[back] A Century of Vaccination and What it Teaches by W. Scott Tebb

CHAPTER  3: SOME  OF   THE  CAUSES  OF   THE  DECLINE  IN   THE SMALL-POX   MORTALITY.

SMALL-POX  DIFFUSED  BY  INOCULATION.
FLUCTUATIONS   IN   SMALL-POX   MORTALITY.
SALUTARY EFFECT  OF  OPEN  SPACES.
INCREASE  OF  METROPOLITAN  AIR-SPACES.
THE  WINDOW-TAX 
DOMESTIC  INSANITARY  CONDITIONS. 
EIGHTEENTH  CENTURY PRISONS.
AGE-INCIDENCE AND  SANITATION.
BURIAL  GROUNDS AND  MORTALITY.
COMMERCIAL  DEPRESSION.
THE EFFECTS  OF   WAR.
MALTHUS  DISCOVERS A  NEW  PRINCIPLE.
THE  ZYMOTIC  DISEASES  REPLACE  EACH  OTHER.  

In the last chapter attention was directed to the fact that although some of the epidemics of small-pox in the present century have been nearly as severe as those of the two previous ones, yet they took place at longer intervals; and thus there has been an important reduction in the mortality from this malady. The disease began to subside, however, before the introduction of vaccination, and was part of a general improvement in the public health which was taking place about this time. This is seen in the following table compiled by Dr. Farr.

London.—Average annual death-rates per 100,000 living  at  six different periods, from 1629-1835.¹

                                          All causes.              Small-pox.²      Fever.
1629-35            ...           ...    5,000                     189             636
1660-79       ..................       8,000                      417             785
1728-57       ......................   5,200                      426             785
1771-80             ...           ...  5,000                      502             621
1801-10              ...           ... 2,920                      204             264
1831-35        .............           3,200                       83              111

1 "M'Culloch's Statistical Account of the British Empire," vol. ii., p. 579.    Second edition.    London.    1839.
2. In a pamphlet by Mr. Ernest Hart, entitled "The Truth About Vaccination" (1880, p. 35), it is stated that "In Dr. Farr's valuable article on Vital Statistics in M'Culloch's 'Account of the British Empire,' it is shown that in the twenty-seven years, 1629-35 and 1660-79, the annual mortality from small-pox in London was equal to nearly 16,000 per million persons living; and in the forty years, 1728-57 and 1771-80, to nearly 18,000 per million living."  It is not at first sight apparent how these high rates have been deduced from Dr. Farr's figures.

Commenting on these figures, Dr. Farr says :—

" Small­pox attained its maximum mortality, after inoculation was introduced. The annual deaths of small pox registered 1760-79 were 2,323 ; in the next twenty years, 1780-99, they declined to 1,740; this disease, therefore, began to grow less fatal before vaccination was discovered, indicating, together with the diminution of fever, the general improvement of health then taking place."

Considering, also, that since the commencement of registration smallpox has completely ignored the fluctuations in the amount of vaccination, it is begging the question to assume that this is in any way relevant to the diminution that has been recorded. I propose, therefore, in the present chapter, to indicate some of the causes which have led to the decline of the disease.

It will be convenient at this juncture to consider the effect produced on the small-pox mortality in the displacement of small-pox inoculation by vaccination. As it was only in rare instances, that the inoculated were subjected to any form of isolation, it cannot be denied that they must often have acted as centres of infection and have diffused the disease. Dr. Wagstaffe,¹ writing in 1722, related an instance where, in consequence of a few inoculations, small-pox was spread in the town of Hertford, and occasioned a considerable mortality. In Paris, in 1763, the unusual severity of small-pox was attributed

1 A Letter to Dr. Freind, p. 38.    London.    1722.

SMALL-POX  DIFFUSED  BY  INOCULATION.

to increased infection from inoculation, and a decree was issued prohibiting the practice. The advocates of vaccination were almost unanimous in their opinion, that inoculation was responsible for much loss of life from small-pox; thus Moore¹ declared, that the neglect of the precaution of preventing the spread of infection from the inoculated had "occasioned the loss of millions of lives." The last statement must, however, for obvious reasons, be received with caution.

If we consult the London Bills of Mortality, we find that the small-pox mortality in the eighteenth century exceeded that of the seventeenth century. There are reasons, however, for believing that other causes besides inoculation must be sought for to explain the high small-pox rates in the eighteenth century. One of these is, that small-pox rose to a higher level of mortality about the year 1710; whereas inoculation was not introduced into this country until 1721. Dr. Creighton² informs us, that "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." In London inoculation was revived about 1740, and after a few years became a lucrative branch of surgical practice, but was restricted almost exclusively to the well-to-do.

1 "History of Small-pox," pp.   232,  233.     James  Moore.     London. 1815.
2. " A History of Epidemics in Britain," vol. ii., p. 504.

Gratuitous inoculation commenced with the opening of a hospital in 1746; but it was not till  1751-52, that any considerable number of people were inoculated in connection with the charity.

According to the London Bills it does not appear that the few inoculations which took place during the years 1721-28 had any appreciable effect on the small­pox mortality, nor should we expect them to do so ; but if a diagram be prepared showing year by year the rates of small-pox deaths to those for all causes, it will be found that from 1751 to 1781 a still higher level of small - pox mortality was reached than that which prevailed from 1710 to 1751 ; this seems to suggest an inoculation factor in the case. After 1781 small­pox was certainly at a lower level than that obtained between 1751 and 1781 (although in the one year, 1796, it touched the highest point in the century). This diminution, as Dr. Farr has pointed out, was associated with a decline in the general death-rate, and was no doubt brought about by the sanitary improvements introduced at that period ; and thus small-pox became less prevalent, in spite of the fact that inoculation still remained in full operation.

To sum up the case, it is evident that the large mortality from small-pox in the last century cannot be wholly attributed to inoculation ; but from the facts here presented I am led to believe that the augmentation which took place in 1751, and continued for a large number of years, might with fairness be put down to this cause. The first sign of any diminution in the small-pox death-rate commenced after 1781. This cannot be due to any falling off in the amount of inoculation, but must be associated with a general improvement in the public health then  observable ;  the further decline  after the introduction of vaccination was in part probably brought about by the substitution of a non-infectious process.¹

FLUCTUATIONS   IN   SMALL-POX   MORTALITY.

One of the causes of the spread of small-pox is over­crowding and want of air-space in and around houses. The fifth annual report of the Registrar-General gives the country and the town mortality from various causes for the four years 1838-41 ; in the case of small-pox the former is 507, and the latter 1,045 Per million ; for all causes the figures are 19,300 and 27,073 respectively. This shows, that small-pox is much more influenced by the aggregation of the population than by all other causes of disease combined. The mortality from small­pox appears to vary according to the greater or lesser proportion of open spaces in towns. The following table illustrates this point.

1 As most of the lymph with which the early " vaccinations" were performed was of variolous origin, it is important to show that after a time the cases inoculated with Woodville's lymph ceased to be infectious. The following, in a letter from Jenner to Lord Egremont (Baron's " Life of Jenner," vol. i., p. 342), is very much to the point. Referring to the threads distributed by Dr. Pearson, Jenner says : "In many places where the threads were sent, a disease like a mild small-pox frequently appeared ; yet, curious to relate, the matter, after it had been used six or seven months, gave up the variolous character entirely, and assumed the vaccine; the pustules declined more and more, and at length became extinct. I made some experiments myself with this matter, and saw a few pustules on my first patients ; but in my subsequent inoculations there were none."

For twenty large towns¹ the acres of town area to one acre of park and the average annual death-rate per 1,000, for the ten years 1870-79, from small-pox, measles, scarlet fever, fever and whooping cough.

This table indicates generally, that towns with the greatest amount of park space have low small-pox death-rates, and vice versa. Liverpool appears to be an exception, but it will be noticed that in this town the rates for the other zymotic diseases are also very high, due to overcrowding and sanitary neglect.    It must be

1 Fortieth and Forty-second Annual Reports of the Registrar-General.

SALUTARY EFFECT  OF  OPEN  SPACES.

remembered, that with regard to air supply, small towns would have the advantage of large ones. A single dwelling would be surrounded on all sides with air; but suppose we have a group of houses of equal sizes arranged symmetrically in the form of a square, with five houses to a side, there will be sixteen outside houses with twenty-five altogether, and the fraction 16/25 will represent the external aerial supply ; with one hundred houses to a side, this will be shown by the smaller fraction 396/10,000; and hence the difference in the external ventilation of the two groups of houses would be very large, being represented by the difference between the two fractions 6,400/10,000 and 396/10,000.  Thus, independently of park space, a small town would have better external ventilation for its houses than a large one; this may to some extent explain several exceptions in the table.

It may be, that there are other causes than the amount of park space to account for the difference in the small-pox mortality in the several towns specified, but the figures, in comparison with those of the other zymotic diseases, appear to be so striking as to suggest that external ventilation really exercises an important influence on the prevalence and mortality of this disease.

The epidemic of 1871-72, which largely dominates the small-pox figures in the last table, was conspicuously severe in the mining districts, which, as a rule, are most overcrowded. Durham was one of the most devastated counties, eleven of the thirteen registration districts having enormous small-pox death-rates.

Dudley, in Staffordshire, had a small-pox death-rate of 8,977, Newcastle one of 6,456, and Bedwellty, Pontypridd, Merthyr, Swansea, Abergavenny, rates of 8,520, 7,492, 6,380, 5,627, and 4,768 per million respectively. Thus we see that small-pox picks out its victims from thickly-populated centres, and more especially towns which are imperfectly aerated, and where, as in mining districts, the industrial conditions predispose to overcrowding.

