1670. Sydenham took it to be a moderate effervescence of the -blood from the heat of the summer just over, or from some such excitement. -It was a mild affair, not calling for blood-letting nor cardiac remedies, -and requiring no other regimen than abstinence from flesh and spirituous -liquors, and that the patient should keep in doors, but not all day in -bed. The disease, he says, amounted to hardly more than a name (_hoc morbi -nomen, vix enim altius assurgit_); but it appears that it was sometimes -fatal; and in those cases Sydenham was inclined, after his wont, to blame -the fussiness of the medical attendant (_nimia medici diligentia_). If -convulsions or coma preceded the eruption, a large epispastic should be -applied to the back of the neck and paregoric administered. Whether -Sydenham was describing true scarlatina simplex, or a "scarlatiniform -variety of contagious roseola," it is from him that we derive the name of -scarlatina by continuous usage to the present time[1249]. - -A few years after Sydenham had thus described scarlatina, Sir Robert -Sibbald, physician and naturalist of Edinburgh, professed to have -discovered the same as a new species of disease. "Just as the luxury of -men," he says, "increases every day, so there grow up new diseases, if not -unknown to former generations, yet untreated of by them. Nor is this -surprising, since new depravations of the humours arise from unwonted -diets and from various mixtures of the same. Among the many diseases which -owe their origin to this age, there has been most recently (_nuperrime_) -observed a fever which is called _Scarlatina_, from the carmine colour -(named by our people in the vernacular _scarlet_) with which almost the -whole skin is tinged. Of this disease the observations are not so many -that an accurate theory can be delivered or a method of cure constructed." -He proceeds to append one case--a child of eight, daughter of one of the -senators of the College of Justice, who fell ill with redness of the face -(thought at first to indicate smallpox coming on), became delirious and -restless, then had the redness all over, which disappeared and left the -child well about the fifth day. He had heard from some of his colleagues -that the scarlet rash was sometimes interspersed with vesicles--perhaps -the _miliaria_ so much in evidence a generation or two later. In adults, -Sibbald had seen the cuticle fall from nearly the whole body. But -extremely few (_paucissimi_) had died of this fever. Like Sydenham, he -omits to mention sore-throat and dropsy[1250]. - -Another 17th century reference is by Morton, who practised in London, in -Newgate Street, from about 1667 to the end of the century, and was -frequently called to consult with apothecaries or other physicians in -cases of sickness in middle-class families. In the second volume of his -_Pyretologia_, published in 1694, he has a chapter "De Morbillis et Febre -Scarlatina," and a separate chapter "De Febre Scarlatina." His position -towards scarlet fever is peculiar. He uses the name, he says, in deference -to the common consent of physicians, but, for his own part, he thinks -scarlatina different from measles only in the form of the rash, so-called -scarlatina being confluent measles just as there is a confluent smallpox. -Except in that sense he sees no reason for retaining scarlatina in the -catalogue of diseases. Both arise from the same cause, both have hacking -cough, heaviness of the brain, sneezing, diarrhoea; the single difference -is that in scarlatina the rash is continuous. He gives eleven cases, most -of which are clearly enough cases of measles; but the fourth case, that of -his own daughter, Marcia, aged seven, in 1689, "in quo febris dicta -Scarlatina, tempore praesertim aestivo, quadantenus publice grassabatur," -had no cough, nor redness of the eyes, nor diarrhoea, nor any other -catarrhal symptoms (such as her sister had in 1685), but on the fourth day -a continuous scarlet rash over the whole skin, which ended, not in a -desquamation of fine branny scales, but in parchment-like peeling. The -eleventh instance is complex enough to show that Morton had some reason, -at that early stage in the history of scarlatina, for hesitating to make -the disease a distinct type under a name of its own. - - About midsummer, 1689, he was called to the house of his friend Mr - Hook, merchant, of Pye Alley, Fenchurch Street, and found the whole - household, three young girls, one little boy, and their aunt Mrs - Barnardiston, a matron aged seventy, all suffering from the effects of - some infection of as deleterious a kind as synochus, the symptoms - being hacking cough, coma, delirium, and other signs of malignity. But - on the 4th, 5th, or 6th day, each had a scarlatinal rash all over the - skin, which lasted until the 7th, 8th or 10th day. Two of the girls, - and the boy, had "on the 4th or 5th day of the efflorescence" - extensive parotid swellings, difficulty of swallowing, vibrating - arteries, and other urgent symptoms, for which they were blooded. The - parotid abscesses burst, and discharged a copious acrid, corrosive pus - by the nostrils, ears and throat, for the space of thirty days, during - which the patients gradually got well. The third girl had, on the 3rd - or 4th day of the rash, a painful swelling in the left armpit, not - unlike a bubo; she also was blooded, and recovered completely, the - swelling having broken and discharged pus for many days. The case of - the aunt, aged seventy, was somewhat different; she neglected her - medicines, acquired a "carcinoma" or slough over the pubes, which - became gangrenous, recovered with difficulty, and lived three years - longer. - -Morton calls these cases a veritable _pestis_ or plague; and he goes on in -the same context to say: "what swellings have I seen of the uvula, fauces, -nares, and how protracted! At other times, what turgid lips, covered with -sordid crusts and ulcerated!"--instancing the child of Mr Blaney, who had -these symptoms long after the efflorescence, together with fever and -coma[1251]. These cases, all given under the eleventh history illustrating -the chapter on Scarlatina, are perhaps not different from those which -Huxham, next in order, described in 1735, but not under the same name. It -would appear from a reference in Hamilton's essay on Miliary Fever, -published in 1710, that scarlet fever continued to be seen in London: "If, -in a scarlet fever, miliary pustules should arise, dying away with a red -colour, they promise safety[1252]." - -Several of the annalists of epidemic constitutions agree as to fatal -anginas in the year 1727, with an exanthem of the miliary kind. -Wintringham, of York, mentions the two things apart--in one place a putrid -fever with cutaneous eruptions of a fuscous colour, sometimes dry, -sometimes filled with a clear serum; in another place, "about this time -many anginas were prevalent, attended with extreme suffocation, which -proved fatal unless they were speedily relieved." He mentions the same -putrid fever in the summer of 1728, and again anginae. Hillary, who was -then at Ripon, gives the same fever in 1727 (or perhaps in 1726) with -miliary eruption, and chronicles "a fatal suffocative quinsey" in the -winter of 1727-28, of which many died, especially those that had been -reduced by the fever. Huxham's account of an epidemic malady of the throat -and neck at Plymouth in January and February, 1728, might relate to mumps -(which Hillary and an Edinburgh observer describe clearly enough under -1731); and under October, 1728, he describes an erysipelatous and -petechial fever, often relieved by an eruption of red miliary vesicles -accompanied by sweats, the same miliary fever being again common in the -autumn of 1729. This association of "putrid" fever with sore-throat -became still more notable in the period 1750-60. - -These anginas of 1727-28 are unimportant compared with the outbreak a few -years later. We hear first from Edinburgh in June, 1733, of scarlet fever -and sore throats frequent in several parts of the country near the city, -and continuing all through the summer into the winter and spring of -1734[1253]. Then in April, 1734, begins a series of important notes by -Huxham at Plymouth[1254]. In that month, he says, there began a certain -anginose fever ("for so I shall call it"), raging more and more every day. -It mostly affected children and young people. Among other symptoms were -vomiting and diarrhoea, pain and swelling of the fauces, languor, anxiety, -delirium or stupor, a favourable issue being attended with sweats and red -pustules. In May it was raging worse, with more severe angina and most -troublesome "aphthae." In June it was now miliary-pustular, and not seldom -erysipelatous, while the throat was "less oppressed." On the 6th or 7th -day the cuticle looked rough and broken as if thickly sprinkled with bran; -at length the whole desquamated--sometimes the entire skin of the sole of -the foot coming off. The more copious the rash, the better the chance for -life. It was contagious, affecting several in the same house. In July it -cut off several within six days of the onset. Huxham's references to this -putrid miliary fever in Devon and Cornwall go on for some time, without -farther mention of the throat complication. In April, 1735, "raro nunc -adest strangulans faucium dolor, paucaeque nunc erumpunt pustulae." But, -in September, 1736, he enters again, "febres miliares, scarlatinae, -pustulosae," often attended with swelling of the parotid glands and of the -fauces, and with profuse sweats. - -The most important scene of fatal angina with rash in the same period -(1734-35) was the North American colonies. Before coming to that -remarkable outburst, I shall mention one curious coincident outbreak in -the island of Barbados. Dr Warren, who occupies his pen chiefly with -yellow fever, says[1255]: "In this space of time [1734 to 1738], there -arose here a few other diseases, that were really epidemical and of the -contagious kind too, few escaping them in families where they had once -got a footing. The first was an obstinate and ill-favour'd erysipelatous -quinsey. The second a very anomalous scarlet fever, in which almost all -the skin, even of the hands and feet, peeled off,"--just as Huxham -described for Devonshire. - -It is beyond our purpose to include the evidence from foreign countries; -but it may be noted in this context that Le Cat, in tracing the -antecedents of the great Rouen fever in his paper of 1754, refers to many -fatal anginas in that city about twenty years before[1256]. Thus we find -about the year 1735 evidence of the beginning of a remarkable -"constitution" of throat-disease both in the old world and in the new. But -the facts in America stand out with peculiar prominence, and shall be -given on the threshold of the subject as fully as possible. - - -The Throat-distemper of New England, 1735-36. - -The accounts of the great wave of "throat-distemper" that spread over the -towns and villages of New England in 1735 are singularly clear and even -numerically precise. The arrival of this sickness is one of the most -definite incidents in the whole history of epidemics; it was hardly -possible for the common belief, whether popular or professional, to have -been mistaken about it. Just a hundred years had passed since the first -settlement of the Puritans on Massachusetts Bay and along the Connecticut -river; Boston had grown to a town of some 12,000 inhabitants, and many -small towns and townships had sprung up along the coast and in the -interior. The population was still sparse, although it was growing rapidly -from within; it is difficult to believe that even the largest towns could -then have deserved the strictures which Noah Webster passed upon them two -generations later[1257]. - -In the mother country at that time, smallpox was the great infectious -malady of infancy and childhood. It was not unknown in the colonies, -Boston having had epidemics in 1721, 1730 and 1752, and Charleston an -epidemic in 1738 after an almost free interval of thirty years. Even in -the chief cities of the colonies such epidemics were only occasional, -affecting adults and adolescents perhaps more than infants and as much as -children; while in such a town as Hampton, for which the register was well -kept from 1735, it is known that there were no smallpox deaths in the -twenty years following, or until the period 1755-63, when four died of the -disease, and that only one death from it occurred in the next recorded -period of ten years, 1767 to 1776. It was in these circumstances of a -growing population, almost untouched, at least in the inland towns, by the -great infantile infectious malady of the old country, that the -throat-distemper broke out and raged in the manner now to be described. - -The disease "did emerge," as Douglass says, on the 20th of May, 1735, at -Kingston township, some fifty miles to the east of Boston[1258]. The first -child seized died in three days; in about a week after three children in a -family some four miles distant were successively seized, and all died on -the third day; it continued to spread through the township, and Douglass -was informed that of the first forty cases none recovered. It was vulgarly -called the "throat illness" or "plague in the throat." Some died quickly -as if from prostration, but most had "a symptomatic affection of the -fauces or neck: that is, a sphacelation or corrosive ulceration in the -fauces, or an infiltration and tumefaction in the chops and forepart of -the neck, so turgid as to bring all upon a level between the chin and -sternum, occasioning a strangulation of the patient in a very short time." -In August it was at Exeter, a town six miles distant, but it did not -appear at Chester, six miles to the westward, until October. After the -first fatal outburst in Kingston township it became somewhat milder; but -in the country districts of New Hampshire it was fatal to 1 in 3, or 1 in -4 of the sick, and in scarce any place to less than 1 in 6. This average -was made up by its excessive fatality in some families; Boynton of Newbury -Falls lost his eight children; at Hampton Falls twenty-seven died in five -families. The following table, compiled by Fitch, minister of Portsmouth, -shows the deaths from it in various towns and townships of New Hampshire -during fourteen months from May, 1735, to 26 July, 1736, with the -ages[1259]: - -_Deaths from the throat-distemper in 14 months, 1735-36_ (Fitch). - - Under Ten to Twenty Thirty Above - ten years twenty to thirty to forty forty Total - - Portsmouth 81 15 1 -- 2 99 - Dover 77 8 3 -- -- 88 - Hampton 37 8 8 1 1 55 - Hampton - Falls 160 40 9 1 -- 220 - Exeter 105 18 4 -- -- 127 - Newcastle 11 -- -- -- -- 11 - Gosport 34 2 -- -- 1 37 - Rye 34 10 -- -- -- 44 - Greenland 13 2 3 -- -- 18 - Newington 16 5 -- -- -- 21 - Newmarket 20 1 -- 1 -- 22 - Stretham 18 -- -- -- -- 18 - Kingston 96 15 1 1 -- 113 - Durham 79 15 6 -- -- 100 - Chester 21 -- -- -- -- 21 - --- --- --- --- --- --- - 802 139 35 4 4 984 - -The meaning of these figures in the townships of New Hampshire will appear -from the case of Hampton. In the year 1736 its burials from all causes -were 69, and its baptisms 50; while the throat-distemper alone, during -fourteen months of that and the previous year, cut off 55. As we have -seen, Hampton had no smallpox to ravage its children; but the -throat-disease of 1735-36 had almost the same effect as the occasional -disastrous epidemics of smallpox had upon English towns of a corresponding -population or annual average of births. - -This plague in the throat attacked the children of the most sequestered -houses, especially those situated near rivers or lakes. It was least fatal -to those who lived well, both Douglass and Colden assigning the salt diet, -and other things likely to produce _psora_, as the reason of its greater -severity. In the country districts or townships, in which the fatalities -were most numerous, it would appear that an eruption, scarlet or other, -was not only not the rule but even something of a rarity. Douglass, who -was familiar with the exanthem in the Boston cases, assigns its absence in -the country to a mistaken evacuant treatment, by which "the laudable and -salutary cuticular eruption has been so perverted as to be noticeable only -in a few, and in these it was called a scarlet fever." - -When the disease broke out in due course at Boston it proved much less -malignant than in the country. The first case, on the 20th August, had -white specks in the throat and an efflorescence of the skin. A few more -soon followed in the same locality, of which none were fatal; they had -soreness in the throat, the tonsils swelled and speckt, the uvula relaxed, -a slight fever, a flush in the face and an erysipelas-like efflorescence -on the neck and extremities. The first death was not until October, the -disease becoming more frequent and more fatal in November, and reaching -its worst in the second week of March, when the burials from all causes -rose to 24, the average per week in an ordinary season being 10. The -fatalities in Boston were so few for the enormous number of cases that -many could scarce be persuaded that it was the same disease as in the -Townships. In the corresponding weeks (1 Oct. to 11 May) of eight ordinary -years preceding, the average deaths were 268, whites and slaves; during -this sickness they were 382, or an excess of 114, which were probably all -due to the throat-distemper, as many as 76 fatal cases having come to the -knowledge of Douglass himself. He estimates the whole number of attacks at -4000, giving a ratio of one death in thirty-five cases; but it is clear -that very slight cases of sore-throat were counted in. - - The fatal cases in Boston seem to have shown a great range of - malignant symptoms: "We have anatomically inspected persons who died - of it with so intense a foetor from the violence of the disease that - some practitioners could not continue in the room." Among the bad - symptoms were the coming and going of the miliary eruption, dark livid - colour of the same, the vesicles large, distinct and pale, like - crystalline smallpox; an ichorous discharge from the nose; many mucous - linings expectorated, resembling the cuticle raised by blisters; pus - brought up where no sloughs could be seen in the fauces; extension to - the bronchi, with symptoms of a New England quinsey (? croup); in some - children, spreading ulcers behind the ears; the tongue throwing off a - complete slough with marks of the papillae. Among the after-effects in - severe cases were anasarca or dropsy of the skin, haemorrhages, - urtications, serpiginous eruptions chiefly in the face, purulent - pustules, boils, or imposthumations in the groins, armpits and other - parts of the body, indurations of the front of the neck (the same by - which many in the country were suffocated, and a few in Boston), - hysteric symptoms in women, and epileptic fits. - - Douglass gives special attention to the eruption, which he calls - miliary in his title-page. Some had a sore-throat without any - eruption, and a very few had an eruption with no affection of the - throat beyond the tonsils and uvula swollen. In some the eruption - preceded the soreness of the throat, in some the two came together, - but in the general case the eruption was a little later than the - affection in the throat. The ordinary course was a chill and - shivering, spasmodic wandering pains, vomiting or at least nausea, - pain, swelling and redness of the tonsils and uvula, with some white - specks: then followed a flush in the face, with some miliary - eruptions, attended by a benign mild fever; soon after, the miliary - efflorescence appears on the neck, chest and extremities; on the third - or fourth day the rash is at its height and well defined, with fair - intervals; the flushing goes off gradually with a general itching, and - in a day or two more the cuticle scales or peels off, especially in - the extremities. At the same time the cream-coloured sloughs or specks - on the fauces become loose and are cast off, and the swelling goes - down. Where the miliary eruptions were considerable the extremities - peeled in scraps or strips like _exuviae_; in one or two, the nails of - the fingers and toes were shed. Some who had little or no obvious - eruption underwent a scaling or peeling of the cuticle. - -The epidemic having spent its force upon the New England towns from the -autumn of 1735 until the summer of 1736, gradually travelled westward, and -was two years in reaching the Hudson River, distant only two hundred miles -in a straight line from Kingston, where it first appeared in May, 1735. It -continued its progress, with some interruptions, until it spread over the -colonies from Pemaquid in 44 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-coloured - foetid matter, to the patient's relief and ultimate recovery. Not a - few had gangrenous sloughs in the mouth, which formed quickly. Some - had foetor of the breath as an early symptom, but others had it not. - Some were merely feverish and hoarse. - -When Huxham came to describe the disease at Plymouth a year or two later, -he laid the emphasis on other symptoms than those mostly dwelt upon by -Starr, describing really a sloughing sore-throat with rash. But he has -this also: "The windpipe itself was sometimes much corroded by it, and -pieces of its internal membrane were spit up, with much blood and -corruption; and the patients lingered on for a considerable time, and at -length died tabid." - - -Fothergill's Sore-throat with Ulcers, 1746-48. - -Meanwhile we have to overtake Fothergill's history of the ulcerous -sore-throat in or near London[1271]. It broke out at Bromley, near Bow, -Middlesex, in the winter of 1746 (Short says that it was in Sheffield in -1745). So many children died suddenly, some losing all and others the -greater part of their families, that people were reminded of the plague. - - It began with a chill and rigor, followed by heat. The throat became - sore, and there were nausea, vomiting and purging. The face turned red - and swollen, the eyes were inflamed and watery, the patient was - restless, anxious and prostrated. The seizure was often in the - forenoon, and in all cases the symptoms became much worse towards - night, to be relieved by a sweat in the morning, as in an intermittent - fever. The uvula, tonsils, velum, inside of the cheeks, and the - pharynx, were florid red, with a broad spot or patch, irregular in - figure, of pale white colour like the blanched appearance of the gums - when they have been pressed by the finger. Usually on the second day - of the disease, the face, neck, breast and hands to the tips of the - fingers became of a deep erysipelatous colour with perceptible - swelling, the fingers in particular being often of so characteristic a - tint as at once to suggest an examination of the throat. A great - number of small pimples, of a deeper red than the skin around them, - appear on the arms and other parts; they are larger and more prominent - in those subjects, and in those parts of the same subject, where the - redness is least intense, which is generally on the arms, the breast, - and lower extremities. With the coming out of this rash, the sickness, - vomiting and purging cease. The white spot or spots on the throat are - now seen to be sloughs; they come first usually in the angles above - the tonsils. They are not formed of any foreign matter covering the - parts but are real mortifications of substance leaving an ulcer with - corrosive discharge behind. The nocturnal exacerbation now takes the - form of delirium and incoherent talking. The parotids are commonly - swelled and painful; and if the disease be violent, the neck and - throat are surrounded with a large oedematous tumour threatening - suffocation. The pulse is 120, perhaps hard and small. The urine is at - first crude and pale like whey; afterwards it is more yellow, as if - from bile; and towards recovery it is turbid and deposits a - "farinaceous" sediment. The initial purging having ceased, the bowels - become irregular. The disease had no crisis, but in general, if the - patient were to recover, the amendment began on the third, fourth or - fifth day, when the redness disappeared and the sloughs in the throat - were cast off. - -Such is the main outline; the following symptoms have less general value. - - At the outset, the patient complained of a putrid smell in the throat - and nostrils, which caused nausea. The nostrils were often inflamed, - yielding a sanies, and the inside of the lips covered with vesicles - filled with an excoriating ichor. Some had the parts about the anus - excoriated. Fothergill was inclined to think that either the - excoriations or the ichor from them extended down the whole intestinal - tract, and accounted for the purging, with other bowel symptoms, - which sometimes remained for weeks after the primary disease and - caused death by emaciation[1272]. In some there was bleeding at the - nose, or mouth, which might be fatal; in one case there was a like - accident from the ear. Several cases are given in which there were no - sloughs of the throat, but a dry glossy redness or lividity; in these - cases, there was a general brawny swelling of the neck, a coldness of - the hands and feet, involuntary evacuations, a glassy eye and certain - death. Three of Fothergill's five briefly reported cases are of that - variety. In one of them, a boy of 14 years, he says there was "deep - redness of the face, hands and arms, with a plentiful eruption of - small pimples, which induced those about him to apprehend it was a - scarlet fever." - -That is the only reference to a possible diagnosis of scarlet fever in the -whole essay. In the New England throat-distemper of 1735, "scarlet fever" -was in like manner the name given by the laity, and disapproved by the -profession. Fothergill, adopting the erudition of Letherland, identified -the ulcerous or gangrenous sore-throat of London in 1746-48 with the -_garrotillo_ of Spain in the 16th and 17th centuries, the famous -throat-plague of Naples and other places in Italy and Sicily from 1618 -onwards, and the "plague in the throat" mentioned by a traveller, -Tournefort, in 1701 as occurring among children in the island of Milo, -(Douglass having already identified the Levantine plague in the throat -with the throat-distemper of New England in 1735.) - -After the outbreak at Bromley and Bow in the winter of 1746, the ulcerous, -or putrid or gangrenous angina continued in London and the villages near -until the date of Fothergill's writing (1748). By credible accounts, he -says, it was also "in several other parts of this nation." Short, of -Rotherham, a professed epidemiologist, says that the malignant angina -"never left Sheffield entirely since the year 1745[1273]." Fothergill -himself, in his monthly accounts of the weather and diseases of London -from 1751 to 1755, refers to the sore-throat once or twice; thus, in -October, 1751: "epidemic sore-throat, in both children and adults"; and -again, in July, 1755: "The ulcerated sore-throat likewise appears in many -families, with the greatest part of its usual symptoms, but gives way -without much difficulty, if no improper evacuations have been made, to the -method heretofore recommended (XXI. 497)[1274]." - - -"Scarlet Fever" at St Albans, 1748. - -The same disease that Fothergill described for London and villages near -was seen at St Albans in the autumn of 1748, and described as "a -particular kind of scarlet fever," by Dr Nathaniel Cotton, who kept a -madhouse there. Among his friends were the poet Cowper (at one time his -patient), and Young, of the 'Night Thoughts.' Cotton himself had the same -melancholy cast of mind, and found the same solace in making verses, which -have probably served more to keep his memory green than his essay in -medicine[1275]. He professes to describe "a particular kind of scarlet -fever" in his title-page; and in the text he has this remark: "From this -diversity of symptoms, I have found some practitioners inclined to think -that this disease could not with propriety be called a scarlet fever. But -I imagine that such disputes are about words only." It is, indeed, -difficult to find any real difference between his particular kind of -scarlet fever and the "sore-throat with ulcers" which Fothergill wrote -upon a few months before, or, again, between his scarlet fever and that of -Withering thirty years after. - -The sickness began about the end of September, 1748, in St Albans and some -towns adjacent. At first it attacked children only, afterwards also -adults. The symptoms given are just those detailed by