And Figure 5 shows the importance in English of the introduction of inoculation in 1721-5: the introduction of the Suttonian system in the late 1760s, and to a lesser extent the controversy over how to deal with smallpox in large towns in the late 1770s.

1768 is the year in which more was published on inoculation, and in more languages, than in any other single year in the eighteenth century, and the impact of the relative ease and simplicity of the Suttonian system, as well as the impetus afforded to it by Dimsdale’s publication and activities, are clearly apparent [39] . These titles are set out in Table 1. [40]

Table 1: 1768 Publications on Smallpox

Sources: Krünitz, Verzeichnis der vornehmsten Schriften von den Kinderpocken und deren Einpfropfung, (Leipzig, 1768); F. Olberg, Beiträge zur Litteratur der Blattern und deren Einimpfung, vom Jahre 1768 bis 1790 (Halle, 1791); A.C. Klebs, Bibliography of variolation (Yale, 1913), and internet search.

The titles for 1768 identified to date number 73, of which 48 relating to Robert Sutton’s procedure (author’s name underlined) appeared in seven languages − fifteen in English, ten in French, nine in German, six in Dutch, three each in Italian and Latin and two in Russian. The influence of Suttonian inoculation may be understated as it has not been possible to inspect all the titles, and in addition authors such as Paulet and Gontard who advocated different approaches could not have been unaware of it. Some titles were published in one country and language about another, for example Von Schlözer’s German language piece about Russia, and others in translations, for instance Maty from Gatti’s French in London and Tiemann and Leuthner from Dimsdale’s English in Leipzig and Munich, but most vernacular titles are in the language of the place where they were published. And nearly all were private initiatives by authors, translators and publishers.

The 1768 list fits some known trends in the spread of information and the development of publishing in the second half of the eighteenth century. Medicine, mathematics and science as a category rose as a proportion of the total output of English-language books from 1763 to 1783 reflecting an increasing output of monographs, such as books on inoculation, rather than periodicals, which only claimed an increasing share of the market towards the close of the century. Latin still clung to its role as a ‘lingua franca’ and was indeed in evidence, but apart from its use for all the theses, was only present in terms of the inoculation debate in the publications of Maximilian Locher at Vienna. The replacement of Latin by the vernacular might suggest that knowledge was being directed into or emerging in unconnected linguistic pools, but this was not so, for translation was stepping in to reinforce communication between them, and in the case of several of the books on inoculation − notably Schinz’s Zürich German language version [42] of Dimsdale, for whose writing he nevertheless professed profound admiration − the translation was augmented by the translator’s sometimes decided contrary views, based on his own experience. And books on inoculation, while primarily of interest to professionals, were early contributors to the vogue for vulgarisation because the operation was often performed by all manner of unqualified people. Another trend illustrated by the translations from English into other languages is that of a growing interest in English ideas, sometimes characterised as ‘Anglomania’, although this is only one feature of the nascent contribution in the later eighteenth century of the vernacular − allied to print capitalism − to the growth of nationalism [43] .

This flood tide of essentially practical titles was identified and analysed by the distinguished Swiss physician Arnold Klebs (1870-1943) much of whose career was spent in the United States, where he rose to prominence in the campaign against tuberculosis. He retired to Switzerland in 1910: made a collection of eighteenth-century inoculation titles, which he bequeathed to Yale University [44] , and published two overlapping articles – one in English [45] and the other in German [46] – constituting an analysis of inoculation in the West. As a physician and researcher himself he had a sharp eye for the most impressive operators, such as the Genevan Théodore Tronchin (1709-81): innovators, such as Gatti, and physicians who were most effective as writers, such as the Vaudois (Swiss) Samuel-Auguste Tissot 1729-97), and he was at pains to account for the advances and setbacks of inoculation throughout the West by familiarising himself with the contents of his collection of titles through a network of correspondents and translators. Klebs concluded that inoculation was slowly gaining ground and that until the advent of Jennerian vaccination at the close of the century it bid fair to establish itself as the remedy of choice [47] . Since he wrote, much work on what occurred in many countries and languages has been published, shedding more light on and generally in support his conclusions. What follows here is not an exercise intended to catalogue the experience of inoculation country by country and empire by empire but an attempt to highlight those issues and personalities which and who loomed largest to contemporaries and, through them, trace the influence and impact of Suttonian inoculation during and after its initial launch.

