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Revisioning smallpox (ver. Apr. 13, 2000

Revisioning Smallpox, ver. May 17, 2000

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“Revisioning smallpox in Mexico City-Tenochtitlán, 1520-1950:

What difference did charity, quarantine, inoculation and vaccination make?”

Robert McCaa, University of Minnesota

Large bumps spread on people, some were entirely covered. They spread everywhere, on the face, the head, the chest, etc. [The disease] brought great desolation; a great many died of it.

1.1. Smallpox first erupted in Mexico Tenochtitlán, the ancient capital of the Mexica, in 1520. While the siege and conquest of the City by Hernán Cortés’s army and his native allies took less than four months (April 28-August 13, 1521), conquering smallpox took more than four centuries. In 1950, the City’s last smallpox deaths were recorded, four years before the virus was permanently eradicated from the Republic of Mexico, and almost three decades prior to its extinction from the planet. If mortality from any single smallpox epidemic in the City was never as great as Cortés’s murderous siege of 1521, over the centuries periodic eruptions of the disease killed thousands, even tens of thousands, often in a matter of weeks. Total smallpox deaths over the intervening 430 years probably exceeded those caused by the many invasions, wars, rebellions, and revolutions which afflicted the City.

1.2. Almost every Mexican school child can recite the dates of the nation’s major wars, but the chronology of smallpox in the City is not well known, even by historians. Likewise much of the history of the numerous, heroic efforts by City authorities to contain, prevent, and, finally, eradicate the disease remains to be written. The story of the virus in the City reveals much about the evolution of notions of charity, the nature of charitable initiatives, the class and character of the beneficiaries, and ideologies concerning public health.

2.1. Chronology. The first smallpox epidemic to strike the City is precisely known because in ancient times the disease was completely alien to the Americas, until introduced, inadvertently by Christians or their vassals, to the Caribbean in 1518. Almost two years passed before the disease spread to the Aztec capital, Tenochtitlan. Indian auxiliaries from Cuba accompanying an expedition to capture the rebellious Cortes provided the reservoir. Spanish chroniclers, aware of the foreboding omen for the native populations of the appearance of the pestilence on tierra firme, precisely identify the disease’s leap ashore in May 1520. The agent of transmission was one Francisco Eguia, a Black slave. The desultory spread of this virgin soil epidemic from the coast to the Mexica capital is surprising. Some four months were required to traverse a distance of 400 kilometers—over what must have been frequently traveled routes. Finally in late September or early October 1520, the smallpox plague erupted in Tenochtitlan. Transmission of the virus was, once again, by natives because the outbreak began at least two, but more likely three, months after the deadly flight of the Spanish invaders from the City on “noche triste,” June 30, 1520. In that battle, all captured Christians were sacrificed without delay. Therefore, months later when the epidemic erupted in the City itself, none were still alive to aid in containing the disease or caring for its victims, should any have been inclined to do so.

2.2. A native chronicle written in Nahuatl provides the best description of this first smallpox outbreak in the City:

It began in Tepeilhuitl [at the end of September according to the contemporary Spanish gloss]. Large bumps spread on people, some were entirely covered. They spread everywhere, on the face, the head, the chest, etc. [The disease] brought great desolation; a great many died of it. ...

The disease of the pustules lasted a full sixty days; after sixty days it abated and ended. ...

It broke out in Teotl eco, and it abated in Panquetzaliztli. The Mexica warriors were greatly weakened by it.

2.3. For most historians, a crude Darwinism explains the greater devastation of native peoples attacked by virgin soil epidemics, such as that of 1520. The conventional argument made by many historians of the early Americas is that natives lacked genetic immunity against the disease. Yet among geneticists and immunologists the notion that Europeans enjoyed genetic immunity against the smallpox virus remains an unproven, even unproveable, hypothesis.

2.4. Was the greater destruction a matter of genes or care? Epidemiology may offer a means of resolving this conundrum. Since dehydration often leads to death in poorly-treated fever-causing viral infections such as smallpox, virgin soil mortality is heightened by the fact that adults, who might provide fluids, care and comfort for what is normally a childhood affliction, are themselves often deathly ill. Upon first exposure to smallpox, all adults—including Mexica warriors, according to the Nahuatl texts—as well as children succumbed to the disease. Mortality was unusually high due to a lack of healthy adult caregivers to provide water, food, or even a comforting word.

2.5. Chroniclers, native and Spanish alike, lament that the first epidemic was so great that there was no one to provide care, or even prepare tortillas, the staple of every Mexica meal. Unfortunately tortillas must be prepared fresh, otherwise they toughen and sour quickly if not consumed soon after preparation. Europeans enjoyed advantages, indeed, but they were above all epidemiological, rather than genetic. In Europe, the disease occurred with sufficient regularity so that most were afflicted in childhood. The immune systems of the overwhelming majority of survivors were tuned to successfully repel further infection from the virus. If genetic adaptation occurred, it was more likely in the DNA of the extremely short-lived, although highly stable, orthopox-virus than in much longer-lived humans.

2.6. In 1538, a second smallpox outbreak occurred in Mexico Tenochtitlán. The authoritative pictorial year signs for the City, the Codex “Telleriano-Remensis,” depicts a male and female adult pair with “spotted bodies”, their “closed eyes” signifying death. The accompanying Spanish gloss explains that in that year “many people” died of smallpox, as opposed to “a great many” in the epidemic of 1520. That many adults were also victims of the outbreak of 1538 suggests that the virgin soil epidemic of 1520 was not universal, even in densely settled Tenochtitlán.

2.7. Curiously, for the entire sixteenth century, there is only one additional reference to the disease in or near the City and that for an earlier episode in 1531/32. The native chronicler Chimalpahin, writing in Nahuatl almost a century after the fact, stated: “Also in this year the epidemic of smallpox [çahuatl] proliferated and they were small pustules from which died [many] children.” For 1532, he continues, “In this year there was a great die-off in Chalco because of the smallpox; many elderly died in Tlalmanalco and in all of Mexico.” Other contemporary sources, texts and native pictographs attribute the cause of this second, less devastating, pestilence introduced by the Christians to measles.

2.8. Throughout the sixteenth century great epidemics abound in the former Aztec capital, now renamed Mexico City, reconstructed, and increasingly Hispanized. Attributed variously to measles (zahuatl tepiton), mumps, cocoliztli (great pestilence), typhus (matlazahuatl), or multiple symptoms, which cannot be identified as specific diseases, smallpox is wholly absent from the list. Spaniards knew the smallpox scourge first-hand, from centuries of experience with epidemic outbreaks. Natives rapidly became familiar with the disease, coining, at first contact, the words “totomonalliztli” (pustules) and “huey zahuatl” (the great spots or leprosy) to identify it. Thus, there was little confusion among Spaniards or natives in recognizing an outbreak of smallpox. Then too, had there been further deadly eruptions of the disease it is unlikely that both chroniclers and authorities would have failed to seize the opportunity to attribute another massive die-off to the hand of god, rather than the hand of man.

