Extent of Inoculation in Britain to the end of the 18th Century.
From 1721 to 1727 the inoculations in all England were known with considerable accuracy to have been 857; in 1728 they declined to 37; and for the next ten or twelve years they were of no account. The southern counties led the revival in the fifth decade of the century, so that before long some two thousand had been inoculated in Surrey, Kent, Sussex and Hampshire. Frewen, however, who could point to 350 cases done by himself in Sussex previous to 1749, says that it “gained but little credit among the common sort of people, who began to dispute about the lawfulness of propagating diseases, and whether or no the smallpox produced by inoculation would be a certain security against taking it by infection,” etc.
In London, after the revival under Kirkpatrick’s influence in 1743, inoculation became a lucrative branch of surgical practice, and was done by the heads of the profession—Ranby, Hawkins, Middleton and others, and almost exclusively among the well-to-do. In 1747 Ranby had inoculated 827 without losing one; in 1754 his total, still without a death, had reached 1200. In 1754 Middleton had done 800 inoculations, with one death. The operation was by no means so simple as it looked. It required the combined wits of a physician, a surgeon, and an apothecary; while the preparation of the patient to receive the matter was an affair of weeks and of much physicking and regimen. Thus inoculation was for a long time the privilege of those who could pay for it. As late as 1781, when a movement was started for giving the poor of Liverpool the benefits of inoculation, it was stated in the programme of the charity that, “as the matter now stands, inoculation in Liverpool is confined almost exclusively to the higher ranks,” the wealthier inhabitants having generally availed themselves of it for many years[945].
The first project in London for gratuitous inoculation took shape, along with the plan of a smallpox hospital, at a meeting held in February, 1746, in the vestry-room of St Paul’s, Covent Garden[946]. The original house of the charity, called the Middlesex County Hospital for Smallpox, was opened in July, 1746, in Windmill Street, Tottenham Court Road, but was shortly removed to Mortimer Street, and again, to Lower Street, Islington. The charity opened also a smallpox hospital in Bethnal Green, which eventually contained forty-four beds. The Inoculation Hospital proper, used for the tedious preparation of subjects, was a house in Old Street, St Luke’s, with accommodation for fifteen persons. Besides the smallpox hospital at Islington, the charity had, in 1750, a neighbouring house in Frog Lane, for the reception of patients after they had been inoculated in the Old Street house. Down to the middle of 1750 there had been admitted 620 patients in the natural smallpox, while only 34 had gone through the process of inoculation. The latter involved a month’s preparation, and about a fortnight’s detention after the operation was done; so that a new batch of subjects was inoculated but once in seven weeks. In 1752 the governors of the charity purchased a large building in Coldbath Fields, which they fitted with one hundred and thirty beds, as a hospital both for cases of the natural smallpox and for preparing subjects to undergo inoculation (the Old Street house being still retained for the latter purpose). The next important change was in 1768, when a large new hospital was opened at St Pancras, to be solely a house of preparation, the old hospital in Coldbath Fields being now turned to the double purpose of receiving the patients from St Pancras after their inoculation and of receiving patients in the natural smallpox. Thus the inoculation business of the charity, which had begun with being subordinate to the treatment of those sick of the natural smallpox, gradually encroached upon the latter and became paramount. The inoculations, which had been only 112 in the year 1752, reached the total of 1084 in the year 1768, while the admissions for smallpox “in the natural way” from 24 March, 1767, to 24 March, 1768, were 700.
In the year 1762-63, the admissions for natural smallpox had been 844, and for inoculations 439. One reason of the great increase of patients received for inoculation after that date was the rise of the Suttonian practice, which had vogue enough to attract numbers, and at the same time was so much simplified in the matter of preparation and in its results that many more could go through the hospitals in a given time. The inoculations by the Smallpox Charity were done in batches, men and boys at one time, women and girls at another, on some eight or twelve occasions in the year, of which public notice was given.
The following table is taken from the annual report of the Smallpox and Inoculation Hospitals for the year 1868.
| Period | Inoculations | ||
| Previous to Oct. 1749 | 17 | ||
| Oct. 1749-Oct. 1750 | 29 | ||
| Oct. 1750-Oct. 1751 | 85 | ||
| 1752 | 112 | ||
| 1753 | 129 | ||
| 1754 | 135 | ||
| 1755 | 217 | ||
| 1756 | 281 | ||
| 1757 | 247 | ||
| 1758 | } | 446 | |
| 1759 | |||
| 1760 | 372 | ||
| 1761 | 429 | ||
| 1762 | 496 | ||
| 1763 | 439 | ||
| 1764 | 383 | ||
| 1765 | 394 | ||
| 1766 | 633 | ||
| 1767 | 653 | ||
| 1768 | 1084 | ||
These charitable efforts to keep down smallpox in London hardly touched the mass of the people, and did not touch at all the infants and young children among whom nearly all the cases occurred. The charity admitted no subjects for inoculation under the age of seven years. It aimed at giving to a certain number of the working class, or of the domestics or other dependents of the rich, the same individual protection that their betters paid for. Meanwhile there were on an average about twelve thousand cases of smallpox in London from year to year, mostly in infants and young children. The first proposal to apply inoculation to these came in 1767, from Dr Maty, in a paper on “The Advantages of Early Inoculation.” This physician, distinguished in letters and now become a librarian, sought to recommend inoculation for infants by glorifying the purity of their juices and the natural vigour of their constitutions, which was something of a paradox at a time when half the infants born in London were dying before the end of their third year. He saw as in a vision how smallpox would be extinguished by making inoculation universal:
“When once all the adults susceptible of the infection should either have received it or be dead without suffering from it, the very want of the variolous matter would put a stop to both the natural and artificial smallpox. Inoculation then would cease to be necessary, and therefore be laid aside[947].”
Eight years after, in 1775, Dr Lettsom seriously took up the project of inoculating infants in London[948]. He started a Society for Inoculation at the Homes of the People, which effected nothing besides some inoculations done by Lettsom himself during an epidemic “in confined streets and courts.” In 1779 he launched another scheme for a “General Inoculation Dispensary for the benefit of the poor throughout London, Westminster and Southwark, without removing them from their own habitations[949].” That also was frustrated by the active opposition of Dimsdale[950]. The objection to it was that there was no prospect of making the practice universal, and that partial inoculations in the crowded quarters of London would merely serve to keep the contagion of smallpox more active than ever. Lettsom answered that the danger of contagion from inoculated smallpox was more theoretical than real, inasmuch as the amount of smallpox matter produced upon the inoculated was a mere trifle[951].
At Newcastle, Lettsom’s design had at least a trial, under the influence of his friend Dr John Clark[952]. The Dispensary, founded in 1777, was designed from the outset to undertake gratuitous inoculations; but it was not until 13 April, 1786, that it got to work. The “liberality of the public” enabled the managers in that year to offer premiums to parents, to cover the expense of having their children sick from inoculation—five shillings for one child, seven shillings for two, nine shillings for three, and ten shillings for four or more of a family. On the first occasion, 208 children were inoculated, and all recovered. From 1786 to 1801, the cases numbered 3268. It was the aim of Dr Clark to get the operation done in infancy; accordingly in the space of four and a half years (1786-1790), of 1056 inoculations 460 were on infants under one year, 270 from one to two, 122 from two to three, 69 from three to four, 62 from four to five, 66 from five to ten, and 7 from ten to fifteen. This was perhaps the most systematic attempt at infant inoculation from year to year. The other dispensaries at which inoculation was steadily offered to the children of the poor were at Whitehaven (1079 inoculations from 1783 to 1796), at Bath, and at Chester.
Before the society was started at Chester for the purpose, the inoculations were some fifteen or twenty in a year, and these, we may suppose, in the richer families. The society got to work in 1779, but its operations were stopped in 1780 by a singular cause—the general diffusion of smallpox in the town by a regiment of soldiers. The whole inoculations of poor children from the spring of 1780 until September, 1782, were 213, besides which 203 were done in private practice. The year 1781 was tolerably free from epidemic smallpox (8 deaths), but in January, 1782, a very mortal kind prevailed in several parts of the town.