That our ancestors had a less plentiful supply of fresh air in and around their houses goes without saying. It is a well-known fact that our towns have increased in area quite out of proportion to the increase in the population. Mr. John Timbs² observes, that the majority of the London squares were the growth of the last century, and that few of those in the western district existed before 1770, their sites being then mostly sheep-walks,

1   The epidemic was not limited to the years 1871 and 1872, in some cases it extended over several years.
2   " Curiosities of London," pp. 746, 747.    John Timbs, F.S. A.     1867.

INCREASE  OF  METROPOLITAN  AIR-SPACES.

paddocks, and kitchen - gardens; but we know that several of the London squares existed in the seven­teenth century, and there is a reference to Bloomsbury Square in " Evelyn's Diary," under the date February 9, 1665 :—

" Dined at my Lord Treasurer's, the Earle of Southampton, in Blomesbury, where he was building a noble square or piazza, a little towne ; his owne house stands too low, some noble roomes, a pretty cedar chapell, a naked garden to the north, but good aire."

At the beginning of the eighteenth century Grosvenor, Cavendish, and Hanover Squares were laid out, the last two about the year 1718. Portman, Manchester, Finsbury, and Fitzroy Squares were constructed at the end of the last century; and at the beginning of the present century, about 1804, Russell Square, one of the largest in London, was finished, and about this time, also, Bedford and Euston Squares were opened. In 1829 a variety of important improvements were made immediately around St. Martin's Church; a whole labyrinth of close courts and small alleys were swept away, a district including places known as the Bermudas, the Caribbee and Cribbe Islands, and Porridge Island, notorious for its cook-shops;¹ this wholesome and wholesale clearance prepared the site for the construction of Trafalgar Square. Other squares, such as Lowndes and Woburn Squares, were made about 1836; while Blandford, Harewood, and Dorset Squares are of more recent construction.

1 See Cassell's " Old and New London," vol. iii., p. 141.

THE  WINDOW-TAX 

Besides a deficient aeration of towns, our ancestors suffered  under  an  insanitary tax  upon  light and  air, known as the window-tax. This was imposed in order to make good the deficiencies of the clipped money. Its origin, in 1695, has been described by Lord Macaulay:—"It was a maxim received among financiers that no security which the government could offer was so good as the old hearth-money had been. That tax, odious as it was to the great majority of those who paid it, was remembered with regret at the Treasury and in the City. It occurred to the Chancellor of the Exchequer that it might be possible to devise an impost on houses, which might be not less productive nor less certain than the hearth-money, but which might press less heavily on the poor, and might be collected by a less vexatious process. The number of hearths in a house could not be ascertained without domiciliary visits. The windows a collector might count without passing the threshold. Montague proposed that the inhabitants of cottages, who had been cruelly harassed by the chimney men, should be altogether exempted from the new duty. His plan was approved by the Committee of Ways and Means, and was sanctioned by the House without a division. Such was the origin of the window-tax, a tax which, though doubtless a great evil, must be considered as a blessing when compared with the curse from which it rescued the nation."¹

1 "History of England," vol. iv., p. 641.    Macaulay.

The tax first fell largely on the landlord, but by the 20th of George II. (1746) it was levied upon the several windows of a house at so much per window, and consequently  fell   more  cruelly upon the tenants of the tenement houses. By the 21st of George II., cap. 10, all skylights, the lights of staircases, garrets, cellars, and passages, were to count for the purpose of the tax ; and it was further enacted (11th section) that "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." The law was enforced by a corrupt machinery of commissioners, receivers-general, and collectors, who were paid by results, and thus could hardly fail to act injuriously. In 1803 the law was altered, the houses being rated as a whole according to the number of their windows, and at the same time the tax for tenement houses was made recoverable from the landlord ; it thus became a sort of modern house-tax rated on windows.¹

The great speculative builder of the Restoration was Nicholas Barbone, and his method of procedure 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, built 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." ²

1  For the above description of the window-tax, I am indebted to Dr. Creighton's " History of Epidemics."
2  Quoted by Dr. Creighton from "Lives of the Norths."    "A History of Epidemics in Britain," vol. ii., p. 86.

" In these mazes of alleys, courts or  rents,'" Dr. Creighton  says, "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 sub-letting, '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. In 1710, Swift's lodging in Bury Street, St. James's, for which he paid eight shillings a week, 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 connection with the hot summer of the great fever-year, 1685."

In the days of the Tudors and the Stuarts, the personal habits even of the upper classes left much to be desired. Fresh linen being a luxury, the clothes were seldom changed, and the dyer was more often in requisition than the laundress. Sir John Falstaff thus describes the contents of the buck or linen-basket:— " Foul shirts and smocks, socks, foul stockings, and greasy napkins ; that, Master Brook, there was the rankest compound of villainous smell that ever offended nostril."¹

1 " The Merry Wives of Windsor," act iii., scene v.

