A Pox on the Poor

Smallpox​ is the greatest success story in the history of medicine. It once took huge numbers of lives – as many as half a billion people in the 20th century alone – and blinded and disfigured many more. It was, as Thomas Macaulay said, ‘the most terrible of all the ministers of death’, and its preferred targets were children. In the past, you may have had something like a one in three chance of getting the disease and, if you did get it, a one in five chance of dying, though some outbreaks killed 50 per cent of the afflicted. Now smallpox is no more. In 1980, the World Health Organisation declared it eradicated, making smallpox the only infectious human disease ever to have been wiped out. The virus that causes smallpox still exists, officially kept secure at facilities of the US Centres for Disease Control and Prevention (CDC) in Atlanta and the State Research Centre of Virology and Biotechnology at Koltsovo in Siberia. That’s all there is left of it – so far as we know. (There have been intelligence reports that Saddam Hussein’s Iraq once had some and that North Korea keeps stocks, and in 2014 a researcher at the US Food and Drug Administration came across a carelessly kept cardboard box containing six vials of smallpox virus where they should not have been.)

The last naturally occurring case of smallpox occurred in Somalia in 1977, and the last death in 1978, when an accidental release of the virus then held at the University of Birmingham medical school killed a woman who worked there. Routine vaccination in both the UK and the US ended in the early 1970s – and, if you’re old enough to have been vaccinated, you should know that protection tends to decline after about ten years. You can say that there is no threat from smallpox today in the same sense that there is no risk from nuclear weapons – which is to assume no accidents and no effective acts of malevolence. It isn’t so long ago, however, that the US government took bioterrorism seriously enough to mount an elaborate exercise – Operation Dark Winter – to simulate a co-ordinated response to a smallpox attack, and the CDC says there is enough vaccine in the Strategic National Stockpile to vaccinate everyone in the US. Dark Winter took place in June 2001. When 9/11 happened, federal smallpox response teams were mobilised – just in case. Some experts believe that smallpox terrorism is ‘potentially the Big One’: the eradication of the disease and the end of vaccination has created what’s called an ‘immunologically naive’ population – just like the Native Americans who in 1763 so gratefully received gifts of smallpox-infected blankets, arranged by the British general Jeffrey Amherst.

In the 18th century, it was folk knowledge that milkmaids tended to be afflicted with the far more mild cowpox but rarely suffered smallpox. The Gloucestershire physician Edward Jenner knew this too, and the beginning of the end of smallpox came in 1796 when he inoculated an eight-year-old boy with pus from a cowpox sore on the hand of a milkmaid. Over the following months, Jenner repeatedly exposed the boy to smallpox material, but nothing happened: he seemed to be protected. The procedure was called ‘vaccination’ – from the Latin name for cowpox, Variolae vaccinae, that is, the pox deriving from the cow (vacca). It was Louis Pasteur who, many years later, decided that all sorts of inoculation should – in Jenner’s honour – be called ‘vaccination’, even though they had nothing to do with cows.

Jenner’s method was to give you cowpox to prevent you getting smallpox, and, once that was acknowledged to be safe and effective, the transaction was considered an extremely good deal. Acts of Parliament introduced free vaccination in 1840 and made it obligatory in 1853. The traditional story about the triumph of medical science over dread disease routinely starts with Jenner. But he was intervening in a long history of related medical practices. Vaccination was a mode of inoculation, the latter word borrowed from horticulture – the grafting of a bud, or ‘eye’ (oculus), to propagate a plant. Before vaccination, inoculation was intended actually to give you a form of smallpox, a practice widely called ‘variolation’. The variolator (or inoculator: the terms were in effect interchangeable before Jenner) took a small amount of pus from a lesion on a smallpox victim and introduced it under another person’s skin. After perhaps twelve days, the inoculated subject developed a fever, headache and backache – maybe nausea too. Then, several days after that, the characteristic round, pea-like pustules appeared on the skin and in the mouth, though, ideally, many fewer than in cases of smallpox contracted in the natural or ‘casual’ way. In a good outcome, these pustules scabbed over and weeks later fell off, leaving no scars or only minor ones.

So you had smallpox, but, if the procedure worked as it was meant to, you didn’t suffer what was then called the ‘confluent’ or ‘malignant’ form of the disease, in which almost your entire body surface was covered in pustules or flat lesions, with blisters painfully proliferating on the oesophagus, liver and spleen; you didn’t go on to suffer blood poisoning and organ failure; and you didn’t die an agonising death – the sort of thing that was quite likely to happen with casual smallpox. Especially horrific cases could kill in a few days or even hours after symptoms appeared, and in the mid-18th century it was said that one victim’s body putrefied so fast and thoroughly that ‘his limbs fell off as they lifted him into the coffin.’ The contract with the inoculator was to accept a mild form of the disease, and a low chance of death, in exchange for a future secured from the naturally occurring disease, which carried a high chance of killing or disfiguring.

But how could anyone think up such a procedure, with its affront to common sense? The official story here is a pastiche of British medical science and Orientalism. In 1717, the poet and critic Lady Mary Wortley Montagu fetched up in Constantinople with her husband, then the British ambassador to the Sublime Porte. She heard that certain old Greek Christian women in the city were performing what was called ‘ingrafting’. Turks in their thousands accepted intentional infection with smallpox pus. It was done quickly, sometimes in a party atmosphere. There was then a short recovery period, during which the patients were typically put on a vegetarian diet. The procedure was considered effective in guarding against future infection. Lady Mary’s ravaged face bore witness to her own recent bout with confluent smallpox (‘My beauty is no more!’ she later wrote), and her brother had recently died from it. She was sceptical about British medical knowledge and practice, but embraced Ottoman culture and was willing to accept local medical testimony at face value.

Many people simply assumed that their children would eventually get smallpox; large numbers had already lost relatives and friends to the disease. It wasn’t so very odd of Lady Mary, therefore, to calculate that the risk-reward ratio was favourable, and she called on a Scottish surgeon at the embassy to assist an experienced Greek woman in inoculating her five-year-old son. The physician, nervous and disapproving of the woman’s blunt and rusty needle, took charge and did the deed himself. The procedure passed off safely; the boy suffered a manageable number of spots; there was no scarring; and soon he was right as rain. Lady Mary wrote to her friends about what had happened, and even before she returned to London in 1719 inoculation was the talk of the town.

In fact, by the time British doctors encountered Turkish smallpox practices, inoculation was neither new nor did it belong to Western science. For centuries the Chinese had been blowing dried, ground-up smallpox material up the nose, and Arabs had been introducing pus under the skin. Inoculation had long been widespread in North and sub-Saharan Africa. In Boston, inoculation was introduced during a smallpox outbreak in 1721, promoted by the Puritan minister Cotton Mather, who learned of the practice from his recently acquired slave – ‘my Negro-man Onesimus, who is a pretty Intelligent Fellow’. Onesimus had been inoculated himself and told Mather that it was common practice in his African homeland – possibly the area that is now Ghana. ‘Whoever had ye Courage to use it,’ he said, ‘was forever free from the Fear of ye Contagion.’ The Brahmins in India had used inoculation for hundreds of years, maybe longer, and there were reports of inoculation in 17th-century Denmark, Switzerland and Poland. Inoculation had arrived in Constantinople only decades before Lady Mary’s visit, brought by Circassian and Georgian traders, who may have learned it from either Eastern or African sources. And as early as 1600, inoculation was folk medical practice in Pembrokeshire, where it was popularly known as ‘buying the pocks’.

With​ Lady Mary back in London and agitating for inoculation, control now passed to elite London physicians. The doctors were put out of countenance by the Eastern origins of the procedure. How could it be, one asked, ‘that an experiment practised only by a few Ignorant Women amongst an illiterate and unthinking People, should of a sudden, and upon slender experience, so far obtain in one of the Politest Nations in the World?’ They set out to Occidentalise inoculation, improving (as they thought) the techniques of making incisions and inserting pus, assimilating the new practice to humoral views of the body and to pre-existing Western notions of disease. Instead of the Greek women’s little pricks, the London doctors aimed at deep incisions and a more generous dose of pus, making sure that sufficient matter got in and creating a route for presumed poisonous stuff to escape as the incisions healed.

But the major British ‘improvement’ was to replace a quick and easy Ottoman procedure with an elaborate and time-consuming regime that aimed to prepare the patient’s body for inoculation by balancing its humours, cooling its overall temperature and purifying the blood. Strong drink was prohibited; there were bloodlettings and laxatives; and aspects of the regime continued for weeks after inoculation. The purpose was to produce a ‘clean habit of body’ on which the inoculated smallpox material could safely do its work. There were moral directives too: patients were counselled to be temperate, quiet, cheerful – and not to be afraid. ‘Peevish’, ‘irritable’ and ‘froward’ (or contrary-minded) people were sometimes considered poor subjects for inoculation. Early British inoculators gauged patients’ mental and physical states: good outcomes were likely if the subject was in good health; things might turn out badly if inoculation was carried out when body and mind were unbalanced and impure. The selection and preparation of people to be inoculated might be as important as the physical procedure itself.

There was major resistance to inoculation: religious objectors believed that it belonged to God alone to inflict disease; some worried about the risk of accidental death; others were more or less satisfied that the procedure carried only limited risk but didn’t want to take even a small chance of having a child’s death on their conscience. And attitudes differed between the cities – where many people tended to have a fatalistic attitude to endemic smallpox – and the countryside, where occasional outbreaks triggered panicked responses. But Lady Mary and her medical associates did much to make inoculation fashionable. In London, she decided to have her three-year-old daughter inoculated, the procedure witnessed by elite physicians. In 1722, Caroline of Ansbach, then princess of Wales, secured permission from George I to have her children inoculated, and this too passed off safely and properly witnessed. The aristocracy took up the practice, followed by the squirearchy and the prosperous bourgeoisie, buying inoculation for their children and, if they hadn’t had the disease when young, for themselves. Inoculation came to seem safe enough, though there were notable and well-publicised accidents: the earl of Sunderland’s son died after being inoculated and so did a footman of the earl of Bathurst – ‘a strong, hail young Man’.

Those whose lives mattered wanted assurances about safety and efficacy, and so inoculation was first extended to those who didn’t much matter – the poor and the powerless – not as beneficiaries but as uninformed and non-consenting subjects in experiments to establish whether inoculation could save ‘the Lives of the Quality’. In Newgate Prison six volunteers were found who were willing to be inoculated in exchange for commutation of sentences of death or transportation. This experiment was duly carried out and judged successful. Then, specially to reassure the prince and princess of Wales, six more guinea pigs were rounded up, this time orphans: they were inoculated and made available for public inspection at a house in Soho. This experiment went well too, and the ‘Quality’ had further inducements to proceed.

The demand for inoculation was soon being stoked by hard-nosed economic considerations. ‘My face is my fortune,’ the milkmaid said (in the old nursery rhyme), and a pockmarked face reduced value in the marriage market. Better to buy a few pockmarks now than risk facial ruin later. In American slave markets, smallpox was chained to cash value. Slaves who had been inoculated or survived the disease cost more. And in the British market for domestic labour, both inoculation and a personal history of smallpox counted as qualifications: you could then work safely with the employer’s children. Parish officials came to appreciate that a pox on the poor was a risk to the rich, badly affecting both bourgeois health and the availability of labour. Quaker ethics and general altruism were motives for the provision of free inoculation to the working classes, but economic self-interest was just as much a part of it.

What caused smallpox? What were its patterns of distribution? What were the real rates of its morbidity and mortality? Physicians and philosophers disagreed over these questions and many were dissatisfied with the quality of the information and theory available to them. Inoculation introduced further concerns. Was it effective, and how did you reliably assess effectiveness? Did it really offer lifelong protection? How risky was it? Could inoculated persons infect others and, if so, how and how readily? Was the disease contracted through inoculation the ‘real’ smallpox or was it something else? Through the middle part of the 18th century, sentiment drifted towards approving inoculation and regarding it as safe: some reckoned that you had a one in sixty chance of dying from inoculation and a one in seven or eight chance of dying from natural smallpox. (Numbers and vituperations were tossed about like paper aeroplanes in a disorderly classroom, and agreement was hard to come by.) There was also no consensus about how inoculation worked: many practitioners candidly admitted they didn’t have a clue. But the involvement of the physicians and philosophers of the Royal Society in these arguments – and their search for what only later came to be called ‘statistics’ about disease distribution – had consequences for scientific change. In historical accounts of epidemiology and biostatistics, the British inoculation debates of the 18th century are a plausible moment of origin.

Western inoculation began in London and Boston, but because of the extended regimen then involved in patient preparation and aftercare it remained for several decades part of the medical carriage trade. The standardisation, extension and routinisation of inoculation was, however, a provincial affair, led by a Suffolk surgeon called Robert Sutton and, especially, by Daniel Sutton (1735-1819), the second of his six sons. The Suttons were a family firm: all the sons, and some other relatives, were involved in one way or another. It was the Suttons who industrialised the practice of smallpox inoculation and made it into a profitable business. And it is Daniel who is the hero of Gavin Weightman’s new book, which aims to retrieve an ‘untold story’ and recuperate the reputation of a forgotten hero, to bring him and the practice of inoculation out of the shadow of Jenner’s later achievement. It’s a repetitious and occasionally sloppy little book, but it does several things quite well: it exhibits inoculation as something much more than a poor precursor to Jenner; it implicitly tells an intriguing and resonant story about risk management and risk perception; and it treats inoculation as a significant passage in the history of business, making telling use of advertisements and notices in provincial newspapers.

