Perhaps enough has been said to illustrate the subtle casuistry that had gradually arisen out of the old problem of procuring the smallpox by artifice. I make one more citation, from a Hampshire inoculator in 1786, to show how fine were the distinctions, depending, one might suppose, upon the subjective state of the practitioner, drawn between effective and non-effective inoculation:
“The incisions sometimes have a partial inflammation for a few days, which then vanishes without producing any illness; in this case the patient is certainly still liable to infection; but I believe it very rarely happens that there is any matter, or even ichor, in the present slight manner they are made, without producing the smallpox.... I have constantly remarked that when the punctured part inflames properly, and is attended with an efflorescence, rather inclining to a crimson colour, for some distance round the same, about the eleventh or twelfth day from the inoculation, although the patient should have very little illness and no eruption, yet that he is secure from all future infection[944].”
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: