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The War Against Smallpox David W. Tschanz, MSPH, PhD

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Defense in Depth

Since the time of William Shakespeare, milk maids in England had been noted for their complexions and their beauty. In 1792 Edward Jenner (1749-1822), a Gloucestershire physician discovered, while trying to variolate his patients, that some of them were immune despite never having had smallpox. "These patients," he later wrote, "had undergone a disease they called the Cow Pox, contracted by milking cows with a peculiar eruption on their teats." Jenner also noted that "a vague opinion prevailed that it was a preventive of Small Pox."

Jenner was no simple country doctor. He was a careful natural scientist by 18th (or 20th) Century standards. He was the first to associate angina pectoris with changes in the coronary arteries seen at autopsies. He devised a method for purifying tartar emetic by re-crystallization. He was elected a member of the Royal Society because of his description of the unusual behavior and adaptation of the cuckoo, which lays its eggs in the nests of other birds, and whose young then use transient depressions on their backs to expel the rightful tenants, hatched or unhatched.

In 1796 Jenner took material from a cowpox sore on the hand of the milkmaid Sarah Nelmes and inoculated a young boy, James Phipps with it. On July 1, 1796 he inoculated the boy with smallpox, but it failed to take -- Phipps was immune to smallpox. Jenner wrote up his observations and submitted them to the Royal Society in 1797. The paper was quietly returned with a note that if he valued his reputation -- already established by his paper on the cuckoo -- he had better not promulgate such ideas as the use of cowpox for the prevention of smallpox. (Rosen 1958)

Undaunted, Jenner took advantage of a cowpox outbreak in the spring of 1798 to inoculate five other children and later challenge them with smallpox. When they also failed to develop the disease, he published, at his own expense, a small pamphlet recounting his experiments entitled An Inquiry into the Causes and Effects of Variolae Vaccinae, a Disease, Discovered in some of the Western Counties of England, particularly Gloucestershire, and known by the name of Cow Pox.

It was, "as if an Angel's trumpet had sounded over the earth." Jenner's discovery was universally hailed. The Empress Dowager of Russia ordered that the first child vaccinated be named Vacinoff and given an imperial pension for life. She also sent Jenner a diamond ring. The king of Spain, underwrote the Balmis-Salvany Expedition, certainly the most dramatic effort to promote vaccination in his dominions in North and South America and Asia. A living chain of orphan boys, vaccinated in succession during the voyages, brought Jenner's vaccine to the Spanish colonies.

The Duke of York ordered the vaccination of British troops in 1802. Napoleon followed suit shortly afterwards. Keenly interested in military medicine, he had followed Jenner's discovery with enthusiasm. When Jenner wrote the French emperor an appeal, asking for the release of certain English prisoners of war, Napoleon declared "Ah Jenner, I can not refuse Jenner anything!" (Ah Jenner, je ne puis rien refuser a Jenner!)

As the effect of Jenner's vaccine was realized, the possibility of smallpox eradication was first broached. In 1801 Jenner wrote that "it now becomes too manifest to admit of controversy that the annihilation of Smallpox, the most dreadful scourge of the human species, must be the result of this practice (vaccination)." Thomas Jefferson was also of the same mind. "Future generations will know by history only that loathsome smallpox has existed," he wrote to Jenner in 1806, "and by you has been extirpated."

Still smallpox was nothing to be treated lightly, particularly when armies gathered together. During the American Civil War preventing smallpox was a primary concern among the hastily assembled and woefully inadequate medical corps. Coming mostly from farms and small rural communities, the majority of the new soldiers had never before been with so many others in confined spaces. Relatively few had been exposed to the common communicable diseases -- measles, chickenpox, mumps or whooping cough. The results were predictable. They shared experiences and diseases in the cantonments.

Most feared of the "recruit diseases" was smallpox. The disease could go through a regiment like a scythe. Smallpox occurred in 18,952 reported cases of whom 7,058 (37%), died.

The overall problem of smallpox was much milder than would have been expected before Jenner. Army medical doctors looked upon smallpox as contagious (the only disease which they thought was) and placed cases in isolation. The entire 11th Michigan was placed under quarantine (nearly causing a mutiny) in December 1861 because of the rumor of one case in the unit. In addition new recruits were vaccinated as required by the Medical Corps.

Vaccination against smallpox was conducted with the same disregard and lack of appreciation for sterile technique that characterized the surgical procedures of the era. A soldier from Massachusetts described a typical regimental vaccination: "Such a wholesale slashing and cutting never was witnessed before. The commanding officer of each company would march up his men, all with bared arms. The doctor would make three or four passes with a knife, cutting through the skin, and punch a little of the vaccinating matter into the wound."

The American Civil War helped spur the concept of universal vaccination in the United States. Five years later, the Franco-Prussian War, and the smallpox epidemics that followed in its wake, would do the same for much of Europe.

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