At Liverpool the first gratuitous general inoculation was in the autumn of 1781, to the number of about 517. “The affluent,” says Currie, “being alarmed at the advertisement for this purpose, presented their children also in great numbers, and 161 passed through the disease.” There was a second gratuitous inoculation in the spring of 1782 (to which some of the above numbers may have belonged), and it was intended to continue the same at regular intervals; but there is no record of more than those two[953].
Although Dimsdale opposed “general” inoculations in the large towns, for the reasons mentioned, he was in favour of inoculating together all the susceptible subjects in a smaller place or country district; and that kind of general inoculation was not unfrequently undertaken, sometimes hurriedly at the beginning of an epidemic, at other times after an epidemic had been running its course for months, and here or there, it would seem, during a free interval and by way of general precaution.
Dimsdale himself, with the help of Ingenhousz, carried out on one occasion, in Berkhamstead and three or four other villages of Hertfordshire, a general inoculation to the number, he guesses, of some six hundred persons of all ages, including some quite old persons. In 1765 or 1766 Daniel Sutton at Maldon, Essex, inoculated in one morning 417 of all ages, who were said to be all those in the town that had not had smallpox in the natural way. Some hundreds were also inoculated by him at one time in Maidstone.
In the small Gloucestershire town of Painswick in 1786, a very violent and fatal smallpox broke out during a time of typhus and intermittent fever. In consequence of the epidemic, one surgeon inoculated 738 persons from the 26th of May to the end of June[954]. In another Gloucestershire parish, Dursley, a single surgeon in the spring of 1797 inoculated 1475 persons of all ages, “from a fortnight to seventy years.” But in certain villages near Leeds in 1786-7 a general inoculation, organised by a zealous clergyman and paid for by a nobleman, mustered only eighty. About the same time, during an epidemic of malignant smallpox at Luton, Bedfordshire, 1215 were inoculated, and thereafter about 700 more; the average number annually attacked by smallpox during a period of nine years had been about twenty-five[955].
Inoculation was tried first in Scotland in 1726 by Maitland, during a visit to his native Aberdeenshire, but was not persevered with owing to one or two fatalities among the half-dozen cases. About 1733 it was begun at Dumfries by Gilchrist, who practised it during the next thirty years upon 560 persons, most of them, doubtless, paying patients. The returns made to Professor Monro, of Edinburgh, showed in the chief medical practices 5554 inoculations down to 1765; of which 703 were in Edinburgh and Leith, 950 in Glasgow, 208 in Stirling, 260 in Irvine, 157 in Aberdeen, 310 in Banff, 243 in Thurso, and 560 in Dumfries as above[956]. Seventy-two deaths are put down to the practice. When the Statistical Account of the 938 parishes was compiled in the last decade of the century, a few of the parish ministers made reference to inoculation.
Thus, in Applecross, Ross-shire, and three neighbouring parishes, an uneducated man is said to have inoculated 700 after a very fatal epidemic in 1789; it happened, however, that the pestilence reappeared, whereupon inoculation was “generally adopted[957].” Applecross may have been populous then; now there is not a smoke to be seen in it for miles. Again, the practice is said to have become “universal” in Skye from about 1780[958]. In Durness parish, which the tourist may now traverse for thirteen miles to Cape Wrath without seeing anyone but a shepherd, inoculation was rendered “general” about 1780 by the benevolence of a gentleman belonging to the parish[959]. From October, 1796, to July, 1797, a surgeon of Thurso inoculated 645 in that town and in country parishes of Caithness during a very severe epidemic[960]. In the parish of Jedburgh the cost of an inoculation was defrayed by the heritors, in that of Kirkwall by the kirk session, in another by the commissioners of annexed estates, in Earlstown, Berwickshire (on 70 children) by the chief proprietor. The ministers who mention it at all were mostly strong advocates of it, but they usually imply that the common people were (or had been) apathetic or prejudiced. It was sometimes recommended from the pulpit, and actually done by the ministers; it was even recommended that students of divinity should be instructed in the art. Statements that it had become “general” or “universal” are made for several parishes, mostly in the Highlands or Islands. The very full and trustworthy account of the parish of Banff says that “inoculation is by no means become general among the lower ranks[961];” which is perhaps about the truth for the country at large.
