Reviled for its tendency to leave victims permanently scarred, smallpox was, by the sixteenth century, a permanent and particularly loathsome fact of life in Europe. Although outbreaks of the disease remained relatively mild and primarily targeted children prior to the Restoration, an exceptionally virulent series of outbreaks that swept though Europe in the latter half of the seventeenth century marked a devastating turning point in the disease's potency. The expansion of urban centers and the growth of trade routes hastened the spread of smallpox and weakened existing immunities, unleashing an unprecedented wave of mortality and disfigurement. The disease's mounting virulence and propensity for striking indiscriminately consequently provoked a spate of panic that transgressed social boundaries and prompted writers and moralists, ranging from John Dryden to Edmund Massey, to pen treatises, memorials, and cautionary tales in an effort to come to terms with the trauma of smallpox. In recent years, the disease's cultural iconography and rich literary legacy have continued to pique the interest of medical historians, particularly Genevieve Miller and Donald R. Hopkins, who have explored the social and demographic impact of smallpox through the lens of early modern medical discourse and pathological theory.

Although Miller and Hopkins have shed much light on contagion hypotheses and controversies surrounding eighteenth-century smallpox inoculation efforts, David Shuttleton argues that they have generally overlooked literary constructions of the disease in favor of epidemiological approaches that draw rigid distinctions between science and literature. In Smallpox and the Literary Imagination, 1660–1820, Shuttleton persuasively demonstrates that divisions between the disease's sordid reality and literary representations are artificial, downplay the therapeutic role played by eighteenth-century literature, and deny the multifaceted ways in which imaginative and scientific responses to smallpox were intricately interwoven. He contends that fear, which informed popular understanding of the disease, not only became an ubiquitous motif in the literature of smallpox but was also cited as a physiological risk factor by leading physicians and medical theorists, who shared a common repertoire of poetic images and metaphors with imaginative writers.

By analyzing an impressive array of source material, including canonical medical texts, elegies, moral essays, plays, and eighteenth-century novels, Shuttleton's study leaves virtually no stone unturned and reveals that literary responses to smallpox reflected the complex ways in which political concerns, the social imagination, colonial ambitions, and gendered discourse shaped contemporary understanding of the disease. Perhaps most illuminating is Shuttleton's analysis of autopathographical smallpox narratives. These rare firsthand accounts, ranging from the popular pamphlets of Frances Flood to the urbane poetry of William Thompson, offer an important point of contrast with the elite medical gaze and demonstrate the ways in which the subjective experience of smallpox reflected existing belief systems, particularly the prevailing redemptive Christian framework through which survivors ascribed meaning to the trauma and isolation associated with contracting smallpox.

Shuttleton's analysis of survivor narratives not only enables him to address the relationship between the experience of smallpox and preexisting cultural paradigms but also opens a window into the ways in which gender shaped responses to the disease. Although the transgressive role played by Lady Mary Wortley Montagu as smallpox survivor and inoculation proponent has been widely acknowledged by gender historians such as Isobel Grundy and Jill Campbell, Shuttleton adds a new dimension to discussions of gender and smallpox by exploring the ways in which aesthetic and moral responses to women afflicted with the disease both constricted and expanded their social opportunities. He contends that disfiguring smallpox scars rendered them unmarriageable but legitimated their public voice by removing them from the marriage pool. Moreover, rather than focusing exclusively on the ways in which scarred women experienced and represented the disease, Shuttleton incorporates a widely overlooked but necessary point of comparison by exploring the wide range of responses to men disfigured by the emasculating scars of smallpox.

While Shuttleton's assessment of gendered responses to smallpox expands existing discussions in bold new directions, perhaps the greatest strength of his book lies in its shrewd assessment of the ways in which political ends, which were themselves highly gendered and racialized, often shaped perceptions of smallpox. In particular, Shuttleton places smallpox within the context of post–civil war social anxiety and the discourse of imperialism and demonstrates that literary responses to inoculation were heavily tied to often competing programs of patriotism, colonial pacification, and fears of social degeneration.

A welcome contribution to the scholarly debate on smallpox, Shuttleton's study offers a well-rounded and illuminating analysis of the disease's semiotic underpinnings and the relationship between preexisting cultural paradigms and the experience of smallpox in the seventeenth and eighteenth centuries. By abandoning a traditional progressive narrative in favor of an intertextual framework that acknowledges the central role played by divergent literary traditions, Shuttleton deftly elucidates the ways in which myth, metaphor, and the imagination actively shaped the disease's identity. Despite his somewhat anachronistic comparison between the early modern experience of smallpox and post-9/11 fears of bioterrorism, Shuttleton's argument resonates in the wake of current debates about the implications of retaining active stores of smallpox in government laboratories. As Shuttleton convincingly demonstrates, the rhetoric of smallpox cannot be limited to a monolithic medical model, since prevailing political fears and social anxieties shaped and continue to define the ways in which the disease is embedded within the popular imagination.