Fothergill, as well -as by Douglass for New England: - - Sickness with purging at the outset, rapid swelling of the tonsils and - (or) the parotids and maxillary glands, whitish sloughs on the - tonsils, small ulcers up and down the fauces, the eyelids puffed as in - measles, swelling of the neck, arms and hands in many, in some - swelling of the body also, intense red efflorescence, coming on either - suddenly or tardily, with thick spots as if dipped in blood. On the - face, neck and breast, the rash was even with the surface, elsewhere - it was miliary or shagreen. Some were restless or anxious, and - delirious, others so drowsy that when awakened to receive a draught or - the like, they relapsed at once into stupor. The attack, if not - violent, ended on the fourth or fifth day; there were few in whom the - fever did not return on one, two or more evenings thereafter, so going - off gradually. In one or two, the parotids swelled after the fever was - gone, continuing hard for a fortnight and then suppurating. In nearly - all, the cuticle peeled off "as in other scarlet fevers." In some the - nervous system was much shaken; in particular they dreaded the - approach of evening with an unusual kind of horror, and started at the - shadows of the candles on the wall. In convalescence some complained - of universal soreness. The spots where blisters had been applied - continued to discharge in some cases eight or ten days or more. - -Besides the reference to swelling of the neck, arms or body among the -early symptoms, there is no reference to oedema, while the pallid dropsy -of convalescence, which Withering described in 1779, is not mentioned. It -is noteworthy that Cotton, who lays the emphasis on the scarlatina, and -not on the throat-disease, was of opinion that the copiousness of the -eruption was not a measure of the security of the patient, although that -was clearly the opinion of Huxham and others, who laid the emphasis on the -sore-throat. - - -Epidemics of Sore-throat with Scarlet rash in the period between -Fothergill and Withering. - -The years 1751-52, and indeed the whole of that decade, saw a good deal of -the same diseases, after which little is heard of them until 1778. -Huxham's accounts for Plymouth, which are of the first importance, begin -with 1751[1276]. They are of importance because his memory went back to -the anginose fever of 1734, in which the miliary eruptions, with sweats, -were critical or relieving to the throat, and because he could not clearly -distinguish between them and the sore-throats of 1751-52, although he -follows Fothergill in identifying the latter with the Spanish -_garrotillo_. The throat affection began in the end of 1751, and became -most severe in October, November and December, 1752, in Plymouth and at -the Dock and all around, carrying off a great many adults as well as -children. It ceased in May, 1753. He describes the sloughing patches in -the throat, the excoriated nostrils with acrid dripping discharge, the -swelling of the parotids and sometimes of the whole neck, just as other -writers had done; and gives the account of laryngeal or tracheal membranes -already cited (p. 695). It is perhaps more important to dwell upon his -account of the rash. Most commonly the angina came on before the -efflorescence, but in many instances the cuticular eruption appeared -before the sore-throat. "A very severe angina seized some patients that -had no manner of eruption, and yet even in these a very great itching and -desquamation of the skin sometimes ensued; but this was chiefly in grown -persons, very rarely in children." Commonly there was a rash, general or -partial, on the second, third or fourth day. - - "Sometimes it was of an erysipelatous kind, sometimes more pustular; - the pustules were frequently very eminent, and of a deep fiery-red - colour, particularly in the breast and arms, but oftentimes they were - very small and might be better felt than seen, and gave a very odd - kind of roughness to the skin. The colour of the efflorescence was - commonly of a crimson hue, or as if the skin had been smeared over - with the juice of raspberries, and this even to the fingers' ends; and - the skin appeared inflamed and swollen, as it were; the arms, hands - and fingers were often evidently so, and very stiff and somewhat - painful. This crimson colour of the skin seemed indeed peculiar to - this disease." The eruption seldom failed to give relief; but there - were also cases of an universal fiery exanthem which proved fatal. An - early and kindly eruption, when succeeded by a very copious - desquamation of the cuticle, was one of the most favourable symptoms. - -Comparing it with the _febris anginosa_ which he had entered in his annals -under the year 1734, at a time when the ulcerous or malignant sore-throat -was still unheard of, he says that the earlier type differed from the -later in being more inflammatory, and less putrid; the sore-throat of -1751-52 might seem to be a disease _sui generis_, but it differed from the -anginose fever of 1734 only in the above respect: "In a word, the high -inflammatory smallpox differs as much, or more, from the low malignant -kind, as the _febris anginosa_ from the pestilential ulcerous -sore-throat." In the latter he found the remarkable evidences of putridity -already cited in connexion with putrid fevers[1277]. He gives the case of -a boy of twelve whose tongue, fauces and tonsils were as black as ink; he -swallowed with difficulty, and continually spat off immense quantities of -a black, sanious and very foetid matter for at least eight or ten days; -about the seventh day, his fever being abated, he fell into a bloody -dysentery, but recovered eventually. In a few the face before death became -bloated, sallow, shining and as if greasy, and the whole neck swollen. -Even the whole body might be oedematous in some degree, retaining the -impression of the finger. - -Perhaps it may be said that Huxham had really to do with two diseases; and -he does in one place say: "The anginose fever still continued, and we had -several of the malignant sore-throats in September, many more in October, -&c."--as if the two were not the same. But he generalized the "epidemic -constitution" of 1751-52, in another way: "In all sorts of fevers there -was a surprising disposition to eruptions of some kind or other, to -sweats, soreness of the throat and aphthae. The smallpox were more fatal -in August, and sometimes attended with a very dangerous ulceration in the -throat and difficulty of swallowing. Indeed the malignant ulcerous -sore-throat was now also frequent, probably sometimes complicated with the -smallpox." Even pleuritic and peripneumonic disorders were attended during -this constitution with a sore-throat, aphthae, and some kind of cuticular -eruption. - -Some facts about the throat-disease at Kidderminster and other places in -Worcestershire will complete this part of the somewhat perplexing history. -Dr Wall says it appeared about the beginning of 1748 chiefly in low -situations[1278]: "It then went generally under the name of scarlet fever, -the complaint in the throat not being much attended to, or at least looked -upon only as an accidental symptom." His first cases were at -Stratford-on-Avon--a young lady who recovered with difficulty, and then -two sisters who died, all three having been treated by blood-letting and -the cooling regimen. By these cases Wall was convinced that the disease -was more putrid than inflammatory, that it was infectious, that the -antiphlogistic treatment was a mistake, that bark was the grand remedy, -that the throat was the principal seat, and that the scarlet efflorescence -was rather an accidental symptom than essential to the disease, some -having petechiae and purple spots. He adopts Mead's name of _angina -gangraenosa_. The malady had been rife in the city of Worcester, and most -of all at Kidderminster, where it was in a manner epidemical. He was told -that nine or ten poor persons had died of it there one after another. -Having been called to the child of a respectable tradesman, he treated the -case with bark and the cordial regimen. He persuaded the Kidderminster -surgeons and apothecaries to adopt the same method, which they did with -such success that, as he found afterwards in the books of one of them, -there were only 7 deaths in 242 cases of the disease, while Dr Cameron did -not fail once, and Wall himself had fifty recoveries and only two deaths. -It is said, however, on the authority of the parish register, that a -hundred persons died at Kidderminster of the malignant sore-throat in -1750, "in the months of October and November only[1279]." Dr Wall goes on -to say that the "Kidderminster sore-throat" had a vast variety of -symptoms, the only certain ones being aphthous ulcers and sloughs on the -tonsils and parts about the pharynx. "Very few here [which may mean -Worcester] have had the scarlet efflorescence on the skin." Dr Johnstone, -senior, confirms this in a measure for Kidderminster[1280]: "The anginous -fever was not always, though often, attended with cutaneous eruptions; and -these, for the most part red, were sometimes also of the christalline -miliary kind." And in writing again in 1779, when Withering's scarlet -fever was dominant in place of Fothergill's sore-throat, Dr Johnstone -said: "A scarlet eruption was a much more frequent symptom of this disease -than it used to be when I first became acquainted with it nearly thirty -years ago." But, as it is known that the rash of true scarlet fever is far -less constant in adults than in children, and as many of the attacks -referred to by Wall and Johnstone were in adults, the so-called -Kidderminster sore-throat may have been a fairly uniform scarlatina. -Still, it is clear that all the leading writers, excepting Cotton, of St -Albans, distinguished between sore-throat (gangrenous, malignant, or -ulcerous) and scarlatina, identifying the former with the old _garrotillo_ -of Spain and Italy[1281]. The distinction may have been really between -scarlatina simplex and scarlatina anginosa, as Willan believed; but -whether the disease were malignant scarlatina, or diphtheria, or a mixture -of the two (as in Cornwall), or an undifferentiated type with the -characters of both, it was certainly new as a whole to British experience -in that generation, and, if we except the reference by Morton to certain -cases which may have been sporadic, it was a disease hitherto unheard of -in England since systematic medical writings began. We may realize the -impression which it made, both in the American colonies and in England in -the middle third of the 18th century, by recalling the sudden appearance -of diphtheria some thirty-five years ago; but, whereas the diphtheria of -1856-58 came upon a generation of practitioners who had seen much of the -very worst kinds of scarlatina for twenty years or more, the -contemporaries of Huxham, Letherland, Fothergill, Johnstone and Wall in -England, or of Douglass, Colden and Bard in America, knew no scarlet fever -but scarlatina simplex. The outbreaks of the 18th century throat-distemper -in certain families were of the same tragic kind as diphtherial outbreaks -in our own time. Instances of whole families swept away have been cited -from the New Hampshire epidemic of 1735. Horace Walpole gives the -following instance of a noble family in London: - - "There is a horrid scene of distress in the family of Cavendish; the - Duke's sister, Lady Bessborough, died this morning of the same fever - and sore throat of which she lost four children four years ago. It - looks as if it was a plague fixed in the walls of their house; it - broke out again among their servants, and carried off two a year and a - half after the children. About ten days ago Lord Bessborough was - seized with it and escaped with difficulty; then the eldest daughter - had it, though slightly: my lady attending them is dead of it in three - days. It is the same sore throat which carried off Mr Pelham's two - only sons.... The physicians, I think, don't know what to make of - it[1282]." - -The medical accounts of the sore-throat of those years are none the easier -to interpret in a modern sense owing to the frequent use of the term -"miliary" to describe the rash. Douglass had used this term in the title -of his Boston essay in 1736. Bisset applies it to a Yorkshire epidemic -some twenty years after[1283]. The disease began among adults at Whitby in -September and October, 1759, and spread over the country between the coast -and Guisborough in the spring of 1760, as well as in some places to the -westward of the latter; afterwards it became epidemic in all the western -parts of Cleveland in August and September of 1760, the summer months -having been almost a clear interval. It was remarkable, he says, that some -persons in the eastern parts of Cleveland who had escaped it when it was -epidemical in the spring, were attacked by it in the autumn after it "had -got a good way to the westward of them." This epidemic progression is -spoken of as of a single but composite disease,--"the epidemic -throat-distemper and miliary fever that appeared in the Duchy of Cleveland -in 1760." In adults it was mostly an affection of the throat, few having -the miliary eruption, and only one adult dying "within the circle of my -observations." But in children the fever with miliary rash was -predominant, and of it the fatality is put at one death in every thirty -cases. There is no discussion as between the names of scarlet fever and -miliary fever; but the following on the peeling of the skin is -significant: "From the ninth to the thirteenth day the scarf-skin begins -to peel off in cases that were attended by a copious rash; and that of the -hands and feet sometimes came off almost entire." Soreness of throat often -happened in this fever of children; and, to repeat, the sore-throat of -adults and the miliary fever of children are described as parts of one and -the same epidemic[1284]. An account which probably relates to the same -disease comes from Rotherham or Sheffield in a letter by Dr Short, the -epidemiologist, to Rutty, of Dublin. It was very violent, he says, in -July, 1759, and cut off whole families of children. The attack was -attended with diarrhoea, swelled tonsils, oedema of the face, an eruption -like measles all over the body, and a discharge of sanious humour from the -nostrils. "In some there was an efflorescence on the skin like the scarlet -fever, and these recovered[1285]." - -Another complication arises owing to the prevalence, in the same period, -of putrid or miliary fevers, which had sometimes an anginous or "throaty" -character. This source of perplexity extends from near the beginning to -near the end of the 18th century, but it is greatest in the middle period, -when the "constitution" was most decidedly "putrid[1286]." The -relationship was most definitely expressed by Johnstone, of Kidderminster: -"This malignant fever (_vide supra_, p. 123) was very often, though not -constantly, complicated with, and in general had great analogy with the -malignant sore-throat which at this time prevailed in many parts of -England." An Oxford practitioner, in 1766, actually wrote a dissertation -to distinguish the "putrid sore-throat" which attended the "putrid" -continued fever of the time, from the "gangrenous sore-throat" of -Fothergill, Huxham and others: in the former, the aphthae and sloughs of -the tonsils and uvula, as well as of the mouth, were only symptomatic of -the putrid fever, and late in showing themselves; in the latter, the -throat affection was the primary and dominant one, present from the -beginning of the illness[1287]. - -The last complication of the highly complex circumstances in which -scarlatina first became a great disease in England is with "putrid" or -malignant measles. In the same years as the epidemic described above for -Yorkshire, namely, 1759 and 1760, there occurred an "anomalous malignant -measles," which for some months had made a melancholy carnage amongst -children in the west of England. The symptoms were difficult breathing, an -amazingly rapid pulse, white or brown tongue, and "some red eruptions -which run in irregular groups and splatches on the surface of the skin." -The attack was apt to be attended by colliquative diarrhoea. A fatal issue -was indicated by a sunken and very quick pulse, the abatement of the -dyspnoea, and the eruption coming and going. Some rapid cases in infants -ended in convulsions on the third day. Children from one to six years were -attacked most[1288]. Perhaps the only reason for not including this among -epidemics of measles is the author's remark: "I look upon the poison of -the disease to be a good deal akin to that of the ulcerated sore-throat so -very rife and fatal some years since," although he does not allege -throat-complications in the malady which he describes. - -Three years later, in 1763, there was an epidemic at the Foundling -Hospital, London, which Watson, the physician to the charity, described in -a special essay as one of "putrid measles." Willan, writing in 1808, -challenged the diagnosis on the ground both of the symptoms as given by -Watson, and of the names given to the malady in the Infirmary Book at the -time. The first entry in the apothecary's book is on 23 April, 1763, a -case of "fever with a rash," the next on 30 April, a case of "scarlet -fever," then on 7 May, ten cases of "eruptive fever," and, for the rest of -May and all June, very long lists of "eruptive fever," the name of measles -not occurring at all in that outbreak, while the names of "morbillous -fever" and "fever" are given to a smaller but still considerable outbreak -in November of the same year. Among the symptoms, Watson mentions that the -fauces were of a deep red colour, that the rash came out on the second -day, and that there was no cough. The most remarkable character of the -epidemic as a whole was a tendency to sloughing in various parts: - - "Of those who died some sank under laborious respiration: more from - dysenteric purging, the disease having attacked the bowels; and of - these one died of mortification in the rectum. Besides this, six - others died sphacelated in some one or more parts of the body. The - girls who died most usually became mortified in the pudendum. Two had - ulcers in their mouth and cheek, which last was so covered by them - that the cheek, from the ulcers within, sphacelated externally before - they died. Of these one had the gums and jawbone corroded to so great - a degree that most of the teeth on one side came out before she died. - The lips and mouth of many who recovered were ulcerated, and continued - so for a long time." The anatomical examination of those who died - showed the bronchitic affection, in one case pleurisy, and in some a - gangrenous condition of the lungs. One died of emaciation six weeks - after the attack. Eleven others succumbed shortly after to smallpox, - out of eighteen who caught the latter during recovery from the - preceding epidemic disease[1289]. - -Long after, in 1808, when the diagnosis between measles and scarlatina was -fixed, Dr James Clarke saw at Nottingham in several cases of measles "a -great tendency to gangrene," the sites of blisters having mortified in two -(as in scarlet fever) and two having gangrene of the cheek and -mortification of the upper jaw[1290]. Huxham, he says, saw such cases, -Willan never; and that was one of the reasons why Willan claimed the -Foundling cases as scarlatina. The diagnosis is important; for, in the -same year, 1763, the bills of mortality record 610 deaths from measles in -London, and Watson expressly includes the 19 deaths in the Foundling -Hospital (in 180 attacks) as part of the general epidemic in London. - -The confusion between measles and scarlatina is farther shown by the -entries in the Infirmary Book of the Foundling Hospital from the beginning -to the end of an extensive epidemic in 1770: On 31 March, 23 children are -in the infirmary with "measles," and on 7 April, 37 children still with -"measles"; on 12 May the long list is headed "measles and ulcerated -sore-throat," on 19 May, "putrid fever," and on 26 May, "fever and -ulcerated sore-throat[1291]." - -Whether or not we agree with Willan in taking the Foundling epidemic of -1763 (and perhaps with it the general epidemic in London) for one of -scarlatina, it can hardly be doubted that the Foundling epidemic of 1770 -was the latter disease, the names of "measles with ulcerated sore-throat," -"putrid fever," and "fever and ulcerated sore-throat" clearly indicating -scarlatina anginosa. Grant also records the prevalence of epidemic -sore-throat in London in 1770[1292], and Dr William Fordyce, writing in -1773, dealt with the "ulcerated and malignant sore-throat" as a question -of the day[1293]. - - It was not until forty years ago, he says, that they had become - acquainted in England with ulcerated and malignant sore-throat, while - "both kinds" are now very common. His aim is to separate the ulcerated - from the malignant, and he instances an outbreak in a gentleman's - house at Islington, where the worst symptoms of the malignant occurred - in the children, while only the ulcerous prevailed among the servant - maids. In 1769 it was reported to be seldom fatal in London and - Westminster, and in the villages around; but within these last twelve - months (1773) it had appeared of a bad type in high situations such as - Harrow, in the months of June and July. In a later note, he adds that - "it still continues to make a havock so considerable as to keep up the - alarm about it both in the metropolis and all over England," his own - last experience of it having been two fatal cases in a noble family a - few miles to the west of London. Fordyce identified this disease with - Fothergill's sore-throat, and described the eruption as "the general - erysipelatous colour that comes about the second day on the face, - neck, breast and hands to the finger ends, which last are tinged in so - remarkable a manner that the seeing of them only is sufficiently - pathognomonic of the malady [this is a repetition of Huxham and - Fothergill]; and finally a great number of small pimples, of a colour - more intense than that which surrounds them, appearing in the arms and - other parts of the body." He gives the following as a case of the - malignant sore-throat in a young gentleman five or six years old: - "Every part of the body that bore its own weight was gangrened, as - well as the orifices where he had been blooded twice before I saw him - (which was three days after the seizure); the parotid glands were very - much swelled, the whole body was more or less oedematous, and the skin - throughout of an erysipelatous purple; he died the third day after I - saw him." - -Although Fordyce, and probably most others, still adhered to Fothergill's -view of the sore-throat with ulcers as a disease apart, yet there appear -to have been at this date some who followed the line taken with regard to -it by Dr Cotton in 1749. Sometime about the end of 1771 or beginning of -1772, a physician at Ipswich sent to a London physician, who sent it to -the _Gentleman's Magazine_, an account of a "Successful Method of treating -the Ulcerated Sore Throat and Scarlet Fever," by tartar emetic, calomel -&c.[1294] He begins: "The ulcerated sore-throat and scarlet fever has been -very rife in this place and the neighbourhood for some months past, and -has been in a considerable number of instances fatal. It has in every -respect answered the description given of it by Dr Fothergill"--so much so -that he does not give the symptoms, but only the treatment, which, in his -own hands, had been singularly successful: "I have had considerably more -than one hundred patients, and have not buried one," his cases, between -the writing and printing of the paper (3 June) having "increased to near -three hundred with the same success." This must have been an interval of -mild scarlatina, during which the prevalence of the malady, however -extensive, had attracted little notice. The outburst in 1777-78, from -which the diagnosis and naming of scarlatina anginosa properly date, was -obviously an interruption of a quiet time of the disease. - - -Scarlatina anginosa in its modern form, 1777-78. - -Dr Levison[1295], who was physician to a London charity called the General -Medical Asylum located at No. 4, Tottenham Court-road (afterwards in -Welbeck Street), observed the outbreak, on 15 July, 1777, of a malignant -sore-throat, "nearly such as described by Dr Fothergill and Dr Huxham -(only without the efflorescence and attended with costiveness)," among -children from three to seven years, by which many were cut off in the -space of six to eight days, some by suffocation and others by vomiting of -blood. It became more general in August, and in some was very malignant, -being joined with an erysipelatous inflammation and a diarrhoea. It raged -with great fury in Kentish Town, and at Enfield Chase it swept away many -in twenty-four hours. But on the high ground about London, as at Hampstead -and Highgate, it was of a benign type. It was worse in the villages round -than in the capital itself. - - In the milder form, there was only a superficial whiteness of the - uvula, tonsils and velum; in the more severe, the same parts were - beset with thick ulcerations, running very deep in the fauces. Both in - the milder and in the more severe cases the neck became swollen on the - second or third day. The commencement was usually with shivering and - nausea, followed by heat, and an efflorescence over the breast, the - limbs, and often the whole body, of a crimson red. "Some were spread - over with a kind of little millets, similar to that in the miliary - fevers, and which scaled off the skin the sixth or seventh day; in - which cases the ulcerations were very slight, as also all other - symptoms of malignancy." The mouth was apt to be full of sloughs, the - teeth covered with black crusts. The urine was scanty, high-coloured, - with a thin suspended cloud. Some bled from the nose. The nostrils - were apt to be stuffed with greenish sanies, which dropped out - continually. The efflorescence and sore-throat were often met with - separately. Most had cough throughout, great dejection of spirits, and - oppressed breathing. The disease had no regular progress and no - crisis; the whole of the symptoms would often cease suddenly about the - eighth or ninth day. In one case there was recovery after three weeks' - illness. Several cases had suppuration of the glands of the neck. In - one fatal case, a tumour behind the right tonsil was found to contain - three ounces of 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-coloured matter - discharges in great quantities from the nostrils, or the ears, or - both, and continues so to discharge for many days. Sometimes this - discharge has more the appearance of pus mixed with mucus. Under these - circumstances, when the patients do recover, it is very slowly; but - they generally linger for a month or six weeks from the first attack, - and die at length of extreme debility." These discharges, compared by - a writer a generation before to glandered secretions, are not to be - confused, says Withering, with the matter from abscesses on both sides - of the neck, under the ears, which "heal in a few days without much - trouble." The submaxillary glands were generally enlarged. Adults - usually had a ferretty look of the eyes, and sometimes small circular - livid spots about the breast, knees and elbows. Some had a succession - of boils. One man had "lock-jaw." Most patients had the fauces, - particularly the tonsils, covered with sloughs, which separated and - left the parts raw, as if divested of their outer membrane. The most - troublesome symptom was exulcerations at the sides and towards the - root of the tongue; these were painful and made it impossible to - swallow solid food. Some threw out several white ash-coloured sloughs, - though no such sloughs were visible upon inspecting the throat. - -With reference to the diagnosis between scarlatina anginosa and angina -gangraenosa (of Fothergill) Withering says: "They are both epidemic, they -are both contagious; the mode of seizure, the first appearances in the -throat, are nearly the same in both; a red efflorescence upon the skin, a -great tendency to delirium and a frequent small unsteady pulse are -likewise common to both. With features so strikingly alike, and these, -too, of the most obvious kind, is it to be wondered that many -practitioners considered them the same disease?" And again: "But perhaps -he will never be able precisely to draw the line where the light begins -and where the penumbra ends[1301]." - -The extent of the epidemic of scarlatinal sore-throat, of which we have -particulars from Middlesex, Warwickshire and Worcestershire in 1778, -cannot be ascertained. It is heard of, as we saw, in the north of Scotland -in 1777. According to Barker, of Coleshill, the scarlet fever which "in a -manner raged in the neighbouring town of Birmingham," occurred in only a -few cases in his own parish, and these mild[1302]. It appears to have been -in Carlisle the year after, 1779, under which date Heysham says that "two -epidemics swept off a great number of children--smallpox and a species of -scarlet fever[1303]." Nothing more is heard of it in Carlisle for the next -eight years, during which Heysham kept an account of the diseases. The -epidemic of 1778-9 fell also upon Newcastle: - - From the month of June, 1778, until the 1st September, 1779, there - were treated 146 cases of "ulcerated sore-throat," of which 18 were - fatal. The epidemic was at its height in September and October. The - ages were: under ten years, 98, ten to twenty, 25, twenty to thirty, - 18, above thirty, 5. Dropsy followed in 23; 75 were mild scarlatina - and sore-throat, 33 were angina maligna. During the ten years - following, until 1789, only 57 more cases were treated from the - Newcastle Dispensary, of which 8 were fatal[1304]. - - -History of Scarlatina after the Epidemic of 1778. - -In London, according to Dr James Sims, scarlatina with sore-throat -occasioned a great mortality in the latter half of 1786. The bills of -mortality assign only 19 deaths to sore-throat, while they give 793 for -the year to measles. But Sims says that "measles were not present in -London during the whole year; at least I saw none, and I saw about two -thousand cases in private and at the General Dispensary." - -The deaths from scarlet fever, he thinks, had been given under measles and -also under "fevers," which were a large total for the year. The epidemic -was very virulent, going through families; many lost two children, some a -larger number; many adults fell victims to it who were supposed to die of -common fever. - - Sims' first case was of a youth at Camberwell, in March, with scarlet - rash and sloughs of the throat. He saw no more cases for several - weeks, and then, on 1 May, he was called to a case of sore-throat in a - school at Hampstead; the illness was slight, and there was no - efflorescence; but in June there occurred in the same school an - explosion of scarlatina, twenty of the girls being seized within a - short time. It was in other suburban villages in the summer, but did - not enter London until August, after which Sims saw three hundred - cases of it; of some two hundred treated by him in a certain way, only - two died. The symptoms of the epidemic were the usual ones of scarlet - fever with ulcerated or sloughing throat. In November and December, - swelling attacked the face and extremities, which were painful but not - oedematous. The parotids were swollen. Several had the angina without - the rash; others the rash without the angina[1305]. - -The same epidemic in London was one of the early medical experiences of Dr -Robert Willan, who gave some account of it in the volume 'On Cutaneous -Diseases' which he published in 1808, shortly before his death[1306]. It -began in the autumn of 1785, was superseded by measles for a time, and -revived again in 1786, to last into 1787. It was most malignant in the -narrow courts, alleys and close crowded streets of London, but existed -also in the villages near. While admitting the existence of measles in the -winter of 1785-86, he confirms Sims in saying that it was not measles (as -in the Bills) but scarlatina that caused the high mortality in 1786: "The -cases of scarlatina during the year 1786 exceeded in number the sum of all -other febrile diseases within the same period." The deaths were mostly -between the seventh and eighteenth day of the fever. The following is his -classification of over two hundred cases seen by himself: - - 1786 - - Scarlatina Scarlatina Scarlatina Sore-throat - simplex anginosa maligna without eruption - - April -- 3 -- -- - May 6 10 2 -- - June 4 12 1 4 - July 2 11 1 3 - August 1 17 4 4 - Sept. 2 29 9 12 - Oct. 3 24 5 7 - Nov. 0 38 12 10 - Dec. 0 8 5 2 - -- --- -- -- - 18 152 39 42 - - The infirmary book of the Foundling Hospital has long lists of - patients sick of "scarlet fever with sore-throat" in August and - September, 1787, as many as 76 being under treatment in one week, the - next week 39 sick of scarlet fever, besides 45 recovering from it. - This is the first unambiguous entry of an epidemic of scarlet fever in - the Foundling Hospital records[1307]. Under the same year, 1787, - Barker, of Coleshill, records "scarlet fever, smallpox, and chincough" - in a neighbouring city, as well as pestilential sore-throats - "epidemical everywhere in the terrible foul weather of winter." His - next entry of "scarlet fever and sore-throat" is under the year - 1791[1308]. - - An account by Dr Denman, of London, dated 28 November, 1790, of "a - disease lately observed in infants," but otherwise unnamed, appears to - relate to diphtheria. Eight cases in young infants were seen, one per - month from April to October, of which six proved fatal. The signs were - "thrush in the nose," fulness of the throat and neck, the tonsils red, - swelled, and covered by ash-coloured sloughs or extensive ulcerations. - The skin sloughed at places where blisters were applied. Nothing is - said of a scarlet rash[1309]. - - -Scarlatina (1788) and Diphtheria (1793-94) described by the same observer. - -One good observer at the end of the 18th century, Rumsey, a surgeon at -Chesham, in Bucks, has left full accounts of two epidemics in his -district, one in 1788, which he calls "epidemic sore-throat[1310]" and the -other in 1793-94, which he calls "the croup[1311]." The one corresponds to -scarlet fever, the other to diphtheria. The author does not think it -necessary to enlarge on the distinction between the "epidemic sore-throat" -and "the croup" as it was so obvious; yet the former was "Fothergill's -sore-throat," which some English writers of the present time assume to -have been diphtheria; while the disease which Rumsey calls "the croup" -corresponds with laryngeal and tracheal diphtheria, not unmixed with -diphtheritis of the tonsils, uvula and velum. There is hardly anything in -the history of scarlatina and diphtheria more instructive than the -juxtaposition of those two excellent descriptions by Rumsey, who grudged -the name of scarlatina to the former epidemic because the rash was not -invariable, and called the latter by the name of croup although it was not -confined to the larynx and trachea, and was epidemic in the summer months. - -The epidemic of "sore-throat" in 1788 began in April and lasted until -November, attacking those of every age except the very old, but especially -children, and mostly women among adults. - - The throat was slightly sore for twelve or twenty-four hours; it then - became fiery red, the uvula and tonsils being much swelled. About the - second or third day there were whitish or yellowish sloughs on the - tonsils and uvula, which in many cases left deep, ragged ulcers. It - was many days before the sloughs were all exfoliated. Some spat up an - astonishing quantity of mucus; in young children there was apt to be a - discharge of mucus from the nostrils, and in a few cases from the - eyes. The parotid and submaxillary glands were often enlarged, - sometimes suppurating or sloughing. A white crust separated from the - tongue on the third or fourth day, leaving it raw and red. In some - cases there was sickness with vomiting, in some diarrhoea. In many - cases there was a scarlet eruption over the whole body, usually on the - second or third day. The fatal cases had all a very red eruption, and - the skin burning to the touch. In some the eruption was so rough as to - be plainly felt. In a few cases, after the efflorescence broke out, a - number of little pustules made their appearance about the breast, - arms, &c., of about the size of millet seeds, which died away in - twenty-four or thirty-six hours. This was not common; but in one - family the mother and three of the four ailing children had pustules. - One young man had large white vesicles on the sixth day; another young - man, in November, had vesicles on the arms, thighs and legs as large - as a half-crown piece, filled with yellow serous fluid, or gelatinous - substance, with a good deal of erysipelas round them. The red - efflorescence was always followed by peeling. Many had the - throat-disease without rash, but none had the efflorescence without - the sore-throat. - -Rumsey decides against two distinct types of disease; it was the same -contagion acting on different constitutions; yet he could not help -thinking that scarlatina anginosa was an improper term for it, inasmuch as -the rash was not constant. It was a less putrid disease than that -described by Fordyce in 1773 (_supra_, p. 707), and carried off but few -considering the great numbers who were affected by it. Two of the -fatalities in children were from the anasarca of the whole body, with -scanty urine, which came on a week or two after. He bled only once, -applied leeches to the temples in several, and saw many recoveries with no -treatment but topical applications. - -The epidemic five or six years after in the same town in a valley of -Buckinghamshire and on the hills for some six miles round was something -unusual. Rumsey had about forty cases of "the croup" from March, 1793, -until January, 1794; whereas his father, who had practised there above -forty years, could not recall more than eight or ten cases of "croup" in -all his experience. The cases were all in children from one to fourteen -years; there were sometimes three attacked in one family; most of the -fatal cases occurred in summer; the epidemic was distributed impartially -in the valley where Chesham stands and upon the hills enclosing it. Rumsey -gives full details of seventeen cases, eight that died and nine that -recovered, with post-mortem notes for some. - - His first case was in March, 1793; then came a succession of cases - about June and July, of which four that proved fatal were in children - just recovered from measles. All those earlier cases had the disease - coming on insidiously, then the peculiar cough and tone of voice, if - any voice remained, paroxysms of choking, expectoration of shreds of - membrane, giving relief to the distress, and the trachea found after - death lined with a coagulated matter[1312]. Among these summer cases - were three children in one family, of whom two died, both being just - out of the measles. The later series of cases in the winter of 1793-94 - were less often fatal; the epidemic constitution, he says, became less - severe towards the end; he also used mercurials freely on the later - cases; but it is farther noteworthy that "most of the cases which - occurred in November and afterwards, were attended with inflammation - and swelling of the tonsils, uvula and velum pendulum palati, and - frequently large films of a whitish substance were found on the - tonsils"--so that the disease was in its extension more than cynanche - trachealis, or croup, even if it had not been also an epidemic - infection. - -In only one case, the eighth recorded, does he seem to have hesitated -between "the croup" and sore-throat: "ulcerated sore-throats being at this -time [6 Sept. 1793] somewhat prevalent, induced me to inspect the fauces, -and I observed a swelling and no inconsiderable ulcer on the left tonsil." -It was in the autumn and winter that these throat complications of "the -croup" mostly appeared; and it was because he found "so much disease about -the tonsils" in the tracheal and laryngeal cases that he forebore to -bleed, and used mercurials. Also in the same season when "the croup" was -joined to disease of the tonsils, uvula and velum, there was a certain -epidemic constitution prevalent: "In the autumn, likewise, and winter, -many children suffered by erysipelatous inflammation behind the ears, in -the groins, on the labia of girls, or wherever the skin folded, attended -with a very acrid discharge"--precisely the complication of the -"throat-distemper" of America described by Douglass and Colden as well as -by Bard, also of the Irish throat-epidemic in 1743 mentioned by Rutty, of -the morbus strangulatorius in Cornwall described by Starr, and of the -sore-throat described by Fothergill. In systematic nosology, do the -corrosive pustules behind the ears, in the groins, labia, &c., belong to -scarlatina or to diphtheria? - - * * * * * - -It is perhaps the same juxtaposition, or intermixture of scarlatina -anginosa and diphtheria, that we find in the north of Scotland about the -same time of the 18th century. Various parish ministers who contributed to -the first edition of the _Statistical Account_ make mention of "the putrid -sore-throat" about 1790 and 1791, without any reference to fever or -scarlet rash. The following relates to three localities in Aberdeenshire: - - New Deer: "In the autumn of 1791, a putrid kind of sore-throat, which - first made its appearance about the coast side, found its way into - this parish. Since that, it has continued to rage in different places - with great virulence and little intermission, and is peculiarly fatal - to the young and people of a full constitution[1313]." Crimond, a - coast parish: "The putrid sore-throat raged with great violence two or - three years ago [1790 or 1791] in most parishes in the neighbourhood, - and carried off great numbers: but though a few were seized with it in - Crimond, none died of that disorder[1314]." Fyvie, an upland - parish:--"There has been no prevalent distemper for some time except - the putrid sore-throat, which raged about two years ago [probably - 1791] and proved fatal to several people. It has appeared this winter, - but is not so violent as formerly[1315]." - -From Aberdeen the epidemic is reported in a letter by one of the -physicians, in May, 1790, in such terms as not to imply that it was -scarlatina: "The malignant sore-throat has been most prevalent and very -fatal, no period of life being exempted." In children from six months to -three years there was observed a livid appearance behind the ears which, -in seven or eight cases, spread over the external ear, causing the latter -on one or both sides to drop off by sloughing before death[1316]. - -The scarlet fever, with sore-throat, which reappeared in London about -1786-87 (and at Chesham in 1788) is said to have been somewhat steady -until 1794. Willan, who began his exact records in 1796, says -retrospectively that the scarlet fever with an ulcerated sore-throat had -been prevalent every autumn from the year 1785 to 1794, "and proved -extremely fatal[1317]." Lettsom gave a particular account of it in the -spring of 1793[1318]; it was seen first in the higher villages about -London, gradually descended into lower situations, and visited the -metropolis pretty generally about the end of February. "It has been -remarked for many years that this disease appears in the vicinity of -London before it visits the metropolis," beginning often among the -numerous boarding-schools in the suburbs, to be carried thence by the -dispersion of pupils to their homes. In some villages private families -suffered greatly; in a few Lettsom heard of half the children dying, as -well as of deaths among the domestics and other adults. The same epidemic -of 1793 also called forth one of the numerous essays of Dr Rowley, who had -written on the "malignant ulcerated sore-throat" in 1788[1319]. - - -Scarlatinal Epidemics, 1796-1805. - -The history of scarlatina in London, as of most epidemic maladies, is -enriched for a few years by Willan's monthly or quarterly accounts of the -cases treated at the Carey Street Dispensary. From the beginning of 1796 -to the end of 1800, scarlet fever is hardly ever wanting, and is -occasionally the principal epidemic. It is only now and then, however, -that a death from it appears in the Parish Clerks' bills of mortality. -Willan remarks that they gave only one death from that cause between the -8th and 29th November, 1796, "a period during which there occurred many -fatal cases of that disease." The bills have only three deaths from it in -the quarter 27 Sept.-27 Dec. 1796. The Parish Clerks did not adopt scarlet -fever fully into their classification until 1830; long after it had become -an important factor in the mortality, they placed the deaths from it under -"fevers" or under "measles." According to Willan's experience, it must -have been as common as measles from 1796 to 1801. It was, he says, always -most virulent and dangerous in the month of October and November, but -generally ceased on the first appearance of frost. He records a spring -epidemic as an exceptional thing in 1797: "Since the beginning of May, the -scarlatina anginosa has become more frequent than any other contagious -disease, both in town and in many parts of the country; the disease has -generally occurred in its malignant and fatal form, which, at this season -of the year, is very unusual." The bills give only one death from 18th -April to 18th May. Willan says that it was rife again in the autumn of -1797 and of 1798. Dr James Sims, who had described the scarlatina of -London in 1786, found the epidemic in the end of 1798 so different from -the former, and attended with so great fatality, that he made it the -subject of a second paper[1320]. It was preceded in the winter and spring -of 1797-98 by a remarkable epidemic among the cats of London (an angina, -with sanious discharge from the nostrils and running at the eyes), which -killed "myriads" of them[1321]. In Sept.-Oct. 1798, he heard that a -scarlet fever had been fatal to some adults about South Lambeth, and -afterwards to several children there, five dying in one family and three -in another. The swellings on each side under the jaw were so great as to -force the chin up into the horizontal; there was much acrid foetid -discharge from the nostrils, the pulse sank about the seventh day, and the -scarlet eruption remained out until near death, which took place usually -about the ninth or tenth day. Along with this malignant type, a mild or -simple scarlatina was also prevalent. Sims wrote when the epidemic seemed -to be "in its infancy," and so it proved; for Willan describes it as -prevailing to the end of 1798 and rising still higher in the first months -of 1799, his report for February and March being: "Scarlatina anginosa in -its malignant form has been very prevalent, and has proved in many -instances fatal; and in those who recovered, it produced after the -cessation of the fever, anasarca, swelling of the abdomen, swelling of the -lips and parotid glands, strumous ophthalmia, with an eruption of the -favus, and hectical symptoms of long duration. The disease spread from -London to the adjacent villages, and was almost universal in Somers Town -during the month of February." It continued throughout the year, and into -1800, being second in importance among the epidemic maladies only to -typhus, which, in that time of distress, was the grand trouble of the -poorer classes in London. Willan's reports cease with the year 1800; but -it appears from other sources that a very malignant scarlet fever and -sore-throat prevailed in London in the summers and autumns of 1801 and -1802, becoming milder in 1803[1322], and in various parts of England -during the same three years. The provincial accounts for those years give -the impression that this was the first general outbreak for some time, -perhaps since the one described by Withering and others in 1778; and that -is also suggested by the statistics of the Newcastle Dispensary: in the -two first years of its practice, from 1 October, 1777, it treated 146 -cases, with 18 deaths; in the next ten years 1779-1789, it treated only 57 -cases, with 8 deaths; and from 1790 to 1802, it treated 152 cases, with 7 -deaths[1323]. Accounts of very general scarlatina come from various -parts of England. In the summer and autumn of 1801 it ran through many -parishes of Cornwall, sparing others. In the parish of Manaccan, twelve -out of the twenty-five burials in the year 1801 were from scarlatina--the -malignant or putrid form, which was often fatal before the third day. In -many other cases, the first untoward symptom was the dropsical swelling -which came on as the fever went off. Three years after, in 1804, there was -much scarlatina in and around Falmouth[1324]. In 1805 it caused 12 in a -total of 20 deaths in Revelstoke parish, South Devon. - -In Northamptonshire in 1801 it was observed "in a form similar to the -epidemic described by Dr Withering[1325]." At Cheltenham in 1802 it was -also compared to the epidemic described by Withering: "in consequence of -the number of persons who have gone through the disease, it has for this -month past (20th December) been gradually on the decline[1326]." At Derby, -in 1802, it had been the prevailing complaint in the last eight months of -the year[1327]. In the district of Framlingham, Suffolk, in 1802-3, it had -proved very malignant and fatal in many families[1328]. It is heard of -also from Lancaster[1329], and from various other parts of England, being -casually mentioned in reports on the influenza of 1803. - -To this period also belong several incidents of a kind that had attended -scarlatina from its first appearance, namely, school epidemics of it. One -of these was an outbreak in the Quaker boarding-school for boys and girls -at Ackworth, in Yorkshire, in 1803. Although many of the children -dispersed, yet no fewer than 171, in a total of 298 on the roll, were -attacked with scarlatina in the course of four months, of whom seven -died[1330]. In the same year Dr Blackburne published a treatise on the -preventive aspect of the disease, with directions for checking the spread -of it "in schools and families[1331]." It broke out in 1804 among the boys -in Heriot's Hospital, Edinburgh, and in the city generally in 1805[1332]. -Ferriar makes mention of a "destructive epidemic of scarlet fever" in -Manchester in 1805, which he supposed to have been introduced from -Liverpool[1333]. - -The general prevalence of malignant scarlet fever in the first years of -the 19th century is farther shown by the accounts from Ireland, which were -recalled by Graves in a clinical lecture of the session 1834-35, during -the prevalence of a scarlet fever as malignant as that of thirty years -before[1334]. - - "In the year 1801," he says, "in the months of September, October, - November and December, scarlet fever committed great ravages in - Dublin, and continued its destructive progress during the spring of - 1802. It ceased in summer, but returned at intervals during the years - 1803-4, when the disease changed its character; and although - scarlatina epidemics recurred very frequently during the next - twenty-seven years, yet it was always in the simple or mild form, so - that I have known an instance where not a single death occurred among - eighty boys attacked in a public institution. The epidemic of - 1801-2-3-4, on the contrary, was extremely fatal, sometimes - terminating in death (as appears by the notes of Dr Percival kindly - communicated to me) so early as the second day. It thinned many - families in the middle and upper classes of society, and even left not - a few parents childless. Its characters seem to have answered to the - definition of the scarlatina maligna of authors." - -The long immunity from malignant scarlatina which Graves asserts for -Ireland after 1804, is made probable also for England and Scotland after -1805, by the fewness of the references to it in medical writings. Bateman -in 1804 resumed the regular reports on the prevalent diseases of London, -which Willan had left off at the end of 1800, and continued them until -1816[1335]; but he makes very few references to scarlatina compared with -his predecessor. The two occasions when it is said to have been somewhat -common were in 1807-8, during the severe epidemic of measles (and then it -was "generally mild, presenting the eruption with a slight sore-throat"), -and in 1814 when it was "very prevalent" along with measles. In Scotland -during the same epidemic of malignant measles, in 1808, scarlatina was -only occasional, and mild. It is heard of in its old malignant form from -two localities of England, during the time of distress and typhus fever in -1810-11. At Nottingham it was "very prevalent, passing through whole -families," in September, 1810, and in October became more violent and -often fatal[1336]. In the district around Debenham, in Suffolk, where it -was last reported by the same observer in 1803, it made its appearance in -February, 1810, in its very worst forms, causing deaths of children and -adults in many houses, and destroying some children within forty-eight -hours from the first attack. "All the surgeons for ten miles round have -had to attend to scarlatina maligna in a variety of cases in all ages, -from infants to fifty and sixty years." It was still raging in October, -1810, and was breaking out "in different spots around this country, that -appear to have had no communication with the afflicted[1337]." - -It is not until 1831 that we begin to hear much of malignant scarlatina -again. But it is clear that scarlet fever was common enough all through -that interval, probably in its milder form. It was now the usual epidemic -trouble of schools. In September and October, 1814, there were fifty-five -cases, mostly mild, in children and two in adults in the Asylum for Female -Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal -Military College at Marlow, having been followed by anasarca in only one -instance[1339]. Heysham, whose exact records of epidemics at Carlisle were -made twenty or thirty years earlier, mentions casually in 1814 that -scarlet fever had been "more frequent of late," but that it did not spread -as formerly[1340]. Other references to it in this interval are to show how -seldom fatal it was under the cold water treatment or the lowering -regimen[1341]. At the Newcastle Dispensary fully twice as many cases of -scarlatina were attended in the twenty-five years 1803-27 (795 cases) as -in the twenty-five years 1777-1802 (355 cases); but in the larger total, -which an increasing population might account for, there were actually -fewer fatalities (30) than in the smaller (33); the highest number in any -one year was 71 in 1824, of which every one is entered as having -recovered. This is the impression derived from various sources--that the -scarlatina from about 1803 until about 1830 may have been frequent, but -that it was mild, or easily treated, or not often fatal. Macmichael, -writing in 1822, not only testified that the "scarlatina of last summer -was very mild," but argued that the malady in general was taken by many in -those years in so mild a form that it was not recognized as scarlatina, "a -name that sounds so fearfully in the ears of mothers," and a rare disease -in families compared with measles or even with smallpox. His point is that -scarlet fever was in fact as nearly universal as measles, but that, as it -was often extremely slight, it passed for rose rash or the like; at the -same time he identified these slighter forms with true scarlatina by -simply pointing to the oedema which might follow them[1342]. - -The testimony of Graves, of Dublin, who occupies many pages of his -'Clinical Medicine' with the disastrous scarlatina in various parts of -Ireland about 1834, is conclusive that the severe type was new in the -experience of that generation: - - "I have already mentioned that the disease called scarlet fever - assumed a very benign type in Dublin soon after the year 1804, and - continued to be seldom attended with danger until the year 1831, when - we began to perceive a notable alteration in its character, and - remarked that the usual undisguised and inflammatory nature of the - attack was replaced by a concealed and insidious form of fever, - attended with great debility. We now began occasionally to hear of - cases which proved unexpectedly fatal, and of families in which - several children were carried off; still, it was not until the year - 1834 that the disease spread far and wide, assuming the form of a - destructive epidemic[1343].... Many parents lost three of their - children, some four, and in one instance which came to my knowledge, - five very fine children were carried off." The severe cases were mixed - with others of scarlatina simplex. The violence of the attack lay in - the throat-affection, the congestion of the brain, or the irritability - of the stomach and bowels, nausea, vomiting and diarrhoea being early - symptoms, as in the malignant sore-throat with rash a century before. - -Graves proceeds, with much candour, to show how mistaken had been the -reasons assigned equally for the mild type of scarlatina between 1804 and -1831 and for the severe type of it previous to 1804: - - "The long continuance of the period during which the character of - scarlet fever was either so mild as to require little care, or so - purely inflammatory as to yield readily to the judicious employment of - antiphlogistic treatment, led many to believe that the fatality of the - former epidemic was chiefly, if not altogether, owing to the erroneous - method of cure then resorted to by the physicians of Dublin, who - counted among their numbers not a few disciples of the Brunonian - school; indeed, this opinion was so prevalent, that all those whose - medical education commenced at a much later period, were taught to - believe that the diminished mortality of scarlet fever was entirely - attributable to the cooling regimen and to the timely use of the - lancet and aperients, remedies interdicted by our predecessors. This - was taught in the schools, and scarlet fever was every day quoted as - exhibiting one of the most triumphant examples of the efficacy of the - new doctrines. This I myself learned--this I taught: how erroneously - will appear from the sequel. It was argued, that had the cases which - proved fatal in 1801-2 been treated by copious depletion in their very - commencement, the fatal debility would never have set in, for we all - regarded this debility as a mere consequence of previous excessive - reaction. The experience derived from the present [1834-35] epidemic - has completely refuted this reasoning, and has proved that, in spite - of our boasted improvements, we have not been more successful in - 1834-5 than were our predecessors in 1801-2." - -From 1829 to 1833 there are numerous references to the scarlatina maligna -in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in -1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346] -in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348] -in 1832-1833. It is in 1830 that scarlet fever begins to have a line to -itself in the old and inadequate bills of the Parish Clerks of London, the -deaths that year being 94; in the next seven years they are 143, 388, 481, -523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths -from it in Glasgow[1349] for five years, during which they fell much below -the deaths from either measles or smallpox. - -_Deaths from Scarlatina in Glasgow._ - - Under one 1-2 2-5 5-10 10-20 20-30 30-40 40 and up. Total - - 1835 27 50 89 73 23 7 2 2 273 - 1836 34 57 136 86 25 9 5 3 355 - 1837 4 9 34 22 5 3 1 1 79 - 1838 3 15 42 17 7 1 1 1 87 - 1839 29 45 104 74 10 -- -- -- 262 - -The two first years of this period, which had the most scarlatina deaths, -correspond to the years of the Dublin epidemic, and were also the years -when it was common in Edinburgh[1350]. Probably the smaller mortality of -Glasgow in 1837 and 1838 was general; for, when registration of the causes -of death began in England and Wales in the latter half of 1837, it found -the scarlatina mortality at a much lower figure than it reached in 1839 -and continued to keep thereafter. - - -Scarlatina since the beginning of Registration, 1837. - -The first returns of the causes of death under the new Registration Act -happened to correspond with a great epidemic of typhus fever, and with an -equally great epidemic of smallpox which took its victims in largest part -among infants and young children. The deaths from scarlatina were also -considerable during those two years and a half; but in 1840 scarlatina -nearly doubled its mortality, and continued year after year for a whole -generation to be the leading cause of death among the infectious maladies -of childhood. The figures for England and Wales are given in a table at p. -614, in comparison with the annual deaths by smallpox, measles, and -diphtheria. The enormous number of deaths from scarlatina during some -thirty or forty years in the middle of the 19th century will appear in the -history as one of the most remarkable things in our epidemiology. There -can be no reasonable doubt that this scarlatinal period was preceded by a -whole generation with moderate or small mortality from that disease, just -as it is now being followed by annual death-rates which are less than a -half, perhaps not more than a third, of the average during forty years -before 1880. - -The first great epidemic all over England was in 1840 (it had reached a -maximum in London the year before), another came in 1844, a third in 1848 -(in which the London death-rate was 2.12 per thousand living). In the next -decennial period, 1851-60, the worst years for scarlatina were 1858-59, -which were also the years of the return of diphtheria; in the period -1861-70, the great scarlatinal years were 1863-64 and 1868-70; in the -period 1871-80, the year 1874 was the epidemic year. The annual average -death-rates per million inhabitants in all England and Wales were as -follows in four decennial periods: - - 1851-60 832 - 1861-70 972 - 1871-80 716 - 1881-90 338 - -In the greatest epidemic years since 1863 the death-rates per million for -the whole country have been: - - 1863 1498 - 1864 1443 - 1868 1020 - 1869 1275 - 1870 1461 - 1874 1062 - -In those years scarlatina made from four to six and a half per cent. of -the deaths from all causes. - -While no county of England has been free from this infection, the bulk of -the deaths have fallen upon the capital, the great Lancashire and West -Riding towns, the Black Country of Staffordshire with Warwickshire, the -mining districts of Durham and South Wales, and, in the earlier part of -the period, upon the south-western counties. - -_Highest Mortalities by Scarlatina in three Epidemics._ - - /-----------\ /-----------------\ - 1863 1864 1868 1869 1870 1874 - - England and Wales 30475 29700 21912 27641 32543 24922 - ------------------------------------------------------------------- - London 4955 3244 2916 5841 6040 2648 - Lancashire 4580 4854 4445 4890 3702 6404 - West Riding 2218 3135 1676 2870 3718 3779 - Durham 1216 403 2678 1512 983 1941 - South Wales 501 1990 285 804 1370 1388 - Staffordshire 1147 1134 943 1198 1064 1270 - Devonshire 778 1054 60 155 646 72 - Cornwall 995 572 254 161 587 50 - Somerset 773 1013 55 154 584 173 - -In Lancashire and South Staffordshire there has been less fluctuation of -the mortality from year to year than elsewhere. The stress of an epidemic -has not fallen equally on all the principal centres in the same year or -years: thus Durham has had the epidemic in advance of other centres, while -South Wales has had it in arrear. The decline of the south-western -counties from their leading position in 1863-64 has been remarkable. -Plymouth, Devonport and Stonehouse, which had contributed most to the high -scarlatinal death-rate of Devonshire in 1863-64, were found on the average -of the next decennial period to have low rates from scarlatina, but -death-rates from measles which were unapproached in any other region of -England. In the following table four Devonshire towns are compared with -certain Staffordshire registration districts in which the scarlatinal -death-rate has remained high. - -_Annual average Death-rates per 1000 living, 1871-80._ - - All causes Scarlatina Measles - - {Plymouth 22.63 .25 1.13 - {E. Stonehouse 28.23 .33 1.79 - {Stoke Damerel 20.42 .37 1.19 - {Exeter 24.99 .50 .82 - - {Stoke-on-Trent 25.80 1.22 .49 - {Wolverhampton 22.78 1.05 .35 - {Walsall 22.82 1.21 .30 - {Dudley 24.24 1.18 .59 - -This looks like a correlation between measles and scarlatina. The -excessive death-rate from measles in Plymouth, Stonehouse and Devonport -was due to a disastrous epidemic in the last two years of the decennium, -1879 and 1880 (338 deaths at Plymouth, 121 at Stonehouse, and 235 at -Devonport). Measles remained high in Plymouth all through the next -decennium, scarlatina still continuing low until the very end of it, when -in 1889 there was a mortality of 270, equal to a death-rate of 3.39 per -1000 living. In like manner Stoke-on-Trent had its great epidemic of -measles in 1888, causing 342 deaths, or a rate of 2.8. The high Plymouth -death-rate, after nearly twenty years with extremely little scarlet fever, -was surpassed in 1882 by an epidemic of 346 deaths in the colliery -townships of Aberystruth and Tredegar, Monmouthshire, equal to a -death-rate of 6.1 per 1000. Other high death-rates for single years were -at Wakefield and Swansea in 1889 and at Neath in 1890. The highest -death-rates from scarlatina on an average of ten years, 1871-80, were at -Durham 1.70, Todmorden 1.64, Auckland 1.63, Gateshead 1.60, Sheffield -1.49, Leigh 1.41, Wigan 1.30, Newcastle 1.28. The purely agricultural -counties have the lowest death-rates[1351]. - -As to age-incidence, the proportion of deaths under five has been almost -exactly two-thirds steadily for the last four decennial periods (supra p. -625). The following table by Dr Ogle, the Superintendent of Statistics, -shows both age and sex of the scarlatina mortality[1352]: - -_Mean annual Mortality from Scarlet Fever per million living at successive -age-periods 1859-85. England and Wales._ - - Age Males Females - - 0-1 1664 1384 - 1-2 4170 3874 - 2-3 4676 4491 - 3-4 4484 4332 - 4-5 3642 3556 - 0-5 3681 3482 - 5-10 1667 1613 - 10-15 346 381 - 15-20 111 113 - 20-25 59 77 - 25-35 36 58 - 35 and upwards 13 15 - All ages 778 717 - -From certain hospital statistics on a large scale, and some figures of -cases and deaths at Christiania, it was also found that the attacks of -scarlatina were much more fatal in the first years of life, the fatality -decreasing rapidly after five. This was only to be expected. But it was -somewhat surprising to find that more girls were attacked than boys, while -the fatalities among boys were more than among an equal number of girls at -all ages until womanhood, when the few females attacked by scarlatina had -more fatalities among them than the somewhat fewer males of the same ages. -A slight excess of fatality in the female sex over the male between the -ages of ten and twenty years, is shown also for smallpox by the table at -p. 618. Recent notifications of infectious diseases to medical officers of -health have enabled a comparison to be made between the number of cases of -scarlatina notified, with age and sex, and the number of deaths certified -in the corresponding time and place to the Registrar-General; from which -the above generalities as to the proportions of fatal cases in the several -age-periods of either sex have been confirmed[1353]. - -The enormous mortalities of some years may be taken to have depended in -part upon an increased prevalence of the disease, but still more upon an -increased fatality among the subjects of it. Since the establishment of -the Metropolitan Fever Hospitals in 1870 the percentage of deaths to cases -has ranged from 15.3 in 1879 to 6.6 in 1873 and 6.7 in 1891. Among the -smaller totals of the London Fever Hospital the percentage of deaths has -ranged even more widely from year to year[1354]. What is thus -statistically proved is also a matter of common experience; there have -been whole epidemics, extending perhaps over two or three years, marked by -high malignancy, and epidemics just as uniformly marked by mildness of -type. The severe type has usually been made by the sloughing in the neck -or throat; but there has also been a class of cases tending to a fatal -issue early in the attack by a sunken pulse and with few external -manifestations. The cause of these variations in the severity of -scarlatina is the old problem of epidemic constitutions: sometimes the -constitution is "putrid" or "pestilential" or malignant, sometimes it is -mild or benign. - -Graves, in the passage above cited, has sufficiently exposed the fallacy -of attributing changes of type to modes of treatment. On the other hand -there is reason to think that the percentage of deaths (by which the -"type" is usually judged) is higher in children carried off to hospitals -than in those treated at home. As the same fact has been uniformly -observed in epidemics of Asiatic cholera, when the ambulances have been -almost as busy as those of the Metropolitan Asylums Board during an -ordinary autumnal rise of scarlatina, it is probable that the reasons -which used to be given in the former case hold good also in the latter. - -_Scarlet Fever in London, 1890 and 1891._ - - All Cases Treated Treated in Fatalities Fatalities in - Year Notified at Home Hospital at Home Hospital - - 1890 15330 8793 6537 348 510 - or 3.95% or 7.8% - - 1891 11398 6136 5267 232 357 - or 3.8% or 6.8% - -This is a comparison of two parts of the same epidemic, which had a very -moderate fatality in any case. The real problem of malignity or severity -of type arises over such epidemics as those of 1840, 1848, 1858-59, -1868-70 and 1874, in which the doubling of the deaths, for one year, or -for two or even three consecutive years, had depended less upon an -increased number of seizures than upon a higher ratio of fatalities. An -explanation for each occasion will have to be sought either in the -condition of the patients, or in the inherent properties or external -favouring circumstances of the virus. As to the former, the most fatal -epidemic years of scarlet fever have not been marked in any such uniform -way as the great seasons of typhus or relapsing fever; nor is scarlatina -an infection that keeps mainly within the poorer classes. Among factors of -the external kind, a rainfall below the average has been thought a -relevant thing: thus in the three years 1862-64, the annual average -rainfall at Greenwich was only 20.6 inches, the scarlatina death-rate in -London for the same years reaching the high figure of 1.33 per 1000 -inhabitants; in the next three years, 1865-67, the death-rate fell to .56 -(it would have fallen in any case), while the rainfall reached the very -high average of 29 inches; in the three years following, 1868-70, the -death-rate reached the excessive annual average of 1.5 per 1000 in London, -the rainfall of the same period averaging only 22.3 inches. Thereafter for -a number of years the rainfall was moderate and the scarlatina death-rate -low; but in the years 1883-87, they were both low together, the scarlatina -death-rate of .26 being lower than it had ever been since registration -began[1355]. - -Although an empirical correspondence between the great scarlatina periods -and a series of dry years has not been made out without important -exceptions, hitherto unexplained, yet there is a very obvious -correspondence between the great rise of scarlatina deaths in London every -year and the season of late autumn, which is the season when the -ground-water touches its lowest level or begins to rise therefrom to the -high water-mark of spring. Of all the curves of seasonal rise and fall -constructed by Buchan and Mitchell from the weekly bills of mortality in -London from 1845 to 1874, that of scarlatina is the most decided next to -that of infantile diarrhoea, the deaths rising in October and November far -above the mean line of the year, and falling farthest below the mean in -spring and early summer[1356]. This was an old observation--by Sydenham -for the scarlatina simplex of that age, by Willan in the end of the 18th -century (one or two spring epidemics being remarked upon as exceptional). -It is a very curious fact, and one that is as certain (for London at -least) as it is curious. Sydenham explained it by the doctrine of his -time, that the favouring things were in the human body, namely, some -susceptibility of the humours owing to the heat of the preceding summer; -but, according to modern views, it should bring scarlatina into the same -class with the soil-poisons of enteric fever, yellow fever and cholera, -which are believed to become more rife owing to the greater activity of -their respective miasmatic viruses when the pores of the ground are -occupied to the greatest depth with air in place of water. - -It would be singular indeed if, after all, we should have to include -scarlatina among the miasmatic diseases; for it is an exquisite instance -of an infection which is passed from person to person, or by the agency of -volatile contagion, or by fomites in clothes, bed-linen, house-furnishings -and the like. The controversy which has raged so keenly in the past -between contagionists and non-contagionists over the instances of plague, -yellow fever and Asiatic cholera, would become still more keen over -scarlatina--and be still more confused if it were not stated in more -correct terms at the outset. What we all find so hard to learn is, that -the one way of infection does not exclude the other. Plague was for the -most part a miasmatic infection in the air of a plague-stricken town; but -it could be conveyed in clothes or bales, while it was prudent to remain -not too long in the company of a plague-patient. In like manner contagion -from the person was, as Rush said and Blane confirmed, a "contingency" in -yellow fever; and there are some authentic cases of Asiatic cholera which -cannot well be explained except on the hypothesis of contact with the -persons of those sick or dead of the disease. Scarlatina is more -contagious than any of these, because it shows so much on the surface of -the body and scatters its infective matter into the atmosphere of a room -with the fine scales or dust of desquamation. Still, there are conditions -for the contagiousness of scarlatina, just as there are for the rarer -event of contagion from the persons of the sick in the plague, yellow -fever and cholera. It is a remarkable fact that scarlet fever should ever -be sporadic, or that a single case should appear in the midst of a crowded -population (as I have seen in a coast town filled with strangers during -the herring fishery to the extent of one-half more than its usual -numbers), and no other cases follow for months after, although there had -been not the smallest attempt at isolation. Every medical practitioner -knows, if some laymen and legislators do not, that scarlatina is sometimes -highly contagious, and sometimes hardly contagious at all; and who can say -whether the mechanical routine of "stamping out" contagion, which certain -persons pursue with more zeal than knowledge, may not be the means of -turning a mere potency into an actuality? The tact of individuals rather -than the grinding machinery of an Act of Parliament is needed in dealing -with vagaries such as Willan thus describes: - - "I have seen in numerous families one child have scarlatina without - communicating it to any of the rest; yet, perhaps, in the succeeding - autumn, several of them were infected by only passing near a patient - recovering from the disease, or by touching those who had a little - time before visited some persons affected with it[1357]." - -There are two special forms of epidemic scarlatina which may prove to be -finger-post instances for the general pathology. It happens from time to -time in the surgical wards of hospitals for children, where many cases of -suppurating diseases (especially of the bones or joints) are aggregated -and kept together perhaps for months, that groups of the patients acquire -a scarlet rash, or an erysipelatous rash, or a hybrid form of rash, along -with the constitutional symptoms of scarlatina. Whether it be from the -suppuration, or from the blood of operations, this disease must be -reckoned a product of so-called "hospitalism." It is not without -significance that there may be an element of erysipelas in such cases. -They are probably cases of "blood poisoning," in a double meaning of the -term--poisoning of the living blood by dead blood or by pus which is -closely allied to blood[1358]. - -The other special kind of epidemic scarlatina is that which has broken out -among the inmates of houses supplied with milk from a common source. There -have been many such outbreaks, including one most remarkable instance in -which a large number of guests at an evening party, who had partaken of -cream with strawberries, were shortly thereafter attacked by scarlet fever -at their widely scattered homes. There can be no question that milk, or -cream, has been the vehicle of scarlatinal infection. The first hypothesis -tried was that of scarlatina on the dairyman's premises; the effluvia of a -scarlatinal patient might have become mixed with the milk. In some -instances, it was actually shown that there had been a case or cases of -scarlet fever among the dairyman's children; but there were other -instances in which that could not be shown, and it was, of course, -possible to refer the cases, where they did occur, to a common cause in -the milk used at the dairy and in the milk distributed from it. As more -and more outbreaks of the kind came to be investigated, it was indeed made -probable that the infection had got into the milk from the cow[1359]. -Someone threw out the suggestion that the cow suffered from scarlet fever, -the sign of it being soreness of the paps. Without taking seriously so -random a hypothesis as that, we find much agreement as to the fact that -the cows, to which the contaminated milk has been traced, were affected, -one or more of them, with sore paps. In some cases the disease of the -teats had been admitted to be the same as cowpox; in other cases that has -been denied; in a third variety, a cow has had cowpox on one teat and -something else on another. It matters little what name be given to the -affection of the cow's paps. All soreness of the skin of the teats has the -same effect so far as concerns the purity of the milk. Unless the milk be -drawn off by a catheter (according to a German practice), the paps are -necessarily made to bleed by being "stripped"; it has been admitted by -milkers that the blood, pus, and scabs are apt to become mixed with the -milk; and the discharges from the sore paps have actually been seen, by a -scientific witness, to trickle over the fingers of the milkers into the -milk-pail[1360]. The contamination of the milk which produces scarlatina -in those who use it is neither more nor less specific than that. The -disease is blood poisoning in the double sense of the term--poisoning of -the living blood by dead blood. Blood is a peculiar fluid, and so is milk. -When the two come together the result is peculiar. Both are animal fluids -that curdle by some peculiar ferment-change in their constituents. Again, -milk is peculiar in its property of taking up organic effluvia; thus the -milk standing in shallow vessels has been known to acquire the taste and -odour of tar from a tarpaulin in the adjoining farmyard. With such -properties of the milk, a small quantity of blood or pus in it will go a -long way. - -The one thing that connects the scarlatina of surgical wards in children's -hospitals and the scarlatina of the milk-pail is putrefying blood or pus: -the disease is a septic effect of blood, just as a scarlet rash is known -to be a toxic effect of very various drugs in peculiarly susceptible -subjects. The obviously septic varieties of scarlatina make but an -insignificant part of the whole; but they may be finger-post instances. -Thus, if we assume that the infection may be miasmatic from the ground as -well as contagious from the person, there are certain facts, or -suspicions, that will fit the hypothesis of putrefying blood. A theory of -scarlatina was put forward in 1871, on the basis of observations near -Croydon, that its virus came from the blood and offal of slaughter-houses -collected at particular spots to be used as manure[1361]. The first death -in a recent small epidemic within the writer's knowledge was of a -school-girl who lived just across the road from a slaughter-house. The -septic hypothesis of scarlatina might be made to include other corrupting -animal matters. Some practitioners have a suspicion that scarlet fever is -bred in the atmosphere of a horse-mews. On the greater scale, others have -traced a connexion between the more signal outbreaks of angina maligna and -preceding murrains of cattle[1362]. The animal matters which may become -toxic to man, in miasmatic or other form, are indeed many. If scarlatinal -drug-eruptions are any clue to the mystery of scarlet fever, we need not -be surprised to find a somewhat uniform disease-effect produced by a -variety of septic agents[1363]. But, in that hypothesis, the refuse of the -shambles will merit most attention. This was thought the one great -nuisance of London in the sanitary ordinances of Edward III., Richard II. -and Henry VII.; it was then considered a danger to health in the measure -of its offensiveness to sight and smell, but there may still be dangers -from it which are subtle and unperceived. - - -Reappearance of Diphtheria in 1856-59. - -The memorable outburst of epidemic throat-disease in Britain about the -years 1858-59 was part of a sudden uprising of the malady all over the -globe--in Europe, America, North Africa, India, China, and the -Pacific[1364]. It was only in some parts of France, and of Norway and -Denmark, that "diphtheria" had been epidemic in the generation before. Of -its novelty to nearly the whole British profession in 1858, familiar as -they were with the angina of scarlet fever, there can be no question. Its -appearance among diseases coincided with the publication of Darwin's -hypothesis of the origin of species by natural selection; and it was in -the terms of that hypothesis that Farr, of the Registration Department, -spoke of the phenomenon of diphtheria. New diseases, he said, "are only -recognized as distinct species when they have existed for some time. -Diphtheria is an example. It obtains a distinct line in the Tables of this -year [1859] for the first time"--with a total of 9587 deaths. For four -years before that, it had been in a "provisional table" under the names of -"diphtheria" and "cynanche maligna"; but in the general table, the deaths -under these names had been merged with the scarlatinal deaths. This -inclusion for a time of diphtheria under scarlatina could not have been -because practitioners had any difficulty in diagnosing the one from the -other, but probably because scarlatina anginosa seemed the nearest -affinity in the nosological system. Diphtheria in 1858 had no scarlet -rash, and yet it was supposed to be the same disease that had made so much -commotion in England about the middle of the 18th century: "In -Fothergill's account," says Farr, "the symptoms are confused by the -introduction of the eruption of scarlatina into his description"--as if -his description had been a patchwork of his fancy, with some characters -taken from "diphtheria" and some from scarlet fever. The greatest of our -nosologists, Cullen, had long before that separated "cynanche maligna" -from "scarlatina anginosa," but the separation was not made on the ground -of absent or present rash. Both had the rash, the cynanche having, besides -a general exanthem, very distinctively the peculiar scarlet redness, with -swelling and stiffness, of the fingers which Fothergill described, while -the scarlatina rash was "commonly more considerable and universal." Both -also might have a discharge from the nose; but when the coryza did occur -in scarlatina, "it is less acrid, and has not the foetid smell which it -has in the other disease." It was really on the ground of malignancy or -fatality that Cullen separated them. In forty years he had seen scarlatina -anginosa six or seven times prevailing as an epidemic in Scotland, and he -had seen two or three epidemics of cynanche maligna. He had seen mild -cases in the latter, as well as in the former; but whereas there would be -only one or two malignant cases in a hundred of scarlatina anginosa, the -malignant or putrid cases in an epidemic of cynanche were four-fifths of -the whole[1365]. On the other hand Willan, writing just fifty years before -the modern diphtheria made its appearance, maintained that "no British -author has yet described any epidemical and contagious sore-throat except -that which attends the scarlet fever," not even Starr, whose "morbus -strangulatorius" he held to be "the most virulent form of -scarlatina[1366]." - -The name diphtheria, which appeared for the first time among the -classified causes of death in England in the report for the year 1855 -(published two years after), had been given originally in 1826, with the -termination _itis_ according to the then Broussaisian fashion, by -Bretonneau in his account of epidemics at Tours in 1818-21 and at La -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 slope or on heights and hollows, such as -Gateshead, Newburn and Collieston (most of all in Quebec on the steep bank -of the St Lawrence), the infection did not confine itself to the lower -part only. But it was remarked that among the Tyneside villages several on -high ground escaped altogether, although within a mile or two of others -severely visited. This question of elevation comes up more definitely in -the cholera of 1849. - -Another obvious thing in the epidemic of 1832 was that many of the first -victims were among the destitute, drunken or reckless class. But there -were innumerable exceptions, notably in Paris, where the multitude of -victims included several peers, deputies, diplomatic personages and the -prime minister. - - One of the most striking things in the habits or preferences of - cholera in 1832 was the early and unaccountable selection of the - inmates of lunatic asylums, the fatuous paupers of workhouses, - prisoners, or other immured persons badly housed and ill-fed. In most - of these cases it was a mystery how the poison of cholera had got - inside the walls. The earliest important instance was that of the Town - Hospital or pauper infirmary of Glasgow. Other instances were the - lunatic wards of Haslar Hospital, Hanwell asylum, Bethnal Green - lunatic asylum, Lancaster county asylum, the Manchester New Bailey, - situated in Salford, Coldbath Fields Prison, London, Clerkenwell - workhouse (65 deaths), Bristol poorhouse (94 deaths). In the remote - Westmoreland village of Hawkshead, thirteen miles from Kendal, cholera - appeared unaccountably among the sixteen inmates of the poorhouse, - attacking eight of them with sudden and severe symptoms so that four - died; it was impossible to trace the introduction of the virus, but - the poorhouse was nearly surrounded with stagnant water[1534]. - -Hardly anything was more keenly debated than the question as to how -cholera spread. It was not difficult to find some instances of infection -seemingly got from contact with living or dead cholera bodies: cases -suggestive of that occurred at Sunderland at the outset, and later in -Ireland more especially[1535]. In the Swan Street cholera hospital at -Manchester, eight nurses took the infection, of whom four died. But on the -whole the immunity of nurses (as in the Great Gorman Lane hospital of -Dublin) and of medical men was remarkable. Although constantly in the -presence of cholera patients, sometimes lingering over them, as in the -operation of blood-letting, very few took the disease. In Manchester only -one medical practitioner was known to have had an attack, a mild one. -Gaulter says that Dr Alsop, of Birmingham, and Mr Keane, of Warrington, -were the only two medical men known to him to have died of cholera in -England; but two of the Bilston doctors died in the height of the epidemic -there, one died at Musselburgh, seven at Sligo, and two at Enniskillen. -The truth of the matter in cholera appeared to be the same as in plague -and yellow fever, the two great infections that resembled cholera most -closely as soil-poisons: namely, that contagion from the persons of the -sick was a contingency, as Rush, of Philadelphia, had taught for yellow -fever in the end of last century, and Blane had taught after him. A -London writer stated this very fairly in 1832[1536]: - - "I believe that this disease, like many other epidemic diseases, - although communicable by miasma in the atmosphere, and originating or - being producible from a peculiar state of that acting upon the earth, - is sometimes contagious (or communicable from person to person) and - sometimes not contagious. I believe the contagious nature of the - disease depends: first, upon the number accumulated in one place, and - the unhealthiness or ill-ventilated state of that place; or, in other - words, upon the degree in which the miasma is condensed; secondly, - upon the length of time a person remains exposed to the poison; third, - upon the debility, or morbid irritability, and consequent - susceptibility of the person's frame, especially of the abdominal - viscera." The miasmata of an apartment, to be strong enough to become - contagious, must arrive at a certain degree of concentration. - -Cholera was, at all events, very different from typhus fever in the point -of contagiousness: for in the epidemics of the latter many medical men -fell victims, and the susceptibility to contagion was greater in -proportion to the health and vigour of those who mixed with the sick. - -It was well understood in 1832 that foul linen, bedding and clothes were a -most certain means of carrying the poison, especially if they had been -kept concealed for a time, or packed away in a chest or bundle. This was -precisely the old experience of plague. The theory that the poison of -cholera was conveyed in the drinking-water, of which illustrations were -collected in 1849 and 1854, was not applied to any of the particular -outbreaks in 1832. But one writer made a guess at it, assuming, as Snow -did in 1849 and 1854, that the stomach and bowels were the organs by which -the virus entered the system: - - "From an attentive observation of the course this epidemic has taken - in those places and countries which it has hitherto visited, I have - been induced to draw the conclusion that a noxious matter or poison, - being generated in the earth, has been diffused in the different - springs in such situations [therefore he suggests the filtering of - water through charcoal], and that this matter, being conveyed into the - stomach with the fluid in question, produces that train of symptoms - which, commencing in this organ, afterwards extends with more or less - rapidity to the rest of the body[1537]." - - In the treatment of cholera in 1832 many things were tried. The view - taken of the pathology naturally determined the means of cure. To - check the premonitory diarrhoea was seen to be of the first - importance, and to that end laudanum or other form of opium was the - familiar means. Lawrie, at Glasgow, found it most satisfactory, at a - time when the profession in London were, as he says, denouncing it as - a pernicious error. Towards the end of the epidemic in Dublin, Graves - combined with the opium acetate of lead in large doses (a scruple of - acetate of lead with a grain of opium, divided into twelve pills, one - to be given every half-hour until the rice-water evacuations from the - stomach and bowels began to diminish)[1538]. Some professed to find - great benefit from blood-letting at a sufficiently early stage in the - attack[1539]. The enormous drain of the fluids, leaving the blood - thick or tarry, suggested to some that saline substances would be - beneficial. The saline treatment was indeed the principal subject of - writing during the year 1832. One way was to give saline drugs by the - mouth; another way was to inject into a vein a large quantity of - distilled water with some common salt and bicarbonate of soda - dissolved in it, the vein at the bend of the elbow being usually - chosen to operate on. Some were confident that they had saved lives in - this manner, others were equally clear that salines were useless. One - writer had abandoned salines by the mouth as a "most useless remedy," - while he had not lost faith in their intravenous injection, four - having recovered out of twenty-three in which he had tried it. At - length, however, the intravenous use of salines was abandoned - also[1540]. - -It is well known that the greatest of all the lessons taught by cholera -was the need of sanitary reform. The disease in its successive visitations -so obviously sought out the spots of ground most befouled with excremental -and other filth as to bring home to everyone the dangers of the casual -disposal of town refuse. It was not until some years after the first visit -of cholera that much was done in the way of extending the main drainage of -towns, connecting the house-drainage systematically therewith, getting rid -of open nuisances in back yards, and protecting the water-supplies from -contamination. The Report of the Health of Towns Commission, 1844, was -"the great magazine from which sanitary reformers drew their -weapons[1541]." In the next few years an active school of sanitarians -arose, including Sutherland of Liverpool, Grainger of London, and others. -In 1848 was passed the first Public Health Act, administered by a Board of -Health, of which Lord Shaftesbury was chairman, Chadwick and Southwood -Smith members. London was excepted from the scope of the Act; but the City -had a most vigorous medical officer in the person of John Simon, whose -reports dealt with public sanitation on broad principles applicable to the -capital and the whole kingdom. The movement in favour of sanitation, thus -begun, received an irresistible impulse from the cholera of 1849, the -lessons of which were as obvious as those of 1832. - -The cholera which reached Orenburg in 1829 and Astrakhan in 1830 lingered -in one part of Europe or another until 1837, Portugal and Spain having -been its chief theatre in 1833, the south of France in 1834, Italy in 1835 -and 1836, Austria, the Tyrol, Bavaria and (for the second time) Poland and -the Baltic ports in 1837. In England, there was some revival of the seeds -of it in 1833, as many as 1454 deaths being put down to Asiatic cholera in -London from the 1st of August to the 7th of September. There was an -undoubted epidemic of it at the fishing village of Ferryden, near -Montrose, in June, 1833 (27 deaths during four weeks in a population of -700), the infection having been brought by one or more of the crew of the -smack 'Eagle' from the Thames[1542]. In Glasgow a case occurred in Boar -Head Close, High Street, on 30 May, 1833, which had the blueness, pinched -face, whispering voice and cold clammy skin of Asiatic cholera[1543]. In -Ireland there were a good many outbreaks in 1833, especially in villages -or hamlets, and it is believed that these were renewed in 1834. But the -most singular reappearance of cholera in the British Isles was in the -month of December, 1837, some two months after it is believed to have -ceased elsewhere in Europe. Outbreaks of true cholera in that month were -observed at several places in the south of Ireland-around Bere -Haven[1544], at Youghal, at Waterford, and at Dungarvan, where they went -so far as to form a board of health[1545]. It was suspected to have been -in Limehouse, on the Thames, in November. The most remarkable explosion of -it was in the month of January following (1838) among the inmates of the -Coventry House of Industry, of whom no fewer than 55 died in the course of -four weeks--a mortality from choleraic disease that could hardly be -explained on the hypothesis of cholera nostras even if the season had been -the proper one[1546]. - - -The Cholera of 1848-49 in Scotland. - -The invasion of cholera from India, which reached Britain in the autumn of -1848, had progressed as far as Peshawur and Cabul from 1842 to 1844, and -thereafter step by step continuously through Herat, Samarkand, Bokhara, -Astrabad and Teheran by the caravan routes. In the beginning of 1847 it -entered Russia by the two great interior waterways of the Volga and the -Don. Next year, 1848, it reached the German shores of the Baltic and North -Seas, and within a few weeks of its appearance at Hamburg, it was found -established on British soil at Edinburgh and Leith in the beginning of -October. The severe outburst which followed in the south of Scotland was -purely a winter epidemic, like that of Durham, Northumberland and East -Lothian on the last occasion in the winter of 1831-32. It will not be -necessary to give the details of the cholera of 1848-49 so fully as has -been done for 1831-32, but merely to notice special points. - -The cholera of 1848 broke out almost simultaneously at Newhaven and -Edinburgh, on the 1st and 2nd of October, and at Leith on the 9th. At -Newhaven nearly the whole population was suffering from diarrhoea, in the -midst of which epidemic the true cholera raged for four weeks only, to the -28th October, attacking 30, of whom 20 died. In Leith the deaths were 185 -(males 75, females 110). The Edinburgh outbreak lasted until the 18th of -January, 1849, causing 801 attacks, with 448 deaths (or 478 deaths, of -which 196 were males and 282 females). A cholera hospital was opened in -Surgeons' Square on the 28th of October, the admissions and fatalities to -14th December being as follows: - - Females Males Total - - Admitted 152 96 248 - Died 90 64 154 - -Of the whole 248 cases, the Grassmarket sent 42, the Cowgate 37, the -Canongate 33, College Wynd 16, High Street 14, and numerous scattered -localities of the New and Old towns one or more cases each. Severe -outbreaks took place also at Niddry, Restalrig and Loanhead, villages -close to Edinburgh[1547]. While this limited epidemic was proceeding in -and around the capital, the infection appeared in the mining region of -Carron at the head of the Firth of Forth, where there were some 400 cases -after the 6th of December, and in some other mining villages of the Scotch -midlands. - -Glasgow was infected on the night of the 11th November, in the suburban -district of Springburn, on the north-west of the city close to the Forth -and Clyde Canal. The choice of this spot to begin upon was intelligible -enough in one way, but singular in another. Springburn had come into -existence as a poor village of weavers about the year 1820; before the -cholera year of 1832 it had grown to a population of 600, and was thought -a likely spot for cholera inasmuch as it was one of the most wretched -communities in Scotland. It occupied the site of a half-drained bog below -the level of the canal, from which the water percolated into its subsoil; -its houses were low, always damp, and full of filth. During all the -cholera in Glasgow in 1832 there had not been a case in Springburn until -the 6th of September, when a girl of the village came home with it and -died; during her brief illness she was visited by the greater part of the -villagers, but no other case occurred until six weeks after, on the 15th -of October[1548]. At this spot, where the cholera of 1832 may be said to -have left off, it began in 1848 with a sudden explosion of numerous -attacks scattered all over the locality; a doctor attended twenty-one -cases before he found two together in the same house or even in the same -lane. There had been forty cases there in November, before any case was -discovered in Glasgow; at length it seemed to spread from Springburn all -round as if from a centre, while it also lingered there longer than -anywhere else in the city and suburbs[1549]. On the 5th of December a case -was reported on the south bank of the Clyde, and another on the 9th in the -west end. Within a few days the disease fell upon all parts of the city -with the suddenness of a thunder shower; it reached a height in the -Christmas week, one day, the 30th December, having 158 burials from -cholera. After the orgies of the New Year there was a fresh outburst, 235 -cases having been reported on the 5th of January. The proportion of -fatalities was as high as 60 per cent. at the beginning of the epidemic, -50 per cent. about Christmas and the New Year, and thereafter from 30 to -40 per cent. The epidemic was short and sharp, declining irregularly after -the first or second week of January, and ceasing, but for a few dropping -cases, about the 8th of March. - -The deaths in Glasgow, which included many among the wealthier class and -made the festival season of 1848-49 to be long remembered, were about -3800, or 1.06 per cent. of the population (355,800), a higher total but a -lower ratio than in 1832, when the deaths, distributed over many more -weeks of the year and largely due to two revivals in August and October, -were 1.4 per cent. of the population. At Paisley there were 68 deaths from -26 December to 24 February, and at Charlestown 115 deaths all in some five -weeks from 15 January to 19 February. - -It was in the same season of midwinter that the cholera burst suddenly -upon many mining villages of Lanarkshire and Ayrshire. - - In that unlikely season there was an almost universal prevalence of - diarrhoea. At the mining village of Carnbroe, near Coatbridge, there - were five sudden attacks on the last night of the old year, one of - them fatal. On New Year's day there were forty attacks, thirteen of - them fatal in a few hours. Terror seized the whole place: one man cut - his throat in sheer fright. Diarrhoea attacked 1100 of the 1200 - inhabitants, and turned to spasmodic or rice-water cholera in 240 of - them, of whom 94 died, the rate of fatality being excessive only in - the first few days. By the end of February the epidemic was over. - - In the town of Coatbridge, with a population of 4000, the various - grades of sickness were classified as follows: - - Vomiting, - purging and Rice-water Deaths by - Diarrhoea cramp purging Cholera Cholera - - 2659 480 175 107 61 - - In the town of Hamilton, population 9000, the infection was most - malignant, 440 cases yielding 251 deaths from the 24th of December to - the 7th of March. The same ravages of winter cholera occurred at some - of the Ayrshire ironworks, such as Glengarnock, among a very rough and - drunken class, who were made more than ordinarily reckless and drunken - by this unaccountable visitation. It was also severe in Riccarton and - other mining villages round Kilmarnock, but less prevalent in that - town itself. Dumfries and Maxwelltown, which had been among the last - places visited by the cholera of 1832, were infected in the middle of - November, 1848, about the same time as Springburn near Glasgow. One of - the Dumfries doctors died of rapid cholera on the 10th December, the - parochial board fell into disputes with the faculty, and the infection - proceeded amidst great confusion in the poorest parts of the town, - causing about 250 deaths before Christmas. After that it subsided - quickly[1550]. - - The other centres in the south of Scotland were Selkirk (13 deaths), - Kelso (Dec. to end of Jan., maximum of 12 attacks in a day) and - Jedburgh, which last had escaped in 1832 but had now a very rapid and - extensive epidemic in its lower parts among drunken people especially. - A few cases occurred at Moffat, in December; a man who was seized in - crossing the hills died in a shepherd's hut eight miles from Moffat - after twenty-one hours illness[1551]. - -The only recorded epidemic in the north of Scotland in the proper cholera -season, the summer of 1849, was at Dundee. But there was a small outbreak -in March and April at Campbelton (41 cases, 14 deaths) and Inverness (23 -cases, 12 deaths)[1552]. - - The infection began in Dundee on the 29th of May, 1849, in Fish - Street, the filthiest part of the town. It prevailed in high and low - situations, but usually in the old localities of typhus fever. One - group of houses, said to have had a population of 100, had 40 deaths. - Dudhope Crescent, consisting of seventeen large five-storied tenement - houses occupied by clean and respectable people, had 57 deaths. In - about a fourth part of all the fatalities, death was from sudden - collapse; this was a feature of the 1849 cholera also in Ireland; but - in Dundee, as elsewhere, there was usually premonitory diarrhoea, and - a very general prevalence of diarrhoea which never came to true - cholera[1553]. - - -The Cholera of 1849 in Ireland. - -The cholera of 1849 found Ireland in a state of exhaustion and confusion. -The fever and dysentery that followed the great potato famines of 1845 and -1846 were still far from extinct; the workhouses, which had not existed in -1832, were full of paupers. The mortality of nearly half a million in the -famine years, and the emigration of perhaps three times as many, had -reduced greatly the population of the scattered cabins, hamlets and -villages; but the towns were more populous than ever from the immense -number of destitute persons that had gravitated to them. In these -circumstances it was not surprising that the cholera of 1849 should have -been more disastrous than that of 1832. The infection appeared first in -Belfast in November, 1848, in a man who had come with his family from -Edinburgh and had been admitted into the workhouse. Some thirty cases of -cholera among the inmates followed his death, and at length the infection -was started at large in the town, probably by a man who had been -discharged from the workhouse[1554]. The cholera of 1849 in the capital of -Ulster was more fatal than that of 1832, causing 969 deaths in 2705 -attacks. Over Ireland generally its great season appears to have been, as -in England, the summer, and in part also the spring. Excepting Belfast, -the principal cities and towns had fewer deaths than in 1832; Dublin -having only 1664 as compared with 5632, Cork 1329, or nearly the same -number as in 1832, Limerick 746, which was about a fourth less, Galway -less, Waterford about the same as in 1832 and 1833 together, and Drogheda -as severe an epidemic as last time. But the smaller towns and the rural -districts generally suffered more. The deaths for all Ireland returned to -the Board of Health were 19,325, nearly the same total as in 1832; but -there were no returns included from Wicklow, Cavan, Fermanagh and Donegal, -and it is probable that the returns were otherwise incomplete, the census -taken in 1851 giving 30,156 cholera deaths under the year 1849, and 35,989 -in the whole decennial period from 1841. The larger total was distributed -as follows: - - Urban Rural In hospitals In workhouses - - 10,653 10,656 7964 6716 - -The number of rural deaths is much larger than in 1832. There were only a -few towns with over 2000 inhabitants that escaped--one in Connaught, six -in Munster, one out of forty-one in Leinster, while seventeen towns were -visited in Ulster. The counties of Dublin, Carlow, Clare and Galway -suffered most; of the smaller towns, Tralee and Dingle lost heavily, both -among the poor and the rich. The town of Ballinasloe, near the confluence -of the Suck with the Shannon, had 756 deaths from 23 April to 19 August, a -great part of them in the workhouse. In clinical characters, the cholera -of 1849 was noted in Ireland, as in Scotland and England, for the high -proportion of sudden fatalities, about one-third, without the warnings of -diarrhoea or the usual choleraic symptoms. It was remarked also that many -children under the age of seven died of cholera, about one in ten of all -ages. There was a second season in 1850, with 1768 deaths (according to -the census), but hardly comparable to the return of cholera in 1833 in the -country districts more particularly. - - -The Cholera of 1849 in England. - -The brief but very severe epidemic of cholera in the south of Scotland in -midwinter was all over and done with for good before the disease really -began in England. Hull, which had a few cases on board ship in the end of -1848, about the same time as the infection began to rage in Edinburgh and -Leith, was spared its great visitation, the greatest in all England, until -the late summer and autumn[1555]. The progress of the infection in London -also was strangely different from that in Scotland. There were undoubted -cases in Bethnal Green and other out-parishes in the autumn of 1848, and -there seemed no reason why the infection should not run through the -population and exhaust itself at once, as in Glasgow. But it will appear -from the following table of the deaths in London that the real outburst -was delayed until the summer and autumn of 1849: - - Cholera - deaths - - 1848 - Sept. 11 - Oct. 122 - Nov. 215 - Dec. 131 - - 1849 - Jan. 262 - Feb. 181 - March 73 - April 9 - May 13 - June 246 - July 1952 - Aug. 4251 - Sept. 6644 - Oct. 464 - Nov. 27 - -Although a certain number of deaths were returned in October and November, -1848, they came in twos or threes from many parishes of the metropolis and -made no great impression upon any one locality. It was not until the -beginning of December that the presence of cholera was fully realized, -owing to an extraordinary explosion of the disease in a huge pauper -institution at Tooting. The school contained about a thousand children, of -whom some three hundred took Asiatic cholera, with one hundred and eighty -deaths, in the course of three or four weeks: this was the whole cholera -mortality that the parish of Streatham had from first to last. In the -spring months the cases declined all over London in a very remarkable way, -so that it looked for a time as if the infection were extinct, just as in -1832. But in June there was a revival, and thereafter a steady increase to -the maximum of 6644 deaths in September. The table given under the year -1866 shows upon what parishes the mortality fell most--those of Southwark, -Bermondsey, Rotherhithe, Greenwich, Newington, Lambeth and Battersea on -the south side, of Westminster, the City and Liberties, Shoreditch, -Bethnal Green and Whitechapel on the north side of the Thames. It was a -more severe visitation per head of the inhabitants than that of 1832, -cutting off many beyond the limits of the destitute and reckless class who -were its most usual victims on the first occasion. Many of the respectable -class of workmen and small shopkeepers were among the victims. Several -medical men died of it, including one well-known surgeon, Mr Aston Key, -at his house in St Helen's Place, Bishopsgate, on 23 August, after a few -hours' illness. As in Ireland, and at Dundee, an unusually large -proportion of the London deaths, perhaps a fourth part, were from sudden -collapse and blueness, without premonitory diarrhoea or predominant -intestinal symptoms. Opinion was strongly against contagiousness in this -epidemic. There were 478 cases treated in St Bartholomew's Hospital, but -not one of the nurses took cholera. - -The infection seemed to find out the insanitary spots and to act -miasmatically upon the residents. The common remark in all parts of -England, Scotland and Ireland was that the localities that suffered most -from the typhus fever of 1847-48 suffered most also from cholera. The one -black spot in Kensington was a poor district on the north side of the -parish known as the Potteries, where an immense number of pigs were kept. - -One of the most remarkable features of the cholera-seasons of 1848-49 was -the extensive prevalence of common bowel-complaints. Evidence of this has -been given for the south of Scotland just before or during the cholera of -midwinter, a season when diarrhoea is not usual. It was equally remarked -in England in the course of 1849. In the Taunton workhouse, where true -Asiatic cholera broke out in November, there had been many cases of -bowel-complaint, as well as of fever, in the spring (7 deaths from -dysentery and diarrhoea, 5 from fever). In the Exeter workhouse there were -eighteen deaths from dysentery in the end of the year, although there is -nothing said of cholera, which caused only 44 deaths in the whole city. -The efforts of the inspectors sent by the Board of Health were in great -part directed to finding out the cases of "premonitory" diarrhoea, by -house-to-house visitation, and insisting upon the importance of checking -it before it could turn to true cholera. Leeds will serve as an example of -English towns. In an incomplete survey after the month of July there were -found 5129 cases of simple diarrhoea, 1484 cases of dysentery, 1273 cases -of choleraic diarrhoea, and 1090 cases of true cholera[1556]. It was -something of a paradox that, with such excessive prevalence of ordinary -bowel-complaints, an unusual proportion of the cases of true cholera -proved quickly fatal with symptoms of collapse and asphyxia only. - -Just as the first startling indication of the presence of Asiatic cholera -in London was the enormous fatality in the pauper school at Tooting in the -winter, so in some other towns the infection seemed to pick out workhouses -or prisons to begin upon. At Belfast there were forty cases in the -workhouse before there was one in the town. At Liverpool there were 28 -cholera deaths in the first quarter of 1849, of which 8 were in the -workhouse. At Wakefield, 19 died of cholera in January, 16 of these in the -House of Correction. Among the people at large the infection made little -progress until the summer. In the first and second quarters of the year it -is heard of, but to a moderate extent, in the towns and colliery districts -of Durham and Northumberland, which were the scene of its earliest -outbreak in the winter of 1831-32. It was also beginning in the poorest -and filthiest parts of Liverpool, Bristol and Plymouth. Its great season -all over England was July, August and September, the incidence of the -disease according to counties being shown in the table. The right-hand -column, showing the number of deaths at the principal centres in each -county, must serve for a conspectus of the epidemic. - -_Cholera Mortality in England and Wales in 1849._ - - Death-rate - per - 1000 - Deaths inhab. Principal centres in each county - - England and Wales 53293 3.0 - London 14137 6.2 Lambeth 1618, Newington 907, - Bermondsey 734, Southwark 1704 - Surrey, part of 255 1.3 - Kent, part of 1208 2.5 Gravesend, Milton, Rochester, - Chatham, Margate, Ramsgate, - Maidstone - Sussex 346 1.1 Hastings - Hampshire 1245 3.2 Portsmouth 568, Southampton 240 - Berkshire 148 .8 - Middlesex 406 2.7 Edmonton, Barnet - Hertfordshire 323 1.9 Hitchin 127, Hertford 81, Watford - 45 - Buckinghamshire 175 1.2 Marlow, Wycombe 100 - Oxfordshire 117 .7 Oxford 44, Witney 33 - Northamptonshire 141 .7 Northampton 49, Peterborough 49 - Huntingdonshire 14 .2 - Bedfordshire 72 .6 Bedford 37, Biggleswade 28 - Cambridgeshire 269 1.4 Wisbech 138, North Witchford 85 - Essex 580 1.7 West Ham 134, Romford 163, - Rochford 105, Harwich - Suffolk 79 .2 Ipswich 18, Mutford 27 - Norfolk 223 .5 Yarmouth 87, Norwich 38 - Wiltshire 320 1.3 Salisbury 165, Devizes 67 - Dorset 122 .7 Weymouth 59, Poole 31 - Devon 2366 4.2 Plymouth 830, Stonehouse 171, - Stoke Damerel 721, Plympton St - Mary 151, Tavistock 140, - Totnes 107 - Cornwall 835 2.4 St Germans 236, Liskeard 132, St - Austell 135, Redruth 133 - Somerset 923 2 Bridgewater 235, Keynsham 77, Bath - 90, Bedminster 281 - Gloucestershire 1465 3.5 Bristol 591, Tewkesbury 59, - Gloucester 119, Clifton 563, - Dursley 58 - Herefordshire 1 .01 - Shropshire 316 1.3 Bridgnorth 75, Shrewsbury 116 - Staffordshire 2672 4.4 Newcastle-under-Lyme 241, - Wolverhampton (incl. Bilston, - Tipton, Sedgley) 1365, Stoke - 103, W. Bromwich 250, Dudley - 412, Walsall 186 - Worcestershire 432 1.7 Stourbridge 314 - Warwickshire 293 .6 Coventry 202, Birmingham 29, - Warwick 20 - Leicestershire 8 .08 Loughborough 7, Leicester 2 - Rutlandshire 7 .4 - Lincolnshire 372 .9 Gainsborough 246, Boston 35, - Grimsby 29 - Nottinghamshire 137 .5 East Retford 21, Basford 42, - Nottingham 18 - Derbyshire 50 .06 Derby 18 - Cheshire 653 1.6 Nantwich 181, Runcorn 82, - Stockport 72, Birkenhead 139 - Lancashire 8184 4.1 Liverpool and W. Derby 5308, Wigan - 503, Manchester 878, Chorlton - 280, Salford 237 - West Riding 4151 3.2 Huddersfield 52, Bradford 426, - Hunslet 884, Dewsbury 224, - Wakefield 241, Pontefract &c. - 238, Leeds 1439 - East Riding 2140 8.7 Hull and Sculcoates 1834, York - 174, Pocklington 37, Howden 58 - North Riding 47 .2 Whitby 10 - Durham 1642 4.2 Darlington 4, Stockton 248, Durham - 192, Hartlepool, - Chester-le-Street 134, - Sunderland 363, Gateshead 257, - S. Shields 201 - Northumberland 1417 4.8 Newcastle 295, Tynemouth 815, - Alnwick 142 - Cumberland 419 2.2 Carlisle 51, Cockermouth 282, - Whitehaven 79 - Westmoreland 1 .02 - Monmouth 775 4.1 Newport 246, Pontypool 69, - Abergavenny 438 - S. Wales 3544 6.1 Merthyr Tydvil 1682, Cardiff 396, - Neath 738, Llanelly 45, - Swansea 262, Carmarthen 142, - Crickhowell 95 - N. Wales 245 .6 Holywell 86, Montgomery 37, - Carnarvon 21 - -The highest rates in the table are for the East Riding, owing to Hull -(24.1), for South Wales, owing to Merthyr Tydvil (23.4), for -Northumberland and Durham, for Staffordshire, owing to the iron district -round Wolverhampton, for Devonshire, owing to Plymouth, for Lancashire, -owing to Liverpool, and for Monmouth, owing to a few mining places. The -miners suffered most, the lower class in the seaports next most severely. -The Black Country in the south of Staffordshire, which had been the worst -centre of the 1832 cholera, was again one of its chief centres in 1849, -the mortality falling most, as before, upon the town of Bilston, and next -to it upon Willenhall and Wolverhampton. But a great rival to the -Staffordshire coal and iron mining had sprung up since 1832 in Glamorgan; -and it was in this comparatively new region of miners that cholera in 1849 -reproduced the Black Country horrors of 1832 and, indeed, surpassed them. - - Merthyr Tydvil had sprung up more like a vast miners' camp than like a - well-ordered municipality. Along the eastern side of the Taff valley, - on the slopes and in bottoms of the hills, but everywhere at an - elevation of some four or five hundred feet above the level of Cardiff - docks, were numerous groups of mean-looking miners' cottages, with - their attendant ale-houses, small retail shops, schools and - meeting-houses. This peculiar township had drawn to itself the special - notice of the Health of Towns Commission in 1844: "From the poorer - inhabitants (who constitute the mass of the population) throwing all - slops and refuse into the nearest open gutter before their houses, - from the impeded course of such channels, and the scarcity of privies, - some parts of the town are complete networks of filth emitting noxious - exhalations.... During the rapid increase of the town no attention - seems to have been paid to its drainage." - - In this district the registrar had returned 162 deaths from "cholera" - in the year 1841, which must have been from an unusually severe type - of cholera nostras or British cholera. A first case of Asiatic cholera - occurred at Cardiff in a sailor on the 13th of May, 1849, a week after - there was a case at Lower Merthyr, and a week after that another at - Upper Merthyr. In the course of the summer the ravages of the disease - were enormous in the hilly mining regions of the interior of Glamorgan - and Monmouth, as well as severe in the seaports: - - Merthyr Tydvil 1682 - Cardiff 396 - Neath 738 - Swansea 262 - Abergavenny district 438 - Pontypool 69 - Newport 246 - - The peculiar selection of the mining townships was well shown in the - district of Abergavenny: of 378 deaths from cholera in the third - quarter of 1849, only 9 occurred in Abergavenny town, while 157 were - at the iron-works of Tredegar and 210 at those of Aberystruth, just - as, in the winter preceding, the villages of the iron-works all round - Kilmarnock had been ravaged by cholera while there was little of it in - that town itself. - -Another chief centre of cholera in 1849 was the port of Hull. Including -the district of Sculcoates, it had the following enormous mortalities from -cholera in four weeks of September: 398, 507, 524 and 171, the whole -epidemic from July to the 18th of October producing 2534 deaths[1557]. Its -neglect of scavenging became a classical instance of the favouring -conditions of cholera. An open space at Witham called the "muckgarths," -from the refuse deposited upon it, was one of the worst centres, just as -the town moor of Sunderland, used for the same purpose, had been in -1831[1558]. In the other ports, Liverpool, with West Derby, Bristol with -Clifton, and Plymouth with East Stonehouse and Devonport, the infection -was most severe (see Table), and was observed to choose the poorest -streets, lanes and houses, where there had been most typhus for a year or -two before[1559]. On the Tyne, the greatest centre on this occasion was -not Newcastle, but Tynemouth. The city of Durham, which escaped the -cholera of 1832, had a severe visitation. The chief inland centres, -besides the mining districts of Staffordshire and Glamorgan, were -Manchester and the cloth-making towns of Airedale,--Leeds, Hunslet, -Bradford, Dewsbury, and some others in the West Riding. Most of the -Lancashire towns occupied with the cotton industry again escaped with -little cholera--Preston, Clitheroe, Oldham, Bury, Rochdale, Bolton, -Blackburn, Ashton and Chorley. Wigan had nearly twenty times as many -deaths as in 1832; on the other hand Sheffield had only a quarter of its -former cholera mortality, while Nottingham and Norwich had this time very -little. Birmingham, Leicester, Cheltenham, Hereford, Stafford, Ipswich, -Cambridge and Colchester were again almost or altogether free from -infection. The agricultural counties, notably the Eastern counties, -escaped once more with few centres of infection, and these unimportant. -Cumberland as a whole had fewer deaths than in 1832, while Cockermouth had -more. Exeter, which was severely visited on the former occasion, escaped -almost wholly, while Totnes and Tavistock, with the surrounding Dartmoor -country and other towns in Devon, had epidemics of the first degree for -their size. In England as a whole the cholera of 1849 was more severe -relatively to the numbers living than that of 1832, its great centres -having been the same, or of the same kind, on both occasions[1560]. - -The cholera of 1849 reproduced very closely the former characteristics. -The attacks were often in the night, especially in persons who had supped -heartily on the coarser kinds of savoury meat. With the same undoubted -preference for the poorer and more filthy quarters of towns, the infection -showed also a certain apparent caprice in fixing on some places and -avoiding others. - - Thus at Leeds it was most malignant in the locality of York Street and - Marsh Lane (an old centre of plague and typhus), which had lately been - drained at a cost of some thousands of pounds, "whilst in the - adjoining district, which lies nearly level with the river, and will - scarcely admit of any sewerage, I have not heard," writes the - registrar, "of a single case of cholera"--an experience similar to - that of a low-lying district of Bristol in 1832. At Liverpool, where - much had been undertaken for sanitation since the disastrous Irish - fever of 1847-48, the cholera appeared to Dr Duncan, the medical - officer of health, to attack sewered and unsewered streets - impartially. Another singular thing, which used to be noticed in the - plague and is observed in the malarial fevers of towns abroad, was the - choice of one side of a street only: thus, at Rotherhithe, in a street - where numerous deaths occurred, they were nearly all one side of the - street, in houses occupied by respectable private families, only one - house having been infected on the other side; at Bedford, two streets - showed the same thing. - -In London, the least elevated parishes on both sides of the Thames were -again its chief seats. Dr Farr, the superintendent of statistics, deduced -the law that the death-rate from cholera in London was inversely as the -altitude of the parish, and he showed, by a somewhat rough grouping of the -cholera deaths, that the law applied to all England[1561]. An empirical -generality such as that may have some value; but it is the exceptions to -it that show the inward meaning of the fact. - - Merthyr Tydvil, which was the worst cholera-spot in England with the - possible exception of Hull, was five hundred feet above the level of - Cardiff, its seaport, where the death-rate was much lower. Neath, - also, had much more cholera than Swansea. Newcastle-under-Lyme, - situated near the source of the Trent, and the highest town in the - course of that river, had a far more severe visitation of cholera than - any other town upon it all the way to its mouth. At Tavistock among - the Dartmoor hills, cholera "sat for many a week," as Kingsley says, - "amid the dull brown haze, and sunburnt bents and dried-up - watercourses, of white dusty granite." But the poorer and more - populous part of Tavistock was a somewhat peculiarly shut-in basin, - which was "very often involved in fog during the night." The town had - escaped cholera in 1832, but one of its physicians, writing in 1841, - and recalling its dreadful plague of 1626, did not feel sure that it - would escape if cholera came back[1562]. Again, one thinks of - Salisbury as standing among high downs; but it had a wet subsoil, bad - sewerage, and bad water supply, and in 1849 it had 200 deaths from - cholera among all classes in two months[1563]. - - In the not very extensive outbreak at Sheffield, one of its chosen - seats was an elevated district called the Park, inhabited by colliers. - At Bedlington colliery, near Morpeth, the cholera deaths in November - were in the miners' houses on the hill side. The elevated, airy and - clean village of Loanhead, near Edinburgh, had 46 deaths in its - population of 1200, during a few weeks of midwinter. In Dundee, built - upon a steep slope at the waterside, there were bad centres of cholera - in the higher parts as well as in the lower. - -The determining thing appears to have been not so much the elevation as -the configuration of the ground; any basin, or cup, or shelving terrace, -any natural collecting-ground of moisture and organic refuse in the soil, -may become a seat of cholera, whether it be at the sea-level or several -hundred feet above it, provided it have a sufficient number of human -occupants and a mode of drainage inadequate to its peculiar needs. Such -was the situation of Merthyr Tydvil, of Neath, of Newcastle-under-Lyme, of -Tavistock, of some colliery villages, and of certain localities in towns -such as Dundee. Such, of course, was also the situation of the London -parishes next the river on the south and east, of Hull, of Plymouth, of -Liverpool, and of other seaports on estuaries. Neither altitude nor -configuration means anything for cholera unless the ground itself be full -of rotting filth. In all England and Scotland the cholera chose, as if by -an unerring instinct, those not very extensive mining parts of the -counties of Stafford, Glamorgan, Durham, Lanark and Ayr, which had as many -hundreds of inhabitants to the square mile, and as little provision for -the safe disposal of their excrements, as those village communities of -Lower Bengal in which the infection had become established since 1817 as -if it were an annual product of the soil. - -The Report of the Board of Health brought to light many instances in which -it seemed probable that cholera had been favoured, if not induced, by the -water of wells contaminated with organic filth soaking through the ground -or entering with the surface water. This was especially the case at -Merthyr Tydvil. It was during the next cholera, that of 1854, that the -question of contaminated water came into great prominence, in connexion -both with wells and with the vast volumes of water supplied through the -mains of water companies. - - -The Cholera of 1853 at Newcastle and Gateshead. - -The third visitation of Great Britain and Ireland by Asiatic Cholera was -in 1853-54. There had been none of it in any part of the kingdom since -1850; but it is not so clear that all other European countries, especially -Poland, were equally free from it. Whether due to a new approach from -Asia, or to a rekindling of smouldering fires, cholera appeared in the -Baltic ports in the summer of 1853, and soon after reached the Tyne. For -the third time a severe but localized epidemic was the prelude--this time -at Newcastle and Gateshead, just as in 1848 at Edinburgh, Glasgow and the -south of Scotland, and in 1831 at Sunderland and Newcastle. - -In the cholera of 1849, which was the most general and the most severe -visitation that England has had, Newcastle escaped with a light visitation -and Gateshead with a moderate or average one, while Tynemouth (with North -Shields) had about twice as many deaths as Newcastle and Gateshead -together (12.9 deaths per 1000 inhabitants). In 1853 it was the turn of -Newcastle--for no better reason, perhaps, than its escape last time. The -very thorough and masterly inquiry by Messrs Simon, Bateman and Hume did, -indeed, reveal a most unwholesome state of things; but the town was no -worse or only a little worse than in 1849, when the cholera had dealt -lightly with it, and it was probably an average sample of the insanitary -condition of the greater English industrial towns in the time of their -rapid growth and before the period of well-ordered local government had -arrived. In some parts, such as Sandgate, the dwellings of the labouring -class were "not fit to live in"; in the newer mean suburbs, it was found, -as in Glasgow twenty years before, that cellars had become the -dwelling-places of a class who in former times lived above ground. Those -who had been dispossessed by the railways and other public structures had -not been provided for elsewhere; so that, with more trade and better -wages, the working class were worse housed than before. Overcrowding, for -which the ports on the Tyne and Wear are still pre-eminent, was then most -excessive. Only the better-class houses had the water laid on. Excremental -offences to sight and smell were everywhere. There was a system of main -sewers, passably good; but house-drainage or connexions with the main -drains were quite casual. The scavenging of the town was greatly -neglected. Piggeries, slaughter-houses and other such nuisances, were -uncontrolled. The burial-grounds were over-full. With all this the -death-rate of Newcastle could be low enough in a good year, such as 1844, -when it was 20.9 per 1000; in the year of the Irish fever, 1847, it rose -to 32.8; and in other years it fluctuated between those extremes, -according to the nature of the seasons[1564]. - -The cholera of 1853 was a sudden explosion in the heavy stagnant -atmosphere of the month of September. No one knew where the infection came -from; there were, of course, ships arriving from the Baltic, but no -particular source was ever traced. On the 30th or 31st of August, a case -occurred of the rapidly fatal kind; before a week there were about a -hundred attacks daily all over the town. From the 13th of September the -deaths in Newcastle mounted up rapidly as follows: - - Cholera - deaths - - Sept. 13 59 - 14 90 - 15 106 - 16 114 - 17 103 - 18 103 - 19 111 - 20 85 - 21 68 - 22 82 - 23 60 - 24 56 - -In the thirty days of September there were 1371 deaths, and some one or -two hundreds more in the first part of October, when the infection ceased -almost abruptly, the total of deaths to the 4th of November having been -1533. During the same time Gateshead with a population of 26,000, had 433 -deaths, or in a ratio nearly equal to that of Newcastle. On the other hand -Tynemouth, with a population of 30,000, had only twelve deaths, several of -them in vagrants or other arrivals from Newcastle, the rest in a cluster -of pitmen's cottages on the outskirts of North Shields. - - It was freely rumoured at the time, and was even repeated with much - unction in so dry and deliberate a work as the report of the - Registrar-General, that the cholera at Newcastle and Gateshead in - September, 1853, was owing to the sudden contamination of the town's - water with sewage. The facts about the water-supply are as follows: - Previous to 1848, Newcastle was supplied with Tyne water pumped up at - Elswick, and passed through the settling tanks and filtering beds. In - 1848 the Whittle Dean Water Company, incorporated in 1845, had their - new supply ready, and the old company, with its pumping station at - Elswick, was superseded. The new supply was collected from landward - sources, and was apt to be peaty. There was a great demand upon it, - especially for public works (it was supplied to comparatively few - houses), so that the distribution in 1853 had increased 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 coloured Christison's view of relapsing -fever, the so-called relapses being, in his opinion, comparable to the -returning paroxysms of ague. - -[325] Cleland. - -[326] Report signed A. Brebner, provost, printed in Harty, _Historic -Sketch of the Contagious Fever in Ireland, 1817-19_. Dublin, 1820, -Appendix, p. 110. - -[327] _Memoir concerning the Typhus Fever in Aberdeen, 1818-19._ By George -Kerr, Aberdeen, 1820. - -[328] William Gourlay, "History of the Epidemic Fever as it appeared in a -Country Parish in the North of Scotland." _Edin. Med. and Surg. Journ._, -July, 1819, p. 329, dated 20 Nov. 1818. - -[329] _Trans. K. and Q. Cal. Phys. Ireland_, V. 527. - -[330] _Dub. Q. J. Med. Sc._ VIII. 297. - -[331] A succession of thirty-one cases of relapsing typhoid at Charing -Cross Hospital in 1877-78 were made the subject of an able essay by J. -Pearson Irvine, M.D., _Relapse of Typhoid Fever_, London, 1880. - -[332] Cited in Aberdeen Report, 17 Dec. 1818, in Harty, App. p. 110. - -[333] _Report of Select Committee_, u. s. p. 6, and minutes of evidence. - -[334] Prichard, pp. 74, 88. - -[335] Christison, _Month. J. Med. Sc._ X.; Bennett, _Princip. and Pract. -of Med._ 944-5. - -[336] See above, p. 110-11. - -[337] A complementary measure, namely, notification of contagious sickness -to the authorities, was put in practice at Leeds in 1804 on the opening of -the House of Recovery there. The Leeds House of Recovery, with fifty beds, -was opened on 1 November, 1804, the epidemic of fever being then about -over. One of its officers was an inspector, whose duty was "to detect the -first appearance of infection, to cause the removal of the patient to the -House of Recovery, and to superintend the fumigating and whitewashing of -the apartment from which he is removed. So great is the solicitude of the -physicians to promote early removal that rewards are offered to such as -shall first give information of an infectious fever in their -neighbourhoods." It was claimed that this had been a great success, Leeds -having been for twelve years previous to the epidemic of 1817 nearly -exempted from two of the most infectious and fatal diseases, namely, -typhus and scarlet fever. (It happened, however, that the whole of -England, Scotland and even Ireland were exempted to the same remarkable, -and of course gratifying degree.) Whitaker, _Loidis and Elmete_, 1816, p. -85. - -[338] A strange epidemic of the early summer of 1824 in a semi-charitable -girls' school at Cowan Bridge, between Leeds and Kendal, which is the -subject of a moving chapter in 'Jane Eyre,' was inquired into by Mrs -Gaskell, the biographer of Charlotte 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-coloured lenticular spots, (5) that one case, which was the only -one examined post-mortem, had the characteristic ulceration of the -intestine, and (6) that one fatal case had the symptoms of perforation of -the gut. This summary manner, asking in effect to be taken on trust, is -not usually accepted from innovators, none of the great discoverers having -resorted to it. Hitherto, however, no one has thought proper to question -Budd's diagnosis of the epidemic fever in his North Tawton practice, nor -even to remark upon his strange error of treating the epidemic of 1838-39 -all over Britain as purely one of typhoid (_Lancet_, 27 Dec. 1856). But -everyone knew that typhoid fever did not spread in the way that he -described (doubtless correctly for the above cases). After the publication -of his book in 1873 an attempt was made by an influential layman in the -_Times_ (9 Nov. 1874) to popularize Budd's fallacies or paradoxes on the -contagiousness of typhoid. "How," it was asked, after a summary of the -North Tawton epidemic in 1839, "could a disease whose characters are so -severely demonstrable, have ever been imagined to be non-contagious? How -could such a doctrine be followed, as it has been, to the destruction of -human life?" - -[378] "For three years past trade had been getting worse and worse, and -the price of provisions higher and higher. This disparity between the -amount of the earnings of the working classes and the price of their food -occasioned, in more cases than could well be imagined, disease and death. -Whole families went through a gradual starvation. They only wanted a Dante -to record their sufferings. And yet even his words would fall short of the -awful truth; they could only present an outline of the tremendous facts of -the destitution that surrounded thousands upon thousands in the terrible -years 1839, 1840, and 1841. Even philanthropists who had studied the -subject were forced to own themselves perplexed in their endeavour to -ascertain the real causes of the misery; the whole matter was of so -complicated a nature that it became next to impossible to understand it -thoroughly.... The most deplorable and enduring evil that arose out of the -period of commercial depression to which I refer, was this feeling of -alienation between the different classes of society. It is so impossible -to describe, or even faintly to picture, the state of distress which -prevailed in the town [Manchester] at that time, that I will not attempt -it; and yet I think again that surely, in a Christian land, it was not -known even so feebly as words could tell it, or the more happy and -fortunate would have thronged with their sympathy and their aid. In many -instances the sufferers wept first, and then they cursed. Their vindictive -feelings exhibited themselves in rabid politics. And when I hear, as I -have heard, of the sufferings and privations of the poor, of provision -shops, where ha'porths of tea, sugar, butter, and even flour, were sold to -accommodate the indigent--of parents sitting in their clothes by the -fireside during the whole night for seven weeks together, in order that -their only bed and bedding might be reserved for the use of their large -family--of others sleeping upon the cold hearthstone for weeks in -succession, without adequate means of providing themselves with food or -fuel--and this in the depth of winter--of others being compelled to fast -for days together, uncheered by any hope of better fortune, living, -moreover, or rather starving, in a crowded garret, or damp cellar, and -gradually sinking under the pressure of want and despair into a premature -grave; and when this has been confirmed by the evidence of their careworn -looks, their excited feelings, and their desolate homes--can I wonder that -many of them, in such times of misery and destitution, spoke and acted -with ferocious precipitation?" Mrs Gaskell, _Mary Barton_. - -[379] John Goodsir, "On a Diseased Condition of the Intestinal Glands," -_Lond. and Edin. Monthly Journ. of Med. Science_, April, 1842. He does not -enter on the question "as to whether the subject of the present paper -constitutes a distinct species of disease, or be merely a form of the -ordinary continued fever"; but he appears to recognize that a certain -district may have a form of fever special to it, as Reid had probably told -him. - -[380] John Reid, M.D., "Analysis and Details of Forty-seven Inspections -after Death," _Edin. Med. and Surg. Journ._, Oct. 1839, p. 456. - -[381] Reid, u. s., from Home's records. - -[382] Murchison, _Continued Fevers_, 2nd ed. 1873, p. 444. - -[383] Lombard, in _Dublin Journal of Med. Sc._ X. (1836), p. 17. He bore -witness, also, to the rarity of the bowel-lesion in the Glasgow fevers. -This was confirmed by Dr Perry, of that city, _Ibid._ X. 381. See also -Julius Staberoh, M.D., "Researches on the Occurrence of Typhus in the -Manufacturing Cities of Great Britain," _Ibid._ XIII. 426. - -[384] _Trans. Prov. Med. Assoc._ II. (1834), p. 176. - -[385] _Continued Fevers_, 2nd ed. 1873, p. 443. - -[386] Christison, "On the Changes which have taken place in the -Constitution of Fevers and Inflammations in Edinburgh during the last -forty years." Paper read at Med. Chir. Soc. Edin. 4 March, 1857. _Edin. -Med. Journ._ Jan. 1858, p. 577. - -[387] _Continued Fevers_, under the head of "Typhus," p. 47. - -[388] See especially John Rose Cormack, M.D., _Natural History, Pathology -and Treatment of the Epidemic Fever at present prevailing in Edinburgh and -other towns_. Lond. 1843; and the papers by Wardell, _Lond. Med. Gaz._ N. -S. II-V. - -[389] Dr Betty, of Lowtherstown, Fermanagh, _Dubl. Quart. Journ. Med. Sc._ -VII. 125. - -[390] Murchison says that the enteric fever of the end of 1846 was -prevalent at many places in England where the epidemic of typhus never -made its appearance, and that in Edinburgh (according to an unpublished -essay by Waters) most of the enteric cases not only occurred prior to the -outbreak of the epidemic of Irish fever, but came from localities in the -neighbouring country and from the best houses of the New Town--not from -the crowded courts of the Old Town, to which the later epidemic of typhus -and relapsing fever was restricted. Murchison, u. s. p. 49. The following -papers relate to the autumnal typhoid of 1846 in England: Sibson, "Fever -at Nottingham and neighbourhood in Summer and Autumn of 1846," _Med. Gaz._ -XXXIX.; Taylor, "Fever at Old and New Lenton in 1846," _Med. Times_, XV. -159 and _Med. Gaz._ XXXVIII. 127; Turner, "Fever at Minchinhampton in -Autumn 1846," _Med. Gaz._ XLII. 157; Brenchley, "Fever in Berkshire in -1846," _Med. Gaz._ XXXVIII. 1082; Bree, "Epidemic Fever at Great -Finborough in Autumn of 1846," _Prov. Med. and Surg. Journ._ 1847, p. 676. - -[391] In the _Report of the Registrar-General for the year 1847_. - -[392] This was the occasion which furnished Father Newman with a famous -argument for the _bona fides_ of his co-religionists: "The Irish fever cut -off between Liverpool and Leeds thirty priests and more young men in the -flower of their days, old men who seemed entitled to some quiet time after -their long toil. There was a bishop cut off in the North; but what had a -man of his ecclesiastical rank to do with the drudgery and danger of sick -calls, except that Christian faith and charity constrained him?" John -Henry Newman, D.D., _History of My Religious Opinions_, London, 1865, p. -272. - -[393] Leigh, in _Report Reg.-Gen. for 1847_, X. p. xx. - -[394] H. M. Hughes, "On the Continued Fever at present existing in the -southern districts of the metropolis," _Lond. Med. Gaz._ Nov. 1847; -Laycock, "Unusual prevalence of Fever at York," _Lond. Med. Gaz._ Nov. -1847; Bottomley, "Notes on the Famine Fever at Croydon in 1847," _Prov. -Med. and Surg. Journ._ 1847; Ormerod, _Clinical Observations on Continued -Fever at Bartholomew's Hospital_, Lond. 1848; Art. in _Brit. and For. Med. -Chir. Rev. 1848_, I. 285; Duncan, _Journ. Pub. Health_, I. 200 -(Liverpool); Paxton, _Prov. Med. Journ._ 1847, pp. 533, 596 (Rugby). - -[395] The following papers relate to the epidemic in Scotland in 1847: -Orr, "Historical and Statistical Sketch of the progress of Epidemic Fever -in Glasgow during 1847," _Edin. Med. and Surg. Journ._ LXIX.; Stark, "On -the Mortality of Edinburgh and Leith for 1847," _Ibid._ and LXXI.; R. -Paterson, "Account of the Epidemic Fever of 1847-8" in Edinburgh, _Ibid._ -LXX.; W. Robertson, "Notes on the Epidemic Fever of 1847-8," _Month. -Journ. of Med. Sc._ IX. 368; J. C. Steele, "View of the Sickness and -Mortality in the Glasgow Royal Infirmary during 1847," _Edin. Med. and -Surg. Journ._ LXX.; J. C. Steele, "Statistics of the Glasgow Infirmary for -1848," _Ibid._ LXXII. 241; J. Paterson, "Statistics of the Barony Parish -Fever Hospital of Glasgow in 1847-8," _Ibid._ LXX. 357. - -[396] Buchanan, _Report Med. Officer Privy Council for 1864_, and _Trans. -Epid. Soc._ 1865, II. 17; Hamilton, _Lancet_, II. 1867, p. 608 -(Liverpool); Martyn, _Brit. Med. Journ._ July, 1863; Davies, _Med. Times -and Gaz._ II. 1867, p. 427 (Bristol); Thompson, _St George's Hosp. -Reports_, I. (1866), p. 47 (London); Allbutt, _ibid._ p. 61 (Leeds). - -[397] Buchanan, _Report Med. Off. Privy Council for 1865_, p. 210. - -[398] James Stark, M.D., "Remarks on the Epidemic Fever of Scotland during -1863-64-65" etc., _Trans. Epidem. Soc._ N. S. II. 312. See also Russell, -_Glasg. Med. Journ._ July, 1864, and R. Beveridge (for Aberdeen), -_Lancet_, I. 1868, p. 630. - -[399] Weber, _Lancet_, I. 1869, pp. 221, 255; Murchison, _ibid._ II. 1869, -pp. 503, 647; Gee (Liverpool), _Brit. Med. Journ._ II. 1870, p. 246; -Robinson (Leeds), _Lancet_, I. 1871, p. 644; Muirhead (Edinburgh), _Edin. -Med. Journ._ July, 1870, p. 1; Rabagliati (Bradford), _ibid._ Dec. 1873; -Tennant (Glasgow), _Glasgow Med. Journ._ May, 1871, p. 354; Armstrong -(Newcastle), _Lancet_, I. 1873, p. 48. - -[400] Muirhead (l. c.) says: "In no single instance which came under my -observation could starvation be said to be the immediate cause of the -disease. Not one of those individuals could be said to be emaciated.... On -strict and repeated inquiry, not one of them would confess to having been -in destitute circumstances." During the winter of 1870-71 I attended from -the Edinburgh New Dispensary several relapsing-fever patients at their -homes, and can clearly remember having been surprised at the condition of -decency and comfort in which I found them. The appearance of comfort was -certainly due in part to the district visitors, who were numerous and -active during the epidemic. - -[401] Spear, "Typhus Fever in various parts of England, 1886-87." _Rep. -Med. Off. Loc. Gov. Bd._ N. S. XVI. p. 169. - -[402] 2303 of these fever deaths in 1864 occurred in the eight principal -towns of Scotland, classified as follows: typhus, 1450, relapsing fever, -371, gastric, enteric, or typhoid, 382. - -[403] G. B. Longstaff, M.D., _Trans. Epid. Soc._ 1884-5, p. 72, reprinted -in his _Studies in Statistics_, Lond. 1891, p. 402. The seasonal curve for -the typhoid admissions to the London Fever Hospital over a longer period -is nearly the same, as well as that of the registered deaths by typhoid in -all London, 1869-84. - -[404] The following large registration districts besides those in the -Table, had enteric-fever death rates of .5 and upwards per 1000 persons -living, in the ten years 1871-80; in nearly all of them there has been a -marked decline in the ten years 1881-90:--Durham, Hartlepool, Easington, -Houghton-le-Spring, Darlington, Gateshead (county Durham); Morpeth -(Northumberland); Aysgarth, Todmorden, Dewsbury, Pontefract, Barnsley, -Rotherham (Yorkshire); Dudley, Leigh, Ormskirk (Lancashire); Crickhowell -(Wales); Worksop, Radford (Nottingham); Shrewsbury; Peterborough; Portsea -Island (Hants). Of the London districts, Hackney had the highest enteric -fever, 0.46 per 1000 in a general death-rate of 20.78. The high rate of a -decennium is not unfrequently brought up by one great explosion. In many -of the Lancashire, Yorkshire and Midland towns, with rates about .4 per -1000 persons, the rate has been somewhat steady from year to year. In the -decennium 1871-80, many special outbreaks, some of them in villages, were -reported on by the inspectors of the Medical Department, and traced for -the most part to water-supplies tainted by the percolation of excrement. - -[405] The Registration District of Middlesborough was carved out of -Stockton and Guisborough in 1875. - -[406] Registration District containing a population of 72,707 on a mean -between the census of 1871 and that of 1881. In 1891 the population was -146,812. - -[407] F. W. Barry, M.D., in _Rep. Med. Off. Loc. Gov. Board for 1882_, p. -72. The contention of the inspector was that the water-supply had been -tainted by enteric-fever evacuations from a case which began on 22 May in -a cottage some half-mile distant from the reservoir but in communication -with it through ditches and brooks. The area of the water-supply did not -correspond with the area of the fever. - -[408] The report for the Medical Department by F. W. Barry, M.D. (_Enteric -Fever in the Tees Valley_, 1890-91, Parl. papers, Nov. 1893), is an -elaborate argument to prove that the flooded state of the Tees was indeed -the relevant antecedent, not as indexing the rise of the ground-water in -the respective towns, but as dislodging and sweeping down the slops, -sewage and dry refuse of the market town of Barnard Castle, in upper -Teesdale, whereby the water taken in from the Tees two miles above -Darlington to the tanks, filters and reservoirs of the Darlington -Corporation, and of the Stockton and Middlesborough Water Board, was -tainted in some unusual degree--a hypothesis the more remarkable that the -refuse, such as it was, had been suspended or dissolved in an unusual -volume of water, that little refuse could have collected between the first -floods and the second, and that no cases of enteric fever were known in -the upper valley of the Tees. This judicial deliverance has not been -accepted by the authorities of Darlington, Stockton and Middlesborough, -nor by the Royal Commission on Water Supply, before whom it was laid. - -[409] Besides the epidemic at Worthing in 1893, which is still _sub -judice_, the best known instance of typhoid following a certain -water-supply is the explosion at Redhill and Caterham in Jan.-Feb. 1879, -_Rep. Med. Off. Loc. Gov. Board, for 1879_, Parl. papers, 1880, p. 78. The -first instance alleged of the distribution by milk was the Islington -explosion in July-August 1870 (Ballard, _Med. Times and Gaz._ 1870, II. -611). It was soon followed by the Marylebone explosion in the summer of -1873 (_Rep. Med. Off. L. G. B._, N. S. II. 193); but such instances have -become less common, while instances of scarlatina and diphtheria following -a milk-supply have become more common. - -[410] _Second Letter to Sir Hercules Langrishe_, May, 1795. - -[411] Berkeley's _Querist_, Q. 362. - -[412] Radulphus de Diceto, _Imag. Histor._ Eng. Hist. Soc. ed. I. 350. - -[413] "Topogr. Hiberniae" in _Opera_, Rolls ed. V. 67. This and the -preceding reference had escaped the notice of Dr John O'Brien, in the -historical introduction to his _Observations on the Acute and Chronic -Dysentery of Ireland_. Dublin, 1822. - -[414] _Polychronicon_, Rolls ed. I. 332-3. - -[415] "Many of the English-Irish have by little and little been infected -with the Irish filthinesse, and that in the very cities, excepting Dublin -and some of the better sort in Waterford, where the English continually -lodging in their houses, they more retain the English diet." And again: -"In like sort the degenerated citizens are somewhat infected with the -Irish filthinesse, as well in lowsie beds, foule sheetes, and all linnen, -as in many other particulars.... Touching the meere or wild Irish, it may -truely be said of them, which was of old spoken of the Germans, namely, -that they wander slovenly and naked, and lodge in the same house (if it -may be called a house) with their beasts." Fynes Moryson, _Itinerary_, Pt. -IV. p. 180. - -[416] _Ireland's Natural History, &c._ Written by Gerard Boate, late -Doctor of Physick to the State in Ireland. And now published by Samuel -Hartlib, Esquire. Lond. 1652. The author died at Dublin, shortly after his -arrival there, on 9/19 January 1650/49. His information would seem to have -come in part from his brother Arnold Boate, resident in Ireland. - -[417] Hardiman, _History of Galway_, p. 126 _seq._ The plague from July -1649 to Lady Day 1650 is said to have swept away 3700 of the inhabitants, -including 210 of the most respectable burgesses and freemen, with their -families. The capitulation on 5 April, 1652, was followed by famine -throughout the country, and by a revival of plague for two years, "during -which upwards of one-third of the population of the province was swept -away." - -[418] _Cromwell's Letters and Speeches_, II. 55, 77. - -[419] Edmund Borlase, _History of the Reduction of Ireland to the Crown of -England_. 1675, p. 172. - -[420] Boyle's _Works_, fol. Lond. 1744, V. 92. - -[421] The war-pestilence at Londonderry in 1689 is the third recorded -epidemic of the kind there, not including what may have happened in the -capture of the town by the Catholics in O'Neill's rebellion, when Derry -was destroyed, to be rebuilt in 1613 by the London Companies with a new -charter under the name of Londonderry. The first historical occasion of -sickness was in 1566. The troops of Elizabeth were landed on Loch Foyle in -October and built their huts on the site of the old monastery. In the -course of the winter the greater part of a force of 1100 men perished by -dysentery and the infection which it breeds (see former volume, p. 372). -On 12 Dec. 1642, a year after the outbreak of the Rebellion of Confederate -Catholics, a petition of the agents of the distressed city of Londonderry -to the Commons represented that there were 6059 persons in the city, -whereof 5123 were women and children, or sick, aged or impotent; only 2000 -were inhabitants of the city, the rest having fled there for safety. -Spotted fever had broken out. (_Hist. MSS. Comis._ V. "MSS. of the House -of Lords.") - -[422] With the exception of the last quoted piece of information, the most -minute particulars of the siege of Londonderry are in an essay by an army -chaplain, John Mackenzie, _A Narrative of the Siege of Londonderry_, -London, 1690, which was written to correct and augment _A True Account of -the Siege of Londonderry_ by the Rev. Mr George Walker, rector of -Donoghmoore in the county of Tyrone, and late Governor of Derry. London, -1689. - -[423] See former volume, pp. 634-43. - -[424] Minute particulars of it are given in _An Impartial History of the -Wars in Ireland_ [1689-1692]. By George Story, Chaplain to Sir Thomas -Gower's Regiment. London, 1693. Part I. - -[425] Gangrene of the extremities was one of the symptoms of the "plague -of Athens" as described by Thucydides. There is no need to invoke ergotism -for an explanation of it, as some have done. - -[426] At that time there was little systematic knowledge of military -hygiene. Nearly two generations after, the experiences of Pringle, Donald -Monro and Brocklesby in the campaigns of 1743-48 and 1758-63 in Germany -and the Netherlands, yielded many valuable hints, some of which Virchow -made use of in compiling his "Rules of Health for the Army in the Field," -in the Franco-Prussian War of 1870-71. See his _Gesammelte Abhandlungen -aus dem Gebiete der 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 slope of Victoria Peak: "It was said at the time--I do -not know with what truth--that in this turning-up of the soil, several old -Chinese burying-places were included." - -[779] _Essay on the Most Effective Means of preserving the Health of -Seamen in the Royal Navy._ London, 1757, p. 83. - -[780] See _The Eruption of Krakatoa and subsequent phenomena_. Report of -the Krakatoa Committee of the Royal Society.... Edited by G. J. Symons, -London, 1888. - -[781] _Edin. Med. Essays and Obs._ II. 32. - -[782] _Trans. Col. Phys._ III. 62. - -[783] _Gent. Magaz._ 1782, p. 306. - -[784] R. Robertson, M.D., _Observations on Jail, Hospital or Ship Fever -from the 4th April, 1776, to the 30th April, 1789_. Lond. 1789, New ed., -p. 411. - -[785] Trotter, _Medicina Nautica_, I. 1797, p. 367. - -[786] Notes of a lecture on Influenza, by Gregory, taken by Christison -about the year 1817, in the _Life of Sir Robert Christison_, I. 82. - -[787] College of Physicians' Report, _Trans. Col. Phys._ III. 63. - -[788] This is inferred from the varying number of ships in the two fleets -in the several notices of their movements in the _Gentleman's Magazine_, -for May and June, 1782. - -[789] Brian Tuke to Peter Vannes, 14 July, 1528: "For when a whole man -comes from London and talks of the sweat, the same night all the town is -full of it, and thus it spreads as the fame runs." _Cal. State Papers, -Henry VIII._ IV. 1971. - -[790] Webster, II. 63. - -[791] College of Physicians' Report. _Trans. Col. Phys._ III. (1785), p. -60-61. "Information has been received" of the incident. - -[792] _Statist. Report of Health of Navy, 1837-43._ Parl. papers, 1 June, -1853, p. 8. - -[793] _Ibid._ p. 14. - -[794] _Ibid._ s. d. - -[795] _Report on Health of Navy, 1857_, p. 69. - -[796] _Ibid._ p. 41. - -[797] _Ibid._ p. 131. - -[798] _Ibid._ p. 112. - -[799] _Report for 1856_, p. 100. - -[800] 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 negroes), of which number 30 -died and were included in the total of 569. Many of the inoculated, says -Prince, were not careful to avoid catching the infection in the natural -way; "for I have known some, as soon as inoculated, receive visits from -their friends, who had been with the sick of the same disease and 'tis -likely carried infection with them; it seems highly probable that the -inoculated received the infection from them into their vitals." It may be -supposed that the inoculated who were more careful formed a part of the -1843 who "moved out of town." More than a third of the population took -natural smallpox in some four months (April to July) of 1752, more than a -third had had it before, a severe epidemic having occurred in 1730 as well -as in 1721. - -[914] Clinch, _Rise and Progress of the Smallpox, with an Appendix to -prove that Inoculation is no Security from the Natural Smallpox_. 2nd ed. -1725. - -[915] C. Deering, M.D., _An Account of an Improved Method of treating the -Smallpox_. Nottingham, 1736, p. 27. Woodville appears to accept this case -as authentic. - -[916] Pierce Dod, M.D., F.R.S., _Several Cases in Physic_. London, 1746. - -[917] Kirkpatrick, and after him Woodville, treat the alleged experience -of Jones as pure fiction. - -[918] La Condamine, of Paris, an amateur enthusiast for inoculation, did -all he could to upset the case. He got his friend Dr Maty, foreign -secretary of the Royal Society, to make inquiry through the British -ambassador to the Porte. It happened that Angelo Timoni, son of the -inoculator, was at that time an interpreter at the British Embassy; he -applied to his mother, who re-affirmed the facts as to the inoculation of -her child in infancy, and her death by the natural smallpox twenty-four -years after. The only defence left was that the inoculation had not been -done by Dr Timoni's own hand. La Condamine, _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 negroes seized at once by the smallpox on the -coast of Guinea one only died, who refused to drink tar-water; and the -remaining 169 all recovered, by drinking it, without any other medicine, -notwithstanding the heat of the climate and the incommodities of the -vessel. A fact so well vouched must, with all unbiassed men, outweigh, -&c." - -[1041] Prince, _Gent. Magaz._ Sept. 1753, p. 414. - -[1042] Walter Lynn, u. s. 1715, _ad init._ - -[1043] _Reports, &c._ 1819. - -[1044] Whytt, _Med. Obs. and Inquiries_, II. (1762), p. 187. - -[1045] Cleghorn, _Diseases of Minorca_. London (under the years). - -[1046] Hillary, _Changes of the Air, and Epidemical Diseases of Barbados_. - -[1047] Muret, _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 -coloured plates, in his _History and Pathology of Vaccination_. 2 vols. -London, 1889. The plates are in vol. I., the memoirs in vol. II. -Crookshank's volumes, which are a convenient repertory of the more -important earlier writings on cowpox, contain also the author's original -observations (with plates), of cowpox in Wiltshire in 1887-88. - -[1079] In my essay of 1887 (u. s.) I maintained, as an original opinion, -that the true affinity of cowpox was to the great pox of man, and that the -occasional cases of so-called vaccinal syphilis were not due to the -contamination of cowpox with venereal virus but to inherent (although -mostly latent) properties of the cowpox virus itself. This opinion was at -first received with incredulity, but is now looked upon with more favour. -See Hutchinson, _Archives of Surgery_, Oct. 1889, and Jan. 1891, p. 215. -The concessions hitherto made are only for cases that have arisen since my -book was published, such as the case at the Leeds Infirmary in 1889. I -believe that my explanation of vaccinal "syphilis" will at length be -accepted for all cases, past or future. - -[1080] _An Inquiry, &c._ 1798. "Remarks on the term Variolae Vaccinae." - -[1081] That Dr Jenner foresaw this line of proof, and dismissed it as -irrelevant, is made clear by G. C. Jenner, _Monthly Magazine_, 1799, p. -671, in reply to Dr Turton, of Swansea: "It is possible that variolous -virus inserted into the nipples of a cow, might produce inflammation and -suppuration, and that matter from such a source might produce some local -affection on the human subject by inoculation. But all this tends only to -show, what was well known before, that virus taken from one ulcer is -capable of producing another by its being inserted into any other part of -the body." - -[1082] Jenner, _Further Observations on the Variolae Vaccinae_, 1799. - -[1083] Thornton, in Beddoes' _Contributions to Physical and Medical -Knowledge_. Bristol, 1799. - -[1084] Hughes, _Med. and Phys. Journ._ I. (1799), p. 318. Many other -tests, English and foreign, are detailed in my book, _Jenner and -Vaccination_. London, 1889, for which see the Index under "test." - -[1085] Woodville tabulated 511 cases of applicants for inoculation at the -hospital in whom cowpox matter was used, giving "the number of pustules" -opposite the name of each; 90 had from a thousand to a hundred pustules, -215 had less than one hundred. William Woodville, M.D., _Reports of a -Series of Inoculations for the Variolae Vaccinae or Cowpox; with remarks -on this disease considered as a substitute for the Smallpox_. London, -1799. In a subsequent letter (_Med. Phys. Journ._ V., Dec. 1800), he thus -explained the occurrence of smallpox among those recently inoculated with -cowpox: "If a person who has been exposed to the contagion of smallpox for -four or five days be then inoculated for this disease, the inoculation -prevents the effects of the contagion, and the _inoculated_ smallpox is -produced. But if the vaccine inoculation be employed in a case thus -circumstanced, the smallpox is not prevented, although the tumour produced -by the cowpox inoculation advance to maturation. It was not before the -commencement of the present year [1800], that I ascertained that the -cowpox had not the power of superseding the smallpox. For, though from the -first trials that I made of the new inoculation it appeared that these -diseases, as produced in the same subject from inoculation, did not -interrupt the progress of each other; yet as the casual does not act in -the same manner as the inoculated smallpox, and may be anticipated by the -latter, I thought it still probable that the cowpock infection might have -a similar effect. Numerous facts have, however, proved this opinion to be -unfounded, and that the variolous effluvia, even after the vaccine -inoculation has made a considerable progress, have in several instances -occasioned an eruption resembling that of smallpox." - -[1086] _European Magazine_, XLIII. 137. - -[1087] Bateman, u. s. 1819, Aug.-Nov. 1807: "In a court adjoining Shoe -Lane, in the course of one month, twenty-eight persons had died of -smallpox." Autumn, 1812: "In one small court in Shoe Lane, seventeen have -lately been cut off by this variolous plague." Also in the summer of 1812, -"perhaps universally through the metropolis." - -[1088] Extracted from the Annual Reports of the Dispensary. - -[1089] Heysham to Joshua Milne, in the latter's _Treatise on the Valuation -of Annuities_. London, 1815. App. p. 755. - -[1090] Cross, 1819, u. i. p. 2. - -[1091] Most of these were brought to light by inquiries upon the alleged -failures of cowpox to avert the epidemic. The serial numbers of the -_Medical Observer_ contain frequent references to them. - -[1092] Letter to Joshua Dixon, in _Memoirs_, III. 368. - -[1093] Bateman, _Edin. Med. Surg. Journ._ VIII. 515. - -[1094] C. Stuart, _ibid._ VIII. 380. - -[1095] Rigby, _ibid._ X. 120. - -[1096] Joshua Dixon, _The Literary Life of William Brownrigg, M.D._ -Whitehaven, 1801, pp. 238-9. - -[1097] Haygarth says: "With us in Chester, smallpox is seldom heard of -except in the bills of mortality. _There_ its devastation appears dreadful -indeed." _Sketch of a Plan, &c._ 1793, p. 491. - -[1098] Barker and Cheyne, _Account of the Fever, &c._ 2 vols. 1821. I. 92. - -[1099] Francis Rogan, M.D., _Obs. on the Condition of the Middle and Lower -Classes in the North of Ireland_. Lond. 1819, p. 17. He proceeds to -say:--"The numerous cases, which came to my knowledge, of children in the -neighbouring towns who had taken smallpox, after having been vaccinated by -medical practitioners of high respectability, led me to pay particular -attention to those whom I myself inoculated [with cowpox]; and, although -they were numerous both in private practice and at the Dispensary, not one -instance occurred among them." It comes out however that he did not keep -them long in sight; he saw them on the 7th day after vaccination, and -again on the 11th; and as they were meanwhile almost daily exposed to -contagion, without catching it, he concluded that his own cases never -would do so. - -[1100] W. L. Kidd. "A concise Account of the Typhus Fever at present -prevalent in Ireland, as it presented itself to the Author in one of the -towns in the North of that country." _Edin. Med. and Surg. Journ._ XIV. -(1817), 144. He goes on: "A great number of those attacked were _reported_ -to have been formerly vaccinated. At Londonderry, in particular, great -numbers who were _said_ to have undergone vaccination were the subjects of -smallpox; and, whether justly or not, vaccination has in that part of the -country lost much of its credit as a preservative against smallpox." - -[1101] Redhead (dated Ulverston, 3 July, 1816) in _Med. and Phys. Journ._ -Jan. 1817, p. 3. - -[1102] James Black, "On Anomalous Smallpox." _Ed. Med. and Surg. Journ._ -Jan. 1819, p. 39. - -[1103] Henry Dewar, M.D., _Account of an Epidemic of Smallpox which -occurred in Cupar in Fife in the Spring of 1817_. Lond. 1818. - -[1104] P. Mudie, M.D. to Thomson, 18 Oct. 1818: "Many of the cases -occurring after vaccination so much resembled smallpox that, if my mind -had not been prejudiced against the possibility of such an occurrence, I -should have pronounced the eruption to have been of a variolous -nature"--which, of course, it was. - -[1105] Thomson, _Account of the Varioloid Epidemic in Scotland, &c._ Edin. -1820. - -[1106] In Thomson, u. s. - -[1107] Thomas Bent, M.D., "Observations on an Epidemic Varioloid Disease -lately witnessed in the County of Derby." _Med. and Phys. Journal_, Dec. -1818, p. 457. One Jennerian, Dr Pew, of Sherborne, adopted an arrogant -tone towards Bent (_Ibid._ April, 1819, and farther correspondence). -Jenner employed Fosbroke, of Berkeley, son of his friend and neighbour the -antiquary Fosbroke, to traverse the whole case of the epidemic of 1817-19, -in a long paper in the _Medical Repository_ for June, 1819. The object of -the paper appears to be to confuse the issues with a view to a verdict of -_non liquet_. The _Edinburgh Review_ thought Thomson's book on the -epidemic of 1817-19 important enough for an article, which has been -attributed to Jeffrey. The article pronounced vaccination to be a very -great blessing to mankind, but not a complete protection. This was not -enough for Jenner, who wrote of the article: "It will do incalculable -mischief: I put it down at 100,000 deaths at least." - -[1108] John Green Cross, _A History of the Variolous Epidemic which -occurred in Norwich in the year 1819_. Lond. 1820. - -[1109] Cross, u. s. Appendix. - -[1110] W. Shearman, M.D., "Cases illustrating the Nature of Variolous -Contagion and the Modifying Influence of Vaccine Inoculation." _Lond. Med. -Repos._ Dec. 1822. Case of a mother, with good vaccine marks, attacked -with smallpox, which became dry and horny about the fifth day; case of her -child, in which the eruption ran the full course of pustules, but also a -mild case. - -[1111] _Lond. Med. and Phys. Journ._ May, 1818, p. 488: "By Mr Field's -report of Christ's Hospital smallpox in a mild form has been frequent -_post vaccinationem_." - -[1112] Thomas Stone, F.R.C.S. "Table of Deaths from Smallpox in Christ's -Hospital, 1750 to 1850, with remarks," in Appendix to _Papers on the -History and Practice of Vaccination: Parl. Papers_, 1857. In 1761 there -were four deaths from smallpox. For ten years, 1775 to 1784, there were -none. In some other years of the latter half of the 18th century there -were one or two deaths from that cause. There must have been some special -reason for the four deaths in 1761. According to Massey (_supra_, p. 545), -the apothecary in the beginning of the 18th century, not one death -happened in forty attacks, the ages from five to eighteen being the most -favourable of all for smallpox to fall in. In the present century -scarlatina has displaced smallpox as an infectious cause of death in that -school as in others. The deaths from scarlatina at Christ's Hospital -during the six years 1851-56 were nine. - -[1113] John Forbes, M.D., "Some Account of the Smallpox lately prevalent -in Chichester and its Vicinity." _Lond. Med. Repos._ Sept. 1822, p. 208. - -[1114] H. W. Carter, M.D., in _Lond. Med. Repos._ Oct. 1824, p. 267: "The -cases which came to light of smallpox after vaccination were unfortunately -numerous; some, it must be confessed, were exceedingly severe; others were -exaggerated." - -[1115] The vaccinations are given in Cleland's _Rise and Progress of the -City of Glasgow_. Glasgow, 1820. The smallpox deaths from 1813 to 1819 are -given, on Cleland's authority, in the _Edin. Med. and Surg. Journal_, -XXVI. p. 177. - -[1116] R. Watt, M.D., Appendix to _Treatise on Chincough_. - -[1117] John Roberton, _Obs. on the Mortality, &c. of Children_. Lond. -1827, p. 59, _note_. - -[1118] Gregory, _Report of the London Smallpox Hospital for the year -1825_. Cited in the _Med. and Phys. Journ._ Feb. 1826, p. 176. - -[1119] Cross, u. s. - -[1120] Carter, u. s. - -[1121] T. Proudfoot, M.D., _Ed. Med. and Surg. Journ._ July, 1822. - -[1122] C. Stuart, u. s. - -[1123] Dr Stokes, of Chesterfield, _Med. and Phys. Journ._ v. 17. - -[1124] Benjamin Moseley, M.D., _A Review of the Report of the Royal -College of Physicians on Vaccination_. 