SMALLPOX - Massachusetts Medical Society

THE STORY OF SMALLPOX IN MASSACHUSETTS*BY SAMUEL BAYARD WOODWARD, M.D.\s=d\

Mr. President and Fellow Members:

IT is a great honor to be asked to stand hereas the one hundred and twenty-seventh an-

nual orator of this Society.' Greatly handicapped by the fact that I im-

mediately follow that distinguished writer, ora-tor and surgeon, Dr. Harvey Cushing, it occursto me that instead of wandering in fields wheremy somewhat senile mind might easily lead me

astray, I had better confine myself to somethingthat I do know a little about and consequently,and I hope not too lengthily, I propose to tellyou the story of smallpox in Massachusetts.

It was in Massachusetts that inoculation forsmallpox was first tried out on this side of theAtlantic.

Massachusetts was the first state in theUnion in which vaccination against smallpoxwas performed.

The first medical publication in this countrywas a broadside on the treatment of smallpoxpublished in Boston.

The first state compulsory law for the vac-cination of school children was passed by aMassachusetts Legislature.

In proportion to its population, in no statein the Union has less smallpox been of lateyears annually reported. That this compara-tive immunity has been attained, despite thefact that the United States as a whole suffersmore today from smallpox than any country inthe world, bar India, China and possibly Rus-sia, speaks well for its health officers both stateand local.

Massachusetts probably knew smallpox beforethe Mayflower crossed the sea, for when as theHistorian Baylies puts it, "on the bleak shoresof a barren wilderness with the blasts of win-ter howling around them, the Pilgrims of Ley-den laid at Plymouth the foundations of Ameri-can liberty", it is more than probable that tothe recent extermination of the previous inhabi-tants by an epidemic that may well have beensmallpox those who survived that first winter

*The Annual Discourse delivered before the MassachusettsMedical Society at the one hundred and fifty-first reunion, heldin Boston, June 8 to 10, 1932.

\s=d\Woodward\p=m-\President, Massachusetts Medical Society, 1916\x=req-\1919. For record and address of author see "This Week'sIssue," page 1221.

owed their preservation. Seven years earlierthe Narragansetts alone were said to be able tomuster some 3,000 warriors and had but a titheof that number put in an appearance to repelthe invaders, not all the bravery and strategyof Miles Standish and his men could have savedthe half-starved remnant of that little band.The attempt to found a settlement at Plymouthwould have failed as did the similar effort atJamestown in 1607. That some terrible calamityhad destroyed the inhabitants of Plymouth andthe surrounding country is an undoubted fact.The Pilgrims settled in no unknown territory.Whether or no the Norsemen rounding CapeCod named it Kjarlarnes or buried one of theirleaders on the Gurnet at the entrance of Plym-outh harbor, whether or no Sebastian Cabotsailed thus far to the south, it is undoubtedlytrue that the Gosnold Expedition in 1602 gavethe name "Cod" to the cape of fishes, that in1603 the ships of three nations, England, Pranceand Holland, visited the site, that the men withCaptain Pring went ashore there and evenerected a barricade of logs, and it is more thansuspected that here was the Occomock whereCapt. John Smith fought with the Indians in1614. In 1619 Capt. Thomas Derner found"some ancient plantations not long since pop-ulous, now utterly void, a remnant remainingbut not free of sickness". What was thissickness? For many years ships from Europehad been present in North American waters.Since the discovery of the Hudson by Verra-zano in 1524, the French had constantly sailedup that river to trade with the Indians. Asearly as 1527 there were at St. Johns at onetime 14 sail of Normans, British and Portu-guese, and 75 years later France, Spain andEngland had engaged in fishing off that north-ern coast no less than 450 vessels. In 1609Champlain was leading his Algonquins againstthe Iroquois on the lake bearing his name.In 1613 Adrian Block was at New Amster-dam and the next year exploring Long IslandSound. In 1615 a trading post was estab-lished where Albany now stands. It seems im-possible that, with the then universal prevalenceof smallpox, cases were not constantly occur-ring on these vessels and among these adven-

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turers. It also seems unlikely, contact with theIndians being close (some thirty of them inone instance being taken to Portugal and soldas slaves) that, in the course of time, the dis-ease was not communicated to the aborigines.

Samoset, the Wampanoag, with his, "Wel-come, Englishmen", and his invitation to "takethe soil", had learned the language from thosewho came as far south as the Penobscot.

Miles Standish in 1620 found, as did Dernerthe year before, but "a few straggling inhabi-tants, burial places, empty wigwams and someskeletons" and whether it came from the shipsor spread to New England from the distantsouth into which it had been brought by Pizarroand Cortez one hundred years before, I sub-mit that neither malaria, nor yellow fever, northe plague, but smallpox was the blessing in dis-guise that gave our emigrant ancestors an op-portunity to found the state.

Be all this as it may, it was not long beforethe settlers began their own battle with small-pox. The fight is not yet over, perhaps neverwill be, although what is happening in our timeis but a skirmish against outposts comparedwith the contest waged by our predecessors.The opposition to our present laws and theirimprovement would seem but the blowing of asummer zephyr to those who endured the hur-ricane of abuse hurled against the advocates ofinoculation in 1721 and of vaccination in 1800.

For 180 years smallpox was responsible formore deaths than any other one cause. Almostalways sporadically present, coming in epidemicform every few years, few indeed escaped itsravages.

There were deaths from it in Boston within a

year of its settlement in 1630.In 1633 it swept away almost every native as

far north as the Piscataqua and destroyed some300 Narragansetts to the south.

In 1636 the General Court moved to Cam-bridge and later to Roxbury to escape the dis-ease then raging in Boston.

In 1638 Winthrop says that "two ships camein much 'pestered', lost many passengers andsome principal men", that, "many fell sickafter they landed and again many of these diedand many inhabitants with them".

Capt. John Bonner speaks of an epidemic in1640 and there was certainly an outbreak in1649.

In 1659 the General Court sat at Charles-town on account of the spread of the smallpoxin Boston.