The Franche Comté is a former Habsburg possession incorporated into France in the course of the state’s drive to establish a frontier to the south-east on the Jura range. In Besançon in 1765, just when inoculation was beginning to make some impact, a death resulted – apparently from inoculation [48] . The most successful inoculators would feature compelling statistics designed to show the impressive number of successful inoculations by reference to an insignificant number of deaths which had occurred. The ratio was a measure of success. There were also well publicised failures which were attributed to some or other mistake which had been made, or to some unusual circumstance, and supporters of inoculation turned such events into arguments in support of their case. The deaths must very often have been the consequence of some pre-existing ill health or weakness which gave rise to a fatal outcome, or at least aggravated an inoculation which had given rise to unusually serious symptoms, such as very large numbers of pocks. However a feature of pre-Suttonian inoculation was that deaths following inoculation – often of prominent patients – would be given local publicity and would stem inoculation initiatives in an area sometimes for years. In the Besançon case – very unusually – it had the opposite effect. A provincial physician, Jean-François-Xavier Girod (1735-83), had been recognised by the relevant medical official as being an excellent candidate for the post bearing responsibility for dealing with epidemics in the Province [49] , and it was Dr. Girod who was so challenged by the setback, but also so convinced by the potential and worth of inoculation, that he set to work to generalise it so as to afford protection against smallpox to as many of the inhabitants as he could. He was impressed by inoculation as carried out in England at the time and travelled there on two occasions − the second being to ascertain whether there was any truth in a criticism that the system as practiced there was causing fatalities [50] . He concluded that there was not, and succeeded over several years, by means of inspiring trust in the population and by organising a sufficient number of dedicated operators, in coming as close as anyone at that time to comprehensive coverage. The State chipped in with annual grants for the campaign’s expenses and there was recognition for Girod at the highest level. Although he was himself averse to reward he accepted an order and an honorary appointment as a royal physician and was regarded with affection by the King. Closer to home he declined a substantial recompense offered him for inoculating members of the Chalon family, but accepted in lieu their feudal rights in local forests, which he transmitted to his home village, Mignovillard. And at his death he was eulogised in the forum of the nation’s foremost medical institution [51] . Girod’s successful career in inoculation at a local level was unmatched in European terms so neatly did his selfless onset dovetail with the apparatus of government, within which it flourished and was sustained. Its singularity was, however, something of an exception proving a rule. The reception of inoculation in France was never straightforward and the operation suffered repeated setbacks there up to the end of the century. Nevertheless the Franche Comté experience provides a demonstration of the elements – from base to apex – concerned with the reception and the implementation of inoculation – the head of state, the Court, the Ministry, the medical authority, and at de-centralised level the Governor, his medical advisers and administration, the rank and file doctors and operators, and the people themselves.

Another operator, the little known Thomas Houlston, (1745-1787), who was an English medical graduate from Leiden − not to be confused with Robert Houlton, the Suttons’ publicist − was remarkably influential in the introduction of the system to several parts of mainland Europe. He inoculated at Vienna and Linz in 1768, [52] coinciding with Ingen Housz, before moving on to the Veneto and Naples, where he arranged for the translation of Dimsdale’s ‘The Present Method …’ and the publication of an Italian edition, dedicated to Grand Duke Leopold of Tuscany, himself shortly to be inoculated by Ingen Housz, [53] which included some of Houlston’s own case notes.

In the summer of 1770 he moved to Montpellier, which was in the throes of a smallpox epidemic, and where − in spite of several prominent old-style inoculations − the operation had never caught on. There he met another young Englishman − Dr. Batt, shortly to gain his medical degree at the University − and with him conducted some inoculations locally. The subsequent campaign of Suttonian inoculation, which spread westward to Béziers, is described in Foucquet’s 1772 publication, which contained a translation of Dimsdale, but also included a review of the contemporary European inoculation literature demonstrating the extent to which it was it was dominated by Sutton as represented by Dimsdale, and also an account of how it was able to overcome the long sequence of local false starts which was such a feature of the old method. [54] In fact the exercise may have been yet another short-lived one as both Houlston and Batt appear to have left for home by 1773 and I do not know whether or to what extent the Montpellier campaign persisted, but Foucquet’s account remains a telling exposé of how the system took hold there.

As heads of state Empresses Catherine and Maria Theresa and Kings Frederick II (1712-1786) and George III acted within specific settings and adopted strategies calculated to support foreign policy objectives as well as domestic ones. Inoculation, although only ranking as a secondary issue, impinged on both the ever present international diplomatic merry-go-round and the domestic scene. And it recommended itself in various ways to these heads of state as a sphere of influence appropriate to their own personal opinions and circumstances. Catherine had felt humiliated and anguished at having to avoid the Court at St. Petersburg so as to place herself and her heir out of harm’s way when she knew that there was a remedy available which would obviate the need for recourse to such panicky and inconvenient conduct [55] . She not only had the conventional diplomatic network to hand with which to secure the best means of inoculation available abroad, but she also disposed of close counsel in the person of Nikita Panin (1718-83) her first minister, bereft of his fiancée – a victim of smallpox at Court – and trusted and knowledgeable advisers in Ivan Betskoy (1704-95) and Alexander Cherkasov (1728-88) and also a domestic medical service manned by many capable physicians and administrators. And her reach within the Russian empire was backed by her conviction that in so extensive a realm only autocracy could perform with the requisite activity and uniformity. [56] . It was Catherine’s own decision to set a signal personal example to invigorate inoculation in her Empire and the newly minted Suttonian inoculation lay to hand as the obvious tool. She used it with a will. It was not as if the Russian empire lacked eminently qualified and practised inoculators, but these men did not have the international prestige associated with the Suttonian method. The events surrounding her inoculation and that of her son-and-heir Paul were fraught and dramatic but she ensured that the achievement was magnificently publicised, celebrated and broadcast. The trial runs involving cadets had confused her inoculator, but such was her understanding of the procedure that she was able to overcome Dimsdale’s scruples and direct him to proceed in spite of everything. She fully deserved her triumph and made the most of it. Concurrently Ingen Housz had navigated not dissimilar anxieties and scepticism. The two inoculators never forgot their shared celebrity and remained friends for life, but Ingen Housz’s subsequent career was as a pioneering scientist and not – as Dimsdale’s – as a prominent protagonist of inoculation. He never published on the subject, in spite of having considered doing so on at least one occasion [57] [58] .

More than in Catherine’s case, Maria Theresa was stimulated by her own and her family’s bitter experience of smallpox [59] . As had Catherine, she made the decision, which in her situation was less easy because obstructed implacably by Anton de Haen (1704-76), at the summit of European medical repute, who in the tradition of his teacher Boerhaave (1668-1738) despised inoculation as an unaccountable and unscientific folk practice, not unrelated to witchcraft. De Haen believed in providing smallpox patients with the best treatment which could be offered in the event that the disease had not been avoided. Maria Theresa’s approach to the scene of Suttonian inoculation involved an official one through diplomacy and this it was − as we have seen − which stimulated the intervention of Pringle in his capacity as George III’s foremost, though by no means sole adviser, and the appointment to Vienna of Ingen Housz. In contrast to this, the appointment of a person to introduce Suttonian inoculation into Russia was − also as noted − made by the Russian Ambassador in London backed by a direct emissary from St. Petersburg [60] .

Closely concerned with the events of 1768 was Frederick II of Prussia. As his own first minister and as a man deeply interested in medicine, he had a decided view and wrote personally and reproachfully to Catherine, in response to her relation to him of the great success of her own inoculation, about what he considered to be the unjustifiable risk which she had taken [61] . Russian and British interest and diplomacy hoped that he would take a leaf from her book, but he appears to have summarily rejected the approach [62] . However a few years later Frederick took Suttonian inoculation on board from the physician William Baylies (1724-87), who had left England under a cloud but who was a capable operator and exponent of the method and who oversaw its initiation in Prussia [63] .

Elsewhere in Germany, with so many states to reckon with, it is not easy to summarise, but the substantial and ambitious campaign proposals of Johann Christian Wilhelm Junker (1761-1800) in the 1790s stand out in a prospect revealing rather less take-up of inoculation than in France [64] .

In France the introduction of Suttonian inoculation by a head of state was similarly delayed and only provoked by the catastrophe of Louis XV’s death from smallpox in 1774, immediately following which his successor Louis XVI was inoculated [65] . The French Royal inoculation was not, however, a signal of wholesale conversion to the method, but just one of a series of successes, which were often followed by further uncertainty and hesitation. It was only at the end of the century that a physician could publish his view that Suttonian inoculation had prevailed at last, after so much ebb and flow [66] .

In a Europe of many states there were also cases of heads of state undergoing inoculation with little or no effect on wider dissemination [67] . There had also been figurehead inoculations before 1768, but which had not provided anything like the spectacular impetus of the Russian and Austrian imperial ventures [68] .

Two features of inoculation campaigns emerged before 1768 and were re-emphasised in that year. The first was the practice of experiment on convenient controlled populations [69] , such as condemned prisoners, as in 1721 in London [70] , and most usually orphans or cadets. Ingen Housz inoculated orphans at the Foundling Hospital in London [71] and a specially assembled group of children in Vienna [72] while Dimsdale was provided with cadets in St. Petersburg, who, although reportedly indignant, had no choice in the matter [73] . Such inoculations were deemed to be essential precursors of the main event, and problems encountered on the way had to be resolved or rationalised, often in haste, before they took place.

The second feature of inoculation campaigns was the hospital. The London smallpox hospital at St. Pancras − half for smallpox patients and half for inoculation − was built by charitable subscription in 1746 and represented the latest purpose-built version of a series of establishments which had migrated around North London over the years [74] . It operated in an organised though limited way – relatively small numbers of patients for inoculation were involved − but its reputation attracted visits from physicians from other countries considering how best to exploit inoculation back home. A hospital came to be seen as central to any state inoculation campaign. In 1767 a large unused mansion was acquired to serve as an inoculation hospital prior to the St. Petersburg Imperial inoculation and was the first of several throughout Russia [75] , even including a purpose-built Siberian version near Irkutsk.

Signal adoption of Suttonian inoculation by a head of state was one thing, but the extent of its use was another. There were cases of landowners arranging for the inoculation of large households, estates or even entire villages [76] , but not many, and it seems that the kind of extension to all classes which had occurred earlier in Scotland and, following Daniel Sutton’s breakthrough, in England too, did not follow in European Russia. Indeed it is possible that smallpox posed less of a threat there than in the rest of the West. [77] But in another theatre an inoculation campaign was developed which was quite as exemplary and inclusive as was Girod’s in the Franche Comté. That Siberian peoples were particularly badly affected by epidemics was understood, and the Government’s reach and authority caused the organised inoculation of very large numbers of people, some of whom had themselves adopted inoculation as a folk practice [78] . The inoculation of Catherine II, her heir Grand Duke Paul and large numbers of the nobility in 1768/9 in St. Petersburg and Moscow led to the establishment of a government-supported campaign built on the Empress’s exploit, [79] backed by rules and regulations administered by the state, as well as government publicity of many kinds including the publication of Dimsdale’s book in Russian and another simplified version of his method adapted to Russian circumstances. [80] The large hospital which was established in St. Petersburg was followed by others elsewhere in the City as well as in Moscow and other urban centres, and - in time - beyond the Urals, paying special attention to native peoples, [81] this last as exemplified by the carefully planned hospital north of Irkutsk (Figure 6) which played its part in the regional campaign which achieved 15,380 inoculations between 1773 and 1779. [82] A. N. Radishchev, on his way to exile for nine years at Ilimsk, well to the north of Irkutsk, testified in a letter to Count A. R. Vorontsov from Tobolsk in July 1791 to the potential effectiveness of Russian inoculation campaigns when he wrote that ‘the grave can be closed to smallpox [by inoculation]’ in the context of an epidemic of measles which had given rise to many fatalities among children. Empress Catherine, twenty years before, had claimed that greater progress with inoculation was being made in Russia than in any other country. [83] The special hospital set up north of Irkutsk was designed to receive and process nomadic people undergoing inoculation [84] . The Governor was responsible for the campaign and was served by Russian and German administrators and physicians [85] .