Robert Sutton founded the family firm, but Daniel quarrelled with him and, in the early 1760s, struck out on his own. He set up shop in a village near Chelmsford in Essex, inoculating tens of thousands of patients locally, attracting trade from London, and doing the rounds with his kit in the countryside nearby. What became known as ‘the Suttonian Method’ was substantially his achievement. It was widely publicised as a stunning success. On one occasion, Sutton admitted that the family had lost five patients out of forty thousand; on another, stung by fake news claiming that he’d killed some of his patients, he offered a prize of a hundred guineas ‘to any person who can prove he ever lost a single patient by inoculation – that any of his patients ever had Small Pox a second time – or that the constitution of any person was ever injured by his peculiar and successful method’. That was a bold claim, but by the 1770s it was widely accepted that Suttonian inoculation was both effective and safe. Sutton had effectively branded himself: he was ‘the pocky Doctor’.

People were becoming more trusting of inoculation, more discerning in seeking out a reputable brand, and more relaxed about unavoidable and limited risk. Suttonian inoculation was also, at least in some forms, straightforward: on one exceptionally busy day, Sutton reportedly did seven hundred inoculations. The elaborate preparative regime was slimmed down: there was still a lowering diet – vegetables, no strong drink – but it wasn’t as rigorous as the fashionable norm had been. The incisions returned to the Ottoman style of shallow lancet pricks; patients weren’t confined to quarters but encouraged to go out in the cold air. There were proprietary purgatives, but Sutton seems to have ordered less heroic doses than others. And there was product differentiation: for the top of the line service, Sutton offered spa-like pampering in local accommodation set aside for the purpose. His fees too were on a sliding scale, usually ranging from three to ten guineas, with a special service – three to four weeks’ board and lodging – at twenty guineas. Parish councils began to ask for tenders on job-lot inoculation of the local poor. Many inoculators offered to supply the new demand, including the Suttons, but they were not, in general, enthusiastic about charity work.

Splitting the market and niche pricing were aspects of Sutton’s business success, but so too was control of supply. The extended Sutton clan could satisfy a significant chunk of provincial demand, but Daniel also worked out a franchising system, which ‘authorised’ more than fifty partners throughout Britain and abroad to advertise their use of the ‘Suttonian System’ – provided they paid fees for Sutton-compounded purgatives, kicked back a slice of their take, and kept the trade secrets. Control was especially important, since practically anyone could, and did, set up as an inoculator. The Suttons themselves had become surgeons through apprenticeship, but apothecaries, clergymen, artisans and farmers were inoculating, and sometimes parents inoculated their own children. The profits of the provincial press were considerably boosted as practitioners advertised their skills at inoculation and their keen prices. Daniel went after competitors – including his own father-in-law and a younger brother – with vigour, putting it about that the Suttonian Method depended on a set of closely held secrets, to which only he and his approved partners had access. His competitors sought to winkle out these secrets, occasionally pouncing on Sutton’s patients to quiz them about their experiences.

Some thought the big secret might be the source of pus for inoculation. Did Sutton take it from certain sorts of sufferer? (Some modern specialists suggest that he may have selected material from less severe cases, therefore transmitting a strain of the virus causing milder forms of the disease, but there is testimony to the contrary.) Was his technique of shallow incisions decisive? (Again, some virologists guess that the growth of the smallpox virus in the most superficial levels of the skin resulted in its attenuation and a reduction in pathological power, while others say that any introduction of the virus through the skin gives the immune system a head start compared to the inhaled virus.) Were his patients given dietary regimes unknown to others? Was their vigilant aftercare crucial, and would victims of naturally acquired smallpox have fared just as well if they had enjoyed the advantages of close medical attention? How important was it that they go out in the cold after inoculation? Some of Sutton’s competitors were convinced that the secret of his success was the precise compounding and calibrated dosing of chemical purgatives, specifically those containing mercury (which is now known to be toxic but was commonly used in 18th-century medicine). Several of Sutton’s contemporaries suspected, as do some modern researchers, that a key factor in securing good outcomes was the meticulous selection of subjects in very good health. But as long as the secrets were kept, Sutton’s business remained good.

Flush with funds, Sutton transferred his practice from Essex to London, setting up shop in Kensington Gore at a residence named, predictably, Sutton House. By 1764, he had an annual income of 6300 guineas – about $1.2 million in today’s money – and, having made his fortune, he set about making his name. A Pooteresque, pompous and quarrelsome character, he lobbied the heralds for a family coat of arms, ‘to establish me on that due line and rank, which I have ever wished to hold’. After an extended and expensive campaign, Sutton eventually succeeded, rarely thereafter missing a chance to draw attention to his armorial status. The chosen motto (a homage to Asclepiades) was also an advertisement for the Suttonian Method: ‘tuto, celeriter, et jucunde’ – ‘safely, quickly, and pleasantly’.

In 1796, at 61 years old, Sutton decided to break cover and disclose the secrets of his method. He didn’t really: the book of case histories and ‘theory’ in which he claimed to tell all was titled The Inoculator – with the definite article signalling both uniqueness and originality – and it was more self-celebration than revelation. Anyway, by that time practically all of the inoculation world was, or thought it was, or claimed to be, following the ‘Suttonian Method’: shallow incisions, not much pustular matter inserted, quick dietary preparation, and whatever mercurial or antimonial purgatives they believed that Sutton used. Sutton’s own business was no longer what it had been; there was little reason for customers to pay for the branded original when they could have something cheaper and seemingly just as good. Added to the opposing currents was emerging political concern that even if variolation wasn’t dangerous to patients then in the absence of universal variolation – which would be impossible to enforce – it threatened infection to others.

Edward Jenner’s​ vaccination eventually won out over variolation – there’s a Jenner statue in Kensington Gardens and none of Sutton anywhere – but Weightman rightly points out that the victory was neither quick nor unopposed. Jenner offered a new procedure that didn’t give you smallpox, didn’t present any risk of significant illness, required no preparation or aftercare, promised long-lasting protection, and didn’t make you an infectious danger to others, so dispensing with the need for post-procedural ‘self-isolation’ or quarantine. However, many British people still preferred variolation and resisted vaccination. Sutton lived on for more than twenty years after Jenner’s discovery, but variolation survived him, and continued to satisfy British consumer demand for some time. Vaccine scepticism was considerable in 19th-century Britain; it was informed by doubts over its safety, but there was much more to it. Part of the story was familiarity: variolation was once resisted because of its Eastern origins, but it had long been domesticated. Vaccination was something new, and the sharp edge of perceived risk was unsmoothed by custom.

Yet long before there was a science called immunology, the barrier between bodily self and non-self was culturally electrified. Variolation gave you a mild case of the dread smallpox, but the disease itself was a familiar part of the 18th-century human condition. Cowpox came from cattle, and vaccination was the introduction to your body of material from an alien form of life. These considerations were important to some people. Gillray lampooned vaccination by showing cow parts sprouting from the bodies of the just-vaccinated, but anxiety about being cowified was widespread and not everyone took it as a joke. There were fears that vaccination would transmit animal diseases other than cowpox, just as there were fears that the practice of securing vaccine material not ‘cow to arm’ but ‘arm to arm’ (the pustules of one vaccinated person providing stuff for another) might uncontrollably transmit other human ailments, including venereal diseases. But it was the risk of communicating cowness that powerfully lingered among vaccine sceptics through to the end of the 19th century. During a smallpox outbreak in Jenner’s own county of Gloucestershire in the 1890s, some parents resisted vaccination, unwilling to have ‘a beast … put into their children’.*

The first ‘conscientious objectors’ pushed back not against war but against obligatory vaccination. The Newgate prisoners, the London orphans and thousands of the parish poor had variolation inflicted on them, but the practice flourished for the most part as a choice in the 18th-century medical marketplace. It wasn’t long after Jenner’s discovery that compulsory vaccination was talked up, and eventually inscribed in law – first, the banning of variolation and then the mandate to vaccinate. Evidence of the superior safety and effectiveness of vaccination was accumulating, but science never defused defiance, and even as compulsion increasingly made medical sense, there were limits on its capacity to determine political and moral sense. The science involved in 18th and 19th-century arguments about variolation and vaccination weighed the health of society against the risk to individuals. And the moral and political dimensions of those arguments concerned the relationship between the good of the social whole and individuals’ desire to control their own bodies. There is no way that the management of public health can escape those tensions, nor is there a straightforward path from scientific evidence to the right course of action. In a market economy, it’s not so easy to deny the virtue of individual choice. Early on in the history of parliamentary debates over smallpox prevention, a speaker objected to a proposal to ban variolation: ‘The liberty of doing wrong,’ he said, ‘was still left among the privileges of free-born Englishmen.’