Focus on the Community

IT WAS PRECISELY in the area of common diseases—which now obviously became problems in public health—that American experience had most to offer. Some diseases which in Europe seemed part of the inevitable round of life could be avoided here by prudent public measures. Ailments which were endemic, or continually prevalent, in England tended to become epidemic—sudden and dramatic menaces to the community—in America.

Public concern over a disease depends less on the actual mortality than on the dramatic intensity with which it is impressed on the public. Although smallpox probably caused fewer fatalities among white settlers in America in proportion to the population than it had in England, it occurred here almost exclusively in the spectacular form of epidemics. During the 17th and 18th centuries in England and on the European continent, smallpox was a common disease of childhood. By the time a person had grown up he had almost certainly been exposed to it and had either proven himself immune or had acquired immunity by surviving the disease. Smallpox was therefore not an epidemic disease among adults in Europe. But in America, where the disease had not existed until it was introduced by Europeans, it was much less widespread. Many inhabitants lived through childhood without having been exposed.

During the 18th century, a common American objection to sending sons to England for a higher education was the mortal danger from smallpox. When a French visitor, Francis Louis Michel, visited William & Mary College in 1702, he was surprised to find as many as forty students there; he learned that wealthy parents who formerly had sent their sons to England now preferred the intellectual crudities of a colonial education to the perils of the English smallpox. The Rev. Hugh Jones, in 1724, observed that more Virginians would have been given an English education “were they not afraid of the Small-Pox, which most commonly proves fatal to them.” The church of Virginia might not have developed its distinctive features and might not have been quite so autonomous, if parents had been readier to risk an English education for children wishing to enter the church.

Because smallpox had been unknown among the Indians, they proved especially vulnerable. In 1633, as Governor Thomas Hutchinson later recorded in his History, “the small pox made terrible havock among the Indians of Massachusets…. They were destitute of every thing proper for comfort and relief and died in greater proportion than is known among the English. John Sagamore of Winesimet and James of Lynn with almost all their people, died of the distemper.” Even as late as the 19th century, certain Indian tribes which had until then escaped the disease were being wiped out; fatalities in some tribes exceeded 90 per cent. There can be little doubt that more Indians died from epidemics than from white men’s muskets.

Among the white settlers, too, smallpox was primarily an epidemic disease. It swept through the colonies at intervals—sometimes a generation apart—and afflicted large numbers of adults. No longer one of the normal trials of childhood, it became a sudden and terrifying scourge that paralyzed the community and forced the regular activities of commerce and government to be suspended. Where communities were small and nearly all types of skill were scarce, losing the only carpenter or gunsmith put everyone in trouble. Even the very high proportion of fatalities due to disease is no adequate measure of the impact on the life of the community.

Perhaps the most dramatic example of the public-health emphasis in American medicine came from New England, where compact Boston and the Puritan concern with community set the stage. One of the most successful onslaughts against disease in all American history took place there in the 18th century. How to treat the smallpox was publicly debated by doctors, ministers, and journalists. The unlikely hero of the story was none other than Cotton Mather (1663-1728), on whom has been focused the ill-informed hatred of generations of liberal historians. But sober scholarship has lately begun to divest Mather of his Mephistophelian character, so that we can now see him as a vivid symbol of the potentialities as well as the limitations of early New-England science.

Cotton Mather had a strangely miscellaneous, observant, and practical mind. We can understand Mather better if we think of him as an early version of Benjamin Franklin (1706-1790), who in fact heard Mather preach on several occasions in Boston. He had read Mather’s Essays to Do Good (Franklin’s first pen name was “Silence Do-Good”), and in his Autobiography called it the book “which perhaps gave me a turn of thinking that had an influence on some of the principal future events of my life.” In it he probably discovered the literary genre which he was to make famous in his Poor Richard. Even Franklin’s “Junto”—both the general idea and the detailed procedure for its meetings—seems to have been borrowed from Mather’s scheme of neighborhood benefit societies for Boston. Some of the most characteristic of Franklin’s enterprises were thus directly suggested by Cotton Mather, but more important than any direct influence were their intellectual affinities.