In 1666 forty died of the disease.In 1668 a fast was appointed on account of its

prevalence and the election sermon with itstitle of "Nehemiah on the Wall in TroublousTimes" opened with the declaration that—"Thestill outstretching hand of God's powerfulwrath over this poor country, smiting down our

pillars, plucking up our stakes and taking fromus the breath of our nostrils is a matter so dole-ful, solemnly awful and tremendous that onemay well sigh out our sorrows in the wordsof the lamenting church, Lamentations 5 :16:17,'The crown is fallen from our head: Woe untous that we have sinned! For this our heartis faint; For these things our eyes are dim.' "

In the winter of 1677-78 smallpox againraged, brought as usual by English ships, andmany deaths were recorded. Fast days wereheld to stay its progress, but the first of Trous-seau's three epochs of smallpox was at hand,the other two being of course inoculation withand vaccination against it.

Sydenham, the English Hippocrates, was nowto immortalize himself by overturning the prac-tise of centuries in the treatment of fevers andof smallpox in particular. Early in 1666 hepublished his "Methodus Curandi Febres"treating of the continued, pestilential, intermit-tent and epidemic forms. A second edition ap-peared in 1668 and a third much enlarged witha section particularly devoted to smallpox in1676. No longer was the unfortunate victimto be kept in "a chamber close shut, if it bewinter the air to be corrected by large fires",care taken that "no cold air" got to his bed,where he lay covered with blankets, his linennever shifted till after the fourteenth day forfear of "striking in the pock to his irrevocableruin"; he comforted the while by the assuranceof the authority Diemerbröck that "it is farbetter to let the patient bear the stench thanthus to be the cause of his own death". Forall this was to be substituted as Sydenham'sinfluence spread, despite the abuse of his con-

temporaries, rest in bed, plenty of air, mod-erate heat, and light but sufficient covering,cool drinks, and marked dependence on the VisMedicinae Naturae with a following on thephysician's part of the Hippocratic practiceof watching and aiding the natural crises in-stead of trying by active and intrusive meas-ures to force the issue. With but little delaythe proposed change in treatment was broughtto the attention of the people of Massachusetts,for on January 21, 1677 there appeared as abroadside—

"A Brief RuleTo Guide the Common People of New England

How to Order Themselves and Theirs in theSmallpocks or Measles

This was printed by John Foster of Boston andsigned by Thomas Thatcher, the first ministerof the Old South Church. Smallpox was thenagain present in epidemic form for the ninthtime in 47 years. Without question Thatcherwas familiar with Sydenham's publication ofthe previous year. The use of words and theconstruction of sentences betray the broadside'sorigin. We are told of the "boyling of the



blood by which nature thrusts out the impuri-ties from veins to flesh and from flesh to skin"and are warned of "the danger of overhasten-ing or overdelaying this process either by toomany clothes, too hot rooms, cordials like Dias-cordium, Gascon's powder and such like, orby preposterous cooling by bloodletting, glysters,vomits, purges or cooling medicines, lest by thefirst treatment come phrenzies, dangewrassweats or flowing of the pocks together, or bythe latter means there be raked away that sup-ply of blood which should keep them out untilthey are ripe. " " Let him drink, ' ' says Thatcher,"small beer warmed with a 'tost', sup up watergruel made with indian-flour not with oatmeal :

let him eat boiled apples but (and mark thewords) I would not advise any medicines. Butif his blood be enraged that it will admit ofno delay, bleed him. These things have I writ-ten", he continues, "not to inform the learnedphysicians that have much more cause to under-stand all that pertains to the disease than I,but to give some light to those that have notsuch advantages. I am though no physician buta well-wisher to the sick and therefore entreat-ing the Lord to turn our hearts and stay Hishand."

"I amA Friend, Reader,

to thy Welfare.Thomas Thatcher."

Despite his disclaimer Thatcher was, as Dr.Viets has pointed out, one of the outstandingpreacher physicians of the time. He had studiedwith Charles Chauncy, later the second Presi-dent of Harvard College, who also combined thecare of bodies with that of souls and he himselfdied the next year following a visit to a sickperson. This combination of medicine and the-ology was as common in the mother country ason this side of the Atlantic and had existedfrom very early times. Medicine was not adistinct profession but was practised by theclergy, even by those holding exalted positions.The Bishop of Worcester was for example thephysician to Richard the II. Physician or no,Thomas Thatcher by his publication paved theway for a more humane treatment of smallpoxin the Colony and Sydenham's methods becameknown here through his broadside almost assoon as they attracted any marked attentionin the mother country. Though the treatmentbecame more humane, though lives were un-doubtedly saved, the ravages of smallpox ceasednot at all.

In 1690 the disease which had prevailed inBoston before the departure of Sir WilliamPhips' ill-fated expedition against Canadaspread through the fleet and many died bothduring the advance and the retreat, while manymore perished on shore after its return. Pub-lic fasts were decried in March and in July

but it was not until February 23, 1692-3 thata thanksgiving was held for the cessation ofthe scourge.

In 1697 smallpox again held sway, carryingoff in that and the succeeding year some tenhundred of the then seven or eight thousand in-habitants of Boston. Visualize, if you can,what the death of 250,000 of the 2,000,000 peo-ple in Metropolitan Boston of one disease inone year would mean to us, and you picturewhat our ancestors endured during those twelvemonths with what courage they might. Threeyears later, in 1700, Mr. Leverett writes thatJudge Sewall came from Cambridge to openthe Court in the Meeting House, "because theTown House is very near a house that has thesmallpox and people are afraid to go there".May I add, as well they might be?

In 1701 the first smallpox prevention act au-thorized the impressment of houses for the isola-tion of patients.

In 1702 three hundred died, the tolling ofbells at funerals was limited, "there to be onlya first and a second tolling, each bell not toexceed the space of half of one quarter of anhour" and it was suggested that there be mod-eration in the price of coffins, digging of gravesand wages of porters to carry the corpse, butthe unhappy constable was still required to ful-fill that duty of his office which compelled him"to attend the funerals of those dying of thesmallpox" and to walk before the corpse togive notice to "any y't may be in danger of yeinfection".

And then for 19 years Massachusetts was

practically free from the disease, by far thelongest period of immunity since the landingat Plymouth. A whole generation that knew itnot had grown up when in 1721 in the midstof the most terrible outbreak up to that timerecorded inoculation was introduced.

The first hundred years had come and gone.Twelve times present in epidemic form, sporadiccases always cropping up, the only escape flightand that too rarely a successful expedient, small-pox during this century had done more tohinder the growth of the Colony than Indianraids, foreign wars or any other general calam-ity.

A letter describing inoculation as practisedin Turkey sent to Dr. John Woodward of Lon-don in 1713 by Dr. Emanuel Timonius Alspeckof Constantinople and a second letter fromPylarinus, a Venetian physician on the same

subject were published in the PhilosophicalTransactions of the Royal Society in 1714 and1715. Little attention seems to have been paidto these publications in England. It was notso when they reached America, as will be seenin the sequel. Lady Mary Wortley Montagu,wife of the English Ambassador to Turkey, de-scribed the practise in a letter to a friend in



1716, had her son inoculated soon afterwards,and in 1718 returned to England determined todo what she could to bring what she calls "thisuseful convention" into fashion. She later pro-tested that for four or five years after her re-turn she scarcely passed a day without repent-ing her audacity. If she followed up what shewrote to her friend in 1716, she told all andsundry that smallpox so fatal in England was

entirely harmless in Turkey, that old women

operated every autumn on parties of peoplewho decided to have the disease together (theseparties were common in New England later inthe century), that patients were rarely in bedmore than 2 or 3 days, never had more than 20or 30 pocks on their faces and no scars, andthat there was no example of one who had diedof it, but it was not until April 1721, three yearsafter her return to her home, that under theprotection of the Princess of Wales, later QueenCharlotte, she arranged the first inoculation in

_=_E_ngland that of her own child, little MaryAlice. Clamor rose beyond belief. The clergythundered from the pulpit on the impiety ofthus seeking to take events out of the handsof the Almighty, Edmund Massy of St. Albans,for example, preaching against sinfully en-

deavoring to alter the course of nature by pre-sumptuous interposition which he would leaveto the atheist, the scoffer, the heathen and theunbeliever, and concluding that Satan was thefirst inoculator quoted Job 2:7, " So wentSatan forth from the presence of the Lord andsmote Job with sore boils from the sole of hisfoot unto his crown." The common peoplehooted at Lady Mary in the streets as an un-

natural mother; "Four great physicians were",she says in her memoirs, "deputed to watch theprogress of the experiment with an evident un-willingness to have it succeed, manifesting sucha spirit of rancour and malignity that I neverdared to leave the child with them for one sec-ond lest it should in some secret way sufferfrom their interference." Her opinion of theEnglish medical profession was not exalted forshe "would have written from Turkey to some

of them", as she puts it, "if I knew any thatI thought had virtue enough to destroy sucha considerable branch of their revenue for thegood of mankind."

Remembering the high mortality of smallpox,responsible as it was for 1/10 at least of alldeaths, one cannot perhaps wonder at the feel-ing exhibited against one who was deliberatelyand in the popular opinion unnecessarily aidingin its spread.

When, however, we realize that inoculationhad been practised in India from time im-memorial and in China for hundreds of yearswhere inoculation in the nostrils was the usualpractise—the right side being used for males,the left for females—it does seem rather re-markable that it was unknown in England and

indeed in Europe generally 40 years after ithad been practised in Turkey and it comes tous with rather of a shock to read in the courtrecords of 1710, but 11 years before LadyMary's experiment, that one, Thomas Hawkins,"was paid 8d. for whipping two people who hadye smallpox", whether as a cure or a punish-ment does not appear.

The Royal Society's publications containingthe Timonius & Pylarinus letters were broughtto Boston in 1718 by the Scotch physician, Wil-liam Douglas, who had studied medicine inParis and London and was to be for many yearsthe only graduate in medicine in the Colony.These publications he, a man of ability and in-telligence and a masterful writer but tactless,with strong prejudices and a craving for no-toriety and as someone said of him "alwayspositive and sometimes accurate", lent, prob-ably early in 1721, to one whom in a letter toa friend he calls "a vain, credulous preacher".This preacher was the famous Cotton Mather,himself an occasional contributor to the Trans-actions, who to the indignation of Dr. Douglasalmost at once made use of them.

While little Lady Mary still lay ill in Lon-don, the British fleet from the Barbados broughtsmallpox again to Boston where it spread, evenfor those times, with unexampled rapidity. Be-fore it subsided, a year later, 5,759 of the12,000 inhabitants of Boston had been stricken,844 of whom died, while the surrounding townsand very likely those more distant were in equal-ly bad case. Roxbury, Cambridge and Charles-town were particularly affected, 100 dying inthe latter small settlement alone, and so manywere ill that by Christmas the selectmen or-dered that the sexton do not on any accountwhatsoever, without an order from them, tollabove three bells in one day for the burial ofany person, lest it be a discouragement to thosethat were ill with the smallpox. The prosperityif not the very existence of the Colony wasmost seriously threatened. Mather fresh fromhis reading and mindful of the fact that in 1702several of his children were desperately ill ofthe disease wasted no time. On the fourteenthof May the selectmen instructed by the free-holders had waited on the Governor with therequest that the pest-ridden ship Seahorse besent down to Governors Island. On the twenty-sixth Mather wrote in his diary, "The practiseof conveying smallpox by inoculation has neverbeen used in our nation, but how many livesmight be saved by it if it were practised: Iwill procure a consult of physicians and lay thematter before them." On the sixth of Junehe issued an address calling the attention of thephysicians to the new method embodying in itthe two letters from the Transactions previous-ly referred to. He requested them to meet andconsult whether inoculation should be tried inthe emergency then present. The immediate



result of this address was the demand of Doug-las for the return of his pamphlets and hisrefusal to again lend them for use or compari-son, but its perusal pleased Dr. Zabdiel Boyls-ton, a practitioner of the town and as he latersays in his account of what happened, "I re-solved in my own mind to try the experiment,well remembering the destruction the smallpoxmade in Boston 19 years before and how nar-rowly I escaped with my life. It may makea strange figure in New England especiallywhen one or two have made the discovery howthe practise could produce the plague. As theyalso say that Mather did not make a fair trans-cribe of the observations from the Levant, Iprayed that they might be read but Dr. Doug-las, who owned them, refused to allow this."

It is perhaps no wonder that medical menin general paid little attention to Mather's let-ter. He inextricably mixed piety and medicinein many of his publications, thought diseasethe result of sin, sickness Flagellum Dei propeccato Mundi, advised the scattering of wensby the laying on of a dead hand and eulogizedthe healing virtues of a solution of sowbugs. Hebelieved in witch marks and the application ofthe water ordeal which, as Oliver WendellHolmes puts it, means "Throw your grand-mother into the water, if she has a mole on herarm. If she swims she is a witch and must behanged; if she sinks the Lord have mercy onher soul." But Boylston then 42 years of age,a physician of some prominence, impressed ashe says by what Mather had communicated prob-ably talked the matter over with him and nodoubt personally interviewed the slave Onesi-mus, who had been inoculated in Africa wherehe said it was done to everybody and "nobodydied any more of the smallpox". In fact, asMather himself says in the appendix to VariolaeTriumphatae, he was informed of the wonder-ful new practise by this Garamantic servantsome years before he was "enriched with thecommunications of the learned foreigners, whoseaccounts I found agreed with what I receivedfrom my servant, and thus in Africa where thepoor creatures died like rotten sheep, a mercifulGod has taught them an infallible preservation.'Tis a common practise attended with a constantsuccess. ' '

On the twenty-fourth of June, Mather wroteto Boylston a personal letter in which amongother things he tells him, "If you should thinkit advisable to be proceeded1 in, it may save

many lives that we set great value upon." Twodays later Boylston inoculated his son Thomas,aged 6, and not long afterwards John, aged 13,and seven other persons.

The inspiration for inoculation in Massachu-setts came then from Cotton Mather and fromCotton Mather only, but had Zabdiel Boylstonnot been the man he was, bold, determined,

deterred by no obstacles, even Mather's whole-souled advocacy of the new practice, the prodig-ious energy with which his views were pro-mulgated and the influence of his undoubtedstanding in the community would never havebeen enough to lead so many to submit to theoperation, that Boylston became in a few monthsthe leading inoculator not only in the NewWorld, but in the Old as well. English physi-cians had waited seven years before acting.Boylston, with no knowledge of what was hap-pening there, less than three times as many days.The storm broke; the other physicians wouldhave no part in the matter; the mob, believ-ing that inoculation was simply giving small-pox to those who might otherwise escape, wereroused to fury. A legion of incendiary pam-phlets appeared. Men declared that it was im-pious to interfere between the Creator and hiscreatures, that multiplying smallpox by arti-ficial means was a wilful tampering with death.An anonymous writer did not hesitate to saythat "the ministers have generally revoltedfrom the good old days and set up a way thattheir fathers knew not of". "Most of themare for it which induces me to think that it isfrom the devil." The clergy almost unani-mously supported Boylston. The physicians al-most as unanimously derided his efforts. Therewere times when Boylston was truly in greatperil. Thatcher declares that before the ex-citement subsided men patrolled the town withhalters threatening to hang him to the nearesttree, that he once remained secreted in a "pri-vate place" in his own house for 14 days, whileparties entered by day and by night in searchof him and that even after the madness of themultitude had to some degree subsided he wasforced to visit his patients by night and in dis-guise.

A certain Dr. Dalhonde, who had a consid-erable reputation for his knowledge of small-pox, gave it as his opinion that the practisewas attended with the most pernicious conse-

quences. By order of the selectmen he made a

deposition concerning cases he claimed to haveseen in Italy 25 years before and in Flandersand in Spain, all of which went to prove thatthe practise was nothing better than murder.This deposition, later shown to be false as in-oculation was unknown in those countries atthat time, was by authority published and even

reprinted in England and caused, says Boyls-ton, "a melancholy day to inoculation in its in-fancy and almost set the whole town against meand my methods".

In July Boylston in a long newspaper articledescribes anew the process of inoculation as per-formed in Turkey, regrets that the gentleman,"who only hath by him the letters of the for-eign physician," refused to lend them and thathe can therefore not give them in full, speaks



of the considerable number of Africans in townwho can have no conspiracy or combinationagainst us and who tell us what is done inAfrica and says, "I know not why it is un-lawful to learn of Africans." He pays hisrespects to those physicians "who will neitheruse this certain way to save the people's livesnor let anyone else use it", and inquires whether"one who makes the experiment upon himselfthat thousands of precious lives, if it succeed,be preserved shall deserve to be called a mur-derer and not rather esteemed as a great bene-factor". "I take", says he, "the case to bethis. Almighty God in his great mercy to man-kind has taught us a remedy to be used whenthe dangers of smallpox distress us ; may not aChristian employ this medicine and humblythank God for his good Providence in discov-ering it to a miserable world? I have mademy experiments on old and young, on strongand weak, on male and female, on white andblack and on a greater number than I judgeproper, considering the unaccountable rage ofuncounted people. I have patiently borne theclamour and fear not the rage of the people.I might make answer against the scurrilousthings lately published, but I decline foolishcontentions."

Boylston was called before the selectmen andordered to discontinue the practice, but he wentcalmly on inoculating all who came to him,nor was he estopped when later in the year thephysicians of the town, probably at the instiga-tion of Douglas, agreed as they said, "aftermature deliberation, that inoculation had movedthe death of many persons and had broughtdistemper upon many others which in the endproved deadly to them and that the naturaltendency of infusing such malignant filth intothe mass of the blood is to corrupt and putrifyit". One hears much of "malignant filth"from the antivaccinationists of the present day.By October, 60 persons had passed through hishands, and by November 18, when smallpox was

present in every street and almost in everyhouse, 110. The town was by this time in a

panic. Work was generally suspended. Manyfamilies moved away and the selectmen, whenthey later made up the statistics of the epi-demic, declared that but 700 of the 12,000 in-habitants had proved immune to the disease.Such was smallpox 200 years ago.

Before the epidemic was over Boylston hadinoculated some 247 persons, some say 282, buta few were treated by Doctors Thompson andRoby, who took up the work in Cambridge andCharlestown. Despite the statements of thephysicians but six of Boylston's patients diedand if any one of these particular persons hadrecovered, he thinks it would have been a mira-cle. After reading the detailed histories ofthese six, I am inclined to agree with him.