DOMESTIC  INSANITARY  CONDITIONS. 

From a washing tally found behind some oak panelling in the old chaplain's room at Haddon Hall, in Derbyshire, it would appear that towels had not always belonged to the domestic arrangements of this establishment, for in place of that word, which was scratched out, "laced bands " had been written on the horn of the tally.

Some interesting relics called "scratch-backs" have come down to us, the name sufficiently indicating the habits of the aristocracy of the time. A scratch-back is a hand or claw set in a long handle, which was some­times made of silver elegantly chased, and there is one instance where a ring on the finger of the hand is set with brilliants. At one time these implements were as indispensable to a lady of fashion as her fan or her patch-box. They were kept in her toilet, and carried with her even to her box at the play. They belong to a period when personal cleanliness was not considered essential, when the style of dress worn was anything but conducive to comfort and ease, and when ladies wore immensely high head-dresses, which, when once fixed, were frequently not disturbed or altered for a month, and not until they had become almost intolerable to the wearer and to her friends.

In the sixteenth and seventeenth centuries, the state of the public health in London was at a very low ebb. The town ditch was a receptacle for all kinds of rubbish and decomposing organic matter ; the streets were unpaved and saturated with slops and other filth. Instead of regular highways, the out-parishes were reached by a maze of narrow passages and alleys. The dwellings of the  poor were as bad as they well  could  be ;   the houses projected over the roadway, which was so narrow that they almost met at the top ; there was no attempt at ventilation, and up to and even beyond the time of Queen Elizabeth, the floors were strewn with rushes, and, if we may trust to an epistle from Erasmus to his friend Dr. Francis, physician to Cardinal Wolsey, it would appear that these were seldom thoroughly changed, and, the habits of the people being uncleanly, the smell soon became intolerable. He speaks of the lowest layer of rushes (the top only being renewed) as sometimes remaining unchanged for twenty years, a receptacle for beer, grease, fragments of victuals, excremental and other organic matter. To this filthiness, Erasmus (one of the most acute observers) ascribed the frequent pestilences with which the people were afflicted.

Even as late as the beginning of the present century thing's were very different to what they are now. Thus, Willan, writing of fever, says :—

    "Among the poor the mortality from this cause (contagious malignant fever) was nearly one in four of all persons affected, notwithstanding the attentive administration of proper articles of diet, and of suitable remedies, with plenty of wine.
    " The good effects of all these applications are almost wholly superseded by the miserable accommodations of the poor with respect to bedding, and by a total neglect of ventilation in their narrow, crowded dwellings. It will scarcely appear credible, though it is precisely true, that persons of the lowest class do not put clean sheets on their beds three times a year ; that, even where no sheets are used, they never wash or scour their blankets and coverlets, nor renew them till they are no longer tenable ; that curtains, if unfortunately there should be any, are never cleaned, but suffered to continue in the same state till they drop to pieces ; lastly, that from three to eight individuals, of different ages, often sleep in the same bed ; there being, in general, but one room, and one bed for each family. To the above circumstances may be added, that the room occupied is either a deep cellar, almost inaccessible to the light, and admitting of no change of air; or a garret, with a low roof and small windows, the passage to which is close, kept dark in order to lessen the window-tax, and filled not only with bad air, but with putrid, excremental, or other abominable effluvia from a vault at the bottom of the staircase. Washing of linen, or some other disagreeable business, is carried on while infants are left dozing, and children more advanced kept at play whole days on the tainted bed ; some unsavoury victuals are from time to time cooked. In many instances idleness, in others the cumbrous furniture or utensils of trade with which the apartments are clogged, prevent the salutary operation of the broom and whitewashing brush, and favour the accumulation of a heterogeneous, fermenting filth. The rooms do not change their condition till they change their tenants. Often, indeed, so little care is taken that enough of the old leaven remains to infect all the inmates who successively occupy the same premises. I recollect a house in Wood's Close, Clerkenwell, wherein the fomites of fever were thus preserved for a series of years ; at length a friendly fire effectually cleared away the nuisance. A house notorious for dirt and infection, near Clare Market, afforded a further proof of negligence ; it was obstinately tenanted till the walls and floor giving way in the night crushed to death the miserable inhabitants. From all these causes combined there is necessarily produced a complication of fetor, to describe which would be as vain an attempt as for those to conceive who have been always accustomed to neat and comfortable dwellings.
    " The above account is not exaggerated. For the truth of it I appeal to the medical practitioners, whose situation, or humanity, has led them to be acquainted with the wretched inhabitants of some streets in St. Giles's parish, of the courts and alleys adjoining Liquor-pond Street, Hog Island, Turnmill Street, Saffron Hill, Old Street, Whitecross Street, Grub Street, Golden Lane, the two Brick Lanes, Rosemary Lane, Petticoat Lane, Lower East Smithfield, some parts of Upper Westminster, and several streets of Southwark, Rotherhithe, etc.
    " It cannot be wondered at, that in such situations contagious diseases should be formed, and attain their highest degree of virulence. The inhabitants of the second storey in houses occupied by the poor are usually better accommodated, and therefore experience, during sickness of any kind, the best effect from public and private charities. But persons thus stationed suffer from contiguity, and from their friendly attentions to those above them, or to the tenants of the cellars ; so that in whatever part of the house a fever commences, it is soon diffused among all the inmates and their occasional visitors, especially in seasons which favour its progress like the last autumn and winter. ... It is a melancholy consideration that in London and its vicinity hundreds, perhaps thousands of labourers, heads of families, and in the prime of life, are thus consigned to perish annually, being often so situated that medical applications or cordial diet cannot in any wise alleviate their distress."¹

EIGHTEENTH  CENTURY PRISONS.

The sanitary condition of the prisons in the last century, as discovered by the great prison reformer, John Howard, gives some indication of the ignorance that prevailed in regard to the public health at that time. In the Introduction to his book,² he tells us that in his inspection of gaols, he noticed a complication of distress, but his attention was principally arrested by the gaol fever and the small-pox, which he saw prevailing to the "destruction of multitudes," not only of felons in their dungeons, but of debtors also. On page 8, in describing the air in prisons, he says :—

    " My reader will judge of its malignity, when I assure him that my clothes were in my first journeys so offensive, that in a post-chaise, I could not bear the windows drawn up, and was therefore often obliged to travel on horseback. The leaves of my memorandum book were often so tainted, that I could not use it till after spreading it an hour or two before the fire ; and even my antidote, a vial of vinegar, has, after using it in a few prisons, become intolerably disagreeable. I did not wonder that in those journeys many gaolers made excuses, and did not go with me into the felons' wards.
    " From hence anyone may judge of the probability there is against the health and life of prisoners, crowded in close rooms, cells, and subterranean dungeons, for fourteen or sixteen hours out of the four-and-twenty. In some of those caverns the floor is very damp ; in others there is sometimes an inch or two of water, and the straw, or bedding, is laid on such floors, seldom on barrack bedsteads. Where prisoners are not kept in underground cells, they are often confined to their rooms, because there is no court belonging to the prison, which is the case in most city and town gaols."

1  Dr. Willan's "Observations on Diseases in London."    Medical and Physical Journal, vol. iii., pp. 298-300.    (April, 1800.)
2  " The State of the Prisons in England and Wales."    Second Edition.1780.    John Howard, F.R.S.

There was much overcrowding. On page 21 we read :—

"Debtors crowd the gaols (especially those in London) with their wives and children. There are often by this means ten or twelve people in a middle-sized room, increasing the danger of infection."

John Howard observes the effect of the window tax (p. 9):—

"One cause why the rooms in some prisons are so close, is perhaps the window tax, which the gaolers have to pay; this tempts them to stop the windows, and stifle their prisoners."

Concerning the water supply and drainage, we read (pp. 8,9):—"

Many prisons have no water. This defect is frequent in bridewells and town gaols. In the felons' courts of some county gaols there is no water ; in some places where there is water, prisoners are always locked up within doors, and have no more than the keeper or his servants think fit to bring them. In one place they were limited to three pints a-day each—a scanty provision for drink and cleanliness! . . . Some gaols have no sewers, and in those that have, if they be not properly attended to, they are, even to a visitant, offensive beyond expression.    How noxious, then, to people constantly confined in those prisons!" Under these conditions, is it to be wondered at, that typhus and small-pox prevailed to the "destruction of multitudes "?

AGE-INCIDENCE AND  SANITATION. 

Howard's attention was arrested by the insanitary state of the prisons, but it is doubtful whether the poor, especially in the large towns, lived in a much healthier atmosphere than the prisoners. Dr. William Buchan, in his work on "Domestic Medicine," says:

"Whenever air stagnates long, it becomes unwholesome. Hence the unhappy persons confined in jails not only contract malignant fevers themselves, but often communicate them to others. Nor are many of the holes, for we cannot call them houses, possessed by the poor in great towns much better than jails. These low, dirty habitations, arc the very lurking-places of bad air and contagious diseases. Such as live in them seldom enjoy good health, and their children commonly die young."¹

Thus, Dr. Buchan connects the high mortality of children in the last century with overcrowding and filth. From these facts we may infer, that sanitary reform would tend to alter the age-incidence of zymotic disease. This has been fully recognised by the Regrstrar-General in the following notable words :

" That the sanitary efforts made of late years should have more distinctly affected the mortality of the young is only what might be naturally anticipated; for it is against noxious influences to which the young are more especially sensitive that the weapons of sanitary reformers have been chiefly directed."²

1.  "Domestic Medicine," p. 86. Tenth edition. 178S. William Buchan, M.D.
2.  Forty-second Annual Report of the Registrar-General, p. xxiii.    1879.

There is no reason to believe that small-pox is any exception to this general law, and in this connection the following table quoted by Dr. Collins and Mr. Picton is not without interest.¹

The larger proportionate small-pox mortality of children in the towns, compared with rural and insular districts is certainly not due to any difference in the amount of vaccination, and it is difficult to resist the conclusion that the young are more injuriously affected by over­crowding and other insanitary conditions associated with town life than adults.²

1  Royal Commission on Vaccination, Dissentient Commissioners' Statement, section 148.
2  See Paper read by Mr. Alfred Milnes before the Statistical Society, June 15, 1897.

BURIAL  GROUNDS AND  MORTALITY. 

While discussing the subject of sanitation, it is necessary also to allude to the influence of burial grounds on mortality. In the last century it was usual to establish these in the midst of populous towns, and there can be no question, that the constant inhalation of effluvia from dead   bodies,   had   a   deleterious   effect  on   the   living.

Buchan observes (p. 85):

"Certain it is, that thousands of putrid carcases, so near the surface of the earth, in a place where the air is confined, cannot fail to taint it; and that such air, when breathed into the lungs, must occasion diseases."

With the growth of sanitary institutions, reforms have been made with regard to the disposal of the dead, and, in nearly all urban districts, the dead are now buried in outlying cemeteries. The next generation will no doubt witness a great extension of the still more sanitary practice of cremation, already introduced in London, Glasgow, Manchester, Liverpool, and other places.

Besides insanitation, other causes have probably had their effect on the small-pox mortality.

A number of typhus and small-pox epidemics have been intimately associated with periods of scarcity and want. The winter of 1683-84 was very severe. This was followed by a long drought in the summer of 1684, and another severe winter in 1684-85, and not until the spring of 1685 was there plentiful rain.¹ In 1685-86 the country was visited by a terrible epidemic of fever, and in 1685 small-pox was above the average, with 2,496 deaths in London, or a rate of 107 per 1,000 deaths from all causes. The winter of 1708-09 was excessively severe, frost lasting all over Europe from October to March. This was followed by a bad crop of cereals in 1709, the price of wheat per quarter running up from 27s. 3d. on Lady-day, 1708, to 81s. 9d. on Lady-day, 1710.²   In 1710,the proportion of small-pox deaths was 127 per 1,000 deaths from all causes (3,138 small-pox deaths). 2,810 died from small-pox in 1714, or a rate of 106 per 1,000 from all causes.   This followed a rise in the price of wheat.

1 "A History of Epidemics in Britain," vol ii., p. 23.    Creighton.
2  Ibid., pp. 54, 55.

In 1718 the harvest was a bad one; and about this time there was scarcity of employment amongst the weavers in the east end of London ;¹ during the year 1719, there were 3,229 deaths from small-pox in London, or a rate of 114 per 1,000 from all causes. Up to the month of February, 1756, the season had been a forward one, but the early promise of spring was blighted by cold. This was succeeded by a wet summer and autumn ; the fruit crop was ruined, and the corn harvest spoilt by long, heavy rains ; dearth and bread riots followed.² In 1757, the proportion of small-pox deaths rose to 155 per 1,000 from all causes (3,296 small-pox deaths).

A bad harvest in 1794 raised the price of wheat to 55s. (January 1,1795); by August, 1795, it rose to 108s., falling in October to 76s., owing to the action of the Government, in order to avert famine, causing neutral ships —bound to French ports with corn—to be seized and brought to English ports. In the spring of 1796, the acme of distress was reached, wheat being sold for 100s. per quarter.³ Mr. Pitt admitted in Parliament that the condition of the poor "was cruel, and such as could not be wished on any principle of humanity or policy ;"⁴ in this year, the mortality figures showed the largest number of small-pox deaths of any year within the London Bills, being 3,548, or 184 per 1,000 deaths from all  causes.   

1 "A History of Epidemics in Britain," vol. ii., pp. 62, 64.    Creighton.
2 Ibid., p. 125.       
3. Ibid., pp. 158, 159.
4 Eighth Annual Report of the Registrar-General, p. 12.

The  harvest   in   1816 proved  deficient in quantity, and inferior in quality. Prices rose from 66s. a quarter in 1815, to 78s. in 1816, and 98s. in 1817.¹ This was succeeded by epidemics of small-pox, relapsing fever, and typhus in 1817-19.

COMMERCIAL  DEPRESSION.

From the Registrar-General's eighth annual report we learn that the year 1837 was one of great commercial depression. In referring to joint stock banks, Major Graham says :—

" Many of the companies were got up by speculators, for the sole purpose of selling shares. The signal of collapse was given by the failure of the Agricultural Bank of Ireland in November, 1836. The Bank of England assisted the Manchester Northern and Central Bank in December, the large American houses in February and March, 1837. It was in vain. Com­mercial credit fell to its lowest point of depression in the first half of the year 1837."² Again—"In 1837 the price of bread rose rapidly, while trade was depressed, and speculation sat exhausted in the midst of ruin."³

During the several years commencing in 1837, one of the most disastrous small-pox epidemics of the nine­teenth century occurred, and also a very severe epidemic of typhus.

1 Eighth Annual Report of the Registrar-General, p. 16.
2. Ibid., p. 23.         
3 Ibid., p. 24.

THE EFFECTS  OF   WAR.

Another cause of the diffusion of small-pox, as well as of typhus and dysentery, is probably war. Dr. Guy writes :—

" War is a special cause of that more general condition of overcrowding, so destructive to health, so productive of disease. It consists in bringing one crowd of trained, armed, and disciplined men into collision with another, under circumstances highly unfavourable to health.    It reaches its climax in civil war, in prolonged siege operations, and when armies are quartered among civil populations."¹

The shock of battle also, with its attendant anxiety and the high tension of the organism, are important and undeniable factors in the production of epidemic diseases.

Mr. Alexander Wheeler pointed out before the Royal Vaccination Commission (Q. 7,994) that during almost the whole of the last century Europe was one huge battle-ground, and wars continued on and off until the year 1815. The fact, that small-pox was declining during the opening years of the present century, does not exclude war as one of the causes of this disease.

As to the effects of war. In a work by Mr. William F. Fox, entitled "The Losses of the American Civil War," we read:—

"110,070 were killed, 249,458 died of other causes, making 359,528 in all in the Northern army."

In speaking of the 249,458 who died from disease, Mr. Fox says :

" One-fourth died from fever, principally typhoid ; one-fourth from diarrhoea or other forms of bowel complaint; one-fourth from influenza and lung complaints ; and one-fourth from small-pox, measles, brain diseases, erysipelas, and various other forms of disease common to the masses."²

With regard to the Franco-Prussian war, Mr. Wheeler, in his evidence before the Royal Commission, quoted some of the commissioners sent to Eastern France to aid the peasantry. One of these, Dr. Robert Spence Watson, has published his experiences,³ from which the following have been extracted.     I may state that in  1870 there was not more small-pox than usual until the later months of the year. Its increase was at the time of the terrible slaughter following the invasion of France.

1 Journal of the Statistical Society, December, 1882, p. 579.
2 Third Report, Royal Commission on Vaccination, Q. 8056.
3 "The Villages Around Metz."    Newcastle-on-Tyne.     1870.

    "November 6, 1870. Then I went to Lessy and Chatel St. Germain, hearing everywhere the same state of distress. All the crops gone, all the winter's firewood gone, many houses destroyed, and numbers needing help in every village. . . . When the mare's hoofs sunk deep, she knocked up bits of flesh, and the stench was so sicken­ing that 1 should have fainted but for my smelling salts. It was a strange and sad sight; sometimes twenty-five heaps of graves within sight at once. These graves are in a bad state, many of them were too shallow to begin with. The heavy rains have caused them to sink in, and they are covered with an inch or more of black, oily water, which has, when disturbed, a most disgusting stench" (pp. 22, 23).
    " November 7th. All men and officers alike speak of the terrible loss of blood. At Rezonville, and in its neighbourhood, the people say 18,000 Germans are buried. This I doubt, but the number must be enor­mous" (p. 25).
    " November 9th. Metz was literally crammed with soldiers. The Germans—strong, hearty, conscious of victory ; the French—cowed, worn, starved, and miser­able. ... In one place there were fifteen long streets of railway vans, filled with typhus patients ; in another as many streets of canvas tents, also filled with sick. I visited these places, and found them in the filthiest state ; but the Germans had begun to put them into order. At first, you might see soldiers, in full small-pox, walking about the streets, but this was soon forbidden " (p. 28).

Dr. Watson concluded his last letter with the observation that

" unless England puts forth her hand liberally and wisely, the coming winter must see in that beautiful and fertile land an amount of misery, famine, and plague which it is too dreadful to contemplate " (p. 36).

