Few people may be aware that Charleston, South Carolina was an early western pioneer in the use of inoculation to prevent death from smallpox.
Inoculation for smallpox was not vaccination but a kind of proto-vaccination. It involved infecting people with the actual disease, usually by placing matter from smallpox pustules in a small incision in the skin. It was done in hopes of producing a mild case and subsequent immunity. It was the inspiration for today's vaccines. [Image: Inoculating for the Smallpox, 18th century]
Inoculation was essentially unknown in the West at the beginning of the 18th century. It had been practised in the Ottoman Empire and in parts of Africa for some time. Shortly before 1720 knowledge of the procedure arrived in England and in New England, most famously via an English aristocrat, Lady Mary Wortley Montagu, and an African, Onesimus, slave to Rev. Cotton Mather of Boston, Massachusetts. [See Lady Mary Wortley Montagu and Smallpox Inoculation]
The British were slow to adopt inoculation, partly because the disease was endemic, at least in the more densely populated areas. This meant that it was always present. Most people became infected as children. Those that survived were immune. It did not fundamentally disrupt the normal patterns of life and work.
Moreover, inoculation was dangerous. It meant giving someone the disease, hopefully in a milder form. But sometimes, it killed or disfigured the recipients. It could also spread the disease if the inoculated were not carefully isolated. They were contagious until they had passed through the disease. Many people demanded that inoculation be banned or at least strictly regulated, especially when the disease was not present in their communities.
There was also a religious objection. Many of the devout denounced it as an interference with Divine Providence: if God wanted you to have smallpox he would give it to you. Whether you lived or died was God's Will.
That argument lost much of its power after a few decades, however. The 18th century was, after all, the Age of Enlightenment. A counter argument quickly developed, embraced by many religious leaders: Inoculation was a gift from God. By the mid-18th century, some British inoculators were making substantial incomes from the practice.
One of the reasons for an increased uptake of inoculation in Britain (and somewhat later, on the Continent) was the success of the procedure in the British colonies in North America.
The colonists were more receptive to inoculation than people in Britain and Europe. Ironically, in part this was because in the colonies smallpox was normally absent from their lives. It arrived in epidemic waves, generally about twenty or so years apart.
This meant that whenever smallpox arrived, a large proportion of the population was vulnerable. Large numbers would become ill and many would die.
Mortality rates were often 20 percent or higher. Survivors were often left with pock marked faces, and some became deaf or blind. Young women's marriage prospects could be blighted by the pocks. [Image: A severe case of smallpox, early 20th century]
These tragedies aside, economies and everyday life were severely disrupted by quarantines. These differences led to the colonies becoming a kind of experimental laboratory testing the efficacy of inoculation.
The first such "experiment" took place during a smallpox epidemic in Boston in 1721. Mather, armed with knowledge from Onesimus and probably having read some accounts of its in Ottoman lands, convinced a local surgeon, Zabdiel Boylston, to try the method.
Boylston inoculated 287 people. Six of them died, about 2 percent. That may sound terrible. But nearly 6000 contracted the natural disease, of which 844 died, or about 14 percent. Boylston published a famous account of his results, which emboldened others to employ inoculation, especially in the colonies. [Image: Title page of Boylston's Account, 1726]
One of the first places to do so was Charleston, South Carolina. During a minor outbreak in 1732, the South Carolina Gazette published an article describing inoculation. The author claimed that it was effective, but recommended against its use for concern that the inoculated could spread the disease. No one in Charleston seems to have adopted the procedure.
Six years later, another, much more severe outbreak struck Charleston. It began in May and appears to have spread from a newly arrived ship, the London Frigate. On this occasion, a local surgeon, Arthur Mowbray, began to inoculate. His action provoked a lively debate over inoculation, not just the prudence of doing so, but also the proper way of doing it. [image: Charleston Harbor, c.1770]
The South Carolina Gazette published letters by locals, mostly medical men, about inoculation. The doctors were divided. The paper's editor, Lewis Timothy, opposed the procedure as unproven and dangerous. The most vocal advocate of it was a feisty and somewhat mysterious surgeon, James Kilpatrick.
He claimed to be from Ulster in Ireland, and he may have been born there around 1700, but he was a Scot. His real name was not Kilpatrick, but Kirkpatrick. His family had been implicated in Jacobite plots against the Hanoverian monarchy that had replaced the Stuart dynasty in 1714.
He came to South Carolina in the early 1720s, possibly fearing prosecution, which may account for the name change. He had matriculated at the University of Edinburgh prior to his departure.
Kilpatrick wrote an account of inoculation after the 1738 epidemic in Charleston. He gave credit to Mowbray for having begun inoculation, and credit to himself for taking it up and defending it. There was a personal side to his account. One of his children died of smallpox in the early stages of the outbreak. He quickly inoculated the others and his wife.
During and after the epidemic Kilpatrick conducted a rancorous pamphlet duel with another local doctor, Thomas Dale, who accused him (and Mowbray) of spreading the epidemic through careless inoculation. Kilpatrick accused Dale of being ignorant of the disease and inoculating solely for profit. The dispute was not just a matter of income, but of professional rivalry and personal pride. It is likely that both men distorted the facts.
Unfortunately, only one of the pamphlets has survived, by Kilpatrick, and his Essay on Inoculation (1743) is the only first-hand account of the epidemic. Nevertheless, Charlestonians who remembered the events decades later agreed on one thing: inoculation in 1738 had been a great success.
Kilpatrick estimated that about 1 percent of the 800 to 1000 persons inoculated in Charleston in 1738 died. The population of the city was then about 6000. Lewis Timothy, a critic of inoculation, claimed that the death rate among the inoculated was closer to 3 percent. These figures are similar to those reported in Boston and other places within the empire around this time.
These were excellent results, given that smallpox often produced mortality rates of 20 percent or higher. Among Native Americans, it was often much higher, because so few of them had ever been exposed to this Old World disease. In 1738 smallpox was estimated to have killed about 50 percent of the Catawba Nation. Differential immunities of this magnitude helped to cement European dominance of the Americas.
Despite inoculation's success in 1738, the state assembly moved to restrict inoculation several months into the epidemic, by which time it was dying out. The rationale was that inoculation itself could spread the infection and keep the outbreak alive. The assembly did not prohibit it, but mandated that it could not be performed within two miles of Charleston.
The motives behind this restriction were as much economic and military as medical. The epidemic had stifled trade for months due to strict quarantine and country peoples' fear of coming into town.
Also, war had broken out with Spain that year, the War of Jenkins' Ear. The assemblymen feared that as long as cases of smallpox were present in Charleston, they could not rely on country folk to come to the city's defense in case of a Spanish attack.
By the end of 1738, smallpox had retreated from Charleston. It would not return for more than twenty years, once again during war. On this occasion, the demand for inoculation would be much greater, and the opposition much less. The procedure had proved its value. [Continued in Part Two: ]
P.S. James Kilpatrick moved to London in the early 1740s, where he published his Essay on Inoculation about the 1738 epidemic. He established a successful practice in inoculation and obtained his M.D, from Edinburgh University. He published a much longer work on the procedure, An Analysis of Inoculation, in 1754, under the name Kirkpatrick. He died in 1771. One of his sons had a successful career in the British East India Company, and rose to the rank of Colonel. Two of his sons also became ranking officers in the company, and one of them, James Achilles, married an Indian princess. Their story can be followed in William Dalrymple's magnificent and highly informative White Mughals (London, 2002) [Image: James Achilles Kirkpatrick, the grandson of James Kilpatrick/Kirkpatrick of Charleston.
Sources: All the sources for this post may be found in Peter McCandless, Slavery, Disease, and Suffering in the Southern Lowcountry (New York and Cambridge: 2011, 2014)
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