The Mysterious Dr. Kilpatrick

In 1717, a man calling himself James Kilpatrick (sometimes spelled Killpatrick) arrived in Charleston, South Carolina. His exact date of birth is unknown but was sometime in the 1690s. He joined his uncle, David Kilpatrick, who already lived in the colony. 

James Kilpatrick claimed to be a native of Ireland. He set himself up as a doctor, a profession in demand in the feverish colony. He had studied medicine at the University of Edinburgh but had not completed the MD.  

His lack of a medical degree was not a significant problem in the young colony, which lacked any kind of licensing system. The medical "profession" in Charleston at the time included people with little formal medical training, or none at all.   

Kilpatrick achieved some financial success. St. Philip's Parish vestry appointed him visiting physician to the parish poor. He established a pharmacy in the early 1730s -- something that modern doctors cannot do. 

In 1727 he wed Elizabeth Hepworth, an heiress and the daughter of the secretary of the colony. They were married at St. Philip's Church. A few years later he received a joint grant of more than 200 acres, and presumably engaged in a bit of rice planting. 

During Charleston's smallpox epidemic in 1738 Kilpatrick was one of the first doctors to employ the practise of inoculation. One of his children had died of the disease, and he decided to inoculate the rest of his family. He then inoculated several hundred residents. 

He vigorously defended his use of the procedure in the town's newspaper and in pamphlets. His efforts aroused controversy but enhanced his reputation in the long term. 

Upon the outbreak of war with Spain later that year -- the wonderfully named War of Jenkins' Ear -- he enlisted as ship's surgeon. He accompanied General James Oglethorpe's failed expedition in 1740 against St. Augustine, the Spanish stronghold in Florida. [Image: James Oglethorpe]

Around 1742, Kilpatrick moved to London with his wife and children. He established himself in medical practise and completed an MD from Edinburgh. Mysteriously, he also changed his name from Kilpatrick to Kirkpatrick.  

Why did he change his name? An old argument is that he decided that a name that began with "Kill" was not a good one for a doctor. That may be, but there is a more compelling reason: Kirkpatrick was his real name. 

That raises another question: Why did he change it to Kilpatrick on coming to South Carolina? The answer lies in British politics in the early 18th century. The Kirkpatricks were a Scots family who backed the wrong side in the Jacobite Rebellion of 1715.

The aim of the rebellion, and a couple more that followed, was to place the Catholic Stuart claimant "James III" (The Old Pretender) on the British throne, in place of the Hanoverian George I, who had just arrived from Germany.

The rebellion failed. People who had supported it, or were even suspect, were denounced as rebels. Many fled or tried to change their identity. James Kirkpatrick seems to have done both. 

He claimed to have been born in Ireland. Perhaps he was. But his family was Scottish, and he may have been born in Scotland. He attended Edinburgh University shortly before the 1715 Jacobite Rebellion. 

Did he take part in it? Possibly, or perhaps he was assumed to have done so because others in his family did. In any case, the political danger may have made a change of name seem like a good idea. The same goes for his migration to South Carolina. In a frontier colony, it was easier bury one's past and start afresh. The colony's promoters welcomed white men to a place where enslaved Africans already made up a majority of the population.  

When Kilpatrick changed his name back to Kirkpatrick, nearly 30 years had passed since the rebellion in which he may have been involved. Another, and more serious Jacobite rebellion took place in 1745, but no one could argue that he had taken any part in that. In any case, the Jacobite threat ended with the defeat of the army of "Bonnie Prince Charlie" at Culloden in April 1746. It was the last battle fought on British soil. [Image: Culloden]

 

Moreover, while in South Carolina, he had demonstrated his loyalty to the British government by serving as a naval surgeon in the Oglethorpe Expedition to St. Augustine. 

After arriving in London, he published an account of the 1738 smallpox epidemic in Charleston, highlighting the success of inoculation in the epidemic and his own role within it. 

