506 Journal of the Royal Society of Medicine Volume 77 June 1984 Rider Haggard and smallpox'

William A R Thomson MD FRCPEd

I am no Rider Haggard addict. Until last year the only one of his novels I had read was 'King Solomon's Mines' - more or less a stock item in the recommended reading of schoolboys of my generation. My memones of it are vague, which, combined with the fact that I did not read its sequel, 'She', suggests I was not unduly impressed by it. But before recounting my reintroduction to this prolific writer of fiction, perhaps I might be allowed to remind you of the salient features of one of the most fascinating episodes in the history of medicine, culminating in the consignment of one of the major killers all down the ages to the limbo of the past. At least, such is the hope that we all share with the World Health Organization. Smallpox, of course, as every medical student used to know in the good days when medical students were educated, not merely trained, is the small pox to distinguish it from syphilis, the great pox. One of the great killers from time almost immemorial, the procedure of protective inoculation, or variolation as it came to be known, probably goes back as far; though why it should have been introduced and, what is more important, practised, in those ancient days is one of the unsolved problems of medical history. The first recorded evidence of variolation dates back to the end of the sixth century AD - and, almost needless to say, China. Variolation was popularized, if not actually introduced, in this country by Lady Mary Wortley Montagu (1689-1762) (Figure 1), who had learned of the technique when her husband was our ambassador in what was then known as Constantinople. Though not without risk, Lady Mary was obviously a good saleswoman, and, after two carefully controlled clinical trials - one on six condemned criminals in Newgate Prison (offered their freedom if they survived, which they did), and another on six orphans - George I allowed two of his grandchildren to be inoculated a' la Turk. Variolation, however, was not without its hazards, and the whole outlook was changed by the publication in 1798 of Edward Jenner's classical 75-page report: 'An Enquiry into the Causes and Effects of the Variolae Vaccinae, a Disease discovered in some of the Western Counties of England, particularly Gloucestershire, and known by the Name of Cow Pox'. In this model clinical trial he demonstrated that cowpox could be transmitted artificially from one person to another, and that such vaccination, as it came to be known, provided effective protection against smallpox. Outside the United Kingdom Jenner's work was rapidly recognized and hailed as one of the outstanding contributions to the health of mankind, as admirably documented by Paul Saunders (1982) in 'Edward Jenner. The Cheltenham Years 1795-1823.' In Russia the first child to be vaccinated was christened Vaccinof and given a life pension by the dowager Empress. At home, however, Jenner was treated with despicable disdain by the medical establishment and the State. He never received a knighthood and he was refused a State funeral in Westminster Abbey. The only medical corporations that contributed to the memorial fund for a statue in Gloucester Cathedral were - to their lasting honour - the Edinburgh Colleges of Physicians and of Surgeons. Primary vaccination of infants was made compulsory, under penalty of 20 shillings, in 1853. In view of the persisting vocal criticism of it by a minority of the population, the 'Based on paper read to the Section of the History of Medicine, 2 February 1983. Accepted 24 March 1983. Dr Thomson died on 19 November 1983 0141-0768/84/060506-07/$01.00/0 0 1984 The Royal Society of Medicine Journal of the Royal Society of Medicine Volume 77 June 1984 507

Figure 1. Lady Mary Wortley Montagu (1689-1762) Figure 2. Henry Rider Haggard (1856-1925) Government set up a Royal Commission in 1889. This finally reported in 1896, its main conclusion being that vaccination 'diminishes the liability to be attacked by the disease ... modifies the character of the disease and renders it (a) less fatal, and (b) of a milder or less severe type'. During the passage through Parliament of the subsequent Vaccination Acts Amendment Act 1898, the howls of rage of the strident minority of antivaccinationists, the absurdity of whose claims was in inverse ratio to the proven value of vaccination, caused the Government to panic, and at the last minute include a 'conscience clause' whereby objectors could escape the provisions of the 1853 Act by making a declaration of conscience before a magistrate. This, as Parish (1965) has noted, was 'the first relaxation of compulsion, and was a retrograde step'. And this is where Rider Haggard came in but, before switching over, perhaps I may be permitted to complete the story of vaccination. The 1898 Act was followed by a drop in the number of infants vaccinated annually, from around 80% to 71% in 1901. The Vaccination Act of 1907 allowed parents to make a statutory declaration that they were opposed to vaccination on conscientious grounds, without all the rigmarole of satisfying a magistrate as to the validity of their conscientious objections. And this is where I come into the picture temporarily. My father, a Scottish minister, held no very strong views on the subject, and therefore my elder brother and I were duly vaccinated in infancy. When the 1907 Act came into force, however, he took advantage of the relaxation, made the statutory declaration, and so ensured that none of the younger members of the family was vaccinated. Following the 1907 Act the vaccination rate crashed. By 1914 it was down to below 50%, falling to 34% by 1939. With the advent of the National Health Service in 1948, compulsory vaccination of infants came to an end, and in 1971 the Secretary of State for Health and Social Security decreed that vaccination against smallpox need no longer be recommended as a routine procedure in early childhood. Henry Rider Haggard (Figure 2) was born on 22 June 1856 at Wood Farm on the estate of Bradenham Hall which had been the family seat for three generations, 'the impecunious younger son of an obscure, flamboyant, irascible squire'. In 1880, at the age of 24, he married Louisa Margitson, the owner of Ditchingham House, an 18th century mansion close to the main Bungay-Norwich road, with a garden running down to the River Waveney, and known as 'The Mustard Pot' because of its unusually shaped chimneys. Here 508 Journal of the Royal Society of Medicine Volume 77 June 1984 he was to spend much of his married life and write many of his novels. He was knighted in 1912, and died on 14 May 1925, four days after what his surgeons described as an 'entirely successful operation'. He wrote 68 books, including 58 novels. The first appeared in 1882 and the last in 1924. Of his success as a novelist there can be little doubt, as exemplified by the fact that in his autobiography, written in 1912, but not published at his own request until after his death, he records: "'King Solomon's Mines" which was produced as a 5-shilling book, proved an instant success. Published on September 30, 1885, on December 9, Messrs Cassells wrote to me that they had already sold 5000 copies more or less, a large sale for a boy's book by a practically unknown man. I wonder how many copies they have sold up to Xmas 1911! In one form or another the total must run to hundreds of thousands' (Haggard 1926). But he was not merely a successful novelist. As the publisher ofmost ofhis books and editor of his autobiography, C J Longman, points out in his introduction to the autobiography, he journeyed through twenty-seven counties examining the condition of agriculture and published his results in 'Rural England' (1902). He travelled through USA and Canada as a Commissioner appointed by the Colonial Office to report to the Secretary of State on the Labour Colonies instituted by the Salvation Army. In addition he served on the Royal Commission on Coastal Erosion and Afforestation (1906), and the Dominion Royal Commission of 1912. As a Norfolk laird he took a tremendous interest, not only in the development of his estate, but also the social welfare of all who toiled on his land. He therefore accepted enthusiastically the invitation of Charles Longman, his publisher, to keep throughout 1898 a daily diary in which he would record the events of what would be published as 'A Farmer's Year'. This, one of the most fascinating books it has been my lot to read, duly appeared in 1899. In it is brilliantly brought out his duties and activities as a landlord, farmer and magistrate, interested in all the goings-on of the farmers and agricultural labourers with whom he came in contact. In his own words: 'My object in compiling that record.. . was that in its pages future generations might see a picture of the conditions under which agriculture was practised in England at the end of the 19th century'. As I have already indicated, I am no Rider Haggard addict, and it was through D S Higgin's biography, 'Rider Haggard: The Great Storyteller', published in 1981, that my attention was drawn to 'A Farmer's Year'. In this, in due course, I read the entry for 20 July. 'I see in the papers today that the Government has given way suddenly on the Vaccination Bill, and that henceforth 'conscientious objection' on the part of parents is to entitle them to disregard the law and neglect their children'. The result was 'Doctor Therne' (Haggard 1898), described by himself as 'my only novel with a purpose'. 'It deals', he writes, 'with the matter of the Anti-Vaccination craze - not, it may be thought, a very promising topic for romance. I was led to treat of it, however, by the dreadful things I had seen and knew of the ravages of smallpox in Mexico and elsewhere, and the fear, not yet realized, that they should repeat themselves in this country' (Haggard 1926). On my next visit to the London Library - that happy hunting ground of all who love books - I borrowed 'Doctor Therne', which I read with avidity. But, before summarizing the plot, I must make yet another diversion. To my surprise I found the following superscription on the cover of the copy I borrowed: 'LONDON LIBRARY. Gift from the Library of H. M. Queen Mary'. The date of receipt of the book by the London Library was 17 March 1954. To my generation the gracious consort of King George V was the quintessence of primness and propriety: queenship (what the Short Oxford English Dictionary defines as 'the dignity of a queen') personified. Could it be that this regal, prim and proper lady was an addict of the author of such exotic novels as 'She', 'Cleopatra' and 'Nada The Lily'? Was this her form of relaxation in the privacy of her private domain where she could metaphorically let her hair down, forget the courtly fagade of the Queen, and dream her dreams of romance as conjured up by what his biographer describes as 'The Great Storyteller'? Journal of the Royal Society of Medicine Volume 77 June 1984 509 It was an intriguing, titillating thought which pleased me even though it was probably a figment of my imagination. Subsequent investigation, however, suggested that perhaps there was more to it than that. In subsequently reading Haggard's autobiography, I duly came across the following excerpts from a letter from his brother, William, First Secretary at the British Embassy in Athens, dated 30 October 1889: 'It may interest you to hear that the Empress Frederick told me the other night that the last pleasure her husband had on earth was reading your books, which he continued to do through his last days, and that he used to express the hope that he might live to make your acquaintance'. The Empress Frederick, the wife of the German Emperor, Frederick III (1831-1888), was, of course Victoria, Princess Royal of England (1840-1901). In his letter, his brother also wrote: 'You will be glad to hear that the Prince of Wales and his family read "Cleopatra" [published in June 1889] on their way out here and think it your best book'. The mere fact that not only the heir to the throne, but also his family, read Haggard's novels immediately on publication, and had obviously read several, if not all, of them, suggests that perhaps these works were steady additions to the royal library and that it was in this way that the future Queen Mary was introduced to them. Equally intriguing is the interest shown by the juvenile Winston Churchill, as exemplified in the following selection of letters in Haggard's autobiography. In 1886, Lady Constance Leslie, Winston's aunt, writes: 'Dear Mr Haggard. The little boy Winston came here yesterday morning .., beseeching me to take him to see you before he returns to school at the end of the month. I don't wish to bore so busy a man as yourself, but will you, when you have time, please tell me, shall I bring him on Wednesday next, when Mrs Haggard said she would be at home? Or do you prefer settling to come here some afternoon when I could have the boy to meet you? He really is a very interesting being, though temporarily uppish from the restraining hand being in Russia'. Unfortunately, Haggard records that he cannot remember whether this meeting ever took place, but he does quote the following undated letter from the 'uppish' schoolboy, who was born in 1874. 'Dear Mr Haggard. Thank you so much for sending me "Allan Quatermain" [published 1887], it was so good of you. I like "A. Q." better than "King Solomon's Mines"; it is more amusing. I hope you will write a great many more books. I remain, Yours truly, Winston S. Churchill' 'Doctor Therne' was written at Ditchingham, and it is typical of the speed and concentration of mind with which Haggard could write that, though the idea was only mooted in 'A Farmer's Year' in July 1898, it was published before the end of that year. In his introduction the author writes as follows: 'Some months since the leaders of the Government dismayed their supporters and astonished the world by a sudden surrender to the clamour of the anti-vaccinationists. In the space of a single evening, with a marvellous versatility, they threw to the agitators the ascertained results of generations of the medical faculty, the report of a Royal Commission, what are said to be their own convictions, and the President of the Local Government Board. After one ineffectual fight the House of Lords answered to the whip, and under the guise of a "graceful concession", the health of the country was given without appeal into the hand of the "Conscientious Objector". In his perplexity it has occurred to an observer of these events - as a person who in other lands has seen and learned something of the ravages of smallpox among the unvaccinated - to try to forecast their natural and, in the view of many, their almost certain end. Hence these pages from the life history of the pitiable, but unfortunate Dr. Therne. Absit omen! May the prophesy be falsified! But, on the other hand, it may not. Some who are very competent to judge say that it will not; that, on the contrary, this strange paralysis of "the most powerful ministry of the generation" must result hereafter in much terror, and in the sacrifice of innocent lives. The importance of the issue to those helpless children from whom the State has thus withdrawn its shield, is the writer's excuse for inviting the public to interest itself in a medical tale. As for the moral, each reader can fashion it to his fancy'. To which there is an interesting footnote. 