3.1. Epidemic smallpox. Historians of smallpox in Mexico see the disease recurring with great regularity, endorsing the interpretation of the distinguished eighteenth century German scientist baron Alexander von Humboldt. Humboldt wrote that after 1520 smallpox seemed to strike the capital every seventeen or eighteen years. In fact, after 1538, a prolonged respite of almost eight decades ensued, with the next great smallpox epidemic striking the City in 1615. The succeeding bout erupted in 1653, a lapse of almost four decades. Then, the baron’s rule seems to have taken hold. Over the next century and a half smallpox culled 5-10% of the City’s population every decade or two. Significant epidemics are recorded for 1663, 1673, and 1696, totaling five for the seventeenth century. Six outbreaks occurred in the eighteenth: 1711, 1733/34, 1748, 1761/62, 1779/80 and 1797/98.

3.2. Then, in 1804, Jenner’s vaccine became available in Mexico, thanks to a worldwide philanthropic expedition sponsored by the Spanish king Charles IV and led by a Spanish naval officer, Dr. Francisco Javier de Balmis. Popular acceptance of the new procedure was widespread, yet, after the first campaigns, vaccination was practiced intermittently, until a new epidemic threatened. From 1811 to 1825, City officials recorded only 33,736 vaccinations. To reward parents who cooperated with this increasingly desultory campaign small coins and even pastries were offered to obtain serum from the arms of their children.

3.3. Following the epidemic of 1797 in which widespread inoculation was resorted to for the first time, smallpox deaths were halved by means of, first, inoculation, then from 1804, arm-to-arm vaccination. The three greatest smallpox outbreaks of the nineteenth century (1804, 1829/1830, and 1840) struck down a few thousand children each, a minor fraction of the norm for the eighteenth century—notwithstanding the City’s continued demographic growth. From the late eighteenth century, each succeeding epidemic claimed fewer victims than the last, falling from over 14,785 deaths in 1779 to 7,147 in 1797 and 2,878 in 1840. City authorities understood the success of their efforts, explaining that in 1840 “the number of victims was much less than in prior invasions by the same illness.” Aid was organized block-by-block. Mass vaccinations were conducted with as many as 7,000 in a single week, as in 1839.

4.1. Endemic smallpox and vaccination. But deaths were not reduced to zero, and in the 1860s, a concerted arm-to-arm vaccination campaign funded by the municipality was begun to contain the disease. The policy of providing vaccinations free of charge was now made general. Vaccinations were to be conducted by trained city health employees. Since in Mexico the vaccine was maintained by arm-to-arm vaccination, the human reservoir had to be replenished every ten days or so. Beginning in 1864 Luis Muñoz, chief vaccinator of the City, instituted a program of paying one peso to as many as twenty-five mothers per month for the privilege of vaccinating and subsequently harvesting “good vaccine granules” from their babies. Dr. Muñoz’s report for 1864 reveals that the authorities knew exactly what they were about and what the benfits of the campaign would be:

The vaccine, more widely extended than inoculation had ever been, diminished in a considerable way the number of people at risk (“aptas”), and at the same time removed the reservoir (“focos”) of contagion which was necessary for the disease to thrive.

4.2 Thus, in the words for Dr. Muñoz, “in these parts the great epidemics of smallpox were seen to recede or disappear, and only small epidemics remained”.

4.3. This assessment was true only as long as vaccination did not languish, as Dr. Muñoz recognized. Unfortunately, in 1870, only 2,457 vaccinations were performed, and the number did not rise substantially in 1871. A killing epidemic got underway in January 1872 with 552 deaths in a single month attributed to the disease. The authorities immediately redoubled their efforts, vaccinating over 4,000 children in a few weeks. Vigilance continued with over 19,000 vaccinations in the following year, but the total for the entire decade still fell short of 100,000. In 1882, a municipal ordinance requiring mandatory vaccination of new-bornes by six months of age was enacted. The policy was instituted without public outcry or opposition—or full compliance, one must add.

4.4. Compliance was substantial, nonetheless, with over 30,000 vaccinations performed in the capital annually from 1894 to 1903. By the 1890s smallpox mortality in the City was pushed to insignificant levels. From 1892 through 1901 of 176,332 deaths recorded, only 0.9% (1,522) were due to smallpox. In 1903, compulsory vaccination was extended to the entire republic, and the following year deaths attributed to smallpox fell to 102 in the City. Thus, over the course of the nineteenth century, the disease was slowly transformed from epidemic to endemic, thereby greatly reducing smallpox mortality.

4.5. Smallpox remained in check as long as vaccination was nearly universal. In 1910, as revolution erupted on the northern border of the Republic, annual smallpox mortality in the City fell to a half-century low of 90. Then the figure began to rise, to 390 in 1911 and 429 in 1912. As warring and banditry worsened, migration increased and the instinct for survival overpowered charitable inclinations of both parents and public officials. In 1915, the last great smallpox epidemic in the City’s history erupted. Yet, it was a faint shadow of former bouts. From a weekly average of 10 cases (not deaths) over much of 1914, 18 cases were recorded in the first week of 1915, rising to 50 per week in March and 70 in April. Total deaths for the year surged by nearly one-third to 25,000, but smallpox accounted for only a tiny fraction of the increase. Hunger and typhus were the big killers in 1915. Three years later, when annual cause of death statistics for the City become available again, smallpox mortality had fallen to a mere 140 cases.

5.1. Eradication. In the 1920s, the battleground against smallpox became the states and territories, because migrants now accounted for most deaths from the disease in the Capital. Justification for a centralized final assault against smallpox was inscribed in the Constitution of 1917, which provided for a National Public Health Department charged with improving conditions throughout the Republic. This provision finally lay to rest the helter-skelter vaccination policies of state and local health authorities, which prevailed throughout the nineteenth century. The effort was aided by a shift from the dangerous human to safer animal vaccines. A laboratory to produce animal-cultured smallpox vaccine had already been established in 1915, following a half-century campaign to replace the dangerous arm-to-arm method introduced by Balmis in 1804. Arm-to-arm vaccination—tenaciously supported by the Muñozes throughout their careers, and defended until 1907 by the Mexico City medical establishment—was finally abandoned in 1919. Note that this was a mere two decades after the use of human vaccine was made illegal in England.

5.2. In 1931, there occurred a deadly surge in smallpox, with 15,003 fatalities reported for the entire republic. With this tripling of the annual average during the late 1920s, a new strategy was instituted. Mobile vaccination brigades were formed to be on constant alert to encircle and suffocate outbreaks before a more generalized eruption could spread. The goal became to eradicate smallpox from the entire nation, not by attempting the impossible task of vaccinating everyone, but rather focussing efforts on every instance of the disease, encircling all cases by means of quarantine and vaccinating all those who may have come into contact with the infected. Dr. Miguel E. Bustamante, who developed the strategy, commanded a bold troop of young doctors and nurses to respond to the first signs of an outbreak. Over the first ten years of the program, total deaths due to the disease declined by 90%, to 1,341 in 1940 for the entire Republic.

