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

ἀπαθεῖς, 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 à 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 à 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 _à 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].