Contagionism Catches On Margaret DeLacy Contagionism Catches On

Medical Ideology in Britain, 1730–1800 Margaret DeLacy Portland, Oregon, USA

ISBN 978-3-319-50958-7 ISBN 978-3-319-50959-4 (eBook) DOI 10.1007/978-3-319-50959-4

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© The Editor(s) (if applicable) and The Author(s) 2017 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institu- tional affiliations.

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This Palgrave Macmillan imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland ACKNOWLEDGMENTS

This book draws on a reference base of thousands of books and articles. Many of them were borrowed for me by the interlibrary loan department of the Multnomah County Public Library in Portland, Oregon. I thank the library itself and the dozens of libraries that generously made these works available to me through interlibrary loan, in most cases free of charge. This book would have been impossible to write without their help. Many libraries also made materials available online or allowed walk-in access to their holdings. They include the British Library, the Library of the Royal College of Physicians, the University College Library and the Wellcome Library for the History of Medicine in London; the Bodleian Library in Oxford; the Huntington Library in San Marino, California; the Hunt Institute for Botanical Research in Pittsburgh, Pennsylvania; the John Rylands Library in Manchester; Dickinson College in Carlisle, Pennsylvania, the Lancaster City Library in Lancaster; the Lancashire Record Office in Preston; the Liverpool Record Office in Liverpool; the Manchester City Library in Manchester; the National Library of Medicine in Bethesda, Maryland, which also provided and created many microfilms; the Newcastle City Library; the Yale University Library; and, in Portland: the Family History Center of the Church of the Latter Day Saints, the Oregon Health Sciences University, Portland State University Library and Reed College Library. Those libraries and librarians who assisted with specific problems are named in the notes, but I should also like to thank Richard Behles, Geoffrey Davenport of the Royal College of Physicians Library, Gina Douglas of the Linnean Society, Stephen Greenburg of the National Library of Medicine, Christopher Hamlin, David Harley, Jeff and Liz McBride,

v vi ACKNOWLEDGMENTS

Richard Wall and David Zuck, and to acknowledge debts to the late Arthur J. Cain, James Cassedy and Worth Estes. The Humanities, Science and Technology program (part of the National Endowment for the Humanities) provided a three-year grant for 1989–1992 that initiated this project. An earlier fellowship from the American Council for Learned Societies first enabled me to study the history of medicine. My colleagues in the National Coalition of Independent Scholars and the Northwest Independent Scholars Association offered support and encouragement. Family members, including my mother, Elizabeth Eisenstein, and my brother, Edward Eisenstein, read and commented on early drafts; I wish my mother had lived to read the final version. My husband, John DeLacy, not only put up with this seemingly endless project but provided an outstanding in-house information technology service. CONTENTS

1 Introduction 1

2 Fever Theory and British Contagionism in the Mid- Eighteenth Century 19

3 Contagionism after 1750: John Pringle and James Lind 55

4 Animate Disease after 1750: Exanthemata Viva 89

5 Counting and Classifying Diseases: Contagion, Enumeration and Cullen’s Nosology 125

6 John Haygarth and the Campaign for Contagion 165

7 Contagionism, Politics and the Public in Manchester, 1780–1795 207

8 Institutionalizing Contagionism: The Manchester House of Recovery 243

Conclusion: A New Medicine 283

vii viii CONTENTS

Appendix: Four Different Approaches to Organizing Illness Excerpted from Boerhaave, Huxham, Fothergill and Cullen. 285

Bibliography 295

Index 327 ABBREVIATIONS AND SHORT TITLES

BM see MB DM see MD ECCO Eighteenth-Century Collections Online, parts 1 and 2, created by Gale Digital Collections from digitally scanned microfilms of books published in Britain during the eighteenth century FRCP Fellow of the (Royal) College of Physicians of London FRS Fellow of the Royal Society Google Book database at https://books.google.com/ HathiTrust The HathiTrust Digital Library, www.hathitrust.org JHMAS Journal of the History of Medicine and Applied Sciences JP justice of the peace MB Bachelor of Medicine (including Oxford BM) MD Doctor of Medicine (including Oxford DM) MP member of Parliament Munk’s Roll William Munk, The Roll of the Royal College of Physicians of London Phil. Trans. Philosophical Transactions of the Royal Society of London, online at rstl.royalsocietypublishing.org N&R Notes and Records of the Royal Society of London ODNB Oxford Dictionary of National Biography (2004–), www. oxforddnb.com

ix CHAPTER 1

Introduction

Contagionism is the idea that a material substance transmits disease from patient to patient. This book will trace the development of British con- tagionism during the eighteenth century, the interlinked evolution of increasingly definite and detailed ideas about the nature and behavior of contagious diseases during this period, and the effect this had on the transformation of the medical profession, and medical institutions during the early industrial period. Within an apparently ossified and actually chaotic profession, the mainstream conceptualization of many acute illnesses gradually shifted from a “physiological” theory that attributed illness to changes in a patient’s internal equilibrium to an “ontological” theory that blamed diseases on different entities that invaded the body from outside. This shift enabled physicians in different places to cooperate in new ways. Contagionism benefited from broader social developments such as the improvement of transportation, foreign wars, and the growth of provincial towns, but it especially flourished within a community of doctors trained outside England that had emerged from three coincidental transformations within British medicine: in medical ideas, in the nature and content of medical education, and in the sort of men who became physicians. Contagionism has always been contentious and its history has been fragmented, evolving from being uncritically celebratory in the late nineteenth century to predominately negative by the late twentieth century. Historians of the idea have concentrated on particular

© The Author(s) 2017 1 M. DeLacy, Contagionism Catches On, DOI 10.1007/978-3-319-50959-4_1 2 1 INTRODUCTION time periods and places—especially on the formative period for European medical ideas from the mid-sixteenth century to the mid-seventeenth century, and on the nineteenth and twentieth centuries. They have also focused only on certain facets of contagionism. In the late nineteenth and twentieth centuries, historians of medicine traced the development of theories of contagium vivum (living or animate contagion) in the sixteenth and seventeenth centuries, often terminating their accounts in the early 1720s, with the “last” contagionist publications by Richard Mead and Benjamin Marten among other authors.1 The historians saw these authors’ works as “precursors” to Pasteur’s more developed germ theory, which would attribute many communicable diseases to infections by living microorganisms. However, because they were interested in contagium vivum, not contagionism itself, they encoun- tered a puzzling gap in the eighteenth and early nineteenth centuries instead of the smooth trajectory of medical progress they expected.2 As a result, they often skipped from the medical revolution of the seventeenth century to that of the mid-nineteenth century without spending much effort on the rest of the eighteenth century, when nothing of importance seemed to have happened.3 A seminal article by historian Erwin Ackerknecht lent strength to this overall picture of eighteenth-century medicine as backward, complacent and ineffective by referring to the “paradox” that opposition to contagion- ism was strongest in the period immediately before Pasteur’s break- through.4 Ackerknecht’s claims: that liberal reformers at the turn of the nineteenth century were anti-contagionists and that the contagionists who disagreed with them were conservative bureaucrats, made studying eighteenth-century contagionism seem even more pointless. If it had survived at all, early modern contagionism evidently had contributed very little to the transformation of European medicine and society. Some historians have implied that all eighteenth-century doctors were quacks or have settled for colorful accounts of their ineptitude.5 Plenty of evidence supported this depiction, much of it culled from the savage criticisms of eighteenth-century authors or from images by artists such as Hogarth and Gillray.6 Medical historians of recent decades have turned away from this older sort of narrative, viewing efforts to work backwards from a celebrated medical breakthrough as inherently anachronistic because they presumed a “progressive” march to the historian’s own viewpoint.7 They have focused on other facets of medical history such as doctor–patient relations, INTRODUCTION 3 the experience of illness, medical education and the operations of medical institutions. Any effort to trace connections between nineteenth-century ideas and those that preceded them might be infected by “precursoritis,” a disease that fatally afflicted many earlier historians of science and could just as easily doom the professional career of any aspiring medical historian.8 Cultural historians, meanwhile, have emphasized the dark side of contagionism: the way that the fear of contagion became entwined with the fear of the outsider, leading Westerners to brand non-Europeans or members of marginalized groups as a threat to both their health and their culture. Over many centuries, outsiders, foreigners and travelers to Western communities (pilgrims, beggars, Jews, Roma, Asians, Africans and many others) have been unjustly stigmatized as the source of dreaded infectious diseases such as plague, syphilis, typhus, cholera and Ebola.9 Many communities around the world have tried to safeguard their purity and health by imposing quarantines, avoiding contact with outsiders, setting strict conditions on trade, cordoning off whole commu- nities and even expelling, starving or killing members of marginalized groups and sufferers from some illnesses. Although their fears were often manipulated for other ends, they were not entirely unfounded: plague ships did bring devastation; armies carried syphilis and typhus that proved deadlier than fire and the sword; and a handful of explorers and settlers slaughtered millions of indigenous people with measles and smallpox. More recently, following the earthquake of 2010, a few United Nations aid workers took a cholera epidemic to Haiti, poisoning the water and setting off an epidemic that has killed thousands of Haitians and is still simmering.10 The stakes are high; the consequences of misplaced or misused con- tagionism can be just as deadly as the devastation of a terrible disease.11 An underground belief in contagion often seemed to be anything but pro- gressive. For hundreds of years, medical authors warned of the corrosive effects of a belief in contagion on sociability: endangering relationships between different communities, within communities and even within families. Fear itself was, and is, very much to be feared. As they have detoured around complacent “presentism,” and parried a looming xenophobia, most medical historians have avoided a close look at the actual development, contents, and outcomes of contagionist theories during the long eighteenth century and have not distinguished among different ideas about the nature of contagion. In fact, despite a reluctance to embrace theories about contagium vivum that had been hazarded by a 4 1 INTRODUCTION handful of early modern radicals and visionaries, a belief in some form of contagion increased rapidly in Britain during the second half of the century. By the end of the eighteenth century, a substantial segment of doctors adopted contagionism and applied it to an increasing number of diseases. Although this idea could have baneful effects, it also facilitated a rise in medical communication and it played a transformative role in ideas about the nature of acute diseases. Ever since the Renaissance, epidemic and contagious diseases, especially the “new diseases” of plague, typhus and syphilis, had posed problems for classical medicine. They gradually became exemplars, not aberrations. The traditional neo-Galenic view of acute disease as a “dyscrasia”—literally an imbalance or bad mixture of the four humors in the blood—slowly yielded to a conceptualization of diseases as individual things, in a manner analo- gous to the way chemists gradually replaced the traditional four elements (fire, water, earth and air) with many different discrete elements (gold, silver, iron, sulfur, lead, tin, antimony, mercury, phosphorus, etc.), each with its own individual characteristics. The first traces of the early modern conceptualization of diseases as individual entities instead of imbalances appeared in the sixteenth century, together with efforts to track and circumscribe outbreaks of plague by collecting and reporting mortality data. Physiology did not disappear from medicine (it even prospered) but, by the mid-eighteenth century, some doctors believed that studying diseases might be as helpful as studying unique patients. As they refined and clarified their ideas about the char- acteristics of particular diseases, they also noted that some of them spread from person to person by contagion: either by direct physical contact or by the transfer of a physical pathogenic substance between two individuals. The growing emphasis on contagion as a primary factor in the spread of acute diseases created a virtuous cycle. By studying the passage of a disease from person to person, physicians were better able to determine which manifestations were characteristic of the disease and which were merely coincidences. Once they were armed with a clearer picture of the disease, investigators could trace its passage through a community that was always experiencing many different diseases at the same time. This process led to a gradual reconstruction and reconfiguration of British medical thought and practice. This transformation was facilitated by the rapid growth of transporta- tion, trade and population density in British cities, which ensured that the “shock diseases” of the eighteenth century were also mostly contagious. INTRODUCTION 5