Figure 6: Inoculation hospital on the Angara River 180 versts from Irkutsk. SUB Göttingen, Cod. Ms. Asch 263

The limitations of the London Hospital came to be seriously debated in the 1770s. In 1776 John Watkinson (fl.1777) published a case in support of a campaign for inoculating the poor in their homes [86] . He drew on other European opinion and revealed in so doing that there was widespread support for his case and that the embargo on inoculation in existence in numbers of cities and towns acted to exclude the urban poor from the benefits of inoculation. An alarmed and by then powerful medical authority, Dimsdale weighed in against Watkinson’s idea because of the certainty, as he saw it, that inoculated people were bound to remain in circulation and so pass the disease to those who had never had smallpox, often with fatal consequences. A supporter of hospitals, Dimsdale had described an opportunity for enlarging the St. Pancras smallpox hospital [87] which was never in the event taken up. His case against Watkinson − published and circulated in coffee houses − although with little support from other authorities [88] , was a strong indictment stressing the increased number of deaths which he saw as bound to ensue from inoculating the poor in their homes [89] . Both Dimsdale and his opponents used statistical evidence to support their cases without being able to obtain any convincing advantage [90] . John Lettsom (1744-1815), a Dissenter and successful physician and a moving spirit behind the campaign to inoculate the poor sprang into the lists in defence of Watkinson and − as an experienced controversialist [91] − attacked Dimsdale forcefully and to damaging effect, holding him up to ridicule as a person without proper qualification, knowing neither Latin nor any other language than English, in complacent enjoyment of enormous income and dubious foreign honours and prepared himself to inoculate the rich in their urban homes very profitably but not the poor [92] [93] . At one point Lettsom, as part of his campaign got himself invited to a lunch at Dimsdale’s house at Hertford attended by the Russian Ambassador. Having been to it he then succeeded in causing Dimsdale great offence by publishing what appeared to be an account of the private occasion [94] . Lettsom’s gibes provoked further exchanges and other physicians joined in on his side. A well written and even-handed but anonymous contribution on the whole favourable to Dimsdale’s case may have had little effect [95] . Eventually Dimsdale desisted and later appeared to acknowledge that there was something to be said after all in favour of a campaign to extend inoculation so as to embrace cities as advocated by Lettsom and his supporters [96] . Dimsdale’s case was weakened by the lack of interest on the part of the Smallpox Hospital Trustees in extending the building. Nor, in spite of his expectations and being himself a well-connected Member of Parliament from 1780 to 1790, was any Parliamentary or governmental support forthcoming for such a project [97] [98] . His contention that un-inoculated bystanders who had never had the natural smallpox could and would be infected and killed was incontrovertible, and Watkinson’s supporters struggled when confronted with actual cases in point. But Dimsdale’s reading of how the London poor lived − while accurate − did not result in the disastrous consequences which he foresaw, and on the whole the virus proved un-infective [99] . For him, one death was too many, while for his opponents – although they could not say so – a few deaths were more than counterbalanced by inoculation of the poor carried out on a substantial scale. Thus inoculation became generalised in much of England in the sense that it became, potentially at least, an option available to all.

If the provision of large hospitals dedicated to smallpox and inoculation faded, private hospitals for inoculation did not. First employed in 1749 in England [100] they were also met with frequently in the British North American settlements [101] . Such an inoculation house was central to Daniel Sutton’s breakthrough to a wide public at Ingatestone and also to Dimsdale’s practice at Hertford. It is likely, however, that the periodic town and village inoculations which became almost routine depended mostly on ad hoc arrangements rather than private inoculation hospitals [102] . In village, market town and city inoculation can be seen as gradually establishing itself by differing means, always within or alongside the rough and ready framework of the Old Poor Law [103] .

The Dimsdale/Lettsom public dispute marked the confused beginning of inoculation’s availability to a wider cross-section of the public. It also re-asserted to some extent the importance of the practical operator. A practice which had emerged as folklore had been exploited not only by physicians such as Tissot and Gatti but also by surgeons, apothecaries and quite unqualified persons of many kinds. Indeed the Suttons themselves typified this trend, as did Dimsdale – trained at St. Thomas’s hospital, but a son and grandson of unqualified practitioners and who had himself purchased his Aberdeen qualification. Lettsom’s engagement with the issue can be seen as a renewed acceptance of inoculation as much on moral as on scientific grounds, by a new medical cadre which owed much to Scottish universities, with a dash of English Dissent.

Suttonian inoculation had fallen on fertile ground in Ireland and Daniel Sutton’s franchising system was put into operation there, greatly augmented among scattered rural populations by unqualified operators including priests. [104] Transmission in print of Suttonian practice came later to Spain and Portugal than to the rest of Europe, but when it did it was – in the case of Spain – the work of the Irishman Miguel O’Gorman (1749-1814). Having been sent to London to learn Suttonian inoculation he did much to break down resistance to the operation at Madrid and later practised it in the new world at Buenos Aires. [105] This presaged a dramatic enlightened response and campaign by Spanish Imperial authorities in defence of the Maya of Guatemala, that of José Flores (1751-1824) from 1780 onwards, which culminated in a major seaborne expedition to introduce first inoculation and then vaccination to much of the empire. [106] Flores’s method of inoculation − using Cantharides – designed to counter the Maya’s fear of the lancet, was an ingenious adaptation to local conditions.

Like Spain, both France and Britain assumed involvement and responsibility in the New World. The New England colonists famously learned that some of their slaves – originating from West Africa – were familiar with the concept [107] , and inoculation was as widely known as it was back in Britain. At the time of the Suttonian breakthrough, Kirkpatrick (Kilpatrick) (1696-1770), who was an American writer, counted as the best exponent of inoculation writing in English, so that – as in Scotland – systematic exploitation of inoculation pre-dated the Suttonian surge, which manifested itself nevertheless in print and practice when it came. Actual and potential outbreaks of smallpox among armies caused leaders to insist sometimes on quarantine and on other occasions on inoculation on Suttonian lines to avoid repetition of disasters experienced by the colonists in their bid for independence [108] .

In the Caribbean both French and English regimes inoculated slaves of West African origin wholesale in order to protect the productive capacity of their sugar plantations. Again, we are dealing with a population already supportive of and familiar with the concept and there was no attempt made to apply all the early aspects of Suttonian inoculation, and preparation in particular was not featured. There was a Suttonian link between the Caribbean and Europe in the form of Daniel Sutton’s father-in-law Siméon Worlock, who having learned the trade in St. Domingue [109] moved to France to become one of the most prominent Suttonian inoculators there [110] .

The native American populations were just as vulnerable to epidemic smallpox as the Siberian peoples but in the confusion of civil war they had little chance of protection, and on the contrary were, on at least one occasion, purposely infected with smallpox to neutralise them – a startling contrast between the exercise of Russian and British rule, prefiguring further and greater disasters for native North Americans in uneasy association with the newly independent colonists [111] .

British successes in India led to another encounter with folk inoculation, which had been developed by Hindus, who equated smallpox with a goddess – Sitala – to be placated like the Georgian ‘batonébis’ at all costs. This facilitated the task of administrators in the Madras Presidency who were using European inoculation, although their imported technique was sometimes met with suspicion and resistance [112] .

China appears to have been unaffected by Western inoculation. It had a very strong tradition of its own from the seventeenth century, particularly in the south and it experienced − quite independently of the West − many of the developments discussed here, including imperial example: the emergence of inoculators unconnected at first with the medical profession: the striving for attenuation and the shortcomings of quarantine [113] .

The introduction of Suttonian inoculation to Europe and thence to the empires then dependent upon it [114] – sudden and top-down at first but later more gradual – was at no time unaccompanied by a bottom-up impetus, tending through its independent workings to define and establish its place in peoples’ lives. Fear was the emotion which stimulated responses – fear of death or of disfigurement, and fear of disruption of life’s familiar social and economic patterns. The fear was not continuous but recurrent and intense when related to the periodic onset of epidemics, and it was this which most often forced acceptance of inoculation on those who instinctively feared it. And broadcast knowledge of Daniel Sutton’s breakthrough braced the collective resolve of hitherto unimaginable numbers of people in every walk of life, promising the possibility of salvation for everyone. Where smallpox was endemic – a steady toll rather than mass destruction – familiarity to an extent bred contempt, but the fear, although it was less peremptory, was nevertheless intolerable and the chance of protection from the disease was not to be passed up on account of some scruples concerning collateral damage. The motives of those who offered or decreed the remedy of inoculation ranged from the downright commercial to the disinterested, but throughout the spectrum, trade and generosity were usually present in varying proportions in every intervention. Paternalism and Enlightenment [115] kept company with mercantilist ambition and entrepreneurial flair co-habited with the rights of man. The advent of Suttonian inoculation created the possibility of a step change from the numerically and socially limited episodes which it superseded.

If Robert Sutton supplied a practical technique, Daniel attached a secret ingredient and the ambition and organising ability to make it available to thousands, both directly and through franchising. In so doing he ably profited from his offer of a providential solution and – assisted by the scale of his operations – did so at a reduced cost, and sometimes even for free. He made spectacular headway. A few attempts to patent parts of the process had failed before [116] , but he met with notable success, and in so doing – in England certainly – must take the credit for placing lifelong immunity within the reach of an entire population. Before the Suttons, the profits of the then much more limited market had been largely monopolised by doctors, with their equivalent of Daniel’s secret medicine in the form of unnecessarily lengthy preparation. This trade – though diminished – survived the introduction of Suttonian inoculation and – like that of the Suttons – often, in emergencies, tempered the wind to the shorn lamb, sometimes backed by charitable local impulse to augment the poor rate.

The British Crown, ministries and Parliament were not actors in this vital matter of public health at home, but in several other countries, in particular Sweden [117] , Denmark and Norway [118] , Holland, the Genevan Republic and Switzerland governments backed and sometimes initiated and sustained inoculation campaigns. In a few cases their ambitions were manifested before Daniel Sutton’s Essex breakthrough, but all involved were stimulated by that event and availed themselves of the codification and guidance available to them in translation.

In the broad debate on medicalisation [119] where do the decades of Suttonian inoculation fit? Are they a part of the introduction of scholarly medicine to a cross-section of the population [120] ? Do they represent not just the exposure of everyman to ever more comprehensive medical controls from above, but to a set of norms appropriate to the understanding of various social classes [121] ? Or do they bear witness to the hegemonic imposition of elite medicine as one of many prongs of a wider programme of the neutralisation or suppression of village culture [122] ? It is perhaps safest to see Suttonian inoculation as an independent phenomenon operating more or less powerfully and independently of nascent medicalisation and presenting so tempting a benefit to all social classes as to provoke a variety of governmental and societal responses. It could not be and was not ignored − at least not for long – but irresistibly forced the pace of medical care from above as well as from below. On the other hand its successor, vaccination – implemented on a vast scale – was clearly a formidable ingredient of medicalisation, however defined.

An essay about the introduction and spread of a form of smallpox inoculation cannot avoid inclusion of some reference to the consequence in terms of demographic history, if only to note that the once favoured doctrine that inoculation underpinned population growth in England to an extent which facilitated the Industrial Revolution has given way to a far more complex account featuring improving general health and sanitary conditions and the downgrading, indeed elimination, of the activities of doctors as a factor promoting increase of population [123] .

So inoculation should now be viewed as solace, certainly, but as one only of many factors operating to reduce the death rate, itself of less significance than earlier marriage and consequently birth rate. What remains important is that an ancestral fatalistic attitude with regard to an epidemic disease as viewed by the Mingrelians had first been modified in a possibly random scatter of populations around the world through folk inoculation and then, by the close of the eighteenth century, virtually supplanted everywhere by an understanding that salvation could and should be made universally available thus propelling an enlightened idea of rights into the fog of fatalism.

Arnold Klebs concluded in 1913 that: ‘Plentiful suggestions are to be found everywhere which lead one to infer that variolation (inoculation) without vaccination might have furnished the world with an equally safe and perhaps more efficient method of preventive immunisation.' [124] His aim then had been ‘… rather to open avenues for future research than to give a complete and detailed account of the more important phases’ of the course of [inoculation] ‘through the civilised world of the eighteenth century’. His purpose as a doctor was a medical one and a historian [125] writing in 1957 noted this while claiming for historians the duty of examining the issue more comprehensively, and there has indeed been a steady flow of findings since then both on the reception of inoculation: its implementation, and the demographic consequences. Among recent examples relating to the previously unrecognised extent of inoculation one may include France [126] , England [127] , Scotland [128] , Scandinavia [129] , Prussia [130] , Germany [131] , Russia [132] and India [133] − all included in the bibliography below − and debate on the demographic, social and economic consequences for England as contrasted with Europe has continued for decades, but even so it must be suspected that many gaps remain in any account of how far inoculation had become the norm by the end of the eighteenth century. As the issue has been scrutinised country by country, people by people and language by language an impression is borne in that each investigation has tended to support the idea that inoculation – particularly Suttonian inoculation – was more prevalent than had been previously recognised and that further research is likely to provide further confirmation of this state of affairs, and also of the likelihood that – as with folk inoculation – the remedy was adopted on a scale only to be indicated rather than proved. Even so a pattern emerges of more or less implementation of inoculation tending to the better understanding of the reasons for such contrasts, sometimes highlighting that some countries, including England, which adopted inoculation most effectively were slowest to insist on vaccination [134] and others, particularly Spain – a latecomer to inoculation – were to the forefront by the end of the century, at least insofar as empire was concerned, and − post Jenner – substituted vaccination for inoculation almost immediately.

The Suttons − principal actors in the fight against smallpox at the time – and who gave their name to the operation, may have done well enough out of their endeavours [135] . Dimsdale’s attitude to Jennerian vaccination, the triumph of which he lived to see, is not recorded, but by the time of his death at his home in Hertford in 1800 he had come to be associated with much that was outdated [136] . Ingen Housz broke cover near the end of his life to bring Jenner to order for the methodological shortcomings – as noted by a distinguished pioneer scientist − of his great paper [137] . Girod died full of honours at his home village – Mignovillard − where to this day he has not been forgotten. George Hodges, whose death from smallpox at Little Berkhamsted was the only one experienced during the midwinter inoculation there in 1768, stands in through an historical accident [138] as a named ‘unknown warrior’ for the numberless unrecorded children worldwide who became the principal victims of the scourge, which itself now has an afterlife in – it is to be hoped – only two places, both high-security laboratories.

'About the beginning of the Year 1768 George Hodges (he was buried Febr 12^th) a youth of 10 yrs of age was taken desperately ill; His Parents imagined, but did not know it was the Small Pox; after being ill some days they waited upon Mr since Baron Dimsdale for his advice; who readily came in the evening, tho the snow was above a foot deep and his servant got a dangerous fall; He insisted upon me going with him to the Patient We found him in a sad situation full of dirt and sores. The Doctor with a humanity peculiar to himself washed him, removed all nasty obstructions and by his care preserved his life some days upon our return to the Parsonage he told me it was the Small Pox of the worst sort the infection of which wou[l]d certainly go thro the Parish, but if I and the Parish choose it he would inoculate the whole gratis in two days. Immediately used w[h]ich persuasions I cou[l]d; many complied with great cheerfulness and the rest seeing they cou[l]d not prevent the Inoculation taking place, soon came into it, all succeeded and did well: he kindly gave them medicine and attendances Doctor Engen:house; afterwards Physician to the Empress Queen and who inoculated all her Family was for the purpose of experience attending upon Dimsdale. The Inhabitants of Bayford upon seeing our People so cheerfully enter upon it beg’d of the Dr at the same time to exert the same charity to them: their request was complied with, and they did well. ... '

Go to the Bibliography

Acknowledgements

My sincere thanks to Roger Bartlett and Elena Marassinova, whose help with this project has been very much appreciated and who bear no responsibility for any remaining errors in the final text.