5.3. If the national effort was to succeed, an effective quarantine along the nation’s borders was also required. With the disruption of World War II, millions of Mexican guest workers migrated to labor-short factories and fields in the United States. Annual smallpox fatalities in Mexico doubled and then tripled, reaching 4,115 in 1942. In the capital, deaths rose from single digits to 64 in 1943—indirect casualties of war. Nevertheless, by war’s end, Bustamante’s mobile brigades had regained their effectiveness, and fatalities for the entire nation plunged to 54 in 1951. From that year, no further smallpox deaths have ever been recorded in Mexico City. In 1954, the last smallpox fatality in the entire republic was reported, two decades before it was extinguished from the planet. Meanwhile the Mexican national public health bureaucracy had grown enormously and its mission expanded to battle yellow fever, typhus, malaria, and similar threats to the general welfare.

6.1. Charity. Over the centuries the battle against smallpox led to new, more charitable attitudes toward public health and a shift from programs to alleviate suffering to prevention, and ultimately eradication, of the disease. The struggle was prolonged not for a lack of charitable impulses—on the contrary enormous efforts were made from the first years of Spanish rule—, but for a lack of effective means. Five phases may be discerned in this struggle: 1520, native methods; 1538-1779, curative; 1797, preventive by quarantine and inoculation; 1804-1882, reactive vaccination; 1882-1931, proactive vaccination; and 1931-1954, eradication.

6.2. The idea that ancient Mexico was exempt from severe epidemics, and thus had no notions of care against disease, is no longer sustainable. Pre-columbian Mexico was no paradise, as attested by the panoply of gods, remedies, incantations, and expressions for sickness, including pestilence, in the ancient Nahuatl language, iconography, pictographs and written records. Pestilence is recorded in year signs of the codices, such as the Telleriano-Remensis, but annals, narrative texts written down from oral accounts, provide a great many more details. The Annals of Cuauhtitlan are particularly informative on these matters because they report on a region, rather than a single town (altepetl), and are rich in apocalyptic events. “Depopulated because of pestilence” read the annals for five places (variously, towns, districts, or provinces) in the half-century prior to the Spanish conquest. Typhus, diphtheria and influenza have been suggested as possible causes.

7.1. Nahua treatments. The first phase of the battle against smallpox was limited to the outbreak of 1520, when the Nahua sought to fight the disease with conventional indigenous treatments for fevers and pustules. Only native remedies were available in Tenochtitlán because Spaniards, who might have provided aid in the same way that captured Christian crossbow-men were used to shoot arrows at their comrades, had already fled or were dead. For the Nahua, quarantine was a completely alien notion, but treatment or care for skin diseases was not. There are no sources to tell us exactly which remedies were attempted, but the exceedingly thorough historian of the conquest, Hugh Thomas, portrays a plausible scenario:

A special fortune-teller, a tlaolchayauhqui, was asked, as usual, to determine the cause of the new disease by observing the pattern of grains of maize or beans on a white cotton cloak. On this occasion he must have been baffled. The old remedies must have been tried: “The core [of the sore] is removed with a pine resin and squashed black beetles are spread there”.

7.2. What astonished the Nahua was not the failure of conventional remedies but the absence of care, not for lack of a caring impulse, but for a lack of caregivers. The testimony is direct, descriptive, and despairing:

Before the Spaniards appeared to us [again], first an epidemic broke out, a sickness of pustules. They could no longer walk about, but lay in their dwellings and sleeping places, no longer able to move or stir. They were unable to change position, to stretch out on their sides or face down, or raise their heads. And when they made a motion, they called out loudly. The pustules that covered people caused great desolation; very many people died of them, and many just starved to death; starvation reigned, and no one took care of others any longer.

7.3. The accompanying pictures, drawn by native artists a half century after the event, seemingly contradict the text. They show a native woman caring for five prostrate, pockmarked adults. The ill show great pain, despair, or resignation as they lie on petates of plaited rushes and pillows of folded cotton mantas, wrapped in large cotton blankets. Portions of upper torsos and faces are visible. One is crying out, attempting to pull herself from the mat. A second, seemingly near death, is tightly wrapped from neck to feet, but the ominous signs of the pocks are visible on her toes. The caregiver, with grave assurance, tenderly succors a third with her bare hands and soothing voice. Unfortunately her speech goes unrecorded.

7.4. Perhaps the written testimony that “no one took care” should not be taken literally. Or perhaps the pictures reflect care giving as practiced in a subsequent bout with the disease, such as in 1538. What is certain is that care changed as natives quickly adopted Spanish cultural techniques, honed by centuries of experience with the pox. Natives were taught to prepare themselves for the eruption of the pustules. Once erupted, they were comforted, given water, food, and blankets, and cautioned not to bath or scratch until the scabs had fallen away.

8.1. Christian charity. Practices of Christian charity were also introduced from earliest times, providing not only the sacraments, but also water, food, care and solace. Sahagún observed that, since an entire household would often fall ill at a stroke, “there was no one who could give even a jar of water . . .and knowing this the religious walk house to house providing confession and consolation.” In the matlazahuatl epidemic of 1576, Viceroy Martin Enriquez encouraged Spaniards to distribute food, also by going house to house with no suggestion of distinction by race or reputation, class or color. Acts of charity are confirmed by annals, authored by anonymous native intellectuals. The most prolific is for Tlatelolco, twin city of Tenochtitlán, with four references over the sixteenth century of aid campaigns by religious and secular officials, two where food was given “in our homes,” including the provisioning of meat on one occasion.

8.2. These annals also reveal the beginnings of grand religious processions and public prayer. The procession of the Virgin of Remedios, first recorded in 1575, became favored for smallpox epidemics in Mexico City. Her intercession was sought throughout the seventeenth and eighteenth centuries. In the last great outbreak of the colonial era, 1797-98, three processions were organized: la Virgen de los Remedios (week 10 of the epidemic), Santísimo Christo Renovado de Santa Teresa (week 11) and finally, la Virgen de Guadalupe (week 13), for which the Viceroy ordered an eight day holiday. The processions in 1797 came as the disease peaked and then declined as shown in Figure 1.

Figure 1 near here

8.3. Although Totlaçonantzin (“our precious Mother”, as Our Lady of Guadalupe was called in the Nahuatl) had long been a revered symbol of the native born, Creole and Indian alike, it is noteworthy that this was the only time that she was called upon to succor her people from smallpox. While it was 1531 when she first appeared to the “humble commoner” Juan Diego (according to the most authoritive source although written over a century later), it was not until 1544 that her miraculous powers against epidemics, a great plague, or cocoliztli, were proven. Indeed, this is her only intercession against epidemics of the miracles recounted in the classic account of her many miraculous appearances, published in 1648. The account for 1544 reads in part:

The precious friars gathered a great many children, female and male, who had just reached the age of six or seven; they went along flogging themselves. … As soon as they arrived at her churchly home, the friars offered very many prayers. And God the giver of life willed that through the intercession and prayers of the compassionate personage, his precious, revered mother, the epidemic would begin to subside. The next day, not many people were being buried any longer, and finally perhaps two or three people as the epidemic came to an end.

