A History of Epidemics in Britain, Volume 2 (of 2) / From the Extinction of Plague to the Present Time

by Charles Creighton

Results of the first Inoculations; the Controversy in England.

Thus far we have traced the rise of inoculation as an idea. It was one way of procuring the smallpox, which had gradually arisen out of other fanciful or real modes of infection. The populace for long retained a preference for giving their children the smallpox by exposing them to the contagion of it; in the last quarter of the 18th century, Haygarth found the common people of Chester still following the earlier practice of inviting the smallpox in the natural way[896]. It is even more remarkable that Huxham, the ablest epidemiologist in England during the first period of inoculation, preferred that children should take the disease naturally, believing that they might be so “prepared” to receive the seeds of it by the breath as to have always a sufficiently mild but effective dose of it. Still, the insertion of smallpox matter at a puncture or wound of the arm appeared to many to have advantages over the natural way. In London it was taken up by the Court, by the Court doctors, and by the Royal Society, the leading physicians in favour of it having been Sloane, Mead, Arbuthnot and Jurin. It appears that Freind, a more learned physician than any of these, was adverse to it. It was to him that Wagstaffe, physician to St Bartholomew’s Hospital, dedicated a hostile essay on inoculation when it was new; and Freind himself brought into his History of Physic, published in 1725-26, the following sarcastic passage upon John of Gaddesden, whom he regarded as a high-placed charlatan:

“He had an infallible plaster and caustick for a rupture; could cure a cancer from an outward cause with red dock. And if he had lived in our day, he would, I don’t question, have been at the head of the Inoculators; and in this case the position he lays down, contrary to the experience of the best physicians, that one may have the smallpox twice, might have served him in good stead for salvo’s upon many occasions.”

—which means that, in Freind’s opinion, the inoculated smallpox was no security against a subsequent attack in the natural way[897].

Wagstaffe, in his printed letter to Freind, sums up the objections to inoculated smallpox as follows:

“Some have had the distemper not at all, others to a small degree, others the worst sort, and some have died of it. I have given instances of those who have had it after inoculation in the common way; and consequently as it is hazardous, so ’twill neither answer the main design of preventing the distemper for the future. I have considered what the effects may be of inoculating on an ill habit of body, and how destructive it may prove to spread a distemper that is contagious: and how widely at length the authors in this subject disagree among themselves, and how little they have seen of the practice:—all which seem to me to be just and necessary consequences of these new-fangled notions, as well as convincing reasons for the disuse of the practice[898].”

These objections were shared by several, including Blackmore, Clinch, and Massey, the apothecary to Christ’s Hospital.

On the other hand Jurin, who took the lead in defending inoculation, reduced the issues to two[899]:

1. Whether the distemper given by inoculation be an effectual security to the patient against his having the smallpox afterwards in the natural way?

2. Whether the hazard of inoculation be considerably less than that of the natural smallpox?

These questions, thus put forward as of equal moment, did not receive equally full handling. Jurin dismissed the former question in a brief sentence: “Our experience, so far as it goes, has hitherto strongly favoured the affirmative side”—a conditional assent which became an absolute affirmative after a short time. Having thus disposed of the question which has all the scientific or pathological interest, he turned with his whole energy to give a precise arithmetical demonstration of what no one could doubt, namely, that inoculated smallpox was many times less fatal than smallpox in the natural way,—having got the idea of such a comparison from Nettleton as well as a large part of the statistics necessary for it. Jurin’s statement of the questions at issue, and his manner of answering them, became the received mode, so much so that even towards the end of the eighteenth century one finds capable medical men contrasting the almost infinitesimal mortality from inoculation, as then practised, with the high mortality from the natural smallpox, as if that were the question at issue. The permanent impression in favour of inoculation made by Jurin’s arithmetic was shown a generation later, when Dr George Baker pronounced an eulogy upon him in the Harveian Oration before the College of Physicians in 1761[900]. “It was his special glory,” said the orator, to have “confirmed the practice of inoculation by his experiments and his authority.” There was only one experiment, and it was a remarkable one. The Princess of Wales had begged George I. to pardon six Newgate criminals under sentence of death on condition that they would submit to be inoculated. It was assumed that those six had not had smallpox in infancy or childhood, and Sloane, relating the facts in a letter to Ranby some years after, does in fact call them “six condemned criminals who had not had the smallpox[901].” The concurrence of six persons belonging to the criminal classes and about to be hanged together in Newgate, of whom none had already gone through the common infantile trouble of London and other large towns, was singular. They were inoculated, and it was found that they had escaped the death penalty on very easy terms: John Alcock, aged twenty, had most smallpox, but even he had “not more than sixty pustules”; Richard Evans, aged nineteen, had none, but his antecedents were inquired into, and then it was found that he had had smallpox in gaol only six months before. One of the others, a woman named Elizabeth, was chosen for the grand crucial experiment. Sir Hans Sloane and Dr Steigerthal clubbed together to pay her expenses to Hertford where smallpox was then very prevalent; thither Elizabeth went and ministered among the sick; she lay in bed with one in the smallpox, or she lay in bed with various in the smallpox; at all events she exposed herself to contagion and did not catch it, according to certificates from the woman she lodged with and from another person, which certificates were published with much formality and lawyer-like precision[902]. This was the single experiment in which Jurin had any part. What were the chances of her having had smallpox in childhood? What were the chances of her knowing anything about it, or telling the truth about it if she knew? (One of her fellows in the experiment upon the pardoned convicts had smallpox only six months before, but the fact was not discovered until it was wanted.) What were the chances of her taking smallpox at Hertford, supposing that she had hitherto escaped it? These questions do not appear to have been debated[903].

Such was the experiment by which Jurin “confirmed the practice of inoculation.” As for his authority, it was doubtless considerable; but it was more as a follower of the Newtonian mathematics than as a pathologist or physician, and most of all as one of the secretaries of the Royal Society in the last years of Newton’s presidency, that he spoke with authority[904]. His influence, such as it was, availed little. The practice of inoculation fell into total disuse in England after a few years’ trial, so that in 1728 Jurin himself was prepared to see it “exploded.”

The principal reason of inoculation having been tried upon decreasing numbers in England after the first year or two, and of its having been dropped absolutely for a time, was the death of some persons of good family, both adults and children—a sacrifice of life which could not but seem gratuitous. Those deaths were not from the fulness of the eruption but from anomalous effects. When inoculation began in London in 1721, it was according to the Greek method of inserting a minute quantity of matter at two or more places. In the case of the Newgate felons, Maitland had reason to do the inoculations over again after three days, being dissatisfied with the appearance of the original punctures. They are admitted to have had a slight disease (the man who had most had only some sixty pustules on his whole body), so that Dr Wagstaffe, who went to see them, said in his letter to Dr Freind: “Upon the whole, Sir, in the cases mentioned, there was nothing like the smallpox, either in symptoms, appearances, advance of the pustules, or the course of the distemper.” Many of the other early cases had likewise a slight eruption; when numbers are given, the pocks are “not more than eleven to eighteen” (as in Maitland’s case of Prince Frederick at Hanover in 1724), or “not above twenty in all upon her” (as in Maitland’s case of a child near Hertford, in 1721). Of the first six charity children inoculated, one had no eruption; of the next five, three had no smallpox from inoculation. The cases that died after inoculation during the first seven years of the practice—seventeen in England and Scotland and two in Dublin, most of them children—owed the fatal result for the most part to some peculiar prostration or lowered vitality, in two cases actually to pyaemia, the eruption being kept back altogether or but feebly thrown out[905]. This was the danger of arbitrarily procuring the smallpox which Dr Schultz remarked upon in 1677, with reference to the Polish practice of “buying” the disease; most, if not all the cases known to him, although they may have had few pocks, yet fell into more serious illness (gravius reliquis decumbant). The risk of arbitrarily forcing infection upon a child at a time when it might not be ready for it, or in a position to deal with it in its blood, was afterwards recognized, and was provided against in the long and tedious preparation which the subject for inoculation had to undergo.

While those in England who followed Maitland in inoculating after the Greek fashion produced for the most part an infinitesimal number of pustules or watery pimples, there were others at a distance from London who inoculated by a method of their own and gave their patients a more real smallpox. The chief of these were Dr Thomas Nettleton of Halifax, and Dr Zabdiel Boylston, of Boston, New England[906]. Nettleton made a long incision through the whole thickness of the skin of one arm and of the opposite leg, and laid therein a small piece of cotton soaked in smallpox matter, which he secured in the wound with a plaister for twenty-four hours. Boylston says: “The Turkey way of scarifying and applying the nutshell &c., I soon left off, and made an incision through the true skin,” the rest also of his procedure being the same as Nettleton’s. And just as those two inoculators devised for themselves a more real method of giving the smallpox by insertion, taking means to ensure the absorption of the matter into the blood, so they procured in many cases, although not in all, an eruption of pustules on the skin which came near to being the same as that of natural smallpox of the average discrete type.

In the Boston practice, “the number of the pustules is not alike in all; in some they are very few; in others they amount to an hundred; yea in many they amount unto several hundreds, frequently unto more than what the accounts from the Levant say is usual there[907].” Nettleton’s account, which was printed in the same number of the Philosophical Transactions as that from New England, says of the pustules on the skin at large: “The number was very different: in some not above ten or twenty, most frequently from fifty to two hundred; and some have had more than could well be numbered, but never of the confluent sort.... They commonly come out very round and florid, and many times rose as large as any I have observed of the natural sort, going off with a yellow crust or scab as usual[908].”

The smallpox procured by inoculation in these English and American trials was thus a more real form of that disease than at Constantinople; compared with the number of pustules given by Timoni and Pylarini, the Boston and Halifax numbers are multiplied ten times.

Nettleton thus expressed his belief that inoculated smallpox saved from the natural disease, at the same time grounding that belief on the reality or substantial nature of the artificial disease:

“Some of those who have been inoculated, that are grown up, have afterwards attended others in the smallpox, and it has often happen’d that in families where some children have been inoculated, others have been afterwards seized in the natural way, and they have lain together in the same bed all the time; but we have not yet found that ever any had the distemper twice; neither is there any reason to suppose it possible, there being no difference that can be observed betwixt the natural and artificial sort, but only that in the latter the pustules are fewer in number, and all the rest of the symptoms are in the same proportion more favourable[909].”

Nettleton returned to the question of the reality of inoculated smallpox, which is the root of the whole matter, in his second letter, to Jurin[910]: “The question whether the distemper raised by inoculation is really the smallpox is not so much disputed now as it was at first.... There is usually no manner of difference to be observed betwixt the one sort and the other, when the number of pustules is nearly the same; but in both there are almost infinite degrees of the distemper according to the difference of that number. All the variation that can be perceived of the ingrafted smallpox from the natural is, that in the former the pustules are commonly fewer in number, and all the rest of the symptoms are in the same proportion more favourable. They exactly resemble what we call the distinct sort.... It will follow as a corollary, that those who have been inoculated are in no more danger of receiving the distemper again than those who have had it in the ordinary way. And this is also thus far confirmed by experience.”

It does not appear that Nettleton based so much upon the subsequent experience as upon the antecedent probability. Thus he says of some cases:

“These had the eruptions so imperfect as to leave me a little in doubt, but two of these have since been sufficiently try’d by being constantly with those who had the smallpox, without receiving any infection; which makes me inclined to believe they will always be secure from any danger. As to all the rest, neither I nor anybody else who saw them did in the least question that they had the true smallpox.”

Nettleton began his inoculations in and around Halifax during a considerable epidemic of smallpox in the winter of 1721-22, of which the following figures were collected by himself (as well as statistics for Leeds, Bradford, Rochdale and other places):

		Cases		Deaths
Halifax		276		43
Part of Halifax parish towards Bradford		297		59
Another part of Halifax parish		268		28

In the town of Halifax the smallpox was of a more favourable type than usual, whereas in Leeds at the same time (792 cases and 189 deaths) it was more than usually mortal. In the country round Halifax there was more smallpox than in the town; but the epidemic in general ceased in the spring of 1722. As the people mostly disliked the idea of inoculation, Nettleton did not urge it upon them, but inoculated only the children of those who favoured it. Down to the 22nd of April, 1722, he had inoculated about forty, with one death; at the date of 16 June, he had done fifteen more, his total to the end of 1722 being 61. In 1723 he did nineteen inoculations, in 1724 none, in 1725 and 1726 about forty (in an epidemic of 230 cases, and 28 deaths in Barstand Ripponden and another part of Halifax parish), and in writing to Hartley of Bury St Edmunds in 1730, he gave his total at that date as 119, from which it appears that he had ceased to inoculate after 1726. His name does not appear again in the controversy, and it is probable that he acquiesced in the tacit verdict against inoculation which Jurin himself, in 1728, seemed to think was imminent.