On the other hand, when a disease was not contagious or did not spread by contagion alone, contagionism could also lead to confusion, misunder- standing and controversy. Contagion was always a rough abstraction and few diseases followed the pattern of strictly contagious diseases, so con- troversy proliferated and it often traced other fault planes in English society, such as religion, nationality, politics and class. By the late eighteenth century the British medical profession had become divided between more traditional doctors and an increasingly vocal group of reformers. The traditionalists still attributed most acute diseases to some combination of internal humoral and external elemental imbalances. The reformers thought that many species of acute disease resulted from infection by a corresponding species of contagious patho- gen, though few of them specified whether these pathogens were animate, chemical or particulate. This division was exacerbated by the legal institu- tions of a confessional state which determined educational options and fed professional rivalries. Medical practice and medical training in eighteenth-century England took place in a unique and complex professional context. Eligibility for most medical positions depended on the usual eighteenth-century hodge- podge of family, rank, gender, education, patronage, friendship, personal qualities, nationality, locality and marketplace competition. Religious and educational qualifications were negotiable, though they played a role in establishing a successful practice. However, English Anglicans monopo- lized the summit of the profession and their privileges were legally protected. In theory, regular medical practitioners in England were licensed and divided into four different groups: midwives; apothecaries, who dispensed the medicines prescribed by physicians; surgeons, who tended to the external ailments of patients and carried out manual procedures; and physicians, who offered learned counsel to patients on the maintenance of a healthy life and prescribed remedies for internal disorders when their patients fell ill. In reality, practitioners constantly jostled for customers and many of them spanned more than one kind of practice. In Scotland the boundaries between physicians, surgeons and apothecaries were often more porous, which first shaped Scottish education and then English practice. Licensed practitioners also competed with irregular practitioners and with the druggists, mountebanks, booksellers and others who sold med- icines directly to the public. The ranks of the irregular practitioners 6 1 INTRODUCTION extended from well-trained and highly skilled men and women down to ignorant and clumsy quacks. There were also occasional or unpaid practi- tioners such as ministers, housewives and gentlewomen, and quasiregular practitioners such as nurses, pupils, apprentices and clerks.12 In some English towns, guilds regulated medical practice; elsewhere, practitioners obtained a license after providing evidence of their qualifications and taking the oaths of allegiance and supremacy (thus disqualifying Catholics, Quakers, Jacobites and some Baptists).13 Outside London, many doctors combined two or more of the roles of physician, surgeon, apothecary and midwife. Physicians held either a medical degree (Bachelor of Medicine (MB) or Doctor of Medicine (MD)) from a university or a license to practice physic: the MD degree had originated as a qualification to teach, not to practice.14 Apothecaries were trained by apprenticeship. By the early eighteenth century, in addi- tion to dispensing prescriptions, English apothecaries could diagnose ill- nesses, give advice and recommend medications. Although they had become de facto physicians, they were more numerous, often less expen- sive and supposedly of lower status than the licensed physicians.15 Many surgeons were also apprenticed, but after the London surgeons left the Company of Barber-Surgeons and formed their own company in 1745, London surgeons qualified by examination and did not have to provide evidence of apprenticeship.16 Most physicians also aspired to the reputation and wealth of a successful London practice, but to practice legally in London, or within seven miles of London or Westminster, a physician had to be a licentiate, a candidate or a fellow of the London College of Physicians.17 Candidates had sub- mitted an MD degree from Oxford or Cambridge to the college, paid a large fee and passed a grueling set of oral examinations. They could anticipate rapid promotion to fellow after a very long preparation.18 Medical education in the English universities had been disrupted by the English Civil War and the poisonous political climate that followed. Determined to ensure that no religious revolutionaries could ever again seize power, Parliament had passed a series of laws that essentially treated English residents who did not conform to the Church of England as aliens in their own country, denied the right to teach, preach, worship, meet in groups, hold office or serve in the military. Acts of 1662 and 1668 required that anyone who matriculated at Oxford or who graduated or incorporated a degree from Cambridge must take an oath avowing accep- tance of the Thirty-Nine Articles of the Church of England.19 Because INTRODUCTION 7 fellowship of the London College of Physicians was limited to graduates of the English universities, this (in theory) made religious Dissenters ineligible to become candidates or fellows throughout the eighteenth century.20 Because much of the medical instruction at the English universities was academic in the worst senses of the term—irrelevant, scholastic and often entirely absent—many other practitioners were at least as well trained as the fellows of the London College of Physicians. Because people chose their own doctors accordingly, the main effect of this antiquated religious barrier was to cause inconvenience and annoyance to Nonconformist physicians, a shared grievance that brought them closer together. The requirements for degrees at universities outside England ranged from none at all (for an honorary degree) to almost none (testimonials from other physicians) to years of study. Many medical schools (but not all) required either a Latin doctoral thesis or Latin examinations. Even regular medical graduates of Oxford and Cambridge did not have a uniform education; some remained there but others applied for their degrees and then studied elsewhere. From the turn of the century until the death of Herman Boerhaave in 1738, Leiden was especially popular. During the late seventeenth century both the Crown and the College of Physicians had circumvented the rules and conferred many College fellow- ships on Dissenters, so the fellows of the College were more heteroge- neous at the turn of the eighteenth century than they were in later decades as Anglicans with regular English medical degrees replaced older members with a greater range of qualifications. The Crown continued to confer MD degrees by mandate in the eighteenth century but by then almost all these honorary degrees went to Anglicans.21 Anglican graduates of foreign medical schools could also “incorporate” their degrees at Cambridge and become fellows of the College.22 Most fellows of the London College of Physicians had spent years mastering classical languages, reading classical medical texts, and develop- ing an epistemological and linguistic consensus. Although they believed their theory of medicine was based on Newtonian science, in fact it remained a neo-Galenic, physiological approach to disease.23 This frame- work was also expounded by Hermann Boerhaave, the Leiden professor of medicine, whose thought dominated British medical theories for decades. Underneath this apparent consensus, countervailing strands of monist and alchemical ideas survived the turn of the century, especially among Dissenters, and contributed to Enlightenment vitalism and contagionism.24 8 1 INTRODUCTION

British contagionism had emerged among religious Nonconformists who were opposed to traditional scholasticism for religious reasons. This rejection of “establishment” values had spilled over to natural philosophy and medi- cine. Many radical Dissenters admired the work of the chemist Joan Baptista van Helmont. Unlike the Galenists, who saw illness as an internal dysfunc- tion, Helmontian physicians had claimed that acute diseases entered the body from outside and thus had their own identities. They had also proposed trials of various therapies in groups of patients: a generation later, some English “Newtonians” would borrow this idea to evaluate smallpox inoculation. The most anti-clerical Dissenters had criticized both book learning and traditional medical institutions, and instead emphasized knowledge based on direct experience. Many of them believed that a providential God had created a specific healing plant for every disease and had placed it where the disease itself originated. This encouraged them to study ethnobotany at a time when Europeans were increasing their reach as colonists, invaders and traders. This inclination was reinforced by the fact that new trading opportunities overseas were especially enticing to English Nonconformists and Scots, who found many domestic professions closed to them and who faced barriers even among the open occupations. Most Helmontians had advocated replacing the complex botanical polypharmacy of the Galenists with equally complex (and very dangerous) chemical remedies whose preparation and use required long training and experience, but other medics took advantage of a booming market to offer either their medicines or medical publications directly to the public. They provided information about folk medicine and “simples”: herbal remedies that used just a few local ingredients. Instead of replacing one sort of learned medicine with another, they promised to make patients more self- reliant. These ideas, activities and interests had survived into the Augustan world of the physicians Hans Sloane and Richard Mead, who had both been brought up as Dissenters: Mead among London Congregationalists and Sloane among Ulster Presbyterians. Both had acquired a cosmo- politan education overseas. The multilingual Mead, who had lived in HollandandstudiedinItaly,hadfrequentedandhostedgatheringsof foreigners and brought foreign medical works to English audiences.25 As president of both the Royal Society and the London College of Physicians, Sloane had served as the center of a network of connections built both by personal contact and by correspondence. Sloane and his INTRODUCTION 9 circle were especially interested in the medical practices (e.g. moxibus- tion) and herbal remedies used by native populations all over the world. Overseas correspondents sent early accounts of the folk practice of smallpox inoculation to the Royal Society because they knew its members were interested in such topics. Other members of the Royal Society joined the effort to pilot this strange and terrifying procedure through the many obstacles it faced. To defend it, they had collected numerical data to compare the results of inoculation with the risks posed by catching smallpox adventitiously. The data were meaningful only to readers who believed that smallpox was a single, uniform disease entity that had a relatively predictable symptomatology and risk of mortality.26 Thus, by the 1730s, smallpox was being added to the short list of distinct contagions. Although the campaign for smallpox inoculation had aroused interest in alternative approaches to medical knowledge in the early eighteenth century, the real transformation in the composition and outlook of the profession followed the rise of the Scottish medical schools in Glasgow and Edinburgh, beginning in the 1720s. Although the Scottish schools initially taught Boerhaave’s system, over the following three decades they gradually introduced alternatives, culminating in William Cullen’s explicit rejection. Moreover, their graduates came to medicine with a different, less scholarly and more practical background. Unlike the English univer- sities, the Scottish universities prepared students from, and for, every branch of the profession. The Scottish medical schools required no religious oaths from students; they served English and Irish Nonconformists in addition to native Scots, travelers from the colonies and visitors from the Continent. Banned from several other professions and unable to obtain English degrees, English Dissenters in particular found a Scottish education less burdensome and expensive than most alternatives. Only a minority sought an MD. Many Scottish university students had begun their professional lives as apothec- aries or surgeons, or were planning to practice in those branches. They were more likely to be paying their own way without assistance from family or scholarships and they wanted quick and practical instruction.27 With fewer resources than their English counterparts, students often sought opportunities on slave ships, at colonial outposts or in the East India Company. Many Scottish students also served in the military because this was an inexpensive way to begin a medical career. After 1728 both English and 10 1 INTRODUCTION

Scottish military surgeons could practice as surgeons or apothecaries in England without a license from the Company of Surgeons.28 Much of their work in the military was medical, not surgical. After the War of the Spanish Succession and again after the Seven Years War, these military pensioners settled in England and some subsequently obtained MD degrees, often by mail order, from a Scottish university. Throughout most of the eighteenth century, any practitioner who provided two recom- mendations from physicians could buy an Aberdeen or St. Andrews degree by correspondence for a modest sum. This contributed to the distaste for Scottish physicians that influenced the policies of the London College of Physicians.29 A doctor who was ineligible to be a fellow of the college could still in theory apply for a license to practice as a London physician.30 After the rise of the medical schools in Glasgow and Edinburgh, however, men who had worked hard to acquire their MD degrees belatedly discovered that the College considered regular Edinburgh degrees and mail-order degrees equally illegitimate. Although it routinely issued licenses to medical grad- uates from European universities, the college would not even allow Scottish graduates of Scottish universities to take its examinations.31 Some students evaded this rule by obtaining their degrees during a brief visit to Europe, especially at Leiden or Rheims.32 Others settled in grow- ing provincial towns instead. The Quaker physician John Fothergill became the first known English medical graduate of Edinburgh to obtain a license from the College of Physicians in 1744, eight years after he had graduated. The first known Scottish graduate of Edinburgh to become a licentiate appears to have been William Schaw, MD Edinburgh (1735), who finally gained a license in 1752 and became an MD of Cambridge by royal mandate the following year. Although it had begun to license Scottish graduates, the College of Physicians took steps to emphasize all licentiates’ second-class status by ceasing to summon them to the college council meetings (the Comitia) and administering other snubs. As the ranks of college fellows were over- whelmingly Anglican and most of the licentiates were either English Dissenters or had been born outside England, this professional distinction exacerbated the other divisions of political affiliation, religion and nation- ality that chafed the “outsiders.” Many of the licentiates justifiably felt they were better educated than many of the fellows.33 They engaged in a series of well-publicized protests that included unsuccessful litigation and a riot at the college in 1767. INTRODUCTION 11

