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.

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]:

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:

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.

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.

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.

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.

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.

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.

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.

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]:

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.

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: