Distributed December 12, 2002
News Service Contact: Mary Jo Curtis
Smallpox in the Americas 1492 to 1815: Contagion and Controversy
As part of an exhibition at the John Carter Brown Library of Brown University, Stanley M. Aronson and Lucile Newman wrote an essay about the history of smallpox in New England, the text of which follows here. The text is copyright ©2002 by the John Carter Brown Library and may not be further distributed without written consent.
GOD HAVE MERCY ON THIS HOUSE:
by STANLEY M. ARONSON
“Because of the destroying angel standing over the Town, a day of prayer is needed that we may prepare to meet our God.” Thus wrote Cotton Mather in 1721 as his Boston congregation faced the return of smallpox. It was not the first such epidemic in New England but it would prove to be its most lethal. Bostonians knew of few interventions to slow the spread of smallpox. Days of fasting, self-denial, prayer, and strict quarantining were considered the sole means of arresting its remorseless advance.
Smallpox was an old and familiar enemy, known for as long as written documents have been maintained. Its earliest descriptions are found in Egyptian papyri dating to 1350 BCE. Epidemiologists have conjectured that it originated in the distant past somewhere in eastern Africa; from there it passed into the ancient cities of the Nile Valley. Preserved records indicate that the disease first appeared among the Hittites in 1346 BCE; India, 1000 BCE; and Persia, 430 BCE.
Smallpox is an acute, often lethal infection. Its causative virus does not linger in the infected human for any length of time. The victim either dies or recovers within an interval of about fourteen to twenty days. The virus of smallpox will die unless it can then be transferred to a neighboring, susceptible human during this two-week period of infectivity. (There are instances, though, where the smallpox virus has survived on the victims’ bed clothing for as long as a month.) Smallpox cannot therefore prevail indefinitely within small communities such as rural villages once all of the susceptibles have been infected. For the smallpox virus to survive for protracted intervals as a potentially infectious agent, a large, vulnerable population living close to each other is required, with many newborns constantly replenishing the pool of susceptibles. One of the unanticipated consequences of large urban civilizations, hence, is endemic smallpox of childhood.
While the Egyptian papyri clearly described a disease consistent with smallpox, it was the recent post-mortem histopathological examination of the youthful Pharaoh Ramses V, who had died in 1157 BCE, that finally provided convincing laboratory evidence that one of the many plagues of ancient Egypt was indeed smallpox.
The ravages of smallpox could then be followed from the Nile Valley through the urban clusters of the Middle East and southern Asia, reaching China in 48 CE. The first reports of smallpox in Japan are dated to 585 CE. Smallpox did not become endemically rooted in northern Europe until about 700 CE.
Smallpox was known to the Romans as variola (from a Latin word meaning spotted), but to the great majority of Europeans, it was merely called the Pox (or sometimes spelled “Pocks,” an old Germanic word signifying any eruptive skin rash). In the last decade of the fifteenth century a new infectious disease, venereal in nature, appeared in Europe with a disseminated pox-like rash characterizing its subacute phase. Henceforth this newly arrived illness was called “the great pox” (later called syphilis), while variola was then demoted to “the small pox.” Later spellings joined the two words into “smallpox.”
Smallpox was unknown in the Western Hemisphere until 1507 when it appeared on the Caribbean island of Hispaniola. In 1520 a member of the invading forces of Hernando Cortez brought the disease to Mesoamerica with a resulting death toll among the native population exceeding two million persons, according to some estimates.
Smallpox was one of many infectious diseases brought by European explorers to the Western Hemisphere. Still other contagions of Eastern Hemispheric origin, including chicken pox, measles, diphtheria, and yellow fever, decimated the native populations of North and South America and the islands of the Caribbean Sea.
Smallpox arrived in New England during the early years of the seventeenth century with devastating effects upon the native American population. One colonizing Puritan wrote: “The good hand of God favoured our beginnings in sweeping away the multitudes of the Natives by the small pox.” New England’s European colonists had their first local encounter with smallpox in 1677, followed by another siege in 1689–1690. A third Boston epidemic arose in 1702; and then, for nineteen suspenseful years, Boston was utterly free of smallpox.