It was the upstart Edinburgh graduates who established British con- tagionism as a significant movement. After about 1740, the year in which Fothergill began to practice as a physician in London, their new concep- tualization of many “fevers” as separate entities, and the collection and analysis of medical statistics, began to interact in increasingly productive ways. Scots, and doctors educated in Scotland, would nurture a research community that jointly pursued these themes in a more serious, effective and concentrated manner than had been possible in the early years of the century, each member providing the others with both intellectual and political support. This interaction was especially fruitful because there was a dense web of other connections between the participants: these were further enhanced by dramatic improvements in transportation and communication. Fothergill, for example, would grasp many new or improved opportunities to collect and disseminate information by personal contact, mail and publication: he cultivated friendships with sea captains, served as the English advisor for American Quakers and colonial visitors, acted as an administrator and facilitator for British Friends, mentored young men seeking medical instruction, brought groups of Nonconformist physicians together for professional and political action, established a medical journal and wrote articles for the general public.34 Better transportation supported growing correspondence networks by making it easier to communicate by private mail and to receive and contribute to publications. Improved roads and coach travel also made it possible for professional men to earn their livelihoods in one place and meet their colleagues face to face in others.35 Fothergill took a yearly summer vacation in Cheshire where he met northern friends, relatives and colleagues. His friend Joseph Priestley, on the other hand, visited London each winter from his various posts in the north and the Midlands. In earlier centuries, such frequent and distant travel had been limited to the very wealthy, to the young who were not yet employed and were prepared for danger and discomfort, and to those whose lives or liveli- hoods required it. Now it could stitch a community of London medical reformers more closely to their increasingly numerous colleagues else- where in Britain. Neither contagion nor contagionism was new in the eighteenth century but trade, commerce and communication spread both more efficiently. Better communications, increased commerce and greater prosperity also facilitated the mobilization of groups to found, sustain and reform 12 1 INTRODUCTION voluntary institutions such as hospitals and schools. Although traditional sources of patronage such as the government, the established Church and enormously wealthy patrons remained important, it became possible to pool many small contributions to support independently managed secular institutions. Communication networks enhanced both nationalism and cosmopolitanism, strengthening the religious and social ties between the physicians who came to the profession as outsiders. Ambitious outsiders developed and joined new or newly transformed institutions, serving as trustees of the British Museum, journal contribu- tors and editors, curators and librarians, hospital governors and school managers.36 They participated in the new scientific societies, professional associations, academies, libraries and medical clubs that responded to challenges and opportunities after mid-century. These associations became additional conduits for personal connections, and for the exchange and dissemination of information.37 Through the work of a northern circle of doctors, including John Haygarth, John Aikin, Thomas Percival, John Ferriar, Matthew Dobson, John Clark, James Currie and John Bostock, and with the support and participation of their London counterparts, including John Fothergill and John Coakley Lettsom, contagionism would eventually transform ideas of disease specificity and inspire the collection of new sorts of medical infor- mation—with very tangible results. Fothergill, who had been raised as a Quaker in Yorkshire, practiced in London and vacationed in Cheshire, helped tie the northern circle to the London circle that gradually emerged around him and his younger dis- ciple, John Coakley Lettsom. Born into a Quaker family in the West Indies (British Virgin Islands), Lettsom was the only survivor of 14 children. His desperate parents sent him back to be raised in England. Lettsom became the ward of Fothergill’s brother, Samuel, who sent him to school near Warrington, and, like Fothergill, he served an apprenticeship with a Yorkshire apothecary before seeking further medical education in Edinburgh, marrying well, settling in London, and founding the London Medical Society and several dispensaries. In the years between 1740 and Lettsom’s death in 1815, these two men served as nodes in a steadily growing web of doctors who created profes- sional communities in Bristol, Chester, Hull, Liverpool, Leeds, Manchester, Newcastle, Warrington and other provincial English towns. However, unlike the circles around Sloane and Mead earlier in the cen- tury, these groups possessed the resources and resilience to create a true NOTES 13 research community, sustaining themselves and their work into the future without depending on just one or two individuals. By the final decades of the eighteenth century, British medical reformers were routinely sharing their medical ideas across their network, and they were using their obser- vations and research to support a concerted national campaign for institu- tional reform that was predicated on the claim that many acute illnesses were contagious and could be prevented. Their belief in contagion chan- ged the idea of many diseases, from dis-eases to entities, and permanently reconfigured the conceptual map of illness.

NOTES 1. Humbert Mollière, Un Précurseur Lyonnais des Théories Microbiennes: J.-B. Goiffon et la Nature Animée de la Peste (Lyon: 1886); H. F. A. Peypers, “Un Ancien Pseudo-Précurseur de Pasteur, ou ‘Le Système D’Un Médecin Anglois sur la Cause de Toutes Les Maladies’ (1726),” Janus (1896–1897) 1:57–66, 212–31, 251–62; Hector Grasset, “La Théorie Parasitaire et la Phthisie Pulmonaire au XVIIIe Siècle,” trans. by Thomas C. Minor as “The Parasitic Theory and Pulmonary Phthisis in the Eighteenth Century,” Cincinnati Lancet-Clinic (January 4 and January 13, 1900) [ns. 44], 83:22–6 and 38–43; Charles Singer, “Benjamin Marten, a Neglected Predecessor of Louis Pasteur,” Janus (1911) 16:81–9; Singer, The Development of the Doctrine of Contagium Vivum 1500–1700 (London: 1913); William Bulloch, A History of Bacteriology (Oxford: 1938, rpt New York: 1979); Charles-Edward Amory Winslow, The Conquest of Epidemic Disease: A Chapter in the History of Ideas (Princeton, NJ: 1943, rpt Madison, WI: 1980); R. Williamson, “The Germ Theory of Disease. Neglected Precursors of Louis Pasteur (Richard Bradley, Benjamin Marten, Jean-Baptiste Goiffon),” Annals of Science (1955) 11:44–57; Luigi Belloni, Le ‘Contagium vivum’ avant Pasteur, Conférences du Palais de la Découverte, ser. D., no. 74 (Paris: 1961); Richard H. Shryock, “Germ Theories in Medicine Prior to 1870,” Clio Medica (1972) 7:81–109. Earlier comprehensive histories of contagionism, such as C. F. H. Marx, Origines Contagii (Caroliruhae et Badae, 1824), were produced within the contem- porary debate about etiology. 2. For the eighteenth-century “lull,” see Fielding Garrison, An Introduction to the History of Medicine (Philadelphia: 1923), 314 and 317; William R. Le Fanu, “The Lost Half-Century in English Medicine, 1700–1750,” Bulletin of the History of Medicine (1971), 46:319–48 and Nicholas D. Jewson, “Medical Knowledge and the Patronage System,” Sociology (1974) 8:369– 85. K. Codell Carter’s The Rise of Causal Concepts of Disease (Aldershot: 14 1 INTRODUCTION

2003) begins in the nineteenth century and Robert Hudson’s Disease and Its Control: The Shaping of Modern Thought (Westport: 1983) skips from Fracastoro in 1546 to early nineteenth-century anti-contagionism in the space of a page (144–5). See also J. N. Hays, The Burdens of Disease: Epidemics and Human Response in Western History (New Brunswick: 2003), 110; John Waller, The Discovery of the Germ: Twenty Years that Transformed the Way We Think about Disease (Cambridge, UK: 2004) and David Wootton, Bad Medicine: Doctors Doing Harm Since Hippocrates (Oxford: 2006, rpt 2007) 116. Wootton argued that until 1865 medicine did more harm than good. Reviewers criticized him for implying that historians were unaware of the deplorable nature of pre-nineteenth-century medicine, which, they claimed was uncontroversial. Responses to his thesis and his rejoinder are on his website at http://www.badmedicine.co.uk/ debate.php and http://www.badmedicine.co.uk/downloads/bad_med_ postscript.pdf. 3. Later we will review the submerged role that the idea of contagium vivum played in the development of eighteenth-century contagionism. Although outside the mainstream, it still made an impact on disease taxonomy. 4. Ackerknecht, Erwin, “Anticontagionism between 1821 and 1867,” Bulletin of the History Of Medicine (1948) 22:562–93. 5. Jan Bondeson, A Cabinet of Medical Curiosities, esp. “Mary Toft the Rabbit Breeder,” 122–43; Roy Porter, “‘I Think Ye Both Quacks’: The Controversy between Dr Theodor Myersbach and Dr John Coakley Lettsom,” in Medical Fringe and Medical Orthodoxy, ed. W. F. Bynum and Roy Porter (London: 1987), 56–78; Porter, Quacks: Fakers and Charlatans in English Medicine (Stroud, Gloucestershire: 2001); Wootton, Bad Medicine. Guy Williams, The Age of Agony: The Art of Healing c. 1700–1800 (Chicago: 1986) is more balanced than its title or cover description suggest. See also C. D. O’Malley, “The English Physician in the Earlier Eighteenth Century,” in England in the Restoration and Early Eighteenth Century, ed. H. T. Swedenberg Jr (Los Angeles: 1972), 145–60. 6. Fiona Haslam, From Hogarth to Rowlandson: Medicine in Art in Eighteenth- Century Britain (Liverpool: 1996). 7. Adrian Wilson and T. G. Ashplant, “Whig History and Present-Centred History,” Historical Journal (March, 1988) 31, no. 1:1–16; Ashplant and Wilson, “Present-Centred History and the Problem of Historical Knowledge,” Historical Journal (June, 1988) 31, no. 2:253–74. They comment in n. 21, on 264, that “the ways in which, and the extent to which, the discipline of history is necessarily present-centred are difficult questions which demand extended treatment.” Idonotfeeltheiradvice that historians focus on the “source-generating process” resolves the problem. NOTES 15

8. Derek de Solla Price, “On the Historiographic Revolution in the History of Technology: Commentary on the Papers by Multhauf, Ferguson, and Layton,” Technology and Culture (January, 1974) 15:42–8, on 42. 9. Alan M. Kraut, Silent Travelers: Germs, Genes, and the Immigrant Menace (Baltimore: 1995); Rajnarayan Chandavarkar, “Plague Panic and Epidemic Politics in India, 1896–1914,” in Epidemics and Ideas: Essays in the Historical Perception of Pestilence, ed. Terence Ranger and Paul Slack (Cambridge: 1992), 203–40; the essays in Contagion: Historical and Cultural Studies, ed. Alison Bashford and Claire Hooker (London: 2001); Hays, Burdens of Disease, esp. 209–10; Christopher Hamlin, Cholera: The Biography (Oxford: 2009), 141–9; Priscilla Wald, Nancy Tomes and Lisa Lynch, “Introduction,” in Contagion and Culture, a special issue of American Literary History (2002) 14, no. 4:617–24; and Martin S. Pernick, “Contagion and Culture,” in the same issue, 858–65. 10. Chin C-S. et al. “The Origin of the Haitian Cholera Outbreak Strain,” New England Journal of Medicine (2011) 364:33–42. doi: 10.1056/ NEJMoa1012928. 11. Mark Harrison, Contagion: How Commerce Has Spread Disease (New Haven: 2012), 278–81. 12. Midwives were supposed to be licensed by their bishops, but, as the enforce- ment activities of church courts declined, the requirement gradually disap- peared. Barbara Brandon Schnorrenberg, “Is Childbirth any Place for a Woman? The Decline of Midwifery in Eighteenth-Century England” in Midwifery and the Medicalization of Childbirth: Comparative Perspectives, ed. Edwin R. Van Teijlingen et al. (Happauge, NY: 2004), 89–96, on 89. 13. David Harley, “‘Bred up in the Study of That Faculty’: Licensed Physicians in North-West England, 1660–1760,” Medical History (1994), 38:398–420; J. R. Guy, “The Episcopal Licensing of Physicians, Surgeons, and Midwives,” Bulletin of the History of Medicine (1982) 56:528–42; Ian Mortimer, “Diocesan Licensing and Medical Practitioners in South-West England, 1660–1780,” Medical History (2004) 48:49–68. 14. Thus not all physicians were MDs. This distinction helps explain the long interval between matriculation and receipt of the MD at the English universities. We will use the term “doctor” (lower case) gener- ically to refer to a medical practitioner and “physician” for a person practising physic as opposed to a surgeon or apothecary. In eighteenth century England, the title “Dr.” before a name usually implied a regular or honorary doctoral degree. 15. See Harold Cook, “The Rose Case Reconsidered: Physicians, Apothecaries, and the Law in Augustan England,” JHMAS (1990) 45:527–55. The Rose case ratified the right of apothecaries to give medical advice to patients in addition to selling them medications. 16 1 INTRODUCTION

16. See Susan C. Lawrence, Charitable Knowledge: Hospital Pupils and Practitioners in Eighteenth-Century Medicine (Cambridge UK: 1996), 79. The London surgeons also examined all English candidates for naval surgeon. 17. The London College of Physicians was established by a Royal charter from Henry VIII and was often referred to as the “King’s” College or “Royal College” but the “royal” in its name was not ratified until 1960. See Geoffrey Davenport, “When did the College Become Royal?” in The Royal College of Physicians and Its Collections: An Illustrated History, ed. Geoffrey Davenport, Ian McDonald, and Caroline Moss-Gibbons (London: 2001), 26–8. Foreign physicians who practiced in London exclusively among their fellow countrymen did not have to become licentiates or fellows. Neither did physicians who only practiced obstetrics. 18. A regular English MD degree from Oxford took at least 14 years from the student’s first matriculation; one from Cambridge took at least 11. The Oxford term was reduced to 11 years in 1781. Arnold Chaplin, “The History of Medical Education in the Universities of Oxford and Cambridge, 1500–1850,” Proceedings of the Royal Society of Medicine, Section of the History of Medicine (1919) 12 (supplement):83–107, on 91. See also Samuel Ferris, A General View of the Establishment of Physic as a Science in England, by the Incorporation of the College of Physicians, London (London: 1795), 114, which contains the relevant statutes in the Appendix, and Sir George Clark, A History of the Royal College of Physicians, 2 vols. (Oxford: 1964–1966). 19. 13 and 14 Car. II c. 4. 20. Ferris, General View,89–91, traces this restriction to the manuscript college statute of 1647 which stated that a candidate had to be a Briton by birth and have practiced physic for four years. A graduate of a foreign university had to present evidence of incorporation in England and pay double the fees that were charged to English graduates. In 1752 a new statute unambiguously stated that every candidate must be a “doctor of physic of either the University of Oxford or of Cambridge,” Ferris, General View, 104–5. The college, together with the universities, the Privy Council, bishops and arch- bishops, could license anyone to practice physic beyond the 7-mile bound- ary. College licenses to provincial practitioners, known as “extra-licenses,” were distinct from licenses to practice in London. Anyone who held a medical degree from any university could also practice physic without a license outside London. Some authors use the term “Dissenter” to refer only to a member of the three English Protestant denominations of Baptists, Independents or Congregationalists, and Presbyterians. In this book it refers to anyone who was unable or unwilling to subscribe formally to any of the oaths imposed by the Test Acts, including practising Quakers, Unitarians, Catholics and Jews. NOTES 17

21. In 1728, George II awarded one MB and 32 MD degrees during a visit to Cambridge, and 13 of these new doctors eventually became fellows. 22. Incorporation of medical degrees at Oxford required faculty approval, which was very difficult to obtain. 23. “By the fourth decade of the eighteenth century, members of the College of Physicians were still committed to iatromechanism. This commitment con- tinued for several decades more.” Theodore Brown, The Mechanical Philosophy and the ‘Animal Oeconomy’”(New York: 1981), 306. On mon- ism and radicalism, see Jonathan I. Israel, The Radical Enlightenment: Philosophy and the Making of Modernity 1650–1750 (Oxford: 2001), esp. 251–2, Paul Kléber Monod, Solomon’s Secret Arts: The Occult in the Age of Enlightenment (New Haven: 2013) and Margaret DeLacy, The Germ of an Idea: Contagionism, Religion and Society in Britain, 1660–1730 (New York: 2016). 24. Peter Hans Reill, Vitalizing Nature in the Enlightenment (Berkeley, Los Angeles and New York: 2005); Israel, Radical Enlightenment, 251–2; Monod, Solomon’s Secret Arts. 25. Elizabeth Grist, “Rainbow Coffee House Group (act. 1702–1730),” ODNB (Oxford: 2004–2014), http://www.oxforddnb.com/view/ theme/94590. Mead had an MD from Padua (1695) and an honorary MD from Oxford (1707). Sloane had an MD from the University of Orange (1683) and an honorary MD from Oxford (1701). Mead also had a relationship with English Quakers: his uncle William Meade, a close associate of William Penn, married the daughter of Margaret Fell, thewifeofGeorgeFox.ArnoldZuckerman,“Dr. Richard Mead (1673–1754), a Biographical Study,” (PhD dissertation, University of Illinois: 1965), 3. 26. Genevieve Miller, The Adoption of Inoculation for Smallpox in England and France (Philadelphia: 1957) offers the best account of the intellectual responses to this practice. 27. Lisa Rosner, Medical Education in the Age of Improvement (Edinburgh: 1991), 22. 28. Neil Cantlie, A History of the Army Medical Department (Edinburgh: 1974), vol. 1:62; Paul E. Kopperman, Theory and Practice in Eighteenth- Century British Medicine: “Regimental Practice” by John Buchanan, M.D. (Corvallis, OR: 2013), 16. This is the extended online version of a work also published online and in print entitled “Regimental Practice” by John Buchanan M.D.: An Eighteenth-Century Medical Diary and Manual, ed. Paul E. Kopperman (Farnham, UK: 2012). References are to the extended online version. See also Lloyd G. Stevenson, “A Note on the Relation of Military Service to Licensing in the History of British Surgery,” Bulletin of the History of Medicine (1953) 27:420–7. 18 1 INTRODUCTION

29. The “illiterate” Dr Samuel Leeds, the most notorious example of an unqua- lified Scottish MD, did not fall into this category. Leeds had actually attended classes for two sessions in Edinburgh and presented a Latin thesis on asthma. Later events created the strong suspicion that he had purchased the thesis from a ghost writer, a not uncommon stratagem in any university. See R. Hingston Fox, Dr. John Fothergill and his Friends: Chapters in Eighteenth-Century Life (London: 1919), 74–8. Aberdeen began to require examinations for an MD in 1787. 30. Early in the century, many London doctors practiced without a college license but the college became better at stamping this out. 31. Scottish MDs could become fellows of the Royal College of Physicians in Edinburgh without any further examinations. See Rosner, 22. 32. A handful of English doctors with Scottish degrees, including Theophilus Lobb, did become licentiates in the early eighteenth century. See Munk’s Roll, vol. 2: 1701–1800 (London: 1878), entries for Samuel Pye (104), John Eaton (114), Theophilus Lobb (146), George Pile (133) and Daniel Cox (148). Munk’s Roll is now available online. The Royal College of Physicians in London has an online name index at http://munksroll.rcplondon.ac.uk/ Biography/Search. 33. Ferris, General View detailed the licentiates’ claim to better treatment. 34. Fox, Fothergill. 35. For the importance of “weak ties” in a social network, particularly in net- works that combine strong (face-to-face) and weak ties, see Nicholas A. Christakis and James H. Fowler, Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives (New York: 2009), passim but especially 158–67. 36. The contents of the British Museum were amassed by Hans Sloane. His will created the museum but the funding to purchase his collections (including the British Library) came from a public subscription. 37. See, for example, Rebecca Bowd, “Useful Knowledge or Polite Learning? A Reappraisal of Approaches to Subscription Library History,” Library and Information History (2013) 29:182–95, online at http://dx.doi.org/10. 1179/1758348913Z.00000000038. CHAPTER 2

Fever Theory and British Contagionism in the Mid-Eighteenth Century

DISEASE THEORY IN THE EARLY EIGHTEENTH CENTURY Eighteenth-century medical theory evolved slowly; it did not suddenly leap into a different paradigm, nor did it take the form of a simple opposition between two mutually contradictory views across the entire field of disease theory. To see how contagionism developed during the eighteenth century, we must understand what it replaced and how it infiltrated explanatory systems and established practices. The fierce con- troversies of the nineteenth century and the fact that historians tend to work backwards have often distorted or oversimplified eighteenth-century thought; the state of received opinion varied from one disease to another as well as from time to time and group to group. Medical education and practice still relied on the works of Galen, Hippocrates and other classical authors, even though Vesalius and Harvey had undermined Galen’s physiology, and empirical investigation was displacing scholastic reasoning.1 Eighteenth-century medical exami- nations at Leyden, Edinburgh and the London College of Physicians all required candidates to comment in Latin on Hippocratic aphorisms and/ or a passage from Galen.2 College licentiates and fellows took the same examinations until 1767, when, to distinguish between the two, the candidates for fellowships were required to translate passages from Hippocrates and Galen from Greek into Latin with a commentary.3 If classicism still shaped the core of medical practice, “iatromathematics”— a mechanist approach developed by Giovanni Alfonso Borelli (1608–1679)

© The Author(s) 2017 19 M. DeLacy, Contagionism Catches On, DOI 10.1007/978-3-319-50959-4_2 20 2 FEVER THEORY AND BRITISH CONTAGIONISM ... and Lorenzo Bellini (1643–1704)—clothed its surface. At the end of the seventeenth century, members of the college welcomed their work as alter- natives to the chemical theories of Paracelsus and van Helmont. The Scottish Tory, Archibald Pitcairne (1652–1713, MD Rheims), provided further sup- port. Rejecting the older chemical ideas that illness was due to specific “fer- mentations” or the activity of acids and/or alkalis, Pitcairne outlined a “hydraulic” theory that blamed diseases on blockages to the free circulation of fluids through the vessels. This view dovetailed with the fact that some early microscopists, such as Robert Hooke (1635–1703), had interpreted the “cells” they saw in plant and animal tissues as cross-sections of hoses, channels or pores that extended laterally through the body.4 The metabolic research by Santorio Santorio of Padua (1561–1636) also supported it. Using a weighing chair and measuring both his intake and excretion, Santorio had demonstrated that human bodies lose more weight than can be accounted for simply by measurable excretion, and he attributed the balance to an “insensible perspiration” through pores in the skin.5 Eighteenth-century authors concluded that this process enabled the body to remove toxins and restore its humoral balance.6 Some also thought that these pores expanded and contracted in response to changes in temperature and humidity. Others located these changes in the “solids” or “fibers” of the body. Some of Pitcairne’s Episcopalian allies, including the physician George Cheyne (bap. 1673–1743, MD Aberdeen), left dour Presbyterian Scotland for a more congenial England.7 In A New Theory of Continual Fevers (1701), Cheyne claimed that the body was “nothing but a Congeries of Canals.”8 Continued fevers developed when the glands that constantly filtered various fluids became obstructed. Blood backed up in the arteries and nervous fluids backed up in the nerves. The extra blood in the “Canals” produced a “violent and burning heat.” The distended arteries compressed the brain, causing irregular pulses and head- aches. The blocked nervous fluid caused sleeplessness. The obstructed glands also blocked the passage of perspiration, causing heat and thirst. Patients recovered when the quantity and velocity of the blood finally shattered these obstructions. Cheyne claimed that continued fevers in temperate countries were triggered by severe cold winds following excessive heat. After the heat had dilated and softened the glands, the succeeding cold contracted the orifices and congealed the liquors, producing a pathogenic obstruction: DISEASE THEORY IN THE EARLY EIGHTEENTH CENTURY 21

“all Travellers assign this as the cause, having constantly observ’d their Fevers to succeed such sudden changes of the Air.”9 A long spell of very cold weather and dietary excesses also caused obstructions. He explicitly rejected “the most common ...Opinion about Fevers ..., that they are more immediately produc’d by some Morbifick matter; (like a Poison) which mixing and circulating with the mass of the Blood, Produces all those frightful Symtoms.”10 If all the blood had become vitiated, it would be impossible to explain how people “evacuated” the corrupted blood and recovered. In 1734 the physician and Dissenting minister Theophilus Lobb (1678–1763, MD Glasgow) attacked Cheyne’s model as “ground- less”.11 Blending the classical “non-naturals”—air, exercise, sleep, eva- cuation and emotion—with other kinds of factors, Lobb argued that the real causes of fevers were the lax, rigid, weak or strong state of the body’s solids; the quantity and consistency of the animal fluids; the absence of “adventitious unnatural Qualities; e.g. the acid, acrimonious, alkaline, etc.” in the fluids; the action of the heart, lungs and arteries; and deranged excretions.12 Diseases of the fluids arose from inadequate, excessive or unbalanced food, too much motion or rest, too much sleep or waking, happiness and depression, excessive or deficient excretions, the “excessive qualities of the air” (i.e. heat, cold, humidity and baro- metric pressure) and, finally, number 14, “Infectious Effluvia from diseased Bodies.”13 Lobb observed “that infectious Effluvia from Bodies under eruptive Fevers may produce Fevers of the same kind ...is so manifest to every one’s Notice from Facts daily occurring, that nothing need be said to prove it.”14 In 1745 he would claim that the plague was contagious and recommend the separation of plague patients.15 Hermann Boerhaave (1668–1738) developed by far the most popular theory.16 He was appointed lecturer on the institutes of medicine in Leyden in 1701; in 1709 he became professor of botany and medicine. Until 1726 he was the leading medical teacher in Europe.17 He trained many English and Irish Dissenters who were ineligible for medical training at home, and many English Anglicans who wanted more up-to-date training than they could find at Oxford and Cambridge.18 Boerhaave’s views also dominated instruction at Edinburgh’s medical school from its foundation in 1726 into the 1740s, and were only repudiated after the arrival of William Cullen.19 Boerhaave’s theory appealed to physicians because it seemed to combine sound medicine with up-to-date insights from the mechanical