1. Joel Shurkin, The Invisible Fire: Story of Mankind's Triumph Over the Ancient Scourge of Smallpox (New York: G. P. Putnam's Sons, 1979), 182-184; Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago and London: University of Chicago Press, 1983), 93-95; Brand, 46; Anthony S. Wohl, Endangered Lives: Public Health in Victorian Britain (Cambridge: Harvard University Press, 1983), 132-135; Morris C. Leikind, "Vaccination in Europe," Ciba Symposium III, no. 10 (1942), 1111-1115.

2. Most historians agree that the Ethiopians' Siege of Mecca, during the so-called War of the Elephant in A.D. 568, was broken by a sudden, virulent outbreak of smallpox. Ar-Razi, Abu Bacr Mohammed Ibn Zacariya (Abu Bakr Muhammad Ibn Zakariya al-Razi), A Treatise on Smallpox and Measles, William Alex Greenhill, trans. (London: Sydenham Society, 1848).

3. John Lewis Burckhardt, Travels in Nubia, 2 vols. (London: John Murray, 1822) II, 379; Antoine Barthèlme Clot-Bey, Introduction de la Vaccination en Egypte en 1827: Organization du service médico-hygiènique des provinces en 1840: instructions et règlements relatifs à ces deux services (Paris: Victor Masson et Fils, n.d.), 9, 23 (hereafter referred to as Introduction ); Charles Cuny, "Propositions d'Hygiène, de Médecine, et de Chirurgie, Relatives a l'Egypte," Thèse pour le doctorat en Médecine, présentée et soutenue le 31 août 1853 (Paris: Rignoux, 1853), 25.

4. Rosen, A History of Public Health, 184.

5. Clot-Bey, Introduction, iii.

6. Arnold C. Klebs, M.D., "The Historic Evolution of Variolation," Bulletin of the Johns Hopkins Hospital XXIV (1913): 69. Genevieve Miller, The Adoption of lnoculation for Smallpox in England and France (Philadelphia: University of Pennsylvania Press, 1957), offers a comprehensive study of the pre-Jennerian practice of smallpox inoculation. Miller avoided the term "variolation" because eighteenth-century writers used only the terms "smallpox inoculation," "insertion," "engrafting," or "transplantation"; preface, i, ii. In view of the wider connotation of the term "inoculation" in the post-Pasteur era of immunization, this study uses variolation, i.e., inoculation with variola major or smallpox, to denote the earlier practice.

7. Miller, 42-44, 51-63. Adde-Margras de Nancy, Manuel du Vaccinateur des Villes et des Campagnes (Paris: Labe, 1856), 37-51; Muhammad All Bey and Ahmad Zaki al-Hakim, "History of Smallpox and Vaccination," Journal of the Egyptian Public Health Association XXIV, no. 2 (1949): 40; Ahmad Hilmy-Bey, Smallpox in Egypt: Its History and Control (Cairo: Government Press, 1933), 3; Charles Creighton, A History of continue

Epidemics in Britain, 2 vols. (New York: Barnes and Noble, 1965), II, 463-468, 471-477; James Moore, The History of Smallpox (London: Longman, Hurst, Rees, Orme and Browne, 1815), 218-229; Klebs, 70; William L. Langer, "Immunization Against Smallpox Before Jenner," Scientific American, vol. 235 (1976): 112-117.

8. Larrey, I, 519. Burckhardt, 211-212, reported a similar practice among the Nubians called "tattooing smallpox" ( duqq al-jadari; dugg —to strike, hammer, therefore also tattoo). "Tattooing smallpox" remained the common folk term for variolation or vaccination in Egypt until recently. Current Egyptian usage includes both Arabic terms talqih and

9. Cuny; Bowring, 6; Rafalowitch, 520.

10. ENA,

11. ENA, Index Cards: Health,

12. Paul Mouriez, Histoire de Muhammad-Ali, vice-roi d'Egypte , 4 vols. (Paris: Louis Chappe, 1855-58), Ill, 113.

13. ENA,

14. Clot-Bey, Introduction, 9.

15. Ibid.; ENA, Ministry of Education, carton 49, register no. 13, correspondence no. 626, p. 2772, 22 July 1845.

14. Clot-Bey, Introduction, 9.

15. Ibid.; ENA, Ministry of Education, carton 49, register no. 13, correspondence no. 626, p. 2772, 22 July 1845.

16. Cuny; Clot-Bey, Introduction, 10.

17. Ibid., 17-18. The instructions specified that the vaccine collected in arm-to-arm variolation should be deposited in containers of nonoxidizable materials such as glass, ivory, shells, or feather quills to safeguard it from exposure to air, light, heat, or humidity: (1) the vaccine should be dried, then inserted between two strips of glass, ivory, or shell and their edges sealed with wax; (2) a smaller goosefeather quill should be dipped in the vaccine, dried, and inserted into a larger quill; (3) fluid vaccine could be collected in a capillary tube and sealed with wax or by firing; (4) to protect the containers from light, glass plates or quills were to be wrapped in darkcolored paper or sheets of lead, and capillary tubes were to be packed in boxes with powdered charcoal. In 1856, the same procedures for collecting, preserving, and transporting vaccine were current in France, according to a manual published in Paris; Adde-Margras, 167-170.

16. Cuny; Clot-Bey, Introduction, 10.

17. Ibid., 17-18. The instructions specified that the vaccine collected in arm-to-arm variolation should be deposited in containers of nonoxidizable materials such as glass, ivory, shells, or feather quills to safeguard it from exposure to air, light, heat, or humidity: (1) the vaccine should be dried, then inserted between two strips of glass, ivory, or shell and their edges sealed with wax; (2) a smaller goosefeather quill should be dipped in the vaccine, dried, and inserted into a larger quill; (3) fluid vaccine could be collected in a capillary tube and sealed with wax or by firing; (4) to protect the containers from light, glass plates or quills were to be wrapped in darkcolored paper or sheets of lead, and capillary tubes were to be packed in boxes with powdered charcoal. In 1856, the same procedures for collecting, preserving, and transporting vaccine were current in France, according to a manual published in Paris; Adde-Margras, 167-170.

18. ENA, Translations,

19. A series of dispatches forwarded by the British consul general in continue

Alexandria in 1849 indicates that the consular missions acted as intermediaries for procuring vaccine lymph for the quarantine service in Alexandria. FO 78/806, Gilbert, 8 March, 6 June, and 7 August 1849.

20. ENA, Ministry of Education, register no. 2021, minutes of a session of the Consultative Council of Public Instruction held on June 25, 1836, p. 8. The regulations are identified only as the results of the council's deliberations; however, Clot-Bey refers to them (p. 26) as having been enforced and appends a sample of the register called for in paragraphs 4 and 5. The articles omitted in this text dealt with extension of the regulations to Egypt's dependencies in Syria, the Hijaz, Sennar, and Crete.

21. Clot-Bey, Introduction, 22-23.

22. ENA, Ministry of Education, carton 49, register no. 3, Pt. III, correspondence no. 48, p. 839, 25 January 1845.

23. Egyptian Gazette, no. 619, 13 July 1840, p. 3; nos. 101, 109, 113, 119, 123, 128, January-July 1848. The writer could not locate figures for the missing month of April 1848 (Jumadi al-Awwal 1264).

The breakdown of the total number of vaccinations by each month was reported as follows:

24. See n. 8, above. Tattooing was very common in Egypt, for identification as well as for decorative effect (see Lane, 42). Parents were said to tattoo their children's arms for identification should they be lost or stolen, slaves were marked by their masters for recognition in case of desertion, and Christians often had tattooed the sign of the cross on their chest or arm; less often, Muslims might have a crescent marked on themselves; Yates, 235-237. Around 1848, government communications began to refer to vaccination as "duqq" (tattooing) as well, reverting to local usage as they did in referring to cholera as "haida."

25. ENA, Sammarco Papers, box 6, 1831 to 1868, doc. no. 6793; Charles Cuny, "Mémoire sur les services rendus par M. Cuny en sa qualité continue

de médecin, depuis l'année 1837 jusqu'en 1851, qu'il a servile Gouvernment Egyptien," 4 (hereafter referred to as "Mémoire"). It is possible that he exaggerated his accomplishments, but until memoirs or other writings by Egyptian medical officers are uncovered, Cuny's account may serve as a useful description of the experiences of provincial health officers in Egypt in the 1840s.

26. Hamont, I, 507-509.

27. Cuny, "Mémoire," p. 6.

28. Hamont.

29. Cuny, "Mémoire," 10, 12.

30. Egyptian Gazette, no. 59, 7 April 1846, 1.

31. Artemis Rafalowitch, "Briefe eines russichen Artztes (Rafalowitsch) aus der Turkei," Das Ausland XXII (1849), 496, 512, 520. Rafalowitch did not offer any figures for Buhaira or Minufiya governorates. He only observed that the Bedouins in Buhaira, like the nomads in the Sinai desert, were very receptive to vaccinating their children. Nor did Rafalowitch give any particulars on vaccination in Upper Egypt, except to remark that the fallah's old fear of "marking" children for conscription was dying out, and vaccination was getting under way around Asyut and Minia.

32. ENA, Index Cards: Health,

33. Clot-Bey, Introduction, 23.

34. Ibid., iv; Mémoires, 157.

33. Clot-Bey, Introduction, 23.

34. Ibid., iv; Mémoires, 157.

35. See n. 2, chap. 3, for population statistics for Egypt in the early nineteenth century.

36. B. Schnepp, "Considérations sur le mouvement de la population en Egypte," Mémoires de l'Institut Egyptien I (1862), 551.

37. Frank G. Clemow, The Geography of Disease (Cambridge: Cambridge University Press, 1903), 421.

38. Sandwith, I, 134.

39. Ibid., 135-136.

38. Sandwith, I, 134.

39. Ibid., 135-136.

40. Hilmy-Bey, op. cit., 7, 19-22. In the interim, Bedouin who had sought out government vaccinators a century earlier had felt the restraints of the state on their freedom of movement and no longer welcomed official functionaries. In 1933, a public health official reported that the persistence of smallpox among the nomads resulted from the difficulty of enforcing initial vaccination; they resisted it as they opposed registering the births of their children, to avoid military service.