The Boston of 1721 was a prosperous port city of some 11,000 residents with seven churches and, by some estimates, eleven practicing physicians. Most of its residents older than nineteen years had lived through the 1690 and 1702 waves of smallpox, many having contracted the disease and thereby blessed with lifelong immunity. But those younger than nineteen years had never encountered smallpox; and as each smallpox-free day passed, some of the older people with immunity died of unrelated causes while newborns were continually added to the local population of susceptibles. Thus, as the interval between smallpox epidemics lengthened, the fraction of the population with immunity to smallpox diminished, the number of susceptibles increased, and the likelihood of a major epidemic was heightened.
On April 22, 1721, the British vessel Seahorse, recently from the Caribbean, arrived in Boston harbor. It passed the customary quarantine inspection and proceeded then to its dock. Within a day one of its crew was stricken with smallpox and forcibly confined to a house near the docks. A red flag was implanted in front of the dwelling with the emblazoned words, “God have mercy on this house.” Any naïve thoughts that smallpox had been effectively contained were dashed by early May when nine more seamen showed evidence of acute smallpox. Despite frantic efforts to quarantine the latest victims, cases were now appearing among the residents of Boston. And on May 26, the Rev. Cotton Mather entered the following in his diary: “The grievous calamity of the small pox has now entered the town.”
About 1,000 Bostonians immediately fled the community. Of those remaining, 5,980 were ultimately stricken with smallpox and 844 died of the disease before the epidemic finally abated by the following spring. The case fatality rate was 14.1 percent.
Mather was minister to the Second Church of Boston when the smallpox epidemic of 1721 began. His influence in the Boston Bay community, however, extended well beyond his immediate congregation. If genealogy were a determining element, then Mather was destined to become one of Boston’s great religious authorities. Both of his grandfathers, John Cotton and Richard Mather, had been spiritual leaders in the early days of Boston; his father was president of Harvard College 1685–1701 and a prominent minister in Boston. Even without consideration of his illustrious forebears, young Mather gave every indication that he would have a flourishing career. Proficient in the classical languages by the age of nine, by age eleven he was properly enrolled at Harvard where he became the leading student orator of his day despite a distressing tendency to stutter.
Mather’s intransigent views concerning witchcraft, and specifically his role in the 1692 Salem witch trials, have effectively obscured his many scholarly contributions. He is commonly, if unfairly, portrayed as an unhappy, sin-obsessed zealot. But Mather was also educated in the physical sciences, was a corresponding member of the Royal Society of London, and was the author of respected tracts on medical therapies.
Bedside Clerics of the Eighteenth Century
In the century preceding the American Revolution there were few local obstacles to the practice of medicine. Anyone with the urge, temerity, or certitude to practice could do so without hindrance. Practitioners thus included the qualified and the unqualified; the credulous and the skeptical; those who believed that they were the chosen instruments of a higher authority as well as those with more humble motivations.
It required more than a century before medicine had been finally established as a defined profession in the British colonies. In the earlier settlements some doctoring, without license or specific training, had been undertaken as an occasional trade. Healing became transformed to an acknowledged profession, however, only when training requirements were mandated, when professional societies were created, professional boundaries established, and licensure mechanisms finally legislated. These measures elevated the practicing standards of medicine; they also led eventually to a state-sanctioned monopoly restricting medical practice to those given a license, first by local medical societies and then, later, by the states themselves.
In most frontier communities, though, there were neither university-trained physicians nor those specifically skilled in the healing arts. Who, then, filled the void before the apprenticeship system or schools of medicine were widely established? Inevitably the burden of ministering to those with physical illnesses, from croup to fractured legs, fell either to the educated ones or to persons in the immediate community with circumscribed skills such as the midwives. And in most rural places in colonial America the sole educated person was the clergyman.
Many seventeenth-century nonconformist pastors had been educated in England, particularly at Emmanuel College, Cambridge, and many had added courses in anatomy and physiology to their studies. Such learning would come in handy on the colonial frontier where they might preach on Sundays and make medical house calls on weekdays.