It is misleading to separate Mather and Franklin by the academic antitheses between “Calvinism” and “The Enlightenment.” The similarities in the interests and achievements of these two great men reveal distinctive features of American culture in the provincial age: an undiscriminating universality of interest surprisingly unconfined by a priori theories; a lack of originality; an intense practicality; an unsystematic and random approach to philosophy; and, above all, a willingness to be challenged by New World opportunities. In his own day, Cotton Mather’s fame as an observer of American novelties reached British scientists, who awarded him an honorary degree from the University of Aberdeen (1710) and a coveted membership in the Royal Society (1713).

By the standards of his day Mather was an alert and accurate observer of nature. His scientific communications (which counted nearly 100 after 1712) to European friends and fellow-naturalists included notes on American plants and Indian cures; on American birds, including the wild turkey, the eagle and the vast flights of pigeons; on the rattlesnake; on the violence of thunder and lightning in America; on a triton; on an egg found within a hen’s egg; on Indian divisions of time; and on dozens of similarly miscellaneous items. In a letter (July 24, 1716) which accompanied a shipment of six or seven plants peculiar to America, he gave the earliest known account of plant hybridization. His observation significantly concerned Indian corn, a plant which later geneticists also found peculiarly well-suited to their experiments. Mather was even open-minded enough to accept the hypothesis, then newly expounded by Nehemiah Grew, that flowering plants reproduced sexually.

From his early years Cotton Mather had been interested in medicine. He had once thought of making it his profession, but the lack of formal courses on the subject at Harvard had left him to his own devices, and largely to independent reading. In this respect, too, Mather’s career has a later parallel in that of Franklin; for, like Franklin’s discoveries in electricity, Mather’s medical ideas could hardly have grown in the mind of a learned professional.

So far as we now know, the first general treatise on medicine written in the English colonies in America was the work which Cotton Mathet completed in 1724. The title of his work, “The Angel of Bethesda,” came from the name of the famous healing-pool mentioned in the Gospel according to John (5:2-4), but it seems to have been suggested to Mather by the writings of the eminent physicist Robert Boyle. While Mather and others published many fragmentary items on such topics as smallpox and measles, this general work, although widely known to exist in manuscript, was not published during the 18th century. Cotton’s son, Samuel, for a dozen years after Cotton’s death had tried hard to have it published.

Mather’s interest in diseases was probably sharpened by his Puritan theology, with its emphasis on original sin and on the dark dualism of man’s nature. In a devious way the Puritan emphasis on sin thus seemed to reënforce the empirical emphasis of American science; it may even have helped liberate American medical practice from the dogmatism of their learned European contemporaries. To Mather, at least, this connection of ideas seemed obvious enough; he explained at the beginning of his first chapter:

Lett us look upon Sin as the Cause of Sickness. There are it may be Two Thousand Sicknesses: and indeed, any one of them able to crush us! But what is the Cause of all? Bear in Mind, That Sin was that which first brought Sickness upon a Sinful World, and which yett continues to sicken the World, with a World of Diseases.

Mather’s work became a survey of diseases. One of the proposals for its printing called it “An Essay upon the Common Maladies of Mankind: offering, first, The Sentiments of Piety, whereto the Invalids are to be awakened in and from their bodily Maladies. And then, a rich Collection of plain but potent and approv’d Remedies for the Maladies.”

The book made no claim to originality. “Nor, can it be Expected,” Mather explained, “that while Colonies are yett so much in their Infancy as ours are, and have had so many Serpents also to crush while in their cradles as ours have had, they can be so circumstanced as to produce many acute mathematicians, or allow them the Leisure for extraordinary Inventions and Performances.” But Mather did himself an injustice: by the very organization and emphasis of his volume he had put himself among the most progressive medical students of his day. The idea of the separateness of diseases had only begun to make headway abroad. Until the middle of the 16th century the dominating concern of European medical men had been “the general state of the system” of which all diseases were thought to be mere variants. Only with the work of Paracelsus in the Renaissance was there a serious revival of the idea that there were many different diseases, each with its own causes and cures. In the 17th century the English physician Sydenham insisted that particular diseases might be as different as particular plants and animals, and that therefore they must be examined and classified in detail. How little progress had been made by 1700 appears from the fact that there were then known only two specific drugs (cinchona bark yielding quinine against malaria; and mercury against syphilis); even these had probably come directly from folk-medicine.

Mather’s “Angel of Bethesda” expressed an empirical view alien to many learned European doctors. He showed himself less interested in the “causes” than in the remedies of diseases; his pages abound in what he called “remarkable, and often experimented” cures. In a chapter on the “Uncertainties and Contradictions” of Physicians, he illustrated the vagaries of learned doctors by their contradictory prescriptions for the consumption. “And here,” Mather explains, “we will not concern ourselves with the Differences among the Physicians, about the Cause of this Distemper; (whereupon, who can read the Collection made by Dolaeus, and not cry out, The Diviners are mad!) but only see, how they differ about the Cure of it.”

His hope that there might be a way to save the New England community from the scourge of smallpox was aroused by an item he read in the Transactions of the Royal Society of London for 1714. This was a letter from a Turkish doctor describing how “inoculation,” or the deliberate infection of a healthy person with matter from a person suffering from the smallpox, usually produced a light case of the disease from which the patient recovered, and to which he was thereafter immune. Mather then wrote to a doctor in London:

How does it come to pass, that no more is done to bring this operation, into experiment & into Fashion—in England? When there are so many Thousands of People, that would give many Thousands of Pounds, to have the Danger and Horror of this frightful Disease well over with them. I beseech you, syr, to move it, and save more Lives than Dr. Sydenham. For my own part, if I should live to see the Small-Pox again enter into our City, I would immediately procure a Consult of our Physicians, to Introduce a Practice, which may be of so very happy a Tendency. But could we hear, that you have done it before us, how much would That embolden us!

Mather found his opportunity in April 1721, when a ship from the West Indies brought a smallpox epidemic to Boston. The events of the next decades sharpened the contrast between the medical opportunities on the two sides of the Atlantic. During the unusual outbreak of smallpox in London in that year, the fashionable Lady Mary Wortley Montagu, who had brought the practice from Turkey, finally persuaded George I to permit the inoculation of his two granddaughters. Despite the royal example, only about twenty scattered inoculations were performed in London; and, when two deaths occurred, the popular opposition increased and was reënforced by the medical profession. Inoculations temporarily ceased in England. They were soon resumed in considerable numbers in different parts of the country, but not enough in any one community to justify conclusions about the technique as a measure of public health. London, a sprawling city where smallpox was always present, was not a favorable proving-ground. No substantial progress was made until a serious London epidemic in 1752 focused public attention on the problem; and by that time the American successes, widely advertised in England, were an old story.

American progress against smallpox began when Mather publicly appealed to the physicians of Boston in early June 1721 to try inoculation to protect the community. He set off a violent controversy. As a whole the learned doctors—led by the splenetic Dr. William Douglass, the only physician in the city with a medical degree—opposed the experiment. They were understandably annoyed that laymen should try to tell them how to practice their art, and should urge techniques borrowed from “the Mussel-men, & faithful people of the prophet Mahomet.” They did have the solid objection that the practice, as then crudely conducted, actually tended to spread the disease. But they leaned heavily on theological objections: to inoculate, they said, would violate “the all-wise Providence of God Almighty” by “trusting more the extra groundless Machinations of Men than to our Preserver in the ordinary course of Nature.” The New England Courant, just begun by James Franklin with the help of his younger brother Benjamin, true to the conservatism of the colonial press, opposed Mather’s new-fangled practice. But many of the clergy joined Mather in demanding a fair trial for inoculation. Passions ran high. Heated pamphlets were exchanged, with Mather producing over half a dozen. Public opinion became literally explosive: in November a bomb was thrown into Mather’s house.

Everybody agreed that the cure of smallpox was a public problem. Despite the opposition, despite prohibition by the town government, and despite threats of divine vengeance, Zabdiel Boylston, supported by Mather and his clerical cohorts, managed to perform a number of inoculations in Boston during the epidemic. These were sufficiently numerous to provide statistical evidence that the calculated risk of death from inoculation was smaller than the risk in cases naturally contracted. In March 1722, after the worst of the epidemic was over, Mather pointed out to the Secretary of the Royal Society in London that of nearly 300 inoculated in Boston only five or six had died (and perhaps these had already been naturally infected before their inoculation), while of the more than 5000 who caught the disease naturally, nearly 900 had died. This meant that there was about nine times as much chance of death if one caught the smallpox in the ordinary course of infection as compared with the danger from inoculation. The fact that about half the population of Boston had contracted smallpox during the epidemic showed that from the point of view of the community as a whole the risk of inoculation was very much worth taking.

