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.

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.

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.

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.

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:

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.

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

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

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

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

Deaths by Smallpox at Carlisle, 1779-87.

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.

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:

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.

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: