"De vreselijkste aller harpijen": Pokkenepidemieen en pokkenbestrijding in Nederland in de 18de en 19e eeuw: een sociaal-historische en historisch-demografische studie.

By Willibrord Rutten (The Netherlands: A.A.G. Bijdragen 1997. 558pp.).

Disease - just as clothing, music, literature - can be attributed to a period in history. Today, the masses fear being consumed by cancer, heart disease or AIDs. For the nineteenth century it was tuberculosis, typhoid, and cholera and in the eighteenth century it was smallpox. In Willibrord Rutten's dissertation, he examines the successor of the plague in the Middle Ages. In the 17th century after the ravages of the plague had subsided, smallpox, known as de vreselijkste aller harpijen (the worst of all harpies), engulfed the populace of Europe - as generations thereafter were led to believe. Along with this lofty status as assassin of the meek - as children were its main victims - smallpox was accompanied with various myths which Rutten addresses while isolating smallpox epidemics and public embattlement against them in the Netherlands during the 18th and 19th centuries. One of the myths is the exorbitant mortality rate caused by smallpox, sometimes being as high as thirty percent. In the history of smallpox two presumptions are prevalent; one, that smallpox was fatal and two, at the same time it was inevitable. Luckily only one of these is true. These presumptions have prompted Rutten to examine smallpox from a demographic, cultural, social, and political approach. According to death toll statistics gathered in both urban centers and rural areas, the contagious ailment caused more deaths in the larger cities than in the countryside. Thus with this in mind the urbanized Dutch Republic of the 18th century should have become a chain of ghost towns after smallpox epidemics swept through. Yet according to Rutten the death toll in the cities of the Dutch Republic was moderate. In the mortality rate smallpox was represented but was not the only grim reaper, as there were also other diseases which took their toll. One of the myths Rutten's unveils is that the impact of smallpox on the mortality rate of the 18th century has been overestimated. The mortalities of smallpox seem also inconsistent, for example Rutten can find no explanation why the numbers who perished from smallpox were greater in the rural countries of Sweden and Finland than in the urban United Provinces and its border areas in the 18th century.

Around 1750 an innoculation for small pox was being tested on a small scale. The variolating of children could prevent children from developing full scale small pox. However, accompanying innoculations was a religious component which prolonged smallpox. Orthodox Protestants and pious Catholics believed innoculation to be against the will of God. (This notion is still held today by some staunch orthodox Protestants in the Netherlands in regard to the vaccination against polio.) Fortunately in the eighteenth century there was another end to the spectrum. There were enlightened citizens who believed in taking their destiny and the destiny of their children into their own hands - or at least giving a helping hand. In the 18th century of the Dutch Republic the battle against smallpox was a crusade fought by parents who had their children innoculated at their own initiative and at their own risk. This was, however, not without danger because some children died from the procedure. The decentralized state of the United Provinces had little or no influence on public health. The fight against smallpox became a government issue only after Napoleon invaded the Dutch Republic and installed the Batavian Republic in 1796 which was modeled after the centralized French state. This exciting turn of political events in Rutten's study illuminates the contrast between the decentralized Dutch state of the eighteenth century and the centralized state of the nineteenth century accompanied by more reliable methods of innoculation developed by Jenner. The government of the new state - which was primarily populated by enlightened citizens who turned a blind eye to religious arguments against innoculation - made smallpox into public enemy number one. However, the battle was only half won. A crucial obstacle faced by early nineteenth century governments and enlightened officials - who were concerned with improving public health - was selling the medical know-how of vaccination to a populace unacquainted with state authority and even more unaware of medical science. There was a general notion held by many parents that smallpox for children was a rite of passage: a part of growing up, an "inevitable and eventually wholesome disorder that purified the child's body". Innoculation took place only on a small scale. It became obligatory for various groups such as men in the military, children in orphanages, and school children who could be sent home if they were not innoculated. But for a contagious disease that assaulted urban areas these few measures must have seemed like mopping a floor with the faucet still running. Public authorities at the time could only curb smallpox but not wipe it out. Nevertheless, when smallpox epidemics arose throughout the nineteenth century these regulations did have some effect (after all, mopping the floor does remove water). By the end of the nineteenth century, the virtual curtailment of smallpox as a threat to the populace can be attributed to the growing numbers who had been innoculated, supplemented by other factors such as mandatory vaccination of school children which had more effect after 1870 when school absenteeism dwindled, and the public's apprehensiveness about vaccination waned. This was also accompanied with the public's growing awareness of the danger of contamination of the homes of the infected, the isolation of patients and the necessity of quarantine for those who had come in contact with the disease. Another factor was the improvement of the standard of life in the late 19th century which enhanced the resistance to illnesses. In short, the crusade against smallpox is the Netherlands in the 19th century, from the curbing of disease to the virtual annihilation of a public enemy, can be regarded as an evolutionary history. Rutten's holistic approach superbly illustrates how cultural, social, and political factors in each era are equally important in fighting disease.

University of Groningen