When a smallpox epidemic broke out in London in 1746, Kirkpatrick helped found the innovative Smallpox and Inoculation Hospital, believed to be the first in Europe to specialize in that area. It provided free treatment to the working class. [Image: Smallpox and Inoculation Hospital,  Coldbath Fields, London]

Kirkpatrick collaborated on the hospital project with Isaac Maddox, Bishop of Worcester. Maddox later helped him to publish The Analysis of Inoculation (1754), a treatise on its history, theories, and practise. The book was translated into several languages and gained him a reputation as an expert on the subject. 

In the Analysis, he claimed to have revived inoculation in Britain after it had fallen into disuse. This was exaggeration, but he did help to popularize it, especially in France and the Continent. He inoculated members of the French and British aristocracies. 

Kilpatrick/Kirkpatrick harbored poetic as well as medical ambitions. He used them to celebrate the maritime and naval achievements of the British Empire, in a long poem entitled The Sea-Piece. He had composed it, he said, in South Carolina between 1717 and 1738. He published it in London in 1750. 

He praised the works of Alexander Pope, whom he called the poetic lord of the British empire. He wrote several poems commending and defending Pope and an elegy on Pope after his death in 1744. 

Kirkpatrick died in London in 1770. His son James became a high-ranking officer in the British East India Company. He was known as the "Handsome Colonel." Two of the colonel's sons, William and James Achilles Kirkpatrick, also attained high rank in the Company. 

James married an Indian princess in Hyderabad. The marriage ended in tragedy; a story superbly told by William Dalrymple in White Mughals.  

Further Reading: 

James Kilpatrick, An Essay on the Small-Pox Being Brought Into South Carolina in the Year 1738. (London, 1743)

James Kirkpatrick, The Analysis of Inoculation. (London, 1754). 

Peter McCandless, Slavery, Disease, and Suffering in the Southern Lowcountry. (New York and Cambridge: 2011, 2014)

William Dalrymple, White Mughals. (London, 2002)

David S. Shields, Oracles of Empire: Poetry, Politics, and Commerce in British America, 1690-1750. (Chicago: The University of Chicago Press,1990)

 

Dr. David Ramsay: Patriot, Revolutionary Historian, and Gun Victim

Dr. David Ramsay of Charleston was an active participant in and major early historian of the American Revolution. He also has the distinction of being the first of many American politicians to be assassinated. 

Ramsay was born in Lancaster County, Pennsylvania, in 1749, the son of Scottish or Scotch-Irish emigrants. He graduated from The College of New Jersey (now Princeton University) in 1765. In 1773, he became one of the first recipients of the MD degree from the College of Philadelphia (now the University of Pennsylvania) in 1773. [Image: A young David Ramsay, by Charles Wilson Peale]

Ramsay moved to Charleston, South Carolina the following year, upon the recommendation of his mentor, Dr. Benjamin Rush. The city and its environs was then one of the unhealthiest and wealthiest regions of British North America, and a magnet for medical men. After a slow start, Ramsay built a lucrative medical practice. 

He soon became involved in politics. When he arrived in Charleston, conflicts between the thirteen colonies and the British government were escalating towards war. Ramsay joined with the Whigs, or Patriots, as they later called themselves. He served in the state legislature during the War for Independence.

During the British siege of Charleston in the spring of 1780, he served as an army surgeon. After the British captured the city, they sent Ramsay and other Patriot leaders to St. Augustine, Florida. He remained there nearly a year, until he was released in a prisoner exchange. 

He went to Philadelphia, where he became a member of the Continental Congress. He served in that body until 1786, after which he returned to South Carolina. During the 1790s he served several times in the state senate. His hope of becoming a United States senator was dashed when his opponent accused him of being insufficiently supportive of slavery. 

Ramsay had opposed slavery when he first came to South Carolina, but he gradually modified his views on the issue. Without specifically endorsing slavery, he helped to justify it. 

In 1780, he wrote his mentor Rush that he had concluded that God had designed blacks for labor in hot, humid, and sickly South Carolina: "Providence intended this for a Negro settlement. Their constitution is undoubtedly better suited to the climate, and all planters tell us that their lands cannot be cultivated by white men...." 

In later years Ramsay blamed the enslaved themselves for their poor health rather than their living and working conditions. They carelessly exposed themselves to dangerous miasmas, knowing that an illness would gain them some time off from work and the attentions of a medical man. Why they would look forward to time off at the price of being ill, bled, and purged, he did not say. 

Ramsay's change of views on slavery was no doubt influenced by his social, familial, and political environment. As a physician active in revolutionary politics, he became acquainted with many local planters. 

In 1787 he married Martha Laurens, daughter of slave trader, planter, and politician Henry Laurens. She was Ramsay's third wife. The first two, Sabina Ellis (1775) and Frances Witherspoon (1783), had died within a year of their weddings. It may seem that Ramsay was a bit careless with his wives, but there is no clear evidence of that. 

His marriage to Martha Laurens lasted until her death in 1811 and produced at least eleven children. Through his marriage to Martha he became related to some of the wealthiest and most powerful families in South Carolina, families with names like Rutledge, Pinckney, Middleton, and Izard. Each of them, like his father in law, owed their wealth to the labor of hundreds enslaved Africans. [Image: Henry Laurens, c.1782, painted when he was imprisoned in the Tower of London, by Lemuel Francis Abbott]

After the Declaration of Independence Laurens penned a letter to his son John then in London, later published, in which he declared his dislike of slavery and his intention to work for its abolition. But he did no such thing, and only freed one of his slaves in his will. John Laurens, however, took his fathers' words seriously and remained committed to abolition until his death in one of the last skirmishes of the War for Independence in 1782. 

After the Revolution, Ramsay wrote several medical works. They remain useful to the historian of medicine and disease, but his medical ideas were highly derivative. He became an advocate of Benjamin Rush's heroic medicine, which recommended drastic bleeding and purging for most ailments. This medical regime sent many an unfortunate to an early grave. 

On the positive side, Ramsay was an early advocate of Jenner's vaccination for smallpox, and began vaccinating early as 1802. He predicted that a general use of the technique could eliminate the dreaded scourge from the earth. He was right, although the goal was not achieved until the late 1970s. 

It is for his historical works, not his political or medical contributions, that Ramsay is best known today. He wrote some of the earliest histories of the American Revolution. In 1785 he published a detailed History of the Revolution of South Carolina. It describes many events he was witness to or a participant in.  

He followed with History of the American Revolution (1789) and History of South Carolina (1809). A History of the United States appeared in 1816-1817, shortly after his unexpected and unusual death. In these works he took an increasingly nationalist position. [Image: David Ramsay in mid-life, by Rembrandt Peale]

In 1815, Charleston's legal authorities asked Ramsay to examine William Linnen, a tailor who had tried to murder his lawyer. Ramsay reported that Linnen was deranged and dangerous, but not guilty of a crime due to his mental condition. In making this claim, Ramsay was aligning himself with medical and legal ideas that were as yet not widely accepted. 

When Linnen appeared to have regained his sanity, the authorities released him. Linnen threatened Ramsay for calling him a madman, but Ramsay did not take the threat seriously. On May 6, 1815,  Linnen approached Ramsay on Broad Street, pulled out a pistol and shot him twice.

Onlookers carried Ramsay to his home, where he died two days later, insisting to the last that Linnen was "a lunatic free from guilt." Ramsay was buried in the Charleston's Circular Congregational Church. 

Ramsay was the first American politician to be assassinated, but many more would face the same fate, as America pursued its love affair with the gun. 

Further Reading:

Arthur Shaffer, To Be an American: David Ramsay and the Making of the America Consciousness, Columbia: University of South Carolina Press, 1991. 

Peter McCandless, Slavery, Disease, and Suffering in the Southern Lowcountry. New York: Cambridge University Press. 2011, 2014. 

   

Smallpox Inoculation in Charleston, South Carolina, Part One: 1738

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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Dying in Paradise: Colonial South Carolina

South Carolina was the wealthiest colony in British North America at the time of the Revolution. It was also the unhealthiest. It was long notorious for its deadly fevers, notably malaria and yellow fever, both transmitted by mosquitoes. 

Dysentery was another major hazard, transmitted by amoebas or bacteria in water. The “bloody flux” subjected many to enormous suffering and in many cases, an early grave. Smallpox and other periodical contagions added to the grisly toll.

Wealth and unhealth were intimately connected. Both arose largely from the cultivation of rice with enslaved Africans, the majority of South Carolina’s population from 1708 until the early 20^th century. [Image: Africans hoeing in the rice fields]

 It is widely known that whites suffered terribly from disease in the lowcountry plantation areas. In Christ Church Parish [now Mount Pleasant] in the early 18th century, the parish register records that 86% of baptized children died before age 20. 

Between 1750 and 1779, planter Henry Ravenel and his wife had 16 children. Eight died before age 5. Only six survived past 21. Of their seven daughters, none lived to be 20. Elias Ball and Mary Delamere, who married in 1721, had six children. All died before age 20. Many other families fared the same or worse. The death rate for whites in early 18^th century Charleston was roughly twice that of the average parish in England or New England at the time. 

Less well known is that Africans also died in large numbers from these diseases and many others. This is due to the staying power of pro-slavery arguments of the 19th century, which claimed that Africans were virtually immune to the “tropical” fevers that killed so many whites. A benevolent God had “designed” African constitutions for this work. 

Gov. John Drayton summed up this argument in 1802: “these situations are particularly unhealthy, and unsuitable to the constitutions of white persons … that of a Negro is perfectly adapted to its cultivation.” In 1850, the Lutheran minister and naturalist John Bachman claimed that Africans were perfectly designed for laboring in the lowcountry environment. [Images: John Drayton and John Bachman] 

In stark contrast, some 18th century observers commented on the heavy mortality of the enslaved. An example is Alexander Garden, a Charleston physician and naturalist for whom the gardenia is named.  Garden served for several years as port physician in the 1750s. In this capacity he inspected arriving ships for signs of contagious diseases. This included slave ships. 

Garden was shocked by what he found. Many of them had lost as much as one-third to three-fourths of their "cargoes" during the voyage from West Africa. The ships on arrival were "so filthy and foul it is a wonder any escape with life.” (Image: JMW Turner, Slave Ship, showing sick slaves being thrown overboard, alive, based on the infamous Zong Case 1783)

Many Africans also died on the slave ships in harbor waiting to be sold. Their bodies were often thrown overboard into the Cooper River to save the cost of burial. In 1769, the royal governor published the following proclamation in the South Carolina Gazette:

"A large number of dead Negroes have been thrown into the river … the noisome smell arising from their putrefaction may become dangerous to the health of the inhabitants." The governor offered a reward to be paid on the conviction of those responsible  in hopes of ending this "inhuman and unchristian practice." [Image: Charleston harbor, c. 1770] 

It did not end. In 1807, the last year that the slave trade was legal, traders brought almost 16,000 Africans to Charleston in the last four months of the year alone. The local economy could not absorb so much "labor" in such a short time. Hundreds died of disease on the filthy ships while waiting to be sold.

In April 1807, The Courier reported on an inquest on the body of an African woman found floating in the harbor. The jury concluded that she died as a result of "a visitation of God," shifting responsibility to the Almighty. They "supposed her to belong to some of the slave ships in this harbour, and thrown into the river, to save expence of burial."

This was hardly an isolated incident. The newspaper's editor noted that such "burials" had become so common that something ought to be done to stop it. His great concern was the unpleasant thought that Charleston's citizens [whites] might eat fish from the harbor that had "fattened on the carcasses of dead Negroes."

Alexander Garden also treated many sick and injured Africans, of whom he wrote: "Masters often pay dear for their barbarity, by the loss of many valuable Negroes, and how can it well be otherwise -- the poor wretches are obliged to labor so hard ... and often overheat themselves, then exposing themselves to the bad air ... The result was pneumonia and other respiratory disorders, "which soon rid them of cruel masters, or more cruel overseers, and end their wretched being."

Further Reading: Peter McCandless, Slavery, Disease, and Suffering in the Southern Lowcountry (Cambridge and New York: Cambridge University Press, 2011, PB, 2014) Winner of the SHEAR Prize for Best Book on the early American Republic, 2012.

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Yellow Fever and Quarantine in Charleston, South Carolina

During the Covid pandemic, countries, states, localities faced a stark choice: should they restrict human interaction by restricting commercial activity and risk harming the economy? Or should they allow businesses to continue to operate as normal, thus endangering people's lives?

In cities heavily reliant on commerce, epidemic diseases have long posed an agonising dilemma. Closing a city to trade through strict quarantine threatens people’s livelihoods. Leaving it open, even partially open, threatens their lives. As was the case with Covid, both options had their advocates and opponents. 

Charleston, South Carolina, provides an instructive case study of this dilemma. From its foundation in 1670, this southern port was dependent on global trade. At the time of the American War for Independence in the 1770s, South Carolina was the richest of the thirteen colonies. Its wealth derived mainly from exports of rice, indigo, and after 1800, cotton. All of these crops were grown on plantations worked by thousands of enslaved Africans. The reliance on this labour source required regular imports of human cargo. [Image: Charleston Harbor, early 19th century]

As a commercial port, Charleston received unwelcome imports of another sort: diseases from Europe, from Africa, from the Caribbean, and other North American colonies. Some of these imported diseases were highly contagious and deadly, notably smallpox. One, cholera, was transmitted mainly through contaminated water. But nasty as it was, cholera did not arrive until the 1830s and was only an occasional visitor thereafter.

Other imported diseases were transmitted by insect vectors, particularly mosquitoes. The most important were malaria and yellow fever. At least two types of malaria were imported: vivax malaria from Europe and the deadlier falciparum malaria from Africa. Malaria became endemic in South Carolina from the early days of the colony. It flared up every summer and lasted into the late autumn or early winter. Malaria was generally a greater problem in the countryside than in Charleston, especially after about 1750.

Unlike malaria, smallpox and yellow fever were epidemic diseases. They were not an annual problem, but when outbreaks occurred, they could produce widespread terror and high mortality rates. Until the early 19^th century and railroads, yellow fever was largely confined to Charleston and other coastal ports because its vector, the Aedes Aegypti mosquito is a poor flier. Smallpox, by contrast spread widely into the countryside, wherever infected humans travelled. But it came less often than yellow fever.

How to prevent or minimize the effects of epidemics was always a contentious issue for the city’s leaders. It was complicated in the case of yellow fever by difficulties of diagnosis and conflicting views of how it spread. One view was that it spread through the air, through miasmas, or bad air. Another was that it was contagious, passing from person to person. Neither view was correct. The role of mosquitoes in transmitting yellow fever was not established until 1900.

Miasmatists and contagionists differed over the best way to limit the spread of yellow fever. Miasmatists generally believed that disease-causing bad air was generated locally. Closing the port would do little to control the fever, they insisted. Contagionists viewed yellow fever as imported, mainly from Africa or the Caribbean. The best way to control it, they argued, was through quarantine measures. Ships coming from places where yellow fever was common or known to be present should be inspected by physicians. If found to be harbouring the disease, the ships should be ordered into quarantine. Crew and passengers should remain on the ships just outside the harbour or be removed to the pest house or quarantine station until they were no longer considered a danger. 

South Carolina erected the first of several pest houses on nearby Sullivan’s Island around 1707. Quarantine measures were the dominant way of controlling yellow fever, smallpox, and other epidemic diseases in the 18^th century. They were supported by most doctors.