This curiously American tradition of combining the spiritual and physical ministry continued well into the eighteenth century and only diminished when the medical apprenticeship system finally took hold. In the early years of this nation, the ranks of pastor-physicians included such notables as Charles Chauncy (1592–1672), John Fiske (1606–1676), Giles Firmin (1614–1697), Michael Wigglesworth (1631–1705), and Cotton Mather (1663–1728).
Mather’s father, Reverend Increase Mather (1639–1723), was a teaching fellow at Harvard College when Cotton received his baccalaureate degree at age fifteen and a master’s degree three years later, in 1681. During the next few decades Cotton became the preeminent writer and scholar of the Massachusetts Bay Colony, authoring more than 450 texts and tracts, including the massive Magnalia Christi Americana, published in 1702.
Mather’s interests ranged from the intricacies of biblical interpretation to the latest observations of Europe’s leading scientists, and he was one of the first native-born Americans to be elected as a corresponding Fellow of the prestigious Royal Society of London. Through his intense correspondence, Mather learned of those in London who were attempting to protect their children from the ravages of smallpox by intentionally infecting them in a process called inoculation (later called variolation). This intervention, he learned, resulted in self-limiting cases of the disease with few deaths. Variolation, he discovered, had been practiced for centuries in Asia, the Middle East, and Africa. Indeed, Mather’s slave-servant, Onesimus, told him in 1706 that he had undergone such a procedure in Africa when he was a child.
Mather and his friend Zabdiel Boylston, through their advocacy of variolation, were instrumental in reducing mortality during the 1721 smallpox outbreak. Mather was a polymath fascinated with medical matters as well as a pastor eager to enter any controversy. The motives of this very complicated man were often flawed, but he was earnest and at times noble. In his sixty-five turbulent years of life he witnessed the deaths of three wives, thirteen of his fifteen children, and scores of friends taken from life prematurely. He was sustained by a Puritan’s hatred of sin and driven by a physician’s aversion to unnecessary pain and needless mortality.
Heathen Practice of Variolation
Mather had access from time to time to scientific reports emanating from London. One such testimony, an abstract of a letter written by Dr. Emanuel Timonius, an English-trained physician practicing in Constantinople, appeared in the 1714 issue of the Philosophical Transactions of the Royal Society. This report provided details of what was called the Turkish method of inoculation for the prevention of smallpox. The procedure entailed the following: Children not yet touched by smallpox were intentionally inoculated in the arm with a small volume of pus derived from a patient acutely ill with smallpox.
The inoculated child was then kept in bed until the inevitable fever and skin eruption, beginning some six days hence, had subsided. Inoculated smallpox differed from naturally acquired smallpox in many ways: The rash was not generalized, often confining itself to a small region of the arm; the face was typically spared the disfiguring scars of the natural form of the disease; the fever was milder in intensity and duration; and most important, the mortality rate of the intentional form hovered around 1 to 3 percent while the mortality rate for naturally arising cases of smallpox ranged between 10 and 25 percent.
Physicians who favored the inoculation procedure hastened to point out that those so treated could easily infect others and should therefore be secluded in so-called inoculation hospitals as long as their skin rash persisted.
Timonius made no assertions that he had invented the inoculation method. Indeed, variations of intentional inoculation had been practiced for centuries in various Asiatic and sub-Saharan communities. (There were regional variations of skin inoculation. In some regions of China, for example, pox fluid was first dried and the resultant powder then introduced into the child’s nostrils.) The purpose of Timonius’s article, then, was to share the details of the procedure with the scientific community of Western Europe, which at that time was largely ignorant of its existence. Nor, strictly speaking, should the procedure have been called preventive since it merely substituted a mild, controlled form of smallpox for a potentially devastating, disseminated, and frequently lethal form of the disease.
Lady Mary Montagu
The wife of the English ambassador to the Turkish court, Lady Mary Wortley Montagu, arrived in Constantinople in 1718. Remembering her own bitter experiences with smallpox in 1715, she sought to protect her six-year-old son by the inoculation procedure. The procedure was successful; and after two days of mild malaise, her son did well; so well, in fact, that Lady Montagu vowed “to bring this useful invention into fashion in England.”
Decades after these happenings, Lady Montagu’s collected letters were published. In one letter, dated December 1718, she discusses the Turkish inoculation procedure in great detail:
The inoculation procedure protected the Montagu lad from the full effects of smallpox; but in a curious way it also betrayed him when he later ran away from boarding school and was eventually identified by the distinctive inoculation scars on his arms.
England, and particularly the children of the aristocracy, took to this new, preemptive measure. Two of Princess Caroline’s children, for example, were among the first to be inoculated (in 1722, after their older sister barely survived an attack of smallpox a year earlier). Some Anglican clergy, however, proclaimed the inoculation procedure to be anathema on two grounds: first, that only God should bestow disease upon humanity; and second, to the extent that inoculation displaced a more lethal disease, that it was an inherently sinful practice. The Rev. Edmund Massey declared in 1725 that there was a divine reason why diseases descended upon mankind. “It was to test our faith and punish us for our sins. The fear of disease is a happy restraint upon men. If men were more healthy, ’tis a great chance they would be less righteous. Let the atheist and scoffer inoculate.”
In time, the example set by the royal family prevailed, the sermons of righteous indignation faded, and more children were provided with this form of protection. Inoculation remained, though, an intervention confined largely to the children and unexposed adults of the upper and educated classes. Because “variolation” was practiced so selectively, it did little to arrest the devastating effects of smallpox upon the general population.
Mather, Boylston, and the 1721 Epidemic
In 1721, when smallpox returned to Boston, Mather immediately declared his support for intentional inoculation. Mather’s positive views, based on his prior communications with London, were opposed by many of his clerical colleagues who declared the procedure to be heathen practice and a clear contravention of divine intent. Mather enlisted the active participation of his friend Zabdiel Boylston, a practicing physician of neighboring Brookline, in a campaign to promote inoculation.
Most of Boston’s physicians were vigorous opponents of the procedure. Boston’s leading physician, William Douglass, staunchly opposed inoculation on purely secular grounds and roundly condemned those colleagues who employed it. Douglass was the only university-trained physician in Boston, a graduate of Edinburgh’s medical school, and a man of strenuously assertive views. Some said of him that he was always positive and occasionally right. His professional authority and personality, therefore, made him a formidable foe of the effort to persuade Bostonians to submit to inoculation.
Mather, in his 1721 pamphlet, describes Boylston’s courage in undertaking to protect Bostonians from the ravages of smallpox:
Angry public debate, filled with recriminations and damnations, continued through much of the 1721 epidemic. Boston’s daily newspapers reported, in exquisite detail, the charges and countercharges that often taxed the limits of New England civility. Those opposed to inoculation asserted that it infringed on the prerogatives of divine providence, and they demanded the death penalty for those physicians who willfully practiced inoculation. At one point, even Mather’s home was attacked with a fire bomb which fortunately failed to ignite.
Boylston, the chief medical proponent of the inoculation procedure, was a modest man not skilled in debate. In contrast to the articulate Dr. Douglass, he had received his medical training solely through local apprenticeship, largely under his father’s tutelage. While he rarely responded to the public condemnations of his interventions, he did maintain meticulous medical records. As the epidemic abated, his records demonstrated conclusively that inoculation had saved many lives.
Boylston’s records, published in 1726 under the title An Historical Account of the Small-Pox Inoculated in New England, indicate that 280 individuals were intentionally inoculated with smallpox pus, and of these, 274 were personally inoculated by Boylston. Six then died of smallpox, a case fatality rate of 2.2 percent, substantially lower than the case fatality rate of 14.1 percent in the general population of Boston.
In the waning months of 1721 other clergy of Boston joined Mather in advocating inoculation. The Rev. Benjamin Colman of the Brattle Street Church in Cambridge was persuaded that the procedure was a blessing, “an astonishing mercy.” When Massey’s London sermon declaring inoculation to be sinful and medical intervention to be an invasion of divine prerogative (“Diseases are God’s business, not man’s”) was reprinted in Boston, Rev. William Cooper of Cambridge responded: “Let us use the light God has given us and thank him for it.”
Years later, Dr. Douglass quietly adopted the inoculation procedure, but he never retracted his condemnation of Boylston.
Smallpox epidemics recurred in Boston in 1751, 1764, and 1775. Faith in the inoculation procedure was, however, increasing, at least among upper-class families. Between outbreaks of smallpox, it became common practice to take one’s children to an inoculation hospital to undergo induced smallpox. Some declared it to be a way of fighting fire with fire.
In his autobiography, Benjamin Franklin bitterly regretted that he had not inoculated his son Francis who died of smallpox in 1736 at the age of four. And in 1759, Franklin added his voice to those advocating prophylactic inoculation in his introduction to Some Account of the Success of Inoculation for the Small-Pox in England and America. Thomas Jefferson had himself inoculated in 1782 and personally supervised the inoculation of his children.
The specialized inoculation hospitals eventually failed for many reasons. Since they were designed primarily for profit, they often released patients prematurely and thus, unknowingly, they served to spread smallpox into the general community. The abrupt demise of inoculation hospitals, however, was the result of a remarkable new discovery, published in 1798, by a Gloucestershire physician named Edward Jenner.
Jenner’s Humanitarian Triumph
Medicine in eighteenth-century England was not always an all-consuming profession. Physicians of that era sometimes involved themselves in a variety of scholarly pursuits of a non-medical nature. Edward Jenner, for example, took understandable pride in his knowledge of birds and the field geology of his native shire. Jenner, the son of an Anglican clergyman, was born on May 17, 1749, in Berkeley on the Severn River, a market town celebrated as the source of Gloucester cheese.
Jenner’s father had hoped that his son would enter the ministry. However, young Jenner chose instead to embark upon a lengthy apprenticeship with a local surgeon. In 1770, he went for further training in London with the eminent experimentalist, Dr. John Hunter. Jenner also worked with Joseph Banks, England’s leading naturalist and the scientist who had accompanied Captain James Cook on his first global circumnavigation. Jenner’s assignment with Banks was to organize the wealth of botanical, zoological, and geological specimens brought back from the South Seas. Jenner had been offered the post of shipboard zoologist for Cook’s impending expedition. He declined, returning instead to Berkeley to establish a medical practice. While in London he had completed a significant article summarizing his speculations on rheumatic inflammation of the heart, an important landmark paper in understanding the etiology of rheumatic heart disease.
Jenner was an affable, uncomplicated, generous, and intensely curious man. He was also considered to be a fine amateur musician and poet. While his practice in Gloucester flourished, he nonetheless reserved time each week for his personal pursuits, particularly his fascination with patterns of bird migration. In his countryside meanderings, he surveyed the geological substrates of his county. And he was also the first in west England to construct and test a lighter-than-air balloon.
Periodically encountering cases of an eruptive, vesicular rash generally confined to the hands of those who milked cows, Jenner maintained careful records of such cases, finally concluding that the natural life cycle of this limited disease involved three species. The horse, he speculated, was the primary source of the infective process that began as an inflammatory ailment of its hooves. Farmhands typically applied ointments to these sores. If the farmhands then went on to milk cows, the eruptive inflammation, now called cowpox, was manually spread to the udders of the cows. Finally, when dairymaids milked these cows afflicted with cowpox, they too developed scattered pustules of their hands. The rash remained localized. Typically, they recovered after a brief interval of mild fever and general discomfort.
Intrigued by an oral tradition that insisted that farmhands and dairymaids who contracted cowpox became resistant to smallpox, Jenner decided to exploit this curious happenstance of cross immunity. On May 15, 1794, he selected an otherwise healthy eight-year-old boy, James Phipps, and, with fluid taken from a fresh cowpox pustule on the hand of a local dairymaid, he inoculated the child through two superficial cuts in the skin of his arms.
Seven days after the procedure, the boy appeared to be listless and feverish, but he recovered completely within two days. On July 1, about five weeks later, Jenner then intentionally inoculated the boy with infective smallpox material. No disease ensued in the tense weeks that followed. After a number of successful trials with cowpox inoculation followed by an intentional smallpox challenge, Jenner concluded that a person previously affected by cowpox virus “is forever after secure from the infection of the small pox.” Jenner had sufficient faith in his procedure to inoculate his young son with cowpox fluid and then test its efficacy with a subsequent inoculation with smallpox pus.
Jenner published his findings in 1798, in a text entitled An Inquiry into the Causes and Effects of the Variolae Vaccinae, A Disease discovered in some of the Western Counties of England, particularly Gloucestershire and known by the Name of the Cow Pox. He named the infective cowpox agent Variola vaccinae (Latin, vacca, meaning cow and Variola, the Latin name of smallpox). The word “vaccination” used to describe the specific smallpox-prevention procedure was not coined until 1800. In recent years the meanings of the words “vaccine” and “vaccination” have been broadened to signify any fluid or procedure that provokes an immune response.
Vaccination met with the general approval of Britain’s medical establishment and also was enthusiastically sanctioned by the Royal family. The procedure quickly supplanted the older, and somewhat more hazardous, smallpox inoculation (variolation) technique.
Dr. Benjamin Waterhouse, a Boston physician born in Rhode Island, read of Jenner’s discovery and wrote to England to obtain some vaccine fluid. By 1799 Waterhouse, with the strong endorsement of Thomas Jefferson, introduced cowpox vaccination to the Boston community. (In this country, cowpox was generally called kine-pox.) Within five years the procedure was adopted by physicians in all of the United States.
The Royal Jennerian Society was established in 1803 for the express purpose of obtaining charitable funds to underwrite free vaccinations for the impoverished children of London. The practice of vaccination was enthusiastically adopted by many European nations as far east as Russia, and in 1805 Napoleon decreed that all troops under his jurisdiction undergo vaccination.
There were, of course, many who opposed vaccination as a desecration of the human body. Anti-vaccination societies warned that those vaccinated with fluid from cows would eventually sprout bovine horns and snouts.
Many honors were bestowed upon Jenner, although he continued to be unsuccessful in his quest for Fellowship in the Royal College of Physicians. (He failed to qualify in their classical languages examination.)
Jenner’s beloved wife of twenty-seven years died in 1815. He then retired from public life and resumed a limited practice of medicine in Gloucestershire. His final scientific publication, published shortly before his death on January 24, 1823, was On the Migration of Birds.
In the conclusion of Jenner’s monumental 1798 publication on vaccination, he declared his intent to continue these investigations “encouraged by the hope of its becoming essentially beneficial to mankind.” Rarely, indeed, has medicine ever witnessed such a monumental understatement. The procedure that Jenner devised has averted more human suffering and saved more lives than any other single medical intervention.
Benjamin Waterhouse and Kine-Pox
Benjamin Waterhouse, Harvard’s first professor of medicine and the physician who introduced true smallpox vaccination to the Western Hemisphere, was born in Newport, Rhode Island, on March 4, 1754. He lived a long and productive but contentious life, dying in Cambridge during his ninety-second year.
Waterhouse grew up in Newport, a thriving mercantile port, the sometime capitol of the colony and the intellectual center of southern New England. He was a schoolmate of Gilbert Stuart, who was to achieve fame as a portrait artist. Waterhouse’s father was a moderately prosperous cabinetmaker and a Quaker. His mother was cousin to Dr. John Fothergill, London’s most eminent physician.
At the age of sixteen, Waterhouse was apprenticed to a former maritime surgeon and Newport’s leading physician, John Halliburton. Five years later Waterhouse sailed for London to further his medical studies under Fothergill; still later he traveled to the universities in Edinburgh and Leyden to complete formal studies, leading to his completion of a medical degree in 1780.
Following the customary postgraduate year of travel in mainland Europe, Waterhouse returned to Newport and established a medical practice assembled from the remnants of Halliburton’s patient roster after Halliburton, a Tory loyalist, had abandoned his practice in 1775 and fled to Nova Scotia. Waterhouse also joined the faculty of the College of Rhode Island (later called Brown University) and until 1791 was its principal instructor in natural history and applied botany.