Into the turmoil of abuse and opposition had

plunged the redoubtable Cotton Mather, thegreat religious leader of America, member ofthe Royal Society, a writer who left 300 booksto his credit, who wrote with equal facility inLatin, Spanish, Greek, Hebrew and French, andwhose English was forceful to a degree. LikeBoylston he well remembered the epidemic of1702 when three of his children suffered fromthe disease and he was in constant dread lestthe same fate should befall the remainder ofhis family. Four times he alone or in conjunc-tion with his father, Increase, and other clergy-men, for the ministers were with him and againstthe physicians almost to a man, four times, hepublished pamphlets in answer to those of theopposition. "To say, as they have said", hewrote in one reply, "that we, the preachers,have been instruments of mischief and troubleboth in church and state from witchcraft to in-oculation is enough to make the most professedlibertine blush." He speaks of papers "prosti-tuted in hellish servitude" and states that "heknows of no nation in the world that has so

openly and assiduously insulted the ministersof their God and been so strenuous in their en-deavors to make them despicable and detestableto their people". But it was in his diary andparticularly after a lighted hand grenade hadbeen thrown into his chamber window and an-other into the sitting room of Boylston that hepoured out his soul. No less than 71 refer-ences to smallpox and the attitude of the peo-ple of Boston appear between May, 1721, andJuly of the following year. Mather was ter-ribly overworked, writing, debating, preaching,continually visiting the sick and called on tooffer prayers for the dying. (He notes that onone day there were no less than 315 names onthe prayer list of the Old North Church.) Hewas harassed over the serious illness of his wife.Four of his children acquired the smallpox,three in the natural way and one by inocula-tion. He was abused and insulted in publicand in private and it is not to be wondered atthat one finds allusions to "people who haveSatan filling their hearts and their tonguesagainst me and my family", to "the cryingwickedness of a town strangely possessed of thedevil", statements that he "should say thatthe town had become almost a hell on earth fullof lies, murders and blasphemies, as far aswishes and speeches can make it," that heshould speak of "the epidemic rage against thatnotable and successful way of saving the peo-ple from the dangers of smallpox" and con-clude that "the miserable town is a dismal pic-ture and emblem of hell itself". He resents,as well he might, the card tied to the grenadethrown into his house which read, "CottonMather, you dog. Damn you! I'll inoculateyou with this with a pox to you", and speaksof "sottish errors, cursed clamors, senseless ig-norance and raging wickedness, of the miser-



able, detestable and abominable town in whichbehold what my glorious Lord has brought meto. I have been guilty of such a crime as this.I have communicated a never failing and mostallowable method of preventing death and othergrievous miseries by a terrible distemper. Isuffer for nothing but instructing your basephysicians how to save many precious lives".But the gallant defender of what he thoughtwas right was to live to see Dr. Douglas, hisprincipal detractor, recant in the epidemic of1728 and even exercise himself the erstwhiledespised practise. His work in the support ofBoylston is now largely forgotten, while everygraduate of a primer of history is taught, asDr. Dexter well says, "to sneer at his memoryas the cruel and credulous apostle of the witch-craft mania and murders".

So many people poured into town seeking in-oculation that the authorities of Boston trans-ferred them all to the Spectacle Island Quaran-tine Station and Charlestown prohibited on pen-alty of a fine the entertainment of any personin order to receive smallpox by inoculation orotherwise. Inoculation was becoming popular.Improved methods were devised and Boylston,who had stood firm against a storm of abuseand bitterness almost unexampled, the press,civil authorities and the united professionagainst him, laughed at, jeered at, his life indanger, began now to be as greatly lauded ashe had been a year before abused. In 1723on the invitation of Dr. Hans Sloan, Presidentof the Royal Society, he went to England, spokebefore both the College of Physicians and theRoyal Society of wThich latter body he was in1726 elected a member. In eight months hehad inoculated one third as many persons as

were subjected to the operation in all Englandin the seven years 1721-1728. While in Lon-don he published his Historical Account of theSmallpox Inoculation in New England, in whichhe speaks of the cloud of opponents at the be-ginning "yet finding my account in the encour-

agement of good ministers I resolved to carryit on".

The death rate after inoculation in this 1721epidemic had been 2.4%, after natural small-pox 14.8%.

In 1728 smallpox brought in by a vessel fromIreland was kept in a few families until Marchof the next year, when the "watches were re-

moved" and it had free course with the resultthat in 1729 the General Court convened againin Cambridge and, by 1730, when the epidemicceased, there had been 4,000 cases and 500deaths. Four hundred persons were inoculatedat this time, of whom 12 died, 3%, while 13%of those taking the disease in the natural waylost their lives. The Town Council had by thistime modified its views and publicly advised in-oculation, and Dr. Douglas in a most ungraci-

ous letter accepted what he had so bitterlyfought seven years before. He did himself nocredit by writing—"How mean or rash soeverthe beginning of inoculation may have been, ifmany years practised by old women only andneglected by the sons of art in Turkey; if inanother part of the world a person of no lit-erature, of habitual rashness from the thirdhand hearing of an over credulous person, firstattempted it indifferently to all who would payfor it, without regard to age, sex, constitutionor other circumstances and cautions, whichtryals of such consequences require, as it is oneof the inconveniences of human life that all theworld over ignorance assurance and rashnesspushes on some to attempt without fear or dis-cression what would make the most exquisiteartist tremble to touch, nevertheless if in theevent by repeated experiments it ought to proveuseful, it ought to be embraced. And the Rev.Dr. Cotton Mather surreptitiously without theknowledge of his informer, himself, that hemight have the honor of a new fangled noticesets an undaunted operator to work and in thiscountry about 290 were inoculated." Yet thisrecantation ended the opposition on the part ofphysicians. Inoculation became an acceptedprocedure and with each recurring epidemicmore and more submitted to it until in 1792but 232 of the 8,346 persons who had the small-pox acquired it in the so-called natural way.

In 1751, brought in as usual by an infectedship, smallpox attacked but 124 individuals ofwhom 22 died. It spread slowly until May ofthe next year, but in December was again en-

tirely out of control. Fences were built acrossstreets near infected houses, flags of warninghung out, the tolling of bells at funerals sup-pressed, burials made at night, town meetingsheld in the open. Two thousand one hundredand twenty-four persons were inoculated, ofwhom 30 died—one in 70. Five thousand fivehundred and forty-five acquired it in the nat-ural way, 539 died—one in 11.