At the end of an epidemic at Leeds, in 1781, which had attacked 462 and killed 130 during six months, “in the next six months there were inoculated 385, of whom four died” (two by contagious smallpox). A second general inoculation was carried out in Leeds sometime previous to 1788. Lucas, writing in that year, says: “The result of two general inoculations in Leeds has been that the smallpox has since been less frequent and less fatal[962].” This will be a convenient opportunity of considering the gross effects of inoculation upon the prevalence of smallpox.
The first and most obvious consideration is that it usually came too late. “Most born in London,” said Lettsom quite correctly, “have smallpox before they are seven”—i.e. before the age for admission to the inoculation hospital. He might have added that, if they had run the gauntlet of smallpox in London until they were seven, they were little likely to take it at all. The inoculations in London were therefore done upon a very select class (they were, in fact, a very small number), who may be assumed to have escaped the perils of smallpox in London in their childhood, or to have come to London (as many did) from country places where smallpox broke out as an epidemic only at long intervals. In other large towns as well as the capital the inoculated must have been a residual class. At Leeds, with a population of 17,117, “the number of those who were still uninfected was found on a survey to be 700” at the end of an epidemic, of whom 385 were inoculated. If a general inoculation had been tried at Chester after the epidemic of 1774, there would have been only 1060, in a population of 14,713, to try it on. How many of these, above the age of childhood, were constitutionally proof against smallpox? The case of Ware, in Hertfordshire, after the epidemic in the summer of 1777, is so related by Lettsom as to bring out the ambiguity of much that was claimed for inoculation. “After about eighty had been carried off by it, a general inoculation was proposed, to prevent those who had not yet been attacked, and whose number was still considerable, from sharing the same fate. The alarm which had been excited induced most of the survivors to adopt this proposition, after which not one died, and the infection was wholly eradicated.” Eighty deaths in one epidemic is a large mortality for such a place as Ware in any circumstances; the smallpox for once had done its worst. But, says Lettsom, there were a few families of those hitherto untouched by the epidemic who did not submit to inoculation. Not one of them caught the disease—from their inoculated neighbours (Lettsom is arguing that there was no danger in that way), nor, of course, from the epidemic contagion. It cannot but appear strange to us that the natural cessation or exhaustion of an epidemic should not have been thought of. Dr Currie, of Liverpool, records that in the first general inoculation there in 1781 there were 417 inoculated gratuitously and about 100 more in private practice, and that “about three or four thousand liable to the disease were scattered in the same manner [as the inoculated], not one of whom caught the infection.” For a few weeks there was not a case of smallpox known in Liverpool, so that no matter could be got for inoculation. He adds, in the most ingenuous manner: “An important particular has been recalled to my mind by Mr Park; that previous to this first general inoculation, which extinguished the smallpox in so extraordinary a way, the disease raged in town with much violence and was very fatal[963].”
The general inoculations were often carried out in so haphazard a manner as to make them valueless for a scientific as well as for a practical purpose. A Bath surgeon of long experience wrote in 1800: “Whenever the inoculating rage once takes place whole parishes are doomed, without the least attention to age, sex, or temperament—no previous preparation, no after treatment or concern.... Are not scores and hundreds seized upon at once, for the incisions, scratchings, puncturings and threadings, without even a possibility of their being properly attended to? and whether they may or may not receive the infection is just as little known or cared about[964].” It must have been equally little known or cared about whether they had had smallpox in the natural way before. What Dimsdale found to obtain at St Petersburg would have been the rule elsewhere: “The general method was to search for marks, and, if none were found, it was concluded the party had not had the disease[965].”
Thus in any attempt to estimate the gross advantages of inoculation in the 18th century we are met on every hand by sources of fallacy. Whatever its theoretical correctness, it does not follow that the inoculation of smallpox was a practical success to the extent of its trial; and even its theoretical correctness will be thought by some, and was so thought at the time, to have gone by the board when the artificial disease was brought down to a pustule at the point of puncture, with or without a few bastard pocks on the skin near. I have found two instances in the 18th century history in which there are data for a rough practical judgment, although not for a precise statistical one. The first is the town of Blandford, in Dorset; the other is the Foundling Hospital in London.