In September, 1783, the Board of Overseers of Harvard College declared that it would be of great advantage if the college were to offer formal instruction in medicine. To accomplish the task of creating New England’s first medical school, three medical professorships were to be established. Qualifications for these faculty posts, beyond the customary proof of professional excellence, included the stipulation that each professor “be of the Christian religion, as it is maintained in the churches of the Protestant communion, and of strict morals.” Waterhouse was selected for the professorship of the theory and practice of physic (medicine) despite considerable opposition largely because of his nonconformist Quaker affiliation. The two other professors selected for Harvard’s medical faculty were Drs. John Warren and Aaron Dexter.
Waterhouse’s Cambridge lectures were meticulously orchestrated, erudite discussions on the pharmacological effects of natural substances upon the functions of the human body. His talks were enriched by his unique notebook of pressed botanical specimens, his dried garden (hortus siccus). This personal collection, largely of North American flora classified by the Linnaean system, included more than one hundred biologically active botanicals.
In 1799, Waterhouse received a copy of Jenner’s 1798 text from his friend Dr. John C. Lettsom, a prominent practitioner in London. At Waterhouse’s request, Lettsom shipped some of the precious vaccine to Waterhouse who then began to vaccinate his patients.
In March of 1799, Waterhouse published a description of vaccination and its benefits in a local newspaper rather than in a conventional medical journal. He asked the local dairy farmers to seek out the distemper of cowpox since he believed that the local physicians were not yet informed “of an epizootic disease, capable of being communicated from the brute to the human kind, and which, when communicated, is a certain security against the small pox.”
In December of 1800, Waterhouse sent his monograph to Thomas Jefferson along with some of the cowpox material enabling Jefferson to begin the vaccination process at Monticello. Waterhouse boldly asserted that a major disease, smallpox, might now be exterminated by rational human intervention. It was a plausible yet extravagant claim that caused dismay in both medical and theological circles. Almost two centuries would be required before the worldwide extinction of smallpox became a reality.
Waterhouse was inundated with requests from physicians for some cowpox vaccine. To his supporters, Waterhouse’s attempts to control the distribution of the vaccine were commendable, since by exercising control over its distribution he sought to establish procedural standards and regulations. To his detractors, which were the majority of local physicians, his monopolistic domination of the vaccine fluid was held to be morally indefensible.
After a series of bitter disputes with Harvard and his medical colleagues, Waterhouse resigned his professorship and for the succeeding thirty-five years maintained a modest practice in Cambridge. These years were not totally fallow since he also authored a series of influential texts on geology and botany as well as polemical pamphlets on the evils of tobacco and strong spirits. In addition, he may have been influential in convincing a neighbor’s child, young Oliver Wendell Holmes, to pursue a career in medicine.
Dr. Benjamin Waterhouse died in the year 1846. Born when King George II ruled over Rhode Island and Providence Plantations, he lived, contentiously but productively, through the terms of eleven presidents; and he left his indelible mark upon medical education, medicinal botany, and preventive medicine in the United States.
Eradication of Smallpox
Long before the inevitability of death and taxes had been proclaimed, there was the chilling reality that few communities ever escaped the mortal grasp of smallpox. In England and its Atlantic colonies, where better records were maintained, about a tenth of children, on average, succumbed annually to smallpox.
Certainly smallpox was inevitable, but people tried nonetheless to avoid its ravages through prayer, fasting, and talismans. In India, for example, statues of the goddess Shtala, consort to Shiva the Destroyer, were erected in countless villages; and whenever smallpox loomed, these shrines were bedecked with flowers and tokens beseeching protection against smallpox. In medieval France, statues of Saint Nicaise served a similar purpose. The Yoruba of West Africa identified Shopona as the god whose wrath created smallpox.
Smallpox was highly contagious and was therefore a frequent companion of mercantile ventures, invading armies, fleeing masses of refugees, and religious pilgrimages. In contrast to many other scourges, such as plague or typhus, smallpox was carried solely by people, and when people moved from one community to another, voluntarily or involuntarily, so, too, did smallpox. Understanding the dynamics of contagion allowed mankind to establish its first meaningful barrier to smallpox. True, many clergy pronounced smallpox to be a divinely ordained punishment, but the Book of Leviticus had instructed the wandering Israelites to segregate those with grievous sores by removing them from the encampment. Quarantine, an obvious response to infectious disease, became an effective means of affording temporary protection, in some instances, against smallpox. Sometimes the afflicted were ostracized, sometimes an entire community isolated itself from the contaminated world around them; but early on people recognized that if the infected could be effectively segregated from the uninfected, the latter might be spared the ravages of smallpox.
The smallpox pathogen spread from person to person by air, by touch, or, on rare occasions, by a contaminated article of clothing or blanket. Somewhere in the distant past some wise person recognized that when smallpox was inadvertently contracted by limited skin contamination, the resulting systemic infection tended to be less lethal. And thus, in many Asian and African communities was born the concept of intentionally infecting susceptible children as a means of conferring upon them a lifetime immunity to smallpox. By the time of the American Revolution, variolation had become an established procedure, and Washington, who himself had survived smallpox as a young man, had some of his permanent battalions inoculated.
After variolation was supplanted by vaccination through the insight and clinical trials of Dr. Edward Jenner, entire communities sometimes underwent vaccination, and smallpox was locally suppressed. But most children, particularly from impoverished inner city families, were not vaccinated. Smallpox, therefore, continued to flourish during the nineteenth and early twentieth centuries. Medical historian Charles Creighton observed that communicable disease in England “first left the richer classes, then it left the villages, then the provincial towns, to centre itself in the capital.”
The first nation to declare itself smallpox-free was Sweden in 1895. Its public health authorities recognized, though, that this was an illusion and that no nation maintaining commercial ties with other nations could feel itself safely removed from the threat of smallpox as long as the disease prevailed somewhere else in the world. Despite its vigilance, Sweden knew that no nation is an island when confronted with the risk of airborne contagions such as smallpox.
For the First Time in History
In 1966, after years of debate, the United Nations World Health Organization (WHO) made the fateful decision to fund a campaign to eradicate smallpox in all nations. WHO’s global campaign to eradicate smallpox was led by an Amercan physician, D. A. Henderson, who devised a strategy of enforced vaccination within a certain radius of each recent smallpox case, thus encircling and confining each potential source of dissemination. Henderson’s small army of field workers was trained not only in recognition of the disease and in vaccination techniques but also in such mundane skills as truck-engine maintenance. These self-reliant teams ventured to the most remote, inaccessible corners of the globe. To ensure that no case was overlooked, they offered monetary rewards to those who would disclose previously undocumented patients with active smallpox.
The last cases of smallpox in the Western Hemisphere occurred in Bolivia and in southern Texas. By the end of 1969, North and South America were declared to be free of smallpox. But given the immense traffic in humankind among the continents, it would have been naïve to think that this freedom from smallpox could be maintained. All of Europe, for example, was free of smallpox by January of 1972; but in February of that year a Moslem cleric native to Kosovo contracted the disease while on a holy pilgrimage to Mecca. Upon his return to the Balkans, he unknowingly infected some 150 people in his congregation. The Yugoslav government, then led by Marshal Tito, undertook draconian measures to halt the further spread of smallpox. To curtail the movement of people, all forms of national transportation were halted, even those of a humanitarian nature, and the army vaccinated an estimated 18 million people in ten days. The epidemic was efficiently aborted at the cost of such fundamental civil liberties as the freedom to travel to work. In essence, the entire nation was placed in stringent quarantine with local police function assumed by an army given permission to prevent all movement, no matter how essential, and to forcibly vaccinate the entire population.
By 1974 only Pakistan, India, Bangladesh, Ethiopia, and Somalia still harbored cases of active smallpox. By 1977 the disease was confined to the rugged terrain of eastern Ethiopia and the neighboring Ogadan desert of Somalia. And on October 26, 1977, the last case of natural smallpox was found and quickly isolated. The victim was a twenty-seven-year-old health assistant named Ali Maow Maalin. For months thereafter, Henderson’s teams searched the world but found no further cases. For the first time in human history, an infectious disease had been eradicated from the globe.
Smallpox virus persists today solely in culture tubes within guarded vaults in Atlanta, Georgia, and Novosibirsk, Russia. Routine vaccination has ceased since 1972, leaving the majority of the world’s population vulnerable should the smallpox virus ever be deliberately spread by those intent on bioterrorism.