imported it, and the authorities took the trouble to send on board a
    medical officer to investigate the matter.’ He further observes that
    the whole coast, from Vancouver’s Island southward to Valparaiso was
    visited by the epidemic.” It made its appearance on board the
    ‘Satellite’ at Vancouver’s Island in September, and among the
    residents ashore, both on the island and mainland, at the same
    time[795].

    1857: Catarrh “assumed the form of influenza in the ‘Arachne’ [149
    men, 114 cases] while the vessel was cruizing off the coast of Cuba,
    with which, however, she had no communication. There was nothing in
    the state of the atmosphere to attract special attention. A question
    therefore arises whether it might not have been caused by infection
    wafted from the shore.” It was prevalent at the time at Havana[796].

    1857: “Australian Station:--An eruption of epidemic catarrh occurred
    in the ‘Juno’ [200 men, 131 cases], but long after she left the
    station[797].”

    Whilst the influenza was on the American Pacific coast in September,
    1857, it was on the coast of China three months earlier--on board the
    ‘Inflexible’ at Hongkong on the 18th of May, and in the ‘Amethyst’ and
    ‘Niger’ in a creek near Hongkong early in June[798]. But it had been
    on the Pacific coast of South America the year before, according to
    the following:

    “1856: Epidemic catarrh broke out in the ‘President’ when lying off
    the island of San Lorenzo in the bay of Callao, first on the 20th
    October, and the last cases were placed on the sick list on 1st
    November,--the usual period which influenza takes to pass through a
    frigate ship’s company. About sixty required to be placed on the sick
    list.” It had occurred on board English ships of war at Rio de
    Janeiro, on the other side of the continent, some two months before,
    in August, 1856[799].

    1863: The following, in the experience of the French navy, has been
    elaborately recorded[800]: The frigate ‘Duguay-Trouin’ left Gorée,
    Senegambia, for Brest, in February. There were no cases of influenza
    in Gorée when she left; but four days out, an epidemic of influenza
    began on board, the weather being fine and the temperature genial at
    the time. Another French frigate, which had left Gorée, on the same
    voyage to Brest, two days earlier, did not have a single case.

The following instance, here published for the first time, belongs to the
most recent pandemics of influenza, 1890-93. It relates to only a single
case of influenza, in the captain of a merchantship; it would have been a
more satisfactory piece of evidence, if there had been several cases in
the ship; but among the comparatively small crew of a merchantman, the
same groups of cases are not to be looked for that we find on board
crowded men of war; and in this particular case the only other occupants
of the quarter-deck were the first mate and the steward.

    The ship ‘Wellington,’ sailed from the Thames, for Lyttelton, New
    Zealand, on the 19th December, 1891. The epidemic of influenza in
    London in that year had been in May, June and July; the mate of the
    ‘Wellington’ had had an attack of it ashore, on that occasion, but not
    the captain nor the steward. On the 2nd of March, 1892, when
    seventy-four days out and in latitude 42° S., longitude 63 E., near
    Kerguelen’s Land, the captain began to have lumbago and bilious
    headaches, for which he took several doses of mercurial purgative
    followed by saline draughts. The treatment at length brought on
    continual purging, which, together with three days’ starving from the
    22nd to the 24th of March, caused him a loss of weight of eight
    pounds. The navigation had meanwhile been somewhat difficult and
    anxious, owing to a long spell of easterly head winds. Quite suddenly,
    on the 26th March, when the ship was in latitude 44 S., longitude 145
    E., or about two hundred miles to the south of Tasmania, he had an
    aguish shake followed by prolonged febrile heat, which sent him to his
    berth. The symptoms were acute from the 26th to the 30th
    March,--intense pain through and through the head, as if it were being
    screwed tight in an iron casing, pain behind the eyeballs, a
    perception of yellow colour in the eyes when shut, a feeling of
    soreness all over the body, which he set down at the time to his
    uneasy berth while the ship was ploughing through the seas at about
    twelve knots, and a pulse of 110. The head pains were by far the worst
    symptom, and were so unbearable as to make the patient desperate. This
    acute state lasted for four days, and suddenly disappeared leaving
    great prostration behind. The captain, who had long experience with
    crews and passengers, and a considerable amateur knowledge of
    medicine, summed up his illness as a bilious attack, passing into
    “ague” with “neuralgia of the head.” While the acute attack lasted the
    ship had covered the distance from Tasmania to the southern end of New
    Zealand, and on the 31st of March the captain by an effort came on
    deck to navigate the vessel in stormy weather up the coast to
    Lyttelton, which was reached on the 2nd of April. The pilot coming on
    board found the captain ill in his berth, and on being told the
    symptoms, at once said, “It is the influenza: I have just had it
    myself.” The doctor who was sent for found the captain “talking
    foolishly,” as he afterwards told him, and had him removed to the
    convalescent home at Christchurch, where he remained a fortnight
    slowly regaining strength. The doctor[801] could find no other name
    for the illness but influenza, although he had not supposed such a
    thing possible in mid-ocean. They had just passed through an epidemic
    of it in New Zealand, and it is reported about the same time in New
    South Wales, afterwards in the Tonga group, and still later in the
    summer in Peru. The symptoms of this case are sufficiently
    distinctive: the intense constricting pain of the head is exactly the
    “_fierro chuto_” or “iron cap” of South American epidemics; the pain
    in the eyeballs, the soreness of the limbs and body, and the
    unparalleled depression and despair, are the marks of influenza
    without catarrh. The patient was of abstemious habits, and had made
    the same voyage year after year for a long period without any illness
    that he could recall. He had reduced himself by purging and starving,
    on account of a bilious attack during a fortnight of foul winds from
    the eastward, and had doubtless become peculiarly susceptible of the
    influenza miasm before the ship came into the longitude of Tasmania on
    the 26th March.

The Influenzas of Remote Islands.

The full and correct theory of influenza will not be reached by the great
pandemics only. On the other hand some very localized epidemics may prove
to be signal instances for the pathology, although they do not bear upon
the source of the great historic waves of influenza. The instances in view
are the influenzas started among a remote community on the arrival of
strangers in their ordinary health. This phenomenon has been known at the
island of St Kilda, in the Outer Hebrides of Scotland, since the year
1716, when it was recorded in the second edition of an essay upon the
island by Martin. Some thought these “strangers’ colds” mythical, so much
so that Aulay Macaulay, in preparing a work upon St Kilda, was advised to
leave them out; he declined to do so, and Dr Johnson commended him for his
magnanimity in recording this marvel of nature. There is now no doubt
about the fact. H.M.S. ‘Porcupine’ visited the island in 1860; a day or
two after she sailed again, the entire population, some 200 souls, were
afflicted with “the trouble,” and another visitor, who landed ten days
after the ‘Porcupine’s’ visit, saw the epidemic of influenza in progress.
The same thing happened in 1876, on the occasion of the factor landing,
and again in 1877 on the occasion of a crew coming ashore from a wrecked
Austrian ship. A medical account of this epidemic catarrh was given in
1886: The patient complains of a feeling of tightness, oppression and
soreness of the chest, lassitude in some cases, pains in the back and
limbs, with general discomfort and lowness of spirits. In severe cases
there is marked fever, and great prostration. A cough ensues, at first
dry, then attended with expectoration, which may go on for weeks[802].

In the remote island of Tristan d’Acunha, in the South Atlantic midway
between the River Plate and the Cape of Good Hope, the same thing happens
“invariably” on the arrival of a vessel from St Helena[803]. It is
reported also as a common phenomenon of the island of Wharekauri, of the
Chatham Group, about 480 miles to the eastward of New Zealand. Residents,
both white and coloured, suddenly fall into an illness, one symptom of
which is that they feel “intensely miserable.” It lasts acutely for about
four days, and gradually declines. It resembles influenza in all respects,
and is known by the name of _murri-murri_, which is curiously like the old
English name of _mure_ or _murre_. “The mere appearance of murri-murri is
proof to the inhabitants, even at distant parts of the island, which is
thirty miles long, that a ship is in port, insomuch that, on no other
evidence, people have actually ridden off to Waitangi to fetch their
letters[804].”

About equally distant in the Pacific from Brisbane, as Wharekauri from
Christchurch, lies Norfolk Island, originally colonized by the mutineers
of the ‘Bounty.’ A writer in a newspaper says:

    “During a seven years’ residence in Norfolk Island, I had
    opportunities of verifying the popular local tradition that the
    arrival of a vessel was almost invariably accompanied by an epidemic
    of influenza among the inhabitants of the island. In spite of the
    apparent remoteness of cause and effect, the connexion had so strongly
    impressed itself on the mind of the Norfolk Islanders that they were
    in the habit of distinguishing the successive outbreaks by the name of
    the vessel during whose visit it had occurred[805].”

Something similar has long been known in connexion with the Danish trade
to Iceland, the first spring arrivals from the mother country bringing
with them an influenza which the crews did not suffer from during the
voyage, nor, in most cases, during the progress of the epidemic in
Reikjavik. The experience at Thorshaven, in the Faröe Islands, has been
the same[806].

These are important indications for the pathology of influenza in general.
They point to its inclusion in that strange class of infections which fall
most upon a population, or upon those orders of a population, who are the
least likely to breed disease by anything that they do or leave undone.
Veterinary as well as human pathology presents instances of the
kind[807]. In seeking for the source of such an infectious principle, we
are not to look for previous cases of the identical disease, but for
something else of which it had been an emanation or derivative or
equivalent, something which may have amounted to no more than a disparity
of physical condition or a difference of race. And as the countries of the
globe present now as formerly contrasts of civilized and barbarous, nomade
and settled, rude and refined, antiquated and modern, with the aboriginal
varieties of race, it may be said, in this theory of infection, that mere
juxtaposition has its risks. But, in the theory of influenza, the first
requisite is an explanation of its phenomenal uprisings and wave-like
propagation, at longer or shorter intervals, during a period of many
centuries.

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