During the smallpox year 1766, smallpox of a very malignant type broke out at Blandford in the first week of April[966]. It was estimated that 700 persons in the town (population 2110 in 1773) had not had the natural smallpox, and a general inoculation was resolved upon on the 13th April. “A perfect rage for inoculation,” says Dr Pulteney[967], “seized the whole town,” and in the week following the 16th April some 300 were inoculated, the total rising to 384 before the panic ceased; of these, 150 were paid for by the parish. There were thirteen deaths among the inoculated, but most of these confluent or haemorrhagic cases, seem to have been due to the epidemic contagious smallpox, which had been peculiarly fatal, with haemorrhagic symptoms, to the few that were seized before the inoculation began, and continued to be fatal to many. The mortality from smallpox for the year in the parish register was 44, and from all causes 104, or more than twice the normal[967]. The last epidemic of smallpox in Blandford had been in 1753, when 40 died of it, the deaths from all causes being 96. In that year also there had been a general inoculation to the number of 309. The parish register gives the deaths in an earlier epidemic, in 1741, which was a year of great distress and typhus fever all over England: 76 deaths are ascribed to smallpox (102 to all causes), which is a larger total from smallpox than in either of the subsequent occasions when general inoculations were tried. Comparing these three epidemics in a Table, with the associated circumstances, we get the following:
Statistics of Blandford in three Smallpox Years (Population in 1773, 2110).
| Year of Epidemic | Deaths from all causes | Deaths from Smallpox | Inoculations | Annual Averages of eight previous years | ||
| Marriages | Births | Deaths | ||||
| 1741 | 102 | 76 | — | 24·87 | 63·37 | 49·25 |
| 1753 | 96 | 40 | 309 | 19·37 | 50·62 | 49·62 |
| 1766 | 104 | 44 | 384 | 20·62 | 54·12 | 49·12 |
It will be seen that the higher mortality from smallpox in 1741 was associated with other things besides the absence of inoculation. The annual average of deaths for eight years preceding each of the three epidemics is almost the same. But the marriages and births for eight years preceding 1741 were much in excess of those in the periods preceding the other two epidemic years. In the former there was a much larger susceptible population of children, upon which the smallpox mainly fell; and that alone would account for more deaths from smallpox in the epidemic of 1741. But the year 1741 was peculiar in another way; it was the worst year of typhus fever and general distress in the whole of the 18th century, and in the circumstances the deaths from smallpox would have been unusually numerous for the cases. Another epidemic of smallpox without inoculation, in 1731, showed how mild smallpox could be. At a time when sixty families had the disease among them, a fire broke out on 4 June, and burned down the town. It is said that 150 ill of smallpox were removed to gardens, hedgerows and the arches of bridges, and that only one of the whole number died[968]. This is usually cited to show the benefits of fresh air; but if it be true, it shows more than that.
The Foundling Hospital may seem to offer all the conditions for a fair trial of the question. It had been a standing rule of the Governors, since the opening of the charity in 1749, that all children received into it should be inoculated. Sir William Watson, who states the fact, adds that he himself was “in a situation of superintending every year the inoculation of some hundreds.” Still, the rule may not have been uniformly carried out; and even in this community of children, it was not always possible to learn on their admission whether they had had smallpox before in the natural way[969].
The lists of the inoculated are longer in the later periods than in the earlier: thus, from March, 1759 to May, 1766, the annual average is something under a hundred, the inmates having been 312 in 1763; but from May, 1766 to July, 1769, the annual average is some two hundred and fifty, the inmates in 1768 having been 438. Sir William Watson, in his essay upon the inoculations at the Foundling, breathes no hint that such a thing as natural smallpox ever happened there[970]; but in another context he does casually mention that there was an epidemic of sixty cases, with four deaths, in the end of 1762, and another epidemic in the following summer, of “many” cases, nineteen of which, with eleven fatalities, occurred in children who had lately been through the measles and were weakened in consequence[971]. Another epidemic, as I find by the apothecary’s book of weekly admissions to the infirmary, happened in the winter of 1765-66, twenty-six names being entered as admitted for “natural smallpox.” After that date all the great epidemics appear to have been of measles, whooping-cough, influenza or scarlatina; but almost every year smaller groups of “natural smallpox” occur, of which the following have been collected from the available records:
Foundling Hospital, London.