Besides this centre of inoculation in Yorkshire in the midst of epidemic smallpox, the only other of importance in the first trials of the practice was at Boston, New England. The smallpox epidemic there in 1721 was a very severe one. There had been no smallpox in Boston since 1702, so that a large part of the population were susceptible of it. The infection was brought by a ship from Barbados in the middle of April, 1721, and made slow progress at first, according to the following table of deaths from it[911]:

Deaths from Smallpox in Boston.

1721-1722

May		1
June		8
July		20
August		26
September		101
October		402
November		249
December		31
January		6
Total		844

In the course of the epidemic some 5989 persons were attacked, or more than half the population (10,565). All the rest, save about 750, had been through the smallpox before. Inoculation played a very subordinate part amidst these dreadful scenes of smallpox. Its instigator was the Rev. Dr Cotton Mather, who had been shown by Dr Douglass the numbers of the Philosophical Transactions with Timoni’s and Pylarini’s papers in them. The reverend doctor “surreptitiously” employed Douglass’s rival, Dr Boylston, to begin inoculating, in July, 1721, or a few months after the first trials in London. Boylston inoculated 244, whites and negroes, and admitted the deaths of six of them, probably by inhaled infection[912]. But Douglass says:

“The precise number of those who dyed by inoculation in Boston, I am afraid will never be known because of the crowd of the sick and dead whilst inoculation prevailed most, the inoculator and relations inviolably keeping the secret.... Some porters who at that time were employed to carry the dead to their graves say that it was whispered, in sundry houses where the dead were carried from, that the person had been inoculated. I could name some who are suspected, but having only hearsay and conjectural evidence, I forbear to affront the surviving relations. I myself am certain of one more who died ‘after inoculation’ as they express it.”

He then gives the case, which was clearly one of the natural contagion of smallpox acquired at the same time as the inoculation. In the Charleston inoculations of 1738, which were also done in the midst of an epidemic, there is little doubt that the fatalities were mostly from natural smallpox which the inoculated infection had failed to anticipate or prevent. The inoculators were often in that dilemma with their fatal cases: either the inoculation had killed the patient or it had been powerless to keep off the contagion; sometimes they confess the former as an untoward accident, at other times they plead the latter, which appears to me to have been the more usual of the two in a time of epidemic smallpox[913].

Douglass, for all his bitterness against his rival Boylston, and his severity against the extravagant assertions and loose reasoning of the first inoculators, was far from denying the merits of inoculation, whether in theory or in practice. “We may confidently pronounce,” he says, “that those who have had a genuine smallpox by inoculation never can have the smallpox again in a natural way, both by reason and experience; but there are some who have had the usual feverish symptoms, a discharge by their incisions, with a few imperfect eruptions, that may be obnoxious to the smallpox,”—of which he gives instances. In like manner Nettleton, in Yorkshire, who took pains to make his smallpox a real thing, and succeeded in doing so as well as any inoculator ever did succeed, was persuaded that inoculated smallpox counted for a natural attack. He admitted only one failure, a case at Halifax which had been inoculated without an eruption ensuing and took smallpox by contagion a month after. Failures in England, in that sense, were fewer than the deaths directly from inoculation. The deaths were freely admitted, but any alleged failure of inoculation to ward off the natural smallpox was challenged, investigated, and denied, so that Mead, writing in 1747, declared that he knew of none. There were, however, a few cases recorded, which appear to be authentic. One of the six charity children inoculated at the instance of the Princess of Wales had taken natural smallpox twelve weeks after. The child of one Degrave, a surgeon, had a similar experience. Another familiar case was the son of a person of distinction, inoculated on 7 May, 1724, by the Rev. Mr Johnson.