In 1764 the election sermon was omitted onaccount of the prevalence of the disease. Infive weeks, 4,977 persons were inoculated, 46died—one in 109. Six hundred and sixty-ninetook it in the natural way, of whom 124 died—one in 5. Inoculation hospitals were now es-tablished at Point Shirley and Castle William.The hospital at the latter place was eventuallymoved to Noddles Island and Dr. Gelston, whohad successfully treated 80 patients in a hos-pital on Martha's Vineyard, was placed in resi-dence and Doctors Perkins, Whitworth, Lloydand Warren were on call. It had become evi-dent that for obvious reasons inoculation couldnot safely be practised in the midst of thicklysettled communities.

In 1769 and again in 1773 new outbreakscaused the opening of more hospitals, one in



New Boston, the other near Marblehead. Allthese hospitals were chartered by the Governor.

In 1775, during the British occupation, small-pox prevailed both within and without thetown and Washington's army was so seriouslyaffected that wholesale inoculation was resortedto; 4,988 men were treated, 18 died.

In 1776 an act was passed permitting theerection of inoculation hospitals by the coun-

ties of the state and inoculation was forbiddenexcept at such licensed hospitals. It was alsoprovided that on the outbreak of smallpox sucha hospital must be opened and to it all sickand infected persons removed, unless so ill thatsuch removal would be dangerous, while anyhouseholder who failed to give notice of a casein his family was to be fined not less than tenpounds and no more than thirty.

During 1778, 2,121 inoculations were per-formed with 29 deaths, 9% ; 122 other cases wererecorded with 42 deaths, 34%.

In 1792, smallpox being brought in by a ves-sel from Ireland, practically the whole townwas inoculated within a few days. The desir-ability of this procedure was now almost uni-versally accepted. There were, however, atleast as late as 1798 a few conscientious ob-jectors still believing that inoculation would befollowed by divine punishment. So common

was the procedure, so freely did the inoculatedmingle with the general public, that smallpoxwas being kept alive by the very means usedto modify it and was indeed the reigning dis-ease until the end of the century, it being esti-mated that in the years between 1700 and 1800in Europe alone, whether acquired by inocula-tion or in the so-called natural way, it was re-

sponsible for no less than 60,000,000 deaths.The 1792 legislature recognized the dangers

of inoculation as then practised and redraftingthe act of 1776 provided that on the outbreakof smallpox all infected persons must be re-moved to a hospital devoted to their care, re-

pealed the rather drastic fine of ten pounds andthirty pounds for non-notification, forbade on

penalty of $200 the inoculation of any personor one's self or the allowance of one's self to beinoculated save in such licensed hospital andordered a display of red flags to warn travelers.Householders, physicians and others, who neg-lected to notify the authorities of smallpox ontheir premises were to be fined $100 and any-'one violating any of these provisions was as-sessed a similar sum.

In 1797 it was in addition provided that if a

person could for any reason not be moved to a

hospital, provision must be made for him inthe house in which he might be, persons in theneighborhood to be removed by the Board ofHealth. The Board of Health might also turnback travelers, prevent them from moving with-out a license, make them return to the place

from whence they came and fine them for dis-obedience not more than $100. It was alsospecifically provided that under order of a jus-tice of the peace such Board might secure bag-gage, clothing, etc., supposed to be infected,might break open any house or shop, might re-

quire any person to render aid and that suchperson must serve or be fined $10.

In the one hundred years before inoculationthere had been 12 distinct epidemics of small-pox, in the 80 years during which inoculationwas used eight. In the 129 years since the in-troduction of vaccination two general outbreakshave occurred and two only, and yet there arethose who say that vaccination is of no valueand a gentleman now or formerly the Presidentof the American Medical Liberty League writesto me in this year of grace to say that small-pox is not even contagious.

In 1799 Dr. Benjamin Waterhouse of Cam-bridge received from Dr. Lettsom of London acopy of Edward Jenner 's Inquiry into theCauses and Effects of the Variolae Vaccinae or

Cowpox published the year before. Water-house then Hersey Professor of Theory andPractise in the Medical School was probably thebest educated physician in the State at thattime, having spent seven years in study in Lon-don, Edinburgh and Leyden. Dressing alwaysin formal broadcloth and carrying a gold-headed cane, somewhat condescending to hisfellow practitioners whose knowledge he held inlittle esteem, contentious to a fault, with man-ners by no means agreeable, he was always inhot water and was eventually deprived of hisprofessorship at the demand of all the otherteachers in the school. A Jeffersonian demo-crat when all his associates were Federalists, a

member of the unpopular Society of Friends, a

person almost universally disliked, this man

of action overcoming all handicaps was never-theless able by hard work, persistence and thebrilliancy of his intellect to place vaccinationon a firm basis in this country for which workhe was honored by scientific societies both hereand abroad and by the London Medical So-ciety voted the title of the American Jenner.He, like Boylston before him, lost no time inplacing himself on record for on March 12 ofthe same year, 1799, he published in the Colum-bian Sentinel a short account of the new in-oculation method under the title of "Some-thing Curious in the Medical Line. " As he him-self says, this attracted but little attention. "Afew received it, some doubted it, some observedthat wise and prudent conduct which allowsthem to condemn or applaud *as the event mightprove, the greater number absolutely ridiculedit." Later in the year, before a meeting of theAmerican Academy of Arts and Sciences heread a paper based on Jenner 's pamphlet andquoted as much as he could remember of ' ' Pear-



son's Inquiry into the History of Cowpox", abook which he had loaned and lost. At thenext quarterly meeting he read extracts fromWoodville's book just received. Woodvillemade a bad blunder when he vaccinated a num-ber of persons and then in four to five days in-oculated them with smallpox virus, thus pro-ducing both vaccinia and smallpox. This con-taminated virus used as cowpox virus spreadsmallpox far and wide and owing to Wood-ville's prominence in the medical world came

near to shipwrecking the great discovery.Waterhouse finding, as he says, the evidence

in support of the efficacy of vaccination toogreat to be resisted by any mind not pervertedby prejudice, tried to obtain the virus in anactive state. After several fruitless attemptshe at length received some from Dr. Haygarthof Bath and on July 8, 1800 vaccinated his sonDaniel, aged five. The course of the diseasebeing typical, he vaccinated another son, agedthree, with virus from the arm of the first, thena servant boy of twelve with the imported mate-rial and finally an infant of one with its nurse

both from the arm of the three year old. Beit noted that he as well as both Lady Montagueand Boylston before him, only after he had con-vinced himself by experiments on his own fam-ily attempted to induce other people to followhis example. As Waterhouse invited some ofthe physicians to see the boy the first of a longseries of perversions of fact began in a reportindustriously circulated that one of his chil-dren was so ill that a consultation of severalmembers of the faculty was required. Manypersons now applied to him begging for vac-

cination, but he refused to proceed until hehad proved that the new agent really gave theprotection that he was convinced it did. Hetherefore wrote to Dr. Aspinwall, a specialistin inoculation, who was in charge of the small-pox hospital in Brookline in part as follows :