Another commissioner has kindly furnished me with the following statement:—

" Mr. William Jones, of Sunderland, was one of those who went out on behalf of the Society of Friends to relieve the sufferings of the people. He was present at Metz when Marshal Bazaine's army surrendered. The main body were encamped outside the walls of Metz, on low ground near the Moselle, the wetness of the season having converted the camping-ground into a morass. In some places the impress of the men's bodies was left as a cast in the mud in which they had lain. Their clothes and their blanket were saturated with mud. Their food for weeks had only been a biscuit and a bit of horseflesh without salt. Dysentery was universal, and typhus and small­pox raged. Over a wide area around the camp the carcases of dead horses were left to rot and contaminate the air. On the 29th of October, 1870, Mr. Jones and his companion, Mr. Allen, were permitted to enter the city, which had opened its gates to admit the German army, which marched through in triumph. The narrow streets were crowded with French soldiers disarmed, and looking diseased and hunger-bitten. Numbers of them were going about the streets with confluent small-pox fully out over their faces. Black typhus raged in the hospitals. Ultimately the worst cases were removed into 320 railway vans drawn up in the 'Grande Place.'      No   one   was   allowed   to   pass   the   German sentries into the square, but the constant cry of the wretched sufferers for water was distinctly heard by Mr. Jones outside the square in which they were isolated. It was stated that all these black typhus patients perished, and were buried in huge trenches outside the walls of the city.
    " Mr. Jones's companion, Mr. Allen, who was vaccinated, and, he believes, re-vaccinated, took the small-pox, and his own sister, who came over to nurse him, caught the disease from him and died there, and was buried in the cemetery at Plantieres outside the walls of Metz.
    " N.B.—Mr. John Bellows, of Gloucester, who followed Mr. Jones to Metz, states in his pamphlet, 'The Track of the War round Metz,' that, of the twelve commissioners of the Society of Friends who were present in Metz, eight were at one time ill, five being down with small-pox, and one (Miss Allen) died of small-pox."

MALTHUS  DISCOVERS A  NEW  PRINCIPLE.

There is, indeed, some reason to believe that this war was the starting point of the great European pandemic of small-pox in 1871-72.

Another cause of the decline in small-pox during the present century, especially among children, remains to be told. Malthus, in 1803, wrote :—

" For my own part, I feel not the slightest doubt, that, if the introduction of the cow-pox should extirpate the small-pox, and yet the number of marriages continue the same, we shall find a very perceptible difference in the increased mortality of some other diseases."¹

1 "An Essay on the Principle of Population," p. 522. T. R. Malthus. London.     1803.

Malthus, thus early, clearly saw that even if cow-pox had possessed all the virtues that were claimed for it, the reduction in the mortality from one zymotic disease would, other things being equal, have no appreciable effect on the death-rate.

This principle was first worked out experimentally by Dr. Robert Watt, lecturer on the theory and practice of medicine at Glasgow. He examined the Glasgow burial registers over a space of thirty years, from 1783-1812, and divided the thirty years into five periods of six years each. The following table gives his figures for small-pox, measles, and whooping-cough, as per­centages of the deaths from all causes :—1

These statistics proved that while small-pox had diminished, measles and to a lesser extent whooping-cough had increased, so that a child had no better chance of reaching its tenth year in the last period² than in the first. Dr. Watt was somewhat staggered at the result.

1 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 (p. 49).     Robert Watt, M.D.     1813.
2 Dr. Watt remarks that in Glasgow during the last period (from 1807-12) vaccination may be said to have been pretty fully established, "perhaps, as much so, as in any other city in the Empire."

THE  ZYMOTIC  DISEASES  REPLACE  EACH  OTHER.   

He says (p. 6):—

    "Taking an average of several years, I found that more than a half of the human species died before they were ten years of age, and that of this half more than a third died of the small-pox, so that nearly a fifth part of all that were born alive perished by this dreadful malady. I began to reflect how different the case must be now! In eight years little more than 600 had died of the small-pox ; whereas, in 1784, the deaths by that disease alone amounted to 425, and in 1791 to 607, which, on both occasions, exceeded the fourth of the whole deaths in the year.
    " To ascertain the real amount of this saving of infantile life, I turned up one of the later years, and by accident that of 1808, when, to my utter astonishment, I found that still a half or more than a half perished before the tenth year of their age! I could hardly believe the testimony of my senses, and therefore began to turn up other years, when I found that in all of them the proportion was less than in 1808 ; but still, on taking an average of several years, it amounted to nearly the same thing as at any former period during the last thirty years."

Dr. Farr was a firm believer in Watt. He writes :—

"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 wherever 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. By improving the hygienic conditions in which men live, you fortify them against infection ; and further, by isolating the infected, the chances of attack are diminished." ¹

1 Thirty-fifth Annual Report of the Registrar-General, p. 224.

In this chapter, I have attempted to deal with some of the principal causes of the diminution of small-pox. Firstly, I have shown that a part of the decline, and especially that part which has taken place in children, is not necessarily a saving of life, but only a shifting of the mortality on to some other disease, such as measles or whooping-cough, which happens for the time being to be more predominant.

The residue of the diminution is a real gain, and is probably due partly to the displacement of small-pox inoculation by a non-infectious malady; and to this extent was vaccination an advantage as compared with the old variolous inoculation. Other causes have been due to the more abundant air supply in and around houses ; the greater cleanliness of the people in their persons, their houses, and their towns ; and last, but not least, the greater material prosperity and freedom from war, which has been the lot of those who have been fortunate enough to be born into the present century.