| Year | Natural Smallpox | |
| 1766 | 8 | |
| 1767 | 2 | |
| 1768 | 8 | |
| 1769 | 7 | |
| 1770 | 1 | |
| 1771 | 2 | |
| 1772 | 3 | |
| 1773 | 1 | |
| 1774 | 4 | |
| 1775 | 3 | |
| 1783 | 1 | |
| 1784 | 0 | |
| 1785 | 8 (or 16 ?) | |
| 1786 | 0 | |
| 1787 | 5 | |
| 1788 | 4 |
The occurrence of one or more cases seems to have been the signal for a general inoculation; or, again, it may be that the few cases of natural smallpox in the infirmary at one time had followed a general inoculation. Thus, in June-July, 1767, one case is entered on the second day from the inoculation (of a large number), and another on the fourth day. Again, in Nov.-Dec., 1768, one of the four cases of natural smallpox is marked “soon after his inoculation.”
The received cases in which inoculation failed to save individuals from the natural smallpox are few. Besides those already given for the first period of the practice, and the case from Heberden, there are six fully detailed by Kite of Gravesend, in two groups of three each, all in the spring of 1790[972]. Apart from exact records, there are various testimonies more or less trustworthy. The Marquis of Hertford is said to have told Dr Jenner that his father, having been inoculated by Caesar Hawkins, the serjeant surgeon, and thereafter attended by him during a tour abroad, caught smallpox at Rheims and died[973]. Bromfeild, surgeon to Queen Charlotte, is said to have “abandoned the practice of inoculation in consequence of its failure[974].” Jenner and his friends made a collection of cases in which inoculation had failed, to the number of “more than one thousand, and fortunately seventeen of them in families of the nobility[975].” A Bath surgeon said he had heard of “innumerable” cases of attacks of natural smallpox long after inoculation, and had himself professionally seen “not a few[976].” A surgeon of Frampton on Severn knew of four cases, out of five inoculated together in 1784, that took smallpox afterwards in the natural way, of whom one died[977]. In an epidemic of smallpox at Enmore Green, a suburb of Shaftesbury, in 1808, a surgeon from Shaston found that “nearly twenty” of the victims had been inoculated “by the late Mr John White” about ten years before, and were supposed to have had it “very fine[978].” Dr John Forbes learned that some nineteen cases of natural smallpox in and around Chichester in 1821-22 were of inoculated persons[979]. It would be incorrect to say that such cases could be multiplied indefinitely; on the contrary, they are hard to find. Whether that shows that inoculation was on the whole a success, to the extent that it was tried, or that its failures are in part unrecorded, I am not competent to decide. But it cannot be doubted that the usual estimates of the saving of life by inoculation were extravagant and fallacious. La Condamine, a mathematician, counted up the saving to the slave-owner in an ideal plantation of three hundred negroes[980]. Watson, with the epidemics in the Foundling fresh in his memory, estimated that inoculation might have saved 23,000 out of the 23,308 who had died of smallpox in London in ten years, 1758-68[981]. Haygarth[982] reckoned that 351 might have been saved by inoculation of the 378 children who died of smallpox at Chester from 1772 to 1777. Woodville, who wrote the history of inoculation down to the advent of Sutton, declared in 1796 that the art of inoculation, originally a fortuitous discovery, “is capable of saving more lives than the whole materia medica[983].” Arnot, the historian of Edinburgh (1779), asserted inoculation to be “a remedy so compleat that we hesitate not in the least to pronounce those parents, who will not inoculate their children for the smallpox, accessory to their death[984].” The College of Physicians, in a formal minute of 1754, pronounced it “highly salutary to the human race.”
Despite all those academic pronouncements, inoculation was somehow not a practical success. It cannot be maintained that it failed because the people were averse to it; for it continued to be in popular request far into the 19th century, until it was at length suppressed by statute. For the present we may return to the proper subject of epidemic smallpox, premising, on the ground of what has been said, that inoculation made but little difference to the epidemiological history.