Opposition to quarantine measures for yellow fever increased markedly after 1800. The change was undoubtedly connected to economic decline in South Carolina and Charleston’s sagging importance as a trading port. Interruptions of commerce became a more serious problem than they were in the 18^th century. Acknowledgement that yellow fever was present in a port could greatly reduce its seaborne trade and sharply curtail visitors and potential immigrants.  

Merchants, city leaders, and most doctors in Charleston became increasingly reluctant to declare the presence of yellow fever. They would first deny that a problem existed. When the problem became obvious, they denied that the disease was yellow fever but rather something less dangerous. When forced to concede that yellow fever was epidemic, they argued that quarantine measures would be ineffective, because the disease was generated locally through bad air.

The solution, these Miasmatists believed, lay in sanitary improvements. Eliminating sources of bad odours, cleaning the streets, removing organic wastes and offal, and providing clean water. These measures could have improved health in other ways, but they would have done little to stem yellow fever. 

In any case the city’s sanitary condition did not improve much before the early 20^th century, when yellow fever had already ceased to be a problem. One reason is that sanitary improvement was expensive and often collided with personal and property rights.

A miasmatic explanation of yellow fever, combined with attempts to deny the presence of the disease, had a clear economic advantage. It reduced disruptions to seaborne commerce. Imposition of quarantine measures was delayed, limited, or altogether avoided. 

The fact that most of the victims of yellow fever were “strangers” -- visitors and immigrants, mainly Irish and German – may have made that choice more palatable. It also reduced the number of immigrants, which some locals did not much mind. Charleston's reputation as a yellow fever hotspot for foreigners is one reason why it did not receive as many immigrants as New York, Boston, and Philadelphia.

In 1840, Dr Benjamin Strobel of Charleston wrote a highly controversial essay on yellow fever. He accused commercial interests, boards of health, and the medical establishment, of endangering human lives. Worse, he charged them with "exploiting public ignorance" to rouse opposition to quarantine. The very people who would benefit from a strict quarantine were among its most vociferous opponents. [Image: Benjamin Strobel, 1803-1849]

Strobel demonstrated that yellow fever usually broke out and was heavily concentrated in areas of Charleston closest to the wharves and where sailors and immigrants lodged on arrival. He avoided the thorny issue of contagion. Instead, he argued that yellow fever was somehow transmissible. And he was sure it had been transmitted to the city from ships. He was ostracized for his efforts and left town.

In the 1850s, several lethal epidemics coincided with the opening of a steamship link with Havana, Cuba, a port notorious for endemic yellow fever. In the wake of these outbreaks, support for quarantine measures grew, with a Citadel science professor, William Hume, leading the charge. Hume had been an advocate of miasma theory, but his research convinced him that yellow fever was imported, mainly from the Caribbean. His ideas did not receive a warm welcome either. 

Yellow fever was absent from Charleston during the Civil War. Probably not coincidentally, thanks to the Union blockade, so was most seaborne trade. The last documented epidemic in the city occurred in 1877. How much the retreat of yellow fever owed to stricter quarantine is difficult to say. The decline of the port’s seaborne trade after the war may have been more important. Yellow fever continued to strike busier southern ports hard, notably New Orleans, which suffered the last epidemic in North America in 1905, and the region around Memphis, scene of the worst epidemic in the USA, in 1877. 

Yellow fever in the 19^th century South, as Margaret Humphreys has stated, “was above all, a commercial problem.” And sometimes, local authorities chose the health of commerce, as they saw it, over the health of the people. 

Further reading:

Peter McCandless, Slavery, Disease, and Suffering in the Southern Lowcountry (New York: Cambridge University Press, 2011)

Margaret Humphreys, Yellow Fever and the South (Baltimore and London: Johns Hopkins University Press, 1992)







  

Coronavirus, Quarantine, and Contagion: A Historical Perspective

The spread of Covid-19, or coronavirus, has led many countries and localities to resort to quarantine as a mechanism to contain this new disease. Medical isolation, as quarantine is often called today, has a long history, and its use owes little to modern medical science. 

