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].

Year Smallpox deaths Deaths from 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:

Year Smallpox 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.

Year Total deaths Smallpox 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.

Year Deaths from smallpox Deaths from 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: