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.

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.

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.

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.

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:

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.

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.

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.

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:

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:

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.

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).

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.

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:

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.

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:

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.