8.4. Charity, both secular and religious, was made routine over the centuries, assisted by various institutions. By 1525, Hernán Cortes had erected the first hospital in the City. Twelve were in operation by the beginning of the nineteenth century. During crises, whether due to famine, flood, or epidemic, the number of hospitals often doubled or even tripled as public and private quarters were converted into temporary shelters for the afflicted. In 1612, the Junta de Policia was established and charged with the organization of charitable relief and quarantine efforts. In 1646, the doctors’ guild, the protomedicato, was founded. As in Spain, the protomedicato certified doctors and pharmacists for practice and acted as medical counsel to the city government and the viceroy.

8.5. Over time, charitable relief became systematized, better documented, and probably greater in scope. In the matlazahuatl epidemic of 1737, the viceroy allotted four doctors and six druggists to provide medical assistance to the poor at a cost of 43,661 pesos. For comparison, wages of an ordinary worker amounted to a peso for four days labor when paid in cash, or four marks (rayas) in a patron’s account book when paid in kind. Thus charitable expenditures for 1737 was equivalent to remuneration of over 150,000 workdays, in a city that numbered fewer than 100,000 inhabitants.

8.6. In the campaign of 1779-80 expenditures more than doubled the previous record, even though the population had scarcely grown. Donations were collected entirely from individuals and corporations. According to the official report, $109,355 pesos in medicine, food, clothing and other assistance were distributed to 38,461 people who fell ill with the pox. 14,785 died in the epidemic. Some 2,000 of these were felled before the charity campaign began. Another 3,000 died beyond the purview of the councils. An unspecified number of fatalities occurred among the 8,332 City residents who did not require charitable assistance. Within the City, which numbered 105,000 inhabitants according to an archbishopric census taken earlier that year, more than one-in-three fell ill (36.5 percent) and more than one-in-eight died.

8.7. The authorities blamed their relative lack of success on the extraordinary indigence of the vast population of the City. In comparison with any European capital, “here one sees an infinite number of people, unfortunately, who in good health do not have a shirt to wear or a bed to rest in”. These enormous losses notwithstanding, the campaign made a difference. On the outskirts of the City, where no public assistance was provided, the case fatality rate exceeded twenty-five percent, one-third greater than for the City proper.

9.1. The “1797” epidemic. Seventeen years later, the greatest campaign against smallpox in the City’s history got underway on October 26, 1797. The pestilence—still epidemic rather than endemic after one-quarter of a millennium in the circum-Caribbean—entered the viceroyalty of New Spain, in March 1793. From the beginning authorities fought the disease relentlessly, as did Viceroy Marqués de Branciforte, upon his arrival in New Spain two years later. He meticulously plotted the course of the disease, issuing precise orders on quarantine, inoculation and the collecting of information. The disease spread slowly, thanks to draconian efforts at quarantine. In a great roundabout, from Campeche on the southeast Gulf Coast the pox moved haltingly through Chiapas (1794) and then south to the Pacific Coast (1795), before crossing the Tehuantepec peninsula and turning north toward Oaxaca (December, 1796) and central Mexico (1797). This was the longest, most sustained battle to contain any epidemic in two and one-half centuries of Spanish rule, but ultimately the effort failed. In late August 1797, several cases of smallpox appeared inside the confines of the capital. Inoculation, first approved by the Viceroy on February 28, 1797 and again on August 10, began en mass in September for the first time in the City’s history. Over 3,000 were inoculated in six weeks, with only a handful of deaths.

9.2. Finally, on October 26, 1797, Branciforte ordered the mobilization of Councils of Charity, block-by-block as in the 1779 campaign. By the epidemic’s end three months later, 127,894 pesos in aid had been collected from private sources and distributed to 44,516 infected needy, of whom “only” 7,147 died. This figure was one-half that of the previous crisis. Branciforte was pleased as were the City authorities, and, one imagines, the thousands of citizens who participated in the campaign, as well as parents whose children survived.

9.3. Initially, the Councils of Charity garnered the credit for the success. Indeed, the final report recommended that in future epidemics Councils be established at the first sign of an outbreak. However by 1814, inoculation was credited with the major role in reducing mortality in the 1797 outbreak. This was the unanimous opinion of Mexican medical historians, until a few years ago, when Dra. Rodríguez de Romo began to question the efficacy of both care and inoculation in the outbreak of 1797. She argues that the statistics are woefully inadequate, and perhaps deliberately distorted. I too doubted the efficacy of inoculation, not only for Mexico in 1797, but for most times and places. The research for this paper, however, has forced me to accept at least partially and reluctantly, the conventional wisdom on the role of inoculation, with the twist in my view that inoculation broke the quarantine and helped spread the disease.

9.4. The fact remains that there were more than half as many deaths in the 1797 episode than in 1779—7,147 to 14,785, according to more reliable counts derived from parish books. The Council’s figures of only 4,451 make the picture look even better, by including, in the numerator, only deaths among those who actually received assistance, and in the denominator, all people who received assistance whether they were infected or not. Rodríguez de Romo spies deliberate deception in these figures. In contrast, the 1779 report, although incomplete in many respects, refers simply to “contagiados” and “muertos”, yet it, as well as the latter report, omits smallpox deaths occurring before the initiation of the charity campaign as well as those occurring beyond the Council’s jurisdiction. Contentious as these data may be, there is a persuasive coherence among the various sources, including eye-witnesses to both tragedies who express no doubts that fewer deaths occurred in the latter.

9.5. Inoculation was important in saving lives in 1797-98, as we shall see, but the case for care is more difficult to make. Cooper, Price and Rodríguez de Romo question whether care was effective in the battle against smallpox. Since no cure for smallpox was ever developed, their skepticism is warranted and their conclusions are supported by a regression analysis of data on assistance for the city’s 173 districts. Although 75% of the variance in survivors from one block to another can be explained by expenditures on three items (food, clothing, including blankets, and medicine, but not expenditures on doctors) the finding is spurious. The Council seems to have allocated its resources on an entirely laudable basis, that is per capita—with some distinction as to reputation (calidad) and class, as noted in the report itself. An analysis of assistance per capita reduces the correlation from 75 to 5%. Although this model is statistically significant (P<.04), none of its effects are. This finding is all the more surprising because survival rates at the block level varied considerably (from 73 to 98%), as did average assistance (from 0.6 to 8.8 pesos per “sano”). If we accept the Council’s judgment, the smaller number of deaths in 1797 was due to greater, more timely assistance, but the regression equation points to a saving of fewer than 400 lives from this enormous mobilization of charity. Perhaps the Council’s assessment was based on a comparison with the 1779 campaign or on an intuitive appraisal of what happened within the City and without. Care provided comfort and showed great compassion, but it does not seem to have affected levels of survivorship at the block-level, by any considerable degree.

10.1. Inoculation. Inoculation made a difference, but its direct impact is easily exaggerated. While inoculation reduced the likelihood of dying by 90 percent, the procedure was voluntary and in a City of 100,000 only some 3,000 individuals availed themselves of the prophylactic. Had all susceptibles been inoculated, total deaths would have fallen from thousands to hundreds. Since the case fatality rate for “natural” smallpox in 1797-98 was ten percent, inoculation directly saved fewer deaths than care (270 lives versus 400; for the former [[.1-.01]*3000]=270), leaving 7,000 avoided deaths unexplained. The success rate for Mexico City is similar to that for Boston in 1752, when the fatality rate among the 2,124 who were inoculated was 1.4%, compared to 9.7% among the 5,545 who fell ill in a natural way. The difference is a matter of scale. Mexico City’s immunologically naive population was ten-times greater than Boston’s.

10.2. Inoculation may have had an indirect effect as well. An artificially assisted (or induced) epidemic seems to have reduced the malignity of the natural pox. In south-eastern New Spain (Chiapas), where statistics were even more carefully recorded, the direct saving of lives was many times greater than in Mexico City because three times as many people were inoculated. While the natural death rate was twice as great in the Southeast, it was half the figure for the epidemic of 1780. Moreover in Chiapas, susceptible adults, whose natural death rate was higher than for children, were most likely to be inoculated. A regression analysis of the Chiapas data explains half the reduction in mortality at the village level as due to the indirect effects of inoculation. The unexplained remainder might be attributable to the reduced malignancy of the outbreak. Unfortunately detailed statistics on inoculation do not exist for Mexico City so no further analysis is possible.

10.3. The City of Durango offers the sole example in Mexican medical history of general inoculation. Here too, inoculation was a success. Eighty-seven percent of the susceptible population (4,400 individuals) was inoculated in a matter of days, of whom about one percent died. Among those infected with the natural pox, the fatality rate was ten times as great. The risks for the few women who were pregnant at the time were, in contrast, horrifying. Of nine who were inoculated, one died and two aborted. Natural pox struck three. One died, and all aborted. Although the numbers are small, it seems that quarantine, rather than inoculation, would have been the less risky treatment for pregnant women. Indeed, effective quarantine would have been less risky for all.

It required the cruel stimulus of an epidemic to advance the cause of inoculation, not because of scientific opposition to the principle, but because of a certain fear of the common people...

10.4. Contrary to this epigraph, much opposition was based on principle and common sense, although few historians recognize this. The fact that inoculation saved lives in the outbreak of 1797 does not mean that this was the general rule. On the contrary, only during an epidemic was inoculation justified—two centuries of inoculationist propaganda notwithstanding. The rational choice was to delay the dangerous procedure (recall that one percent or more died from the treatment) as long as possible, that is, until the much higher risk of death from the natural pox was imminent. To undergo a one per cent chance of immediate death against a future unlikely risk is not a rational choice. The inoculationists (and later, unquestioning diseaseologists) played an epidemiological shell game, by focussing attention on the ten-fold advantage of mortality rates from the artificial versus the natural pox. The likelihood of dying from smallpox was not simply a matter of the advantage of artificial over natural exposure, but one of timing as well. Once exposure to natural smallpox was imminent, immediate, general inoculation was desirable. Otherwise one should forego the considerable risk of death from artificial pox. There are lessons here for the use of dangerous prophylactics in our own time.

If there be anything that can counteract the effects of agreeable rhetoric, it is perhaps statistics.

Figure 2 near here

11.1. Quarantine. The more serious objection to the artificial pox from the public health view is that it broadcast the natural pox, unless stringent quarantine was imposed. Critics of inoculation understood both these points. The pre-eminent Spanish medical authority of his day, Francisco Gil, affirms as much in his Disertación (paragraph 42; republished in Mexico City by Viceroy Branciforte in 1796): “I am not opposed to inoculation, if it is administered with the necessary precautions.” Gil argued that “inoculation propagates the pestilent effects of smallpox, if exact measures are not taken to quarantine both the natural and artificially infected.” He correctly cited that the successful experience in Vienna was precisely based upon inoculation with quarantine. Turning to London, Gil cited evidence from the Bills of Mortality (paragraph 41) showing that a substantial increase in smallpox deaths followed the general adoption of inoculation in the City after 1747. His analysis was correct (and unnoticed), whatever the defects of the London Bills. The ratio of smallpox to other deaths for London over the eighteenth century follows an unexpected pattern (see Figure 2). Before 1747, that is, before inoculation became frequent (although never general), the ceiling for the nine-year moving average was 0.1 (one-smallpox death for every ten from all other causes). After the practice of inoculation became common and for the next half century, this figure became the floor. Only when vaccination displaced inoculation at the beginning of the nineteenth century, did a secular decline in smallpox mortality occur. William Heberden, from his study of the Bills published in 1801, concluded, “the inoculation of the wealthy keeps up a perpetual source of infection [in London]”. Benjamin Franklin, a witness to the 1752 epidemic in Boston, wrote, “they ‘spread the infection likewise more speedily among those who did not chuse Inoculation’”.

11.2. Inoculationist propaganda has distorted opposition to the procedure as a battle of empiricism versus dogma, enlightenment against ignorance, reason versus prejudice, modernism against antiquity, science versus religion, arithmetic versus theology, etc. While some opponents did at times base opposition to the procedure on one or more spurious grounds, authoritative objections were often based on a very important empirical principle of public health—one which inoculationists studiedly ignored. Raised by Gil and others, inoculationists refused to address the fact that inoculation spread the disease, unless it was accompanied by quarantine (much as the new experimental AID vaccines have been found to spread AIDS as well, although, unlike for the more contagious smallpox, AIDS requires a comingling of bodily fluids). The cost of a couple of weeks of confinement following inoculation could be borne only by the wealthy. Then too, general inoculation was impossible in large cities, such as London, Paris, Madrid or Mexico.

11.3. Inoculationists sought to evade or ignore increasingly stringent quarantine regulations in Europe as well as in the Americas. Boston’s first inoculationists, Cotton Mather and Abdiel Boylston, were criticized in 1722 by Dr. William Douglass for mischievously “propagating the Infection in the most Publick Trading Place of the Town”. The famous English inoculator Daniel Sutton was placed on trial in 1766 for igniting an epidemic by allowing his patients to roam at will. We know now that his defense, that artificial pox did not spread natural pox, was false, although he persuaded the jury otherwise.

11.4. In the case of Mexico City, Viceroy Branciforte rescinded the quarantine restriction on the doubly dangerous prophylactic on August 31, 1797, after months of lobbying by the medical establishment. The order permitted voluntary inoculation in the City without confinement. It is possible, indeed I think likely, that inoculationists actually accelerated the eruption of the disease in Mexico City, because some inoculatorsy worked in secret without quarantining their patients, days or weeks before the Viceroy finally relented.

11.5. An anonymous poem, “scurrilous verses” according to the authorities, alleges as much. Historians continue to misread opposition to the practice as unenlightened superstition. Note, however, that the author of this poem, as well as the opponents to inoculation within the Spanish medical establishment, appeal to evidence, experience, sight and empirical reasoning, not authority, religion, tradition or superstition. The verses read:

Inoculations have been invented by the most poor and needy doctors

…

One sees that the inoculated are infected

Unfortunate Mexico, one regrets that the poor doctors have infected you

With experience one sees the evidence for this

The very poor and hungry doctors who bring the smallpox have invented [inoculation].

12.1. General inoculation. A sympathetic account of this first “general” inoculation notes that those who benefited were the educated, the old aristocracy, the wealthy, bureaucrats, military officers and the medical profession. Although the authorities made a serious attempt to inoculate all groups, less than ten percent of the population was treated, absurdly short of a “general” inoculation. The viceroy’s order in a laudably libertarian, but epidemiologically indefensible, spirit insisted that inoculation was to be voluntary. Without quarantine, the order was a death sentence for one-in-ten of the susceptible population and a serious illness for the remainder.

12.2 “General” inoculation could not work in a dense, urban center, such as Mexico City, with it large mass of oppressed indigent. In Boston, an educated citizenry and a democratically elected town council could effectively regulate inoculation at least to a considerable extent. The first line of defense against smallpox was quarantine, a policy that enjoyed nearly complete support from the Boston citizenry. Inoculation was resorted to, only when quarantine failed. The procedure was voluntary, but those who elected to not be treated were warned to remove themselves from the City. In Mexico City, on the other hand, there was no warning. On the contrary, the “vulgar voice” viewed the authorities with suspicion as the following account by a block leader illustrates:

It is not easy to ascertain the number ill because many women assure that their children have already suffered from the pox, when this is not the case, only because of fear introduced by the vulgar Voice that by means of force their children will be taken from them to be inoculated, the well and the healthy, and to conduct the ill ones to the hospitals.

12.3. In the colony’s smaller towns and the countryside, inoculation could be relatively successful, as in Chiapas, Tehuantepec, and Durango, but not in the largest urban areas such as Mexico City, Puebla, Guadalajara or even Oaxaca.

13.1. Conclusion. With the introduction of vaccination into Mexico in 1804, inoculation was no longer an issue. Vaccination was neither life threatening to the patient nor contagious to others. Once vaccination was introduced, Mexican medical professionals immediately abandoned inoculation, and its use was recommended only as a measure of last resort, when an epidemic was imminent and no vaccine available. Vaccination was enthusiastically and almost universally accepted by all classes of people in all regions of Mexico. To completely eradicate the disease, however, unceasing vigilance by the authorities was required to smother the pox before it could erupt.

13.2. Unfortunately, with independence taxes proved difficult to collect, public resources were redirected to the political and military elite, and a certain malaise infected the City’s bureaucracy. This meant that thousands of its residents, mainly the children of the poor, died needlessly. In three decades, three large smallpox epidemics engulfed the city. Although none were as leathful as any of previous centuries, all could have been prevented by mass vaccination when an imminent outbreak was suspected. Finally with the epidemic of 1840 the lesson was learned that thousands of lives and hundreds of thousands of pesos could be saved by an annual allocation of as little as a thousand pesos for a City-wide vaccination program. The expensive charity campaigns of colonial times were never enough to succor the victims nor stem the spread of disease. Charity was at best a palliative to the poor—not a preventive. More effective was a couple of salaried vaccinators. Ultimately, compulsory vaccination, which became law in 1882, not only forced parents to protect their children in a timely way, but the same law forced authorities to provide ready, inexpensive access for all to a prophylactic that was less expensive than charity, less troublesome than quarantine, less deadly than inoculation, and more effective than all three combined: vaccination.

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Endnotes

� LOCKHART, We People Hear, p. 182.

� PREM, Disease, p. 24.

� There is much confusion among historians about the actual date of eruption in Tenochtitlán, although the native sources are completely consistent on the matter. The problem is that all eyewitness accounts are written in Nahuatl, and the cycle of months changes from year to year in the Mexica calendar. Then too, Nahua annals generally report the 20-day month in which events occurred, rather than a precise date. Finally, “[i]n the Nahua tradition of historical writing, it is the calendar that marches along step by step with no abbreviation or deviation, while actions that occur are individual episodes inserted somewhere in the framework” (LOCKHART, We People Here, p. 12).

Disease determinists favor Spanish sources (usually in English translation) which often ascribe the outbreak of the deadly scourge to the Christian god, who mercifully succored his chosen people in their darkest hour—a comforting myth that arose among the Christians decades after the event. Diseaseologists mistakenly claim that the pox entered the City as the Spanish and their native allies fled, on the “noche triste,” June 30, 1520 (McNEIL, Plagues and People, p. 2; OLDSTONE, Viruses, pp. 3, 32). CROSBY (Columbian Exchange, p. 48) telescopes these events with agreeable rhetoric and obscures the dating by giving voice to one of Cortes’s party: “‘When the Christians were exhausted from war, God saw fit to send the Indians smallpox...’” (perpetuated in COOK’s recently published Born to Die, p. 68). WATTS expansively places the outbreak between the noche triste and the fall of the City more than four hundred days later, on August 13, 1521 (Epidemics and History, p. 89).

The Mexican authority, Dr. Miguel E. BUSTAMANTE, narrows the window to sixty days, between noche triste and September 7, wholly discounting the testimony of the only source cited (La viruela en México, p. 68), which is reproduced here in paragraph 2.2. The translation of the annals of Tenochtitlan (Cronica Mexicanayotl) by the accomplished native linguist, Fernando Alvarado Tezozomoc, who wrote in Latin and Spanish as well as Nahuatl, does not date the epidemic, but his account narrows the chronological window. Alvarado Tezozomoc places the accession of Cuitlahuactzin to the rulership of the City on 16 September and his demise from pustules (“totomonalliztli”, “ampollamiento”) eighty days later, on the third of December (at the end of the month “Quecholli”; pp. 159-160). The epidemic lasted sixty days, according to native chronicles. If Cuitlahuactzin’s death came at the very end of the epidemic then the date of eruption would be the beginning of October, or, if stretched to ninety days, September at the earliest (McCAA, Spanish and Nahuatl Views). THOMAS dismisses as “extravagant” the notion that smallpox affected the outcome of the struggle for the City (Conquest, p. 741 n. 78). He favors late October (Conquest, p. 445).

� LOCKHART, We People Hear, p. 182.

� STEARN and STEARN, The Effect of Smallpox, p. 15; JENNINGS, The Invasion of America, p. 22; BUSTAMANTE, 400 años de viruela, p. 71.

� BLACK, Why Did They Die?, 1739; BIANCHINE and RUSS, The Role of Epidemic Infectious Diseases. Bustamante, an ardent advocate of the genetic immunity thesis, reiterates the fallacy in his publications on smallpox. The following is representative of his thinking: “Human beings isolated in America for thousands of years formed an immunologically autochthonous population, with factors of susceptibility and resistance different from those of the people of the Ancient World” (BUSTAMANTE, La viruela en México, p. 71).

JENNINGS crudely reduces the story to a matter of the survival of the fittest: “...the Europeans’ capacity to resist certain diseases made them superior, in the pure Darwinian sense, to the Indians who succumbed.” And, “smallpox was smallpox...the Indians on the north [bank of the Rio Grande] had as little biological immunity to this epidemic scourge as the Aztecs had” (The Invasion of America, p. 22). CROSBY is more restrained: “those creatures who have been longest in isolation suffer most, for their genetic material has been least tempered by the variety of world diseases” (Conquistador y Pestilencia, p. 322). The Stearns also discern evolution at work: “even in the nineteenth century when some immunity had already been acquired by this race...” (p. 15). Unfortunately genetic immunity has become standard fare in English language colonial Latin American history texts.

WATTS challenges the genetic hypothesis by citing examples of catastrophic smallpox mortality in Europe, such as Iceland and Foula Island (Epidemics and History, p. 102). GORODEZKY’s Genetic Difference is a technically sophisticated discussion of the battle between foreign antigens and T-cell receptors, but no direct evidence is presented regarding smallpox.

The contemporary relevance of the issue continues. The campaign to destroy remaining stocks of the virus (abruptly terminated when President Clinton ordered, wisely I think, their continued preservation) was motivated by the fear that should the virus escape, a great pandemic would ensue among an increasingly, immunologically naive global population (BARQUET and DOMINGO, Smallpox; OSTERHOLM Interview; PRESTON, Demon in the Freezer). If peoples of Old World origin developed genetic immunity is it so readily lost? McNEIL (Plagues and People, p. 8, 49) insists that both acquired and hereditary immunity is necessary to explain the heavy die-off.

� McCAA, Spanish and Nahuatl Views.

� QUIÑONES KEBER, Codex Telleriano Remensis, f45v, p. 236.

� CHIMALPAHIN, Relaciones, v.2:184-5. MOTOLINÍA describes it as measles (“sarampión”), transmitted by a Spaniard (Memoriales, p. 22):

Despues, dende a once años, vino un otro español herido de sarampión, y de el saltó en los indios, e si no que hobo mucho aviso que se les mandó y defendía, y aún se les predicaba que no se bañasen y otros remedios contrarios a esta enfermedad; y con esto plugó al Señor que no murieron tantos como de las viruelas; y a este también llamaron el año de la pequeña lepra, y al primero el año de la grande lepra.

� GIBSON, Aztecs, pp. 448-450; PREM, Disease; MARQUEZ MORFÍN, La evolución cuantitativa.

� STEARN and STEARN, Effect of Smallpox, p. 42.

� GIBSON, Aztecs, p. 448-450; MARQUEZ MORFÍN, La evolución cuantitativa.

� FERNANDEZ DEL CASTILLO, Los Viajes.

� AACM, vol. 3678, leg. 19, 20.

� CIUDAD DE MÉXICO. AYUNTAMIENTO. Manifiesto, p. 7; for 1779, see BNM Raros, Ephemeris astronómica, f. 141; AACM vol. 3680, exp. 67, 76.

� AACM Vacunas, vol. 4776, exped. 8

� MUÑOZ, Resumen de los trabajos, p. 18.

� AHSS, Salubridad Pública, box 1, exp. 51, Oficios de remisión del Gobierno del Distrito Federal al Consejo Superior de Salubridad, para aplicar las medidas pertinentes para contrarrestar una epidemia de viruela and box 1, exp. 29, Informe del Inspector General de la Vacuna Luis Muñoz, 27 de febrero de 1872. To combat ignorance and lassitude of parents (“ignorancia y flojera”), Dr. Muñoz employed roving vaccinators, paid them bounties, and required detailed records be kept for each child vaccinated, including, in addition to name, date, place of vaccination, name of parents and address, the origin of the vaccine (name of the child donor—essential to trace any cases of suspected transmission of syphilis), and, a detailed description of the reaction determined by a follow-up visual inspection 8-12 days later. Donors were selected with extreme care to prevent the inadvertent transmission of syphilis or other communicable diseases. These lists, many of which still survive in the archives, testify to the humanitarian and scientific spirit of Dr. Muñoz and his assistants. Dr. Muñoz received his lancet and lymph from his father, Dr. José Miguel Muñoz, in 1842, and was chief vaccinator in the City for thirty years. In turn, his father received “el grano vacuno y la lanceta” from Dr. Balmis in 1804 (MUÑOZ, Cartilla, p. iii).

� México, Boletin Demografico, p. 787.

� AHSS, box 5, exp. 2, Convención sanitaria internacional.

� PANI, Hygiene, p. 192; or 159 according to the Anuario Estadística, 1907, p. 27.

� AHSS, Salubridad Pública Epidemiología, box 11, exp. 1-2.

� AHSS, Salubridad Pública Estadística, box 10, exp. 27.

� LANDA, Apuntes; Fernandez del Castillo, La Viruela; BAXBY, Jenner’s smallpox vaccine, p. 180.

� BUSTAMANTE, La viruela en México; México, Anuario Estadístico, 1939, p. 177, 1942, p. 273.

� México, Anuario Estadístico, various years. The victory against smallpox in Mexico was officially declared won on June 12, 1952, but smallpox deaths continued to occur over the next two years, according to the Anuario Estadístico (1954, p. 86 and 1955-56, p. 89; BUSTAMANTE, La viruela en México).

� VELÁZQUEZ, Códice Chimalpopoca, pp. 58, 59, 60. Fr. Bernardino de Sahagún’s monumental ethnolinguistic encyclopedia of the Nahuatl contains two proverbs on great pestilences:

The sea, the conflagration. This saying was said when there befell a great war, or a great pestilence [vei cocoliztli]. It was said: ‘It is as if there came upon us, or there passed over us, the sea, the conflagration’—that is, pestilence [cocoliztli] or this same war (Sahagún, Florentine Codex, vol. 6, p. 244).

Our lord bringeth cold water, icy water, upon us. This saying is said of the time when our lord brings something upon us—affliction, pain, or sickness (cocoliztli), or famine. Then it is said: ‘our lord hath brought cold water, icy water, upon us. Our ears, our flanks have been tugged. Our lord hath pierced us, hath admonished us with that which is like a thorn, a bone awl (Sahagún, Florentine Codex, vol. 6, p. 254).

� VIESCA, Epidemiologia, 175-76;

� THOMAS, Conquest, p. 444.

� LOCKHART, We People Hear, p. 181-82.

� SAHAGÚN, Códice florentino, vol. 3, book 12, chapter 29, folio 53.

� CERVANTES DE SALAZAR, Crónica, p. 98; MOTOLINÍA, Memoriales, p. 22.

� SAHAGÚN, Historia General, vol. 3, p. 356.

� MONJARÁS-RUIZ, Obras, vol. 2, pp. 280-299.

� Gacetas de México, vol. 2, pp. 177-78.

� Although Cooper states that the Virgin of Remedios was not called upon in 1797, because of her poor performance in 1779 (Epidemic Disease, p. 142), there is contemporaneous archival evidence that the procession was held (AGN Epidemias, vol. 1, exp. 7, f. 502). In France, according to a comprehensive catalogue of saints, there were 123 for fevers, 85 for childhood illnesses, 70 for dangers of childbirth, 53 for plague, 27 for conjugal sterility, 20 for toothache, 18 for colic, 17 for rabies, 12 for leprosy and 10 for convulsions—but, apparently none specifically for smallpox (BROCKLISS and JONES, Medical World, p. 74).

� SOUSA, POOLE and LOCKHART, Story of Guadalupe, p. 39.

� Ibid., p. 96-7.

� COOPER, Epidemic Disease, p. 18.

� MOLINA DEL VILLAR, Por voluntad divina, p. 61.

� JUNTA PRINCIPAL DE CARIDAD, Noticia, p. 8.

� These are my computations from BNMR, Ephemeris astronomica, fol. 141; and AGI, Varios, vol. 38.

� WIDMER, Pólitica sanitaria, p. 73; McCAA, Inoculation.

� COOPER, Epidemic Disease, p. 106-131; PRICE, State Church Charity, p. 361; RODRÍGUEZ DE ROMO, Inoculación.

� COOPER, Epidemic Disease, pp. 86-147; Rodríguez de Romo, Inoculación.

� COOPER, Epidemic Disease, p. 147.

� Inoculación; the City’s Junta Superior was the first to credit inoculation with the major role (Instruccion formada, written in 1814, published in 1824), p. 14:

Si en la epidemia inmediata pasada de viruelas del año de 1797 se socorrieron por la Junta Principal de Caridad de esta Capital, como ocho mil enfermos mas que en la anterior del año de 1779, y en esta murieron un duplo mas que en aquella, debe atribuirse el buen éxito de la de 1797 (a mas de las activas providencias que por la Junta se tomaron, y el distinto tratamiento curativo) a la inoculación de la viruela, que aunque no adaptada generalmente por capricho y timidez, con todo se verificó una gran parte de lo principal de esta Capital, y aun en muchos pobres, ratificándolos para que se dexasen inocular...

Inoculation receives unconditional credit, contrary to the above citation, from the following authors: COOK (The Smallpox Epidemic of 1797), FERNANDEZ DEL CASTILLO (Los Viajes, p. 64), BUSTAMANTE (La viruela en México), COOPER (Epidemic Disease), LANNING (The Royal Protomedicato), and PRICE (State Church Charity), among others.

� RODRÍGUEZ DE ROMO (Inoculación) argues that the “sanos” figure for 1797 includes any that received relief, not simply those who were “contagiados” as in 1779. I am not persuaded, because the number of “sanos” in 1797 equals about one-third of the population of the City, that would have been born since the 1779 outbreak. PESCADOR’s detailed study of Santa Catarina parish leads him to label 1779 a “super-crisis” with 700 deaths, in contrast to the ordinary “crisis” of 1797 (Bautizados, pp. 98, 103).

� AGI, Estado 27, No. 38, Branciforte sobre extinción de la viruela en Mexico y PueblaCArta no. 598, 28/ii/798:

Es menester hallarse tan tocado, como VE. de la calamidad publica pa. percivir la dulce sensacn. qe. causan en el alma las ideas reunidas de muchos millares de infelices, que yaciendo en el olvido, en la oscuridad, en el polvo, y en la inmundicia de sus chozas, y pequeños reductos; repentinamte. fueron vuscados, sublevados, y auxiliados por los sacerdotes y primeros republicanos aqnes. se encomendo su cuidado, al abrigo qe. se daba a los unos, las medicians qe. se aplicaban a otros, los alimentos, y el aseo qe se procuraba en todos el pasto espiritual abundante, y los socorros [i.d. 59] que universalmte. se les entraban por las puertas, sin tener el trabajo de pedirlos: qe otra cosa habian de producir sino un agradable contraste de la miseria y de la abundancia, decidido al fin por el estremo mas favorable.

Con la gente de mas modo fue necesario otro govierno y tambien se hizo distincion de calidades y clases en la distribucn. de ropas.

� BLAKE, Public Health, p. 87.

� McCAA, Inoculation.

� ESQUIVEL, Sermon eucaristico, pp. 19-22.

� LANNING, The Royal Protomedicato, p. 372.

� CREIGHTON, History of Epidemics, vol. 2, p. 454.

� Observations, p. 36.

� BLAKE, Public Health, p. 86.

� For the inoculationist camp, none is better than the sophistry of MOREL’s Disertacion written to persuade the viceroy to permit inoculation in the City to combat the epidemic of 1779. The dissertation’s arguments were accepted but few people were inoculated. For examples in English, see the recent statements in: WATTS (Epidemics and Empire, p. 114: “During much of the eighteenth century, university-trained doctors steadfastly opposed inoculation” [and] “...continued to rely on the theories of the Ancients”); BROCKLISS and JONES, Medical World, p. 470-72: “The initial prejudice within the medical community to inoculation was perfectly reasonable. In a rationalist age, critics were understandably suspicious of a prophylactic that defended the patient by giving him a dose (albeit mild) of the disease, when there was no rationale underpinning the practice (which, to boot, was of Turkish origin).” RISSE, Medicine in the Age of Enlightenment, p. 190: “lower-class fatalism, fear of accidental contagion, and religious scruples based on the argument that the procedure attempted to interfere with God’s work, were all barriers to its popularization.”

For a reasoned assessment of the risks of inoculation, none is better than Francisco GIL’s Disertación (see paragraphs 40-42, 77, 84). In English, see HEBERDEN, Observations, p. 35 or the modern authority on smallpox, BAXBY, Jenner’s smallpox vaccine, p. 30. LANDERS’s assessment of the London Bills is more cautious: “The practice of inoculation in the capital itself may have reduced mortality among London-born children, but the evidence on this point is insufficient for any definite conclusions to be reached” (Death and the metropolis, p. 356).

� cited in BLAKE, Public Health, p. 57, emphasis in the original.

� SMITH, The Speckled Monster, pp. 44-5.

� COOPER, Epidemic Disease, p. 115.

� COOPER, Epidemic Disease, p. 131.

� COOK, La epidemia de viruela de 1797, p. 306.

� AACM Salubridad, vol. 3678, exp. 2, f. 2.