The collection of these Boston statistics was a pioneer work in public health, one of the first cases of quantitative analysis of such a medical problem. They later proved significant, not only in establishing inoculation as a measure of preventive medicine, but as valuable raw material for the development of the “calculus of probabilities” by mathematicians—Europeans, of course!

More than any other single fact, Mather’s practical success with inoculation established the idea that the smallpox might eventually be conquered, and this incidentally opened men’s minds to the curability of other diseases. Dr. Douglass himself bore witness to the power of the American empirical atmosphere; by the time the next Boston smallpox epidemic was imported from Ireland in 1729-30, he and most of his fellow physicians had been persuaded of the advantages of inoculation when properly controlled and they actually inoculated their own patients. In 1755 Douglass declared that the risk from inoculation was only two to three per cent and could still further be reduced. “I am at a loss for the reasons, why inoculation hitherto is not much used in our mother country, Great-Britain; considering that it has with good success been practised in our colonies or plantations, particularly in Boston, New-York, Philadelphia, and Charles-town of South-Carolina.”

The influence of the Boston experiments spread up and down the colonies. When, early in 1738, a ship from Africa brought a smallpox epidemic to South Carolina—a province having “more Lands than Inhabitants to spare”—which had not suffered such a seizure for nearly thirty years, Dr. James Kilpatrick and his fellow physicians at once used inoculation on a large scale. In Charleston, which then possessed a population of around five thousand, one physician estimated that he inoculated 450 with his own hands. Before the epidemic abated about a thousand had received inoculation. The mortality rate for inoculated persons, according to Dr. Kilpatrick’s account, was somewhere around one per cent, a minute figure compared with the heavy mortality of those naturally infected. In establishing inoculation as an American institution, a strong, if crude, empirical strain, a carelessness of theory, and an insistence on results were decisive. The dubious logic of Kilpatrick’s propaganda pamphlet was often repeated: “That Nothing but the real Success of this Method could ever have continued it to this Time.” But there was good sense in his warning that learned physicians beware of the “natural Shallowness and acquired Obscurity” which tempted them to ignore obviously successful results. There was a conscious continuity in the American practice; Kilpatrick, for example, was careful to offer a statistical chart of the earlier successes in the Boston epidemic of 1721.

At the same time, common sense itself seemed to oppose the practice. “The Novelty of seeking Security from a Distemper, by rushing into the Embraces of it,” Dr. Kilpatrick observed, “could naturally have very little Tendency to procure it a good Reception on its first Appearance.” And when popular and professional fears were reënforced by the “better opinion” back home in England they were not easily overcome. Nearly every colony prohibited inoculation at some time or other, but such laws did not stick. By 1760 the colonies were coming to regulate rather than to prohibit the practice; and by 1775, in the Middle and Southern Colonies at least, the laws aimed only to provide reasonable safeguards against the spread of infection by inoculated persons. Even in New England, where some laws prohibited the practice generally, the laws were suspended to allow inoculation during epidemics. In September 1774, when the Continental Congress was meeting in Philadelphia, the physicians of the city agreed to inoculate no more during the sitting of the Congress, “as several of the Northern and Southern delegates are understood not to have had that disorder.”

Early in the Revolution the army carried smallpox all over the colonies. General George Washington, on the advice of Dr. John Morgan, physician-in-chief of the American armies, ordered the inoculation of the whole army. This mass inoculation, in special hospitals set up for the purpose, was probably the most extensive experiment of its kind until that day. When smallpox came to Boston again in 1792, nearly half of its twenty thousand inhabitants were inoculated.

Before the end of the colonial era, the smallpox menace—which increased in England until nearly 1800—was well under control in America: epidemics were less frequent and stirred less terror. A larger consequence of the American practical success was that it helped prepare men’s minds, on both sides of the ocean, for the next step in the battle against the disease. At the end of the 18th century when Edward Jenner made the epochal discovery of vaccination, fewer people were frightened by the theoretic paradox. Within a dozen years of Jenner’s discoveries and Benjamin Waterhouse’s communication of them to the American newspaper-reading public (March 12, 1799 in the Columbian Sentinel), vaccination was widespread in America. State governments began subsidizing it, and the Congress authorized a Federal Vaccine Agent to send the virus post-free anywhere in the United States.

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