Examples of isolation of the sick can be found in the Bible, in the Islamic World from the 7th century, and in medieval Europe. Interestingly, most of the quarantine measures currently being used to contain or delay the spread of coronavirus have been used for centuries or longer.

The practice of isolating people with diseases in the past, as today, was based on the belief that the sick were contagious: that they could infect the healthy. That was correct for some diseases, but not others. Even among those that were contagious, some were much less contagious than others. For this reason, contagion theory was controversial until the role of microbes in many diseases was firmly established in the late 19th century. Before then, contagionists could seldom demonstrate how diseases could be transmitted from person to person (or animal to animal).

Diseases transmitted by mosquitoes, like yellow fever, or by contaminated water, like cholera, complicated things for contagion theory. Opponents of contagionism pointed out that people in close contact with the ill often remained healthy, while people who had no such contact contracted yellow fever or cholera.

Contagionism's main competitor until the establishment of germ theory was the miasmatic theory. Miasmatists believed that most diseases were conveyed in the air, through miasmas, or "bad air" ("mal aria" in Italian). Marshes and swamps were considered to be major sources of miasmas, as was rotting organic matter, including human and animal wastes. In the late 18th and 19th centuries, the miasma theory gained many adherents, partly because the growing, unsanitary, and often polluted urban areas produced powerful, obnoxious odors. The miasma theory was wrong but it often led to draining of marshes and the implementation of sanitary reforms that reduced disease mortality.

In the 19th century, however, many traders used miasma theory to oppose quarantine, which could literally shut down ports for weeks or months. They argued that the source of the disease was not incoming ships or people, but miasmas generated locally by unsanitary conditions. 

As is the case today, a concern for health competed with a concern for the economy. As Benjamin Strobel, a Charleston, South Carolina doctor, wrote in 1840: "Truth and justice have been too often sacrificed to expediency and policy, and never more so than in reference to yellow fever. Has it not occurred, when the disease actually invaded us, that there were men who, regardless of the lives of others, and listening only to the sordid suggestions of avarice, have endeavored to conceal the fact?" (Benjamin B. Strobel, An Essay on the Subject of Yellow Fever, Intended to Prove its Transmissibility, Charleston, 1840, p. 9).

The term "quarantine" derives from the Italian phrase, quaranta giorni, meaning forty days. From the time of the Black Death in the 1340s, the Italian city-states took the lead in what we would call public health. 

During plague epidemics, 15th century Venice began to enforce forty days' isolation on ships entering the port. Passengers and crew could not disembark until that period had ended with no cases appearing. Passengers stranded on cruise ships where coronavirus has broken out will understand what a terrible prospect that was. And modern cruise ships are far more comfortable and clean than ships of the past.

Other ports imitated Venice, and quarantine was later applied to other diseases such as smallpox, yellow fever, and cholera (from the 1830s). The length of quarantine then and since has varied, and is usually shorter than 40 days.

From the 15th century on, many ports created quarantine stations for isolation. These were sometimes on ships, on islands in or near the harbor, or on the mainland at a distance from highly populated areas. Some were old leper hospitals, often know as lazar houses, after the biblical parable of the beggar Lazarus. The stations established to quarantine for plague were often called lazarettos or pest houses -- "pest" coming from the French for plague, la peste. Venice established the first lazaretto in 1403 on one of the nearby islands. (Below: one of Venice's lazarettos and that in Ancona, also in Italy).

The oldest surviving quarantine station in the United States dates from 1799. and is near Philadelphia (below). American ports began establishing pest houses about a century earlier.

Inland localities have often used a cordon sanitaire to restrict movement of people in and out of a town or region, where an epidemic was underway. The authorities close off the access points to and from the place to prevent infected people from spreading the disease. In effect, the whole population inside the cordon was quarantined.

Sanitary cordons were a common measure used to prevent the spread of cholera in the 19th century, and are being used again to curb or slow the spread of the coronavirus. China has used them in the city of Wuhan and Province of Hubei during the current coronavirus outbreak. Italy has cordoned off some towns in the North ("lockdown"), then the North as a whole, and now the entire country.