On the 14th a rash came out, on the 15th there was fever, on the 16th, very little eruption to be seen and the fever gone, and on the 18th he was pronounced “secure.” On that day (18th May), his sister was inoculated in the same place, both children remaining together at the inoculator’s house until the 2nd of June, when the boy went home. For a day or two before the 8th of June the boy was ill, and on the 9th he began to have smallpox in the natural way, of a good sort, the disease keeping its natural course. He was supposed to have caught it from his sister, who was inoculated after his own protection was over, and was “very full of smallpox” until the 27th of May, her brother being with her[914].

Another case of failure, which must have been known to some at the time, was not published until some ten years after, when Deering brought it to light[915]:

“I was an eyewitness of the inoculation of a little boy, the child of Dr Craft, who is now a sugar-baker in the Savoy. He was inoculated by one Ahlers under the direction of Dr Steigerthal, the late king’s physician in ordinary; and notwithstanding the great care there was taken in the choice of the pus, had the confluent kind severely; and twelve months after had them naturally, and though a favourable sort, yet was very full.”

A boy aged three, the son of Mr Richards, M.P. for Bridport, was inoculated in 1743, and had fifty to sixty pocks which maturated and scabbed. About two years after (“one year ago”) he had smallpox again, the pustules numbering from 200 to 300; when the eruption came out the fever declined and did not return. These facts are given in a letter to Dr Dod from Dr Brodrepp, grandfather of the child, who attended him on both occasions[916].

Such cases were not often heard of. As Mead said, “If such a thing happened once, why do we not see it come to pass oftener?” There was, however, little encouragement for anyone to come forward with adverse evidence; witness the case of an unfortunate Welshman, one Jones, of Oswestry, who had innocently mentioned, in writing to his son in London, that natural smallpox had followed an inoculation done by him, on 9th August, 1723, and was frightened out of his wits by the apparatus criticus which Jurin brought to bear upon him[917]. Another reason why so few failures could be discovered was that the inoculated were not kept long in sight. A child of Dr Timoni, the first writer on inoculation, was inoculated at Constantinople in December, 1717, at the age of six months, and had an average effect, namely ten small boutons. She died of smallpox in 1741, at the age of twenty-four. This failure came to light by the vigilance of the celebrated De Haën, of Vienna, an opponent of inoculation, who had been told of it by a Scots physician at Constantinople[918].

A good instance of the same thing came to light long after in the practice of the celebrated Dr Rush of Philadelphia. “I lately attended a man in the smallpox,” he wrote to Lettsom, “whom I inoculated six-and-twenty years ago. He showed me a deep and extensive scar upon his arm made by the variolous matter”—without which evidence, and the man’s own reminder, confirmed by his mother’s recollection, Dr Rush would probably have had no reason to believe that this particular one of his inoculations had failed[919].

In the nature of the case, such evidence of failure would seldom be opportune. It would have needed a more dramatic presentation of these cases, and many more of them, to discredit the practice of inoculation. It was, indeed, discredited, so much so that it was not practised at all in England from 1728 until about 1740; but that was owing to the disasters directly resulting from it. No amount of evidence as to the inoculated taking natural smallpox afterwards could have touched the popular imagination like the following paragraphs in the London newspapers in 1725:

March 16, died Mrs Eyles, niece of Sir John Eyles, alderman of London, of the smallpox contracted by inoculation. June 17, died of the smallpox contracted by inoculation Arthur Hill, esquire, eldest son of Viscount Hilsborough. August 12, died of the smallpox by inoculation—Hurst, of Salisbury, esquire.

Inoculation seemed hardly worth having on these terms, granting all that was alleged of its protective power; so that it fell in England into total disuse[920]. It came on again after a time and had a long career, at first among the richer classes, and at length among the common people, who did not cease to use it for their children until it was made a felony by the Act of 1840. After its first brief success, it was revived about 1739-40, in consequence of highly favourable accounts from Charleston, South Carolina, and from Barbados and St Christopher. This second period of inoculation brings in certain modifications of the practice by which the casualties of the earlier period were avoided. The danger from blood-poisoning, pyaemia, or the like, was surmounted. At the same time the inoculated smallpox ceased to have anything of that reality, or approximation to the natural disease, which Nettleton succeeded for a time in giving to it.