1808, p. 11. Jenner writing to -James Moore, 18 Nov. 1812 (in Baron, II. 383), enumerates his various -grievances against Pearson, "and finally, finding all tricking useless, -his insinuations that vaccination is good for nothing." - -[1125] The equality of the two methods in this respect comes out -incidentally in two reports of the Whitehaven Dispensary. In the report -for 1796, when smallpox matter was in use, it is said that "173 were -inoculated, all of whom, soliciting little medical assistance, recovered." -In 1801, when cowpox matter had been substituted in every case, the same -phrase is used: "We seldom find any medical assistance required in this -disease." - -[1126] _The Beneficial Effects of Inoculation._ Oxford University Prize -Poem. Oxford, 1807. It seems probable that this was the "Oxford copy of -verses on the two Suttons" that Coleridge (_Biographia Literaria_ (1817), -Pickering's ed. II. 89) professed to quote from in the following passage; -at least it would be remarkable if there had been printed another Oxford -poem on the same subject and in the same manner: "As little difficulty do -we find in excluding from the honours of unaffected warmth and elevation -the madness prepense of pseudopoesy, or the startling hysteric of weakness -over-exerting itself, which bursts on the unprepared reader in sundry odes -and apostrophes to abstract terms. Such are the Odes to Jealousy, to Hope, -to Oblivion, and the like, in Dodsley's collection and the magazines of -the day, which seldom fail to remind me of an Oxford copy of verses on the -two Suttons, commencing with - - 'Inoculation, heavenly maid! descend!'" - -It appears that Coleridge himself contemplated a poem on Cowpox -Inoculation, which was to have exemplified what poetry should be, just as -the 18th century Oxford poem on Smallpox Inoculation exemplified what -poetry should not be. It was clearly more than the difference 'twixt -tweedle-dum and tweedle-dee. Writing to Dr Jenner on 27 Sept. 1811, from -7, Portland-place, Hammersmith, he said: "Dear Sir, I take the liberty of -intruding on your time, first, to ask you where and in what publication I -shall find the best and fullest history of the vaccine matter as the -preventive of the smallpox. I mean the year in which the thought first -suggested itself to you (and surely no honest heart would suspect me of -the baseness of flattery if I had said, inspired into you by the -All-preserver, as a counterpoise to the crushing weight of this unexampled -war), and the progress of its realization to the present day. My motives -are twofold: first and principally, the time is now come when the -'Courier' ... is open and prepared for a series of essays on this subject; -and the only painful thought that will mingle with the pleasure with which -I shall write them is, that it should be at this day, and in this the -native country of the discoverer and the discovery, be even _expedient_ to -write at all on the subject. My second motive is more selfish. I have -planned a poem on this theme, which after long deliberation, I have -convinced myself is capable in the highest degree of being poetically -treated, according to our divine bard's [Milton's] own definition of -poetry, as '_simple_, _sensuous_, (i.e. appealing to the senses by -imagery, sweetness of sound, &c.) and _impassioned, &c._'" _The Life of -Edward Jenner, M.D._ By John Baron, M.D. 2 vols. II. 175. - -[1127] _Edin. Med. and Surg. Journ._ I. 507. - -[1128] Jenner to James Moore, 26 Feb. 1810, in Baron, II. 367. - -[1129] Walker to Lettsom, 1 Sept. 1813, in Pettigrew's _Memoirs of -Lettsom_. Lond. 1817, III. 350. - -[1130] Dr Smith to Dr Monro, Dunse, 2 June, 1818, in Monro's _Obs. on the -different kinds of Smallpox_, 1818. There appears to have been some -reluctance to face the facts. "Though I have seen," says Smith, "a -multitude of cases in which smallpox has in every possible shape taken -place after vaccination, I feel myself placed in the painful situation -[why painful?] of bringing forward many facts to which gentlemen of the -first eminence in the profession will probably give little or no credit." - -[1131] _Lond. Med. Repository._ Sept. 1822. - -[1132] J. J. Cribb, _Smallpox and Cowpox_. Cambridge, 1825. - -[1133] _Ibid._ Letter of Rev. R. Marks, of Great Missenden, 6 May, 1824: -"The summer I came here the smallpox was introduced, and as the weather -was very hot, and the confluent sort was what appeared, the people began -to die almost as fast as they took the plague. Great prejudice prevailed -against vaccination, in consequence of the parish having some years ago -been vaccinated by a gentleman who knew nothing of the matter, and -contaminated the people with decomposed virus, when it was good for -nothing but to make ulcers and produced very wretched arms, and left them -all liable to smallpox, which they were all inoculated for the same year." -This clergyman subsequently vaccinated 500 cases, and the parish surgeon -300: "and here," says the former, "I had the happiness of seeing the -plague and destruction of a most horrid smallpox completely stopped." - -[1134] Robert Ferguson, M.D. _A Letter to Sir Henry Halford, proposing a -method of Inoculating the Smallpox, which deprives it of all its Danger, -but preserves all its Power of Preventing a Second Attack._ London, 1825. - -[1135] John Roberton, _Observations on the Mortality and Physical -Management of Children_. London, 1827, p. 59, _note_. - -[1136] J. Dalton, "Smallpox as it prevailed at Bury St Edmunds in 1825." -_Lond. Med. and Phys. Journ._ May, 1827, p. 406. - -[1137] Cribb, u. s. - -[1138] "Observation on Smallpox as it has occurred in London in 1825." -_Med. and Phys. Journ._ Feb. 1826, p. 117. - -[1139] _Med. and Phys. Journ._ 1826, p. 122. "The general voice of the -public satisfactorily showed that the upper ranks of society suffered -during the past year from smallpox much less than the lower." - -[1140] Gregory, _Report on the Smallpox Hospital_, 4 Dec. 1825. - -[1141] Farr, in the First Report of the Registrar-General (1839, p. 100), -said: "It may be safely asserted that the parish clerks registered little -more than half the deaths that occurred within the limits of the London -bills of mortality." Outside the limits of the bills there were large -parishes, such as St Pancras, Marylebone, Kensington and Chelsea, which -had large mortalities from smallpox in the first years of registration. - -[1142] Tables in Murchison's _Continued Fevers of Great Britain_. - -[1143] _Med. Chir. Trans_, XXIV. 15. His other papers are: "Cursory -Remarks on Smallpox as it occurs subsequent to Vaccination," _ibid._ XII. -324; and "Notices of the Occurrences at the Smallpox Hospital during the -year 1838," _ibid._ XXII. 95. He contributed the treatise on Smallpox to -Tweedie's _Library of Medicine_, I. 1840, and indicated his final opinions -(which are interesting) in his _Lectures on the Eruptive Fevers_, 1843. - -[1144] Kenrick Watson, "Medical Topography of Stourport and -Kidderminster." _Trans. Prov. Med. and Surg. Assoc._ II. 195. - -[1145] John Roberton, "On the Increasing Prevalence of Smallpox after -Vaccination." _Lond. Med. Gaz._ 9 Feb. 1839, p. 711. Roberton had been a -warm supporter of the Jennerian method from as early a date as 1808, when -he was resident in Edinburgh, and again in his book on _The Mortality of -Children_, in 1827. The above cited paper is somewhat satirical, the -disappointing facts of it being referred to the Island of Barataria. His -conclusions are (p. 713): (1) "It is not fact, but conjecture, that the -protective power of cowpox gradually ceases in the human system. (2) It is -not fact, but conjecture, that a person successfully re-vaccinated is less -liable to smallpox than he was before. (3) To affirm that, when -re-vaccination fails in individuals, they are thereby proven to be secure -from smallpox, is conjecture." - -[1146] Cowan, "On the Mortality of Children in Glasgow," _Glas. Med. -Journ._ V. (1831), p. 358, does not give Cleland's figures, but says: "No -bills of mortality except those for the Royalty in the _Glasgow Courier_ -are in existence for the period from 1812 to 1821"; and again: "Finding -that the suburbs were excluded, and the Calton being the burying-place in -which the greatest number of children are interred, I thought it needless -to insert any tabular view of the deaths by measles since the date of Dr -Watt's tables." Watt could have made no tables if he had not gone direct -to the sixteen MS. volumes of burial registers, including those of the -Calton. - -[1147] J. C. Steele, _Glas. Med. Journ._ N. S. I. 60: "From 1812 to 1835 -it is much to be regretted that no record of the deaths from smallpox has -been kept for even a limited period." - -[1148] _Glas. Med. Journ._ I. 105: "There exists at present among the -poorer classes an increasing carelessness and aversion to vaccination, -from a belief that it does not afford adequate protection from the -varioloid disease." - -[1149] Andrew Buchanan, M.D. "Present Condition of the Poor in Glasgow." -_Glasg. Med. Journ._ III. (1830), 437. - -[1150] Chalmers had been urging the repeal of the Corn Law since 1819. In -a letter to Wilberforce, Glasgow, 15 Dec. 1819, he says: "From my -extensive mingling with the people, I am quite confident in affirming the -power of another expedient to be such that it would operate with all the -quickness and effect of a charm in lulling their agitated spirits--I mean -the repeal of the Corn Bill." Hanna's _Memoirs of Dr Chalmers_, 1850, II. -250. - -[1151] J. Orgill, "Obs. on the Measles and Smallpox that prevailed -epidemically in Stranraer, in the autumn of 1829." _Glasg. Med. Journ._ -IV. 351. - -[1152] McDerment, _ibid._ IV. 201. - -[1153] Howison, _ibid._ V. 256-7. - -[1154] J. C. Steele, _Glasg. Med. Journ._ N. S. I. 59. - -[1155] _Eleventh detailed Report of the Regr.-Genl. for Scotland_, 1865, -p. xxxix. The Report says that vaccination was general during the above -period, although there was no Vaccination Act for Scotland (until 1864). -This was familiar knowledge in Scotland, so much so that the necessity for -a compulsory law, on the English model, was not quite obvious in the -medical circles of Edinburgh. See Christison's address to the Social -Science Association at Edinburgh in 1863 (p. 106). In my own recollection -of Aberdeenshire, the vaccination of infants was as little neglected as -their baptism; the law made no real difference. - -[1156] "An Enquiry into the Mortality among the Poor in the City of -Limerick." _Journ. Statist. Soc._ Jan. 1841, III. 316. - -[1157] _The Census of Ireland_, 1841. Parl. Papers, 1843. Report on the -Tables of Deaths, by W. R. Wilde. - -[1158] From the Second Report of the Registrar-General, Lond. 1840, p. -180. - -[1159] 1840. - - 1st qr. 2nd qr. 3rd qr. 4th qr. - - Liverpool 172 184 90 85 - Bath 25 42 22 8 - Exeter -- -- 1 1 - Bristol 6 54 49 76 - Clifton 11 28 22 42 - -[1160] Douglass to Colden, 1 May, 1722, in _Massach. Hist. Soc. Collect._ -Series 4, vol. II. p. 169. - -[1161] Philip Rose, M.D., _Essays on the Smallpox_. London, 1724, p. 76. - -[1162] Rev. R. Houlton, App. to _A Sermon in Defence of Inoculation_, -Chelmsford, 1767, p. 59: "For, had the indictment been found, he would -have assuredly nonsuited his enemies, and have proved beyond a possibility -of doubt that he never brought into Chelmsford a patient who was capable -of infecting a bystander, notwithstanding such person would convey -infection by inoculation. However paradoxical this may seem, it is truth, -and would have been proved to a demonstration." - -[1163] Darwin, _Animals and Plants under Domestication_, II. 356: "From -these facts we clearly see that the quantity of the peculiar formative -matter which is contained within the spermatozoa and pollen-grains is an -all-important element in the act of fertilization, not only for the full -development of the seed, but for the vigour of the plant produced from -such seed." - -[1164] J. C. Lettsom, M.D., _A Letter to Sir Robert Barker, F.R.S. and G. -Stackpoole, Esq. upon General Inoculation_. London, 1778, p. 8. - -[1165] W. Black, M.D., _Observations Medical and Political on the -Smallpox, etc._ London, 1781, p. 103. - -[1166] "But, in the cowpox, no pustules appear, nor does it seem possible -for the contagious matter to produce the disease from effluvia, or by any -other means than contact, and that probably not simply between the virus -and the cuticle; so that a single individual in a family might at any time -receive it without the risk of infecting the rest, or of spreading a -distemper that fills a country with terror." - -[1167] _Parliamentary Papers_, 1807, 8th July. - -[1168] Bateman, _Reports etc._ 1819, p. 102. The principle of the Common -Law on which the judgment rested was, "Sic utere tuo ut alienum non -laedas." - -[1169] Joseph Adams, _An Inquiry into the Laws of Epidemics, with Remarks -on the Plans lately proposed for Exterminating the Smallpox_. London, -1809. The _Edin. Med. and Surg. Journal_ (VI. 231), in a long review of -this essay, declared that Adams was inconsistent in reaffirming his old -faith in cowpox and at the same time demanding liberty for the -inoculators. - -[1170] J. C. Steele, M.D., "Increase of Smallpox in Glasgow." _Glas. Med. -Journ._ N. S. I. 59. The Paris figures are cited from the _Annuaire pour -l'an 1852-53_. - -[1171] I do not, of course, answer for the correctness of Gregory's -statements. - -[1172] _Lancet_, 12 Dec. 1838. - -[1173] 409 of these in Sheffield. - -[1174] There are two notable exceptions, marked +, Lancashire and -Yorkshire; but, in regard to their higher mortality from smallpox in -1837-40, it should be kept in mind that they were the chief scenes of the -great distress among the working class in those years, the same causes -which produced an enormous mortality from typhus fever in adults having -tended to increase the fatality of smallpox among the children. - -[1175] In the first universal and very fatal epidemic of measles, that of -1808, a good many adults, who had not had measles before, were attacked. -See the chapter on Measles. - -[1176] The accounts by Fothergill, Wall and others, of the malignant -sore-throat with scarlet rash about 1740 give prominence to cases in early -manhood or womanhood. - -[1177] _Supplement (Decennial) to the 45th Report of the Regr.-Genl._ -1885, p. cxii. - -[1178] The figures for 1721 are cited above (p. 485) from Douglass and -others. Those for 1752 are given in the _Gent. Magaz._ 1753, Sept., p. -413, as "collected from the Accounts of the Overseers in the Twelve -several Wards," and sent by the Rev. T. Prince. - -[1179] _Supplementary Report of the Registrar-General_, 1883. The mean -death rate per 1000 living, for the period 1838-82, has been 71.0 males, -and 61.2 females under five years of age; but as late as 1878 the annual -average was the mean of the period, namely 71.2 males and 61.1 females. - -[1180] Lettsom (_Gent. Magaz._ 1804, Aug. p. 701), in a preface to Neild's -papers on the state of the prisons, estimated that 40,000 lives might be -saved every year in England by preventing infectious fevers, "for in this -metropolis my respectable friend Thomas Bernard, Esq., whose caution and -accuracy no person will doubt, calculates the number of victims at 3000 -each year [doubtless from the London Bills of Mortality].... If to this -pleasing view we add the preservation of 48,000 victims to the smallpox, -which may now be preferred by the cowpox, we have in our power to possess -the sublime contemplation of forming a saving fund of human life of nearly -88,000 persons annually in this empire, by the exercise of reason, -philanthropy and judicious policy." - -[1181] Duvillard, _Tableaux etc._ Paris, 1806. - -[1182] _Essay on the Principle of Population._ Bk. IV. chap. 5. - -[1183] Robert Watt, M.D. _Treatise on Chincough, with Inquiry into the -Relative Mortality of the Diseases of Children in Glasgow._ Glasgow, 1813. - -[1184] John Graunt, _Natural and Political Observations upon the Bills of -Mortality_, London, 1662, says: "The original entries in the Hall books -were as exact in the very first year [he probably means 1629, which is the -first year of his own extracts from them, but the classification of deaths -began in 1604] as to all particulars, as now; and the specifying of -casualties and diseases was probably more." The searchers, he explains, -were in many cases able to report the opinions of the physicians, -receiving the same from the friends of the deceased; while for certain -causes of death, among which he includes smallpox, "their own senses are -sufficient." - -[1185] _Cal. Coke MSS._ (Hist. MSS. Commis.) I. 21 June, 1628. - -[1186] Sutherland Letters, in _Rep. Hist. MSS. Com._ V. 152. - -[1187] _Cal. State Papers, Domestic. Charles II._ s. d. It appears from -the _Pyretologia_ by Drage, of Hitchin (1665), that the natural history of -measles must have been familiar, for he mentions that its incubation -period was from fourteen to fifteen days: p. 20. - -[1188] _Obs. Med._ 3rd ed. (1675), Bk. IV. chap. 5. - -[1189] Sydenham, _Obs. Med._ 1675, V. 3. "Morbilli anni 1674." It entered -almost every household, as on the last occasion, attacking infants more -especially. It had some points of difference from the measles of 1670. The -rash was less uniformly on the fourth day, now sooner, now later; it would -come on the arms or trunk before the face; nor was it followed by the -branny powdering which was as obvious in the measles of 1670 as it was -usual to see it after scarlatina. Along with these anomalies of the rash, -the consecutive fever and peripneumonia were also more severe, and a more -frequent cause of death. But in the principal characters of measles the -disease of 1674 was the same as that of 1670, and called for no fresh -description. Among Sydenham's patients were the children of the Countess -of Salisbury, who all took measles in turn, and all passed through the -attack and its sequelae without danger, under a particular regimen which -is detailed. It is of great interest to see how this season of anomalous -measles looks in the weekly bills, as in the above table. - -[1190] Richard Morton, M.D. _Pyretologia._ 2 vols. Lond. 1692-94, I. 427. -He places it in the year 1672 and in the six months of autumn and winter; -and in another place (II. 71), where he cites clinical cases, he again -gives the year 1672 as that in which measles "epidemice Londini publice -grassabantur." He compares the epidemic to a _pestis mitior_, and says -that the disease had never been epidemic again to the date of his writing -(1692-94). It is tolerably clear that, in writing twenty years after, he -had forgotten the year and even the season--not the only error in dates in -his work. Sydenham's account of the great measles epidemic of spring and -summer, 1674, was published the year after, and is exactly borne out by -the weekly bills of mortality. Morton's obvious mistake of the date is the -subject of a refutation four pages long by Thomas Dickson, M.D., F.R.S., -physician to the London Hospital, in _Med. Obs. and Inquiries_, IV. -(1771), p. 266. - -[1191] Fothergill (_Gentleman's Magazine_, Dec. 1751) says, in a criticism -of the Bills of Mortality: "If the body is emaciated, which may happen -even from an acute fever, 'tis enough for them to place it to the article -of consumption." And of course they would do so the more readily if the -acute fever, say measles, were past, and its sequelae had been the cause -of death. Referring to Kidderminster in 1756, Johnstone says: "Measles at -this time went through our town and neighbourhood: vast numbers of -children died tabid." It is to be remarked that the fever column is -augmented but little during the measles of 1674, a fact which shows that -the inflammatory causes of death, such as capillary bronchitis and -pneumonia (specially recorded by Sydenham for this epidemic), were more -apt to be entered under "consumption" than under "fevers." - -[1192] See Watson's account of smallpox following measles at the Foundling -Hospital, _supra_, p. 550. - -[1193] It may have been this high mortality that Dover had in mind when he -wrote, in 1733: "I do not remember I ever heard of anyone's dying of this -disease [measles] till about twenty-five years since; but of late, by the -help of Gascoin's powder and bezoartic bolusses, together with blisters -and a hot regimen, the blood is so highly inflamed and the fever encreased -to that degree that it is become equally mortal with the smallpox." -_Physician's Legacy_, 1733, p. 116. - -[1194] Memorial to the House of Commons, _supra_, p. 84. - -[1195] _Edin. Med. Essays and Obs._ V. 26. - -[1196] Pronounced by Sims to have been wholly scarlatina, and by Willan to -have been in part that disease. - -[1197] Monthly reports in the _Gentleman's Magazine_, under the dates. - -[1198] Heberden's paper on measles in _Trans. Col. Phys._ III. (1785), pp. -389, 395. - -[1199] W. Black, M.D., _Obs. Med. and Political on the Smallpox, &c._ -London, 1781, p. 207: "Few escape measles in infancy or childhood, and as -we find one-tenth fewer to die of measles than of smallpox, etc.... In -their future consequences, measles, especially in cities, are not without -hazard, and are not unfrequently followed by hecticks." - -[1200] Percival, in _Med. Obs. and Inquiries_, V. (1776), p. 282. - -[1201] Omitting the year 1760. - -[1202] Compiled from the tables in the _Gentleman's Magazine_, 1742-57. -All Saints parish contained more than half the population. - -[1203] Pearce, writing from St Croix, West Indies, 12 Oct. 1782, to -Lettsom (_Memoirs_, III. 429), says the measles had been "very rife and -fatal" there. - -[1204] MS. Apothecary's Books at the Foundling Hospital. - -[1205] R. Willan, M.D., _On Cutaneous Diseases_. Vol. I. 1808, p. 244. - -[1206] Heysham, u. s., p. 538. - -[1207] James Lucas, "On Measles." _Lond. Med. Journ._ XI. 325, dated 22 -Aug. 1790. - -[1208] _Reports on the Diseases of London, 1796-1800._ Lond. 1801, pp. 2, -13, 18, 32, 229. - -[1209] John Roberton, in _Med. and Phys. Journ._ XIX. 185. Measles seems -to have been more usual than scarlatina in Scotland as well as in Ireland. -In the accounts of the several parishes written for the _Statistical -Account_, about 1791-99, measles is often mentioned (and would appear at -that time to have been more usual in country districts than smallpox), -while hardly anything is said of scarlatina under that name, and not much -of sore-throat. - -[1210] _Med. and Phys. Journ._ VII. (1802), p. 316. - -[1211] "Observations on Measles." By Mr Edlin, surgeon, Uxbridge. _Med. -and Phys. Journ._ VIII. (July-Dec. 1802), p. 28. An earlier epidemic of -anomalous eruptive fever ("dark coloured eruption of the neck and breast -which spread at length over the whole body") was described for Uxbridge -and its vicinity in the summer and autumn of 1799, in an essay reviewed in -_British Critic_, XV. 435. - -[1212] T. Bateman, M.D., _Report on the Diseases of London, 1804-16_. -Lond. 1819, p. 90-91. - -[1213] Samuel Fothergill, M.D., and others, in _Med. and Phys. Journ._ -XVIII. (Dec. 1807), pp. 569, 572; XIX. 91, 185. - -[1214] "The Epidemic Measles of 1808." By Dr Ferguson. _Med. and Phys. -Journ._ XXI. 359. - -[1215] John Roberton, _Med. and Phys. Journ._ XIX. 182, 272, 278, 471. - -[1216] Roberton, _loc. cit._ XIX. 471. - -[1217] In the earlier period, according to Grainger, Lind and others, -numerous cases of measles sometimes occurred on board ships of war. - -[1218] Published as an Appendix to his _Treatise on the History, Nature -and Treatment of Chincough_. Glasgow, 1813. Reprinted by John Thomson, -Glasgow, 1888. Dr Watt is best known by his _Bibliotheca Britannica_ -(Edinburgh, 1819. 4 vols. 4to.), a wonderfully complete bibliography under -the dual arrangement of subjects and authors, which is still indispensable -for research in every branch of knowledge. Perhaps the many who use it are -not all aware that it was the labour of a physician in Glasgow (originally -a surgeon at Paisley), who died (in 1819) at the age of forty-five, having -reached such professional distinction in his own city as to be elected -President of the Faculty of Physicians and Surgeons. - -[1219] _De Febribus_, 1659. Cap. XV. - -[1220] _Sketch of a Plan to exterminate the Casual Smallpox, &c._ London, -1793, p. 152. - -[1221] It was believed that smallpox left ill effects in some -constitutions. William III. is said to have had the dregs of smallpox in -his lungs. Roberton (u. s.) cites Saunders as teaching that smallpox -caused scrofula, and he is himself doubtful whether an attack of it ever -improved the constitution. Dr Moses Younghusband, of New Lebanon Springs, -_Med. Phys. Journ._ XI. (1804), 317, wrote: "I see no more of the -glandular suppurations formerly so frequent and unavoidable" after -smallpox. - -[1222] Johnstone, _Malignant Epidemic Fever of 1756_, London, 1757, says -of Kidderminster during a season of high mortality from fever and other -diseases: "The measles at this time went through our town and -neighbourhood. The children commonly got over the usual course of this -distemper; but vast numbers died tabid of its consequences. The chincough -succeeded the measles." - -[1223] The _Edin. Med. and Surg. Journ._ XXVI. 177, cites from Cleland, -with a reference which I have not succeeded in verifying, the following -Glasgow figures for the period 1813-19: all deaths 22,060, smallpox 236 -(1.07 per cent.), measles 614 (3.69 per cent.). But see Cowan, _Glas. Med. -Journ._ V. 358, _supra_, p. 597. - -[1224] Cowan, _Journ. Statist. Soc._ III. - -[1225] Griffin, _ibid._ III. - -[1226] Macmichael, in an essay on scarlatina and other contagions, 1822, -says: "Parents considering the measles as a disease almost inevitable have -wisely chosen to expose their children to the contagion at such auspicious -times [summer season]; so that the disorder may be once well over, and all -further anxiety at an end." p. 30. - -[1227] P. Macgregor, _Med. Chir. Trans._ V. 436, obtained from Henry, of -Manchester, the burials from measles at the Collegiate Church and St -John's Church for two years, 1812-13, which when compared with those -abstracted by Percival from the former register for twenty years, 1754-74, -showed a higher ratio of measles to the burials from all causes. - -[1228] Cross, u. s. - -[1229] Delagarde, _Med. Chir. Trans._ XIII. 163. - -[1230] A. Campbell Monro, M.D., "Measles: an Epidemiological Study." -Chiefly from the Jarrow statistics. _Trans. Epid. Soc._ N. S. X. -(1890-91), p. 94. The author connects the recent increase with the greater -concourse of children to infant and elementary schools under the Education -Act. - -[1231] _Rep. Reg.-Genl._ LIV. p. xviii, and LV. p. xi. The explanation -given is as follows: "When a county or other area has been visited by a -severe epidemic [of measles] there is for several succeeding years -scarcely sufficient material, in the shape of unprotected children, for -another considerable outbreak, unless it be in very populous areas such as -London or Liverpool; and in such places the disease is endemic." - -[1232] Buchan and Mitchell, _Journ. Scot. Meteor. Soc._ July, 1874, p. -194. - -[1233] Ogle, in the 47th Report of the Registrar-General (for 1884), p. -xv. - -[1234] Cited by Hirsch, _Geogr. and Histor. Pathology_. Eng. transl. III. -28. - -[1235] _Harl. MSS._ No. 2378. Moulton's _This is the Myrour or Glasse of -Health_, circa 1540, is in the main a printed reproduction of this -manuscript prescription-book. The same receipt which is "for ye kink" in -the one, is "for the chyncough" in the other (formula LXXIX.). - -[1236] "Sycknesses happenynge to children:--When they be new borne, there -do happen to them sores of the mouth called aphte, vometyng, coughes, -watchinge, fearefulness, inflamations of the nauelle, moysture of the -eares. When they brede tethe, ytchinge of the gummes, fevers, crampes and -laskes. When they waxe elder, than be they greved with kernelles, -opennesse of the mould of the head, shortnesse of wynde, the stone of the -bladder, wormes of the bealy, waters, swellynges under the chynne, and in -Englande commonly purpyles, measels and small pockes." - -[1237] _Obs. Med._ 3rd ed. Bk. IV. chap. V. 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. - - - - - * * * * * * - - - - -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. - - - -***END OF THE PROJECT GUTENBERG EBOOK A HISTORY OF EPIDEMICS IN BRITAIN, -VOLUME II (OF 2)*** - - -******* This file should be named 43671.txt or 43671.zip ******* - - -This and all associated files of various formats will be found in: -http://www.gutenberg.org/dirs/4/3/6/7/43671 - - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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