"I have collected everything that has beenprinted respecting this distemper cowpoxand have been so thoroughly convinced ofits importance to humanity that I have pro-cured some of the vaccine matter and there-with inoculated seven members of my fam-ily. My desire is to confirm the doctrineby having some of them inoculated by you.I can obtain variolous matter and inocu-late them privately, but I wish to do it inthe most open public way possible. As Ihave imported a new distemper I conceivethe public have a right to know exactlyevery step I take in it. I write there-fore to inquire whether you will on philan-thropic principles try the experiment of in-oculating some of my children who haveundergone the cowpox. If you accede tomy proposal I shall consider it an experi-ment in which we have co-operated for thegood of our fellow citizens."

Dr. Aspinwall, whose living it must be remem-bered depended on the prevalence of smallpox,at once consented and two months after vac-cination the children were sent to him, exposedto the infection of smallpox in the hospital andinoculated with fresh matter taken from a pa-tient. Subjected to this most crucial test withabsolute resistance to the disease Waterhousewas justified in saying as he did, "One,fact insuch cases is worth a thousand arguments."Of Aspinwall he said afterwards, "He took allthose of my family whom I had vaccinated intohis smallpox hospital and there tested them tohis satisfaction and then said to me and toothers, 'This is no sham. As a man of human-ity I rejoice in it though it will take from mea handsome annual income.' " There wastrouble with inert vaccine and it was necessaryto obtain new supplies; there was troublewith vaccination improperly done or doneby incompetent persons; vaccine contami-nated with smallpox virus came into the coun-

try as Dr. A. K. Stone has pointed out. Theother physicians so disliked Waterhouse thatthey were prejudiced against anything that headvocated and it was nearly two years afterPresident Jefferson wrote to him speaking ofhis firmness and perseverance maintainedagainst the persecution of his enemies, religious,,political and professional that he was able topersuade the Board of Health to endorse theexperiment which was to settle once and for allthe question of the value of vaccination as a

preventive of smallpox.Undismayed by the rejecting in 1800 of a

similar request made by James Jackson who hadstudied under Woodville and had supportedhim (Waterhouse) in his work as a vaccinator,he arranged in August 1802 for the admissionof 19 children vaccinated in the preceding No-vember to the smallpox hospital at Noddles Is-land, where they remained for twenty days con-

stantly exposed to infection and were one andall inoculated with smallpox virus. Not one ofthese children developed the disease, but two un-vaccinated children admitted at the same timeand also inoculated showed the typical variolouspustules in profusion. Matter was then takenfrom these children and the 19 re-inoculated,again with no result. There was nothing moreto be said. The value of vaccination was con-clusively proved. All these proceedings wereunder the supervision of a committee of physi-cians consisting of James Lloyd, Samuel Dan-forth, Isaac Rand, John Jeffries, John Warrenand Charles Jarvis. Waterhouse's memorial tothe Board of Health is a model of persuasiveargument. He speaks of vaccination as the mostimportant discovery since the world began, itbeing no less than the extermination of themost loathsome and widely wasting pestilencethat Providence ever permitted to affect the hu-man race. He gives the story of Jenner in de-



tail, derides those wise sceptics on account ofthe so-called lowly origin of the practise andends by telling the Board that the propositionis brought forward by no cringing solicitor butby a man conscious of his duty and zealous inproducing a public benefit of more value toBoston than all the riches contained within itslimits. "You are not asked", said he, "toaccept blindly but to cause a rigid inquiry tobe made as to the truth of my assertions andhave them subjected to the test of a public ex-

periment by a set of men whose knowledge, ageand virtues will create confidence and inspiresatisfaction." And this was the man whoamong other things had been publicly de-nounced as "an old drone enjoying the sweetsof the beehive without assisting in the laboror paying for the privilege of humming andbuzzing".

Verily the path of those who have tried tobanish smallpox from Massachusetts has beena stony one and the attitude of our professiontoward these men and women has not alwaysbeen one of which to be particularly proud.Indifference, ridicule and opposition hinderedthe few whose clearer vision and greater cour-

age led them to experiment with the new meth-ods and as we shall see later overconfidence anda desire to save themselves and their patientsfrom trouble set back the clock, undid muchof the work already accomplished and allowedthe almost banished disease to return and plaguethe community for a long period of years. Itwas eight years after the first vaccination andsix after the Noddles Island experiment that acommittee of the Massachusetts Medical So-ciety reported to the annual meeting that per-sons who undergo the cowpox are thereby ren-dered as incapable of being affected by the virusof smallpox as if they had undergone the lat-ter disease.

In 1809 the town of Milton repeated the Nod-dles Island experiment with identical results andin that year the Legislature ordered that everytown, district and plantation where no board ofhealth existed should choose three or more per-sons to supervise the inoculation of the inhabi-tants with cowpox, in 1816 that a smallpox pa-tient might be removed from a jail to a hospitalunder guard and in 1827 that a physician visit-ing a patient having smallpox must give noticeto the authorities.

Vaccination had supplanted inoculation.Smallpox had disappeared as a major disease.There had been no epidemic since 1792 and be-tween 1811 and 1837 there were but 39 deathsfrom the disease in Boston. And then the phy-sicians as confident as they had been hesitant in1800 appear in the guise of a committee of theMassachusetts Medical Society before the JointCommittee on the Judiciary complaining thatthe laws passed in 1792 and 1797 were useless,vexatious and burdensome, that personal rights

were interfered with, individuals and the publicsubjected to unnecessary expense, deprived ofthe comforts of home by removal to public hos-pitals and that physicians were now compelled toreport these cases to the proper authorities andthus subject their patients to the provisions ofsevere and as they believed unnecessary laws.This petition was signed by twenty prominentpersons, thirteen of whom were physicians,among them John C. Warren and James Jack-son. The result was most disastrous, for theLegislature at its next session repealed practi-cally all laws for the control of smallpox. Im-mediate transfer to a hospital was no longer re-

quired, isolation of those not so transferred no

longer compulsory, flags were no longer to bedisplayed, travelers turned back, nor physiciansobliged to report cases, and the whole systemof fines was abolished. But, as Dr. Burrage notesin his history of the Society, the Committeeproud of its work reported back to the Council,expressed its confidence in vaccination and theCouncil voted that this Society should furnishfree vaccine to all Fellows who applied for it,but that it was the duty of every Fellow to vac-cinate gratuitously on each Monday of the monthof June annually all persons who might come tothem and be unable to pay the usual fee. Thisvote has never been repealed and this duty is, Imust assume, still annually performed.

In 1839 and 1840 physicians were again or-dered to report cases and fines for neglect were

again legal, but with these exceptions no furtherchanges in the laws were made until 1855, seven-teen years later.

Following this legislative action of 1838 small-pox at once increased, there being in Bostonalone 1,032 deaths in those 17 years, in contrastto the 39 of the previous 26. This could not beallowed to continue and in 1855 the legislatureenacted laws much more drastic than those of1792 thrown into the discard 17 years before.The managers of manufacturing companies, thesuperintendents of almshouses, state schools,lunatic hospitals, masters of houses of correction,jailers, prison helpers and the heads of all otherinstitutions supported in whole or in part by theState were ordered to immediately cause to bevaccinated all inmates and all entrants. Boardsof health were given authority at any time tovaccinate all the inhabitants of any town. Aparent or guardian who neglected to cause hischild or ward to be vaccinated before he attainedthe age of two, unless he had the certificate ofa physician that said child was unfit, was toforfeit $5 for every year during which suchneglect continued and the school committees oftowns and cities were ordered to allow no un-vaccinated child to be admitted to or connectedwith the public schools. There was, however,no efficient enforcement machinery in existence.The State Board of Health was not formed until1869, 14 years later, although a bill for its es-tablishment had been introduced as early as



1849, and throughout the fifties and sixties theyearly deaths from smallpox were not materiallydiminished, the average for the next 18 yearsstanding at 150 culminating in the general epi-demic of 1872-3, incidentally the first one for80 years with its 1,697 fatal cases, 1,040 of whichwere in Boston. That epidemic proved to be a

disguised blessing, for vaccination again becamepopular, the vaccination laws were more rigor-ously enforced and since that date, with the ex-

ception of the state-wide outbreak in 1901-1902with its 3,509 cases and 381 deaths, there hasbeen no year in which the fatal cases have ex-ceeded 100, and there have been a number ofyears with no deaths, the total fatalities in the59 years excluding the outbreak above mentionedbeing but 419, 26 of which have occurred since1913.

The 1855 laws were somewhat modified in1884 and again in 1894. With a physician's cer-tificate an unvaccinated child was allowed toattend school. Per contra children from homeswhere contagious diseases were present were rig-idly excluded. Employees in manufacturing es-tablishments and inmates of institutions were tobe vaccinated as all other persons only on ordersof the Boards of Health. The provision whichexempted from the school law the unvaccinatedchild with the physician's certificate was re-pealed in 1902 to be reënacted in 1908 in whichlatter year the infant vaccination law was wipedfrom the slate, despite the strong opposition ofDr. George W. Gay, at that time President ofthis Society.

For more than fifty years annual attacks havebeen made by the anti-vaccinationists, conscien-tious objectors and Christian Scientists on theschool law, fortunately so far without avail. Thelaw has in fact been strengthened by providingthat the physician giving an exemption certifi-cate should at least have seen the patient, whichin the past had not always been the case.

Smallpox has become instead of the mostdreaded and virulent of diseases one compara-tively rare in this State, one not too difficult tocontrol when it does occur, one absolutely pre-ventable were vaccination universal, yet a per-sistent, well-organized, well-financed oppositiontries year after year to throw open the doors to

the enemy always ready to enter and in due timebring us to the condition of our forefathers,smallpox always present with a serious epidemicevery ten to twenty years.

In no state in the Union has more, not evenso much, been done to control, mitigate and final-ly almost suppress the disease so easily robbed ofits terrors, so easily banished, but so ignorantlyallowed to run its course almost unchecked in a

large portion of the country. It is a melan-choly fact that the countrymen of Jenner,Boylston, Waterhouse and Lady Montague lagso far behind those of other races and othercountries in these controlling efforts. It isshameful to read in the Epidemiologie Intelli-gence of the League of Nations that while Indiareported 148,199 cases of smallpox in 1929, theUnited States 41,705 and England 10,967 noother country reported over 1,000; and stillmore so to learn from the same source that in1930 there were 46,712 cases reported in theUnited States, 11,839 in England and Wales andbut 268 in all continental Europe exclusive ofSpain, Portugal, Greece and Russia. Nor canwe read with satisfaction in this same reportthat the efficacy of smallpox vaccination in pre-venting and limiting outbreaks is clearly shownby the progressive decline or even the eradica-tion of smallpox in countries of central and east-ern Europe where vaccination has become gen-eral, while the disease persists or even spreadsin England and the United States where vacci-nation is not in fact universally compulsory. Thedeath rate is at present in most countries low,but its virulence may at any time increase asit has repeatedly done in recent outbreaks inthe middle west. Forty-eight thousand died ofsmallpox in India in 1930, nobody knows howmany in China, and while virulent smallpoxexists anywhere in the world an unvaccinatedcommunity is always in danger.

It is only by the most persistent efforts thatour law requiring the vaccination of publicschool children has been kept in the statutes andmore or less persistent efforts kept up for now17 years have failed to extend the aegis of com-pulsory vaccination over those attending ourprivate and parochial schools. Some day it willcome. When, I do not know.



SMALLPOX - Massachusetts Medical Society

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