In most cases where a cordon sanitaire has been used, communities have been isolated against their will. But in at least one famous case, in 1665, the inhabitants of a village agreed to cordon themselves off to protect neighboring towns and villages. In that case, the disease was plague. The village was Eyam in Derbyshire, England. The isolation lasted more than a year and killed at least 260 people, possibly more than half the residents who remained. But the disease did not spread beyond the parish boundaries.

During major epidemics, public facilities for quarantining and caring for the infected often became overwhelmed. Authorities often commandeered private houses or other buildings as temporary pest houses or hospitals for the specific disease, such as plague, smallpox, yellow fever, etc. The image below is of a pest house and plague pit in London's Finsbury Fields. The image dates from 1865 but depicts an earlier period, probably the Great Plague of London in 1665. The plague pit next to the pest house can hardly have been reassuring, but the case mortality rate from plague ranged from about 60-90 percent.

Today, many countries are trying to combat the spread of coronavirus by urging people who think they may be infected or are especially vulnerable, to self-isolate at home. Authorities did the same in earlier times, especially during plague epidemics from the 14th century. The isolation was seldom voluntary. Families were often forcibly shut up when one or more became infected. This could be a death sentence for all of them. Daniel Defoe provides a harrowing description of their suffering in A Journal of the Plague Year (1721), a fictionalized account of the Great Plague of London in 1665.

In conclusion, most of the quarantine measures used today have historical parallels. Just as in the past, quarantine may prove more successful in some places than others. We may have the advantage of a better understanding than our ancestors of how many contagious diseases spread, but in the case of coronavirus, we are battling a microbe that is new and somewhat mysterious.

Slavery, Disease, and Suffering

“offers an unparalleled look at the early history of Charleston and the economic region of which it was a part. Focusing on the close relationship between the pursuit of wealth and the risk of death, McCandless forces readers to reassess the economic, demographic, and moral foundations of South Carolina’s past. A riveting, if sobering, work by a masterful historian.”  
Peter Coclanis, University of North Carolina – Chapel Hill, author of Shadow of a Dream

“compassionate, compelling history ... Peter McCandless writes with wisdom and humanity, inspiring us not just to think differently about the past, but also to ask how similar forces are shaping the world today.”  
Elizabeth Fenn, Duke University, author of Pox Americana

“This meticulously researched and smoothly written book provides the first comprehensive history of the Carolina lowcountry’s ferocious disease environment. It navigates masterfully among social, economic, cultural, religious, demographic, military, and medical history, from the 1670s to the Civil War, exploring every aspect of the deadly struggles with malaria, yellow fever, and smallpox.” 
J. R. McNeill, Georgetown University, author of Mosquito Empires

“McCandless does more than provide sound and accessible medical history. He adds an important social and economic twist. The knot that he deftly ties between slavery, disease, and the Lowcountry environment has devastating and lasting implications that stretch far beyond South Carolina. McCandless is quick to absorb and ponder the irony that the continent’s least healthy place swiftly became its wealthiest. Rice, indigo, and then cotton yielded huge profits to a tiny minority of intermarried merchant and planter families, while “most of the population experienced pestilence without prosperity.” Peter Wood, Duke University, author of Black Majority. 

In Slavery, Disease, and Suffering in the Southern Lowcountry, Peter McCandless paints a startling portrait of the troubled and troubling history of disease in the South of the United States from the colonial period to the first half of the nineteenth century....Due to his impressive grasp of a variety of sources, McCandless uncovers the problematic reporting of disease and the convoluted ways that Southern physicians often misdiagnosed illness. This analytical move elevates his book from a mere survey of sickness in the South to a sophisticated evaluation of the representation of disease; Slavery, Disease, and Suffering in the Southern Lowcountry can thus serve as a primer on how to research the history of public health before the microbiological revolution." Jim Downs, Connecticut College, author of Sick from Freedom: African American Illness and Suffering During the Civil War and Reconstruction 

Link: Slavery, Disease, and Suffering