'It need hardly be explained that Dr. Therne himself is a character convenient to the dramatic purpose of the story, and in no way 510 Journal of the Royal Society of Medicine Volume 77 June 1984 intended to be taken as a type of anti-vaccinationist medical men, who are, the author believes, as conscientious in principle as they are select in number'. The book is 'dedicated in all sincerity (but without permission) to the members of the Jenner Society'. The tale told is melodramatic, but gripping. The medical details are commendably accurate and, apart from smallpox, include two fatal cases of puerperal fever (one of whom is Dr Theme's wife who dies from this cause following the birth of their first-born, who becomes the apple of father's eye) and one fatal case of pulmonary embolism. It is recounted in autobiographical form. 'James Theme is not my real name, for why should I publish it to the world?' is the lead-in. The son and grandson of general practitioners, he qualifies from University College Hospital, London, with high honours, being gold medallist in both medicine and surgery. He decides to settle in practice in Dunchester, where both his grandfather and father had practised. Unfortunately he comes up against a former assistant of his father who resents any further incursions of general practitioners into the town. Now Sir John Bell, 'whose good fortune it was to be knighted in recognition of his attendance upon a royal duchess who chanced to contract the measles while staying in the town', there is a delightful portrayal of him. 'By no means a master of his art, Sir John supplied with assurance what he lacked in knowledge, and atoned for his mistakes by the readiness of a bluff and old-fashioned sympathy that was transparent to few. In short, if ever afaux bonhomie existed, Sir John Bell was the man. Needless to say he was as popular as he was prosperous'. A perfect villain for the piece, but the real villain is Therne's dread of smallpox. 'The truth is', he recounts, 'that, although I have no fear of any other human ailment, smallpox has always terrified me... The fear is a part of my nature, instilled into it doubtless by the shock which my mother received before my birth, when she leamed that her husband had been attacked by this horrible sickness'. I do not propose to divulge the plot and so discourage you from reading the novel. The essence of it, however, is Dr Therne standing for Parliament as the radical candidate, with anti-vaccination as the main item- in his election address. There then follows a superb description of the case presented by the 'A.V.'s', as they were known. This is worth giving in detail as a graphic but by no means exaggerated, outline of their case. Thus, describing one of his election meetings, he says: 'Finally I ended by an impassioned appeal to all present to follow my example and refuse to allow their children to be poisoned. I called on them as free men to rise against this monstrous tyranny, to put a stop to this system of organized and judicial infanticide, and to send me to Parliament to raise my voice on their behalf in the cause of helpless infants whose tender bodies now, day by day, under the command of the law, were made receptacles of the most filthy diseases from which man was doomed to suffer'. 'As I sat down', he continues, 'the whole of the great audience - it numbered more than 2000 - rose in their places shouting "We will! We will!", after which followed a scene of enthusiasm such as I had never seen before, emphasized by cries of "We are free Englishmen", "Down with the baby-butchers", "We will put you in, sir". And they did'. The further elaboration of this mass hysteria, however, is worth recalling as it still has a lesson for us today, when medical matters - especially if mishandled by the media and politicians, as they so often are - can assume such strong antisocial feelings. 'That meeting', Therne recalls, 'gave me my cue, and thence forward ... I and my workers devoted ourselves to preaching the anti-vaccination doctrines. We flooded the constituency with tracts headed "What Vaccination does", "The Law of useless Infanticide", "The Vaccine Tyranny", "Is Vaccination a Fraud?" and so forth, and with horrible pictures of calves stretched out by pulleys, gagged and blindfolded, with their underparts covered by vesicles. Also we had photographs of children suffering from the effects of improper or unclean vaccination, which, by means of magic lantem slides, could be thrown life-size on a screen; indeed, one of two such children themselves were taken around to meetings and their sores exhibited'. Today all this may sound melodramatic in the extreme, but to those of my generation it is Journal of the Royal Society of Medicine Volume 77 June 1984 511 merely a factual account of what could be seen in many a shop window and read in many a leaflet broadcast by the 'A.V.' organization. By the grace of God, television did not exist in those days. In an admirable summing up, the author, through the intermediary of Dr Theme, comments: 'The effect of all this was wonderful, for I know of nothing capable of raising honest but ignorant people to greater rage and enthusiasm than this anti-vaccination cry. They believe it to be true, or, at least, seeing one or two cases in which it is true, and having never seen a. case of smallpox, they suppose that the whole race is being poisoned by wicked doctors for their own gain [shades of Bernard Shaw]. Hence their fierce energy and heartfelt indignation'. Just as it is today with new drugs, whooping-cough immunization and the like. In the end righteous nemesis befalls the unfortunate Theme in a superb scene, and the final words of a novel I commend to you all are: 'I swooned away, and, as I sank into oblivion, there leapt from the lips of the thousands I had betrayed that awful roar of scorn and fury which has haunted me from my home and still haunts me far across the seas. My story is done. There is nothing more to tell'. The book had a mixed reception. Charles Longman, his publisher, wrote on 9 September 1898: 'I sat up last night and read Doctor Therne. It is dramatic all through and though the subject is painful and unpleasant there is nothing in the treatment that strikes a jarring note. The question of course is who will read it: you are of course going quite outside your regular clientele'. In the following February he wrote: 'We have sold about 4400 of the 3/6 edition of Doctor Therne - it does not sell very fast now, but does keep moving: 100 have gone in the last ten days. We printed 10000 so that we have over 5000 left, and I fear that if a 6d. edition were now published, nearly all this stock would be rendered worthless'. In his autobiography, Haggard himself is rather more optimistic. 'Although so different', he writes, 'in matter and manner from my other works, this tale has been widely read, and will in due course appear in one of the sevenpenny editions [NB. Note the effect of inflation; 6d. in 1899] which have become so popular of recent years'. But perhaps the last word in this evaluation should be left with The Lancet (1898). In a long anonymous review it wrote: 'His didactic treatise is also an excellent novel... Few sensational scenes in all fiction - we say this quite deliberately - have been better told than where the daughter of the miserable hero discovers her father vaccinating himself at midnight ... Mr Rider Haggard has now entered into an honourable competition with Ibsen and Zola who have not disdained to lend their eloquence to curing the deafness and blindness of the stupid, the ignorant and the mischievous for whom blue-books and statistics are vain things fondly invented.. . In conclusion we must commend Mr Hagfard's courage in thus entering the lists against the anti-vaccination party. As a novelist and a politician alike it is evidently to his advantage to take no step that would be likely to alienate from him any large body of possible supporters. Yet he has risked losing many readers and creating fanatical opposition to whatever he may do in public or private capacity for the sake of telling the truth'. To which, as an appropriate epilogue, might be added the fact that on 22 December 1898, the executive committee of the Jenner Society passed a warm and unanimous resolution thanking him for the work. Rider Haggard may not have been an Ibsen or a Zola, but his picture of the anti- vaccination campaign is a noteworthy contribution to the social history of an era as renowned for its reforming enthusiasm as for its hysterical reactions to such enthusiasms. 'Doctor Therne' may not have had an appreciable effect on the rate of vaccination - certainly not as much as the two major outbreaks of smallpox that were to occur so soon after the turn of the century. On the other hand, it provides a permanent, readable and fair representation of the state of affairs in the control of this disease when Jennerian vaccination was still having to battle for its rightful position in the forefront of the campaign for public health that was gradually receiving the recognition which it had been so long denied. As Christie (1969) wrote nigh on a century later: 'The financial and clerical implications of a world eradication programme, though immense, are perhaps the smallest of the problems: 512 Journal of the Royal Society of Medicine Volume 77 June 1984 man himself is perhaps the greatest, with his ignorance, his helplessness and his stupidity. Education may be the most difficult factor in eradication'. References Christie A B (1969) Infectious Diseases: Epidemiology and Clinical Practice. Livingstone, Edinburgh Haggard H R (1898) Doctor Therne. Longmans, London Haggard H R (1899) A Farmer's Year. Longmans, London Haggard H R (1926) The Days of My Life. Longmans, London Higgins D S (1981) Rider Haggard. The Great Storyteller. Cassell, London Lancet (1898) ii, 1640 Parish H J (1965) A History of Immunization. Livingstone, Edinburgh Saunders P (1982) Edward Jenner. The Cheltenham Years 1795-1823. University Press of New England, Hanover, New Hampshire