MEASURES ADOPTED FOR THE CONTROL OF SMALL-POX

I. Inoculation

About the year 922 of the present era the Arabian physician Rhazes wrote and published (in MS.) the earliest known report of the malady now called Variola or Small-Pox. From this fact the inference should not be drawn that the disease first came into existence in the time of Rhazes, for it can scarcely be doubted that it had already existed in the East for ages before the period mentioned. Since the thirteenth century it has appeared repeatedly in epidemic form in widely separated countries, causing, especially among the eastern nations, a fearful mortality. Sydenham, the great English physician, succeeded during the seventeenth century in devising a method of treatment that in some degree diminished the mortality of this affection, at least in Great Britain. It was, however, in no sense a preventive procedure, and the spread of small-pox continued unchecked until Jenner, in 1796, introduced vaccination; and even then the efficiency of this method was not promptly acknowledged by the Medical Profession; indeed, several years had to elapse before even the best London physicians, the men who possessed the most complete facilities for ascertaining the whole truth with regard to Jenner and his new method, became convinced that a great and most efficacious protection against small-pox had at last been found. In the meantime—that is, for almost half a century—the procedure known as “inoculation” was accepted by the upper classes of the community in all parts of Europe as affording the maximum amount of protection attainable against the disease.

There were in Europe, during the last half of the eighteenth century, two physicians—Baron Thomas Dimsdale, an Englishman, and Dr. ThÉodore Tronchin, of Geneva and Paris—who obtained considerable celebrity as inoculators.

The first-named, Baron Thomas Dimsdale, was born in 1712 and began to practice his profession in 1734 at Hertford, twenty-four miles north of London. Already as early as in 1741 he had acquired so great a reputation for his success, both in performing the operation and in carrying the patient safely through the resulting infection,—that is, through the attack of small-pox thus artificially produced,—that he was sent for to inoculate first the Czarina of Russia, then the Grand Duke Paul, and subsequently the children of many of the first families of the Russian Empire. Shortly after his return to England he was made a member of the Royal Society, and at a still later date the city of Hertford chose him as their representative in the House of Commons. In 1781, on the occasion of his second visit to Russia, he inoculated the Czar Alexander and the Grand Duke Constantine. His death occurred on December 30, 1800.

Among Dimsdale’s published works relating to small-pox and inoculation the following deserve to receive special mention: “The Present Method of Inoculating for the Small-Pox”, London, 1766, 1767 and 1772; “Thoughts on General and Partial Inoculation,” London, 1776; and “Account of a Voyage to Russia and Report of the Procedure Carried out in the Cases of Catherine and Paul.”

Baron Dimsdale, it seems scarcely necessary to add, was not the inventor of the practice of inoculation but simply the individual who revived and made popular, first in England and afterward on the continent of Europe (more particularly in Russia), a practice which long before had been employed in China.

ThÉodore Tronchin, the second inoculator mentioned above, was a native of Geneva, Switzerland,^[15] and was highly esteemed in France as a practitioner of medicine during the period that is now under consideration (1750–1785). Furthermore, it was widely known that he was the family physician of Louis Philippe, Duke of Orleans, as well as the medical adviser and intimate friend of Voltaire, both of which facts undoubtedly aided him in gaining popularity among the members of the fashionable set of Paris. It is therefore easy to understand why, when he espoused the cause of inoculation, he should have so rapidly attained celebrity as a successful inoculator, not only in Paris but also throughout Europe. On the other hand, it is not at all clear why the inoculation method should have been looked upon with any favor by the educated classes, for it soon became increasingly evident that the operation was attended with considerable risk through the danger of introducing other infective agents into the system; and, in addition, no satisfactory evidence was forthcoming that these inoculations possessed the slightest degree of genuine protective power. To-day we are unable to discover in this procedure any other advantages than the following:—The patient is thereby enabled to select the time when, and the surroundings in which, he or she will submit to an attack of small-pox; for, it must be remembered, no well-grounded hope was held out by the inoculators of the eighteenth century that the artificially produced disease would prove less fatal than that which is acquired accidentally. And yet some such hope was apparently cherished by the people of that period, for Benjamin Franklin, writing in 1788, makes the following remark in relation to this very question:—

In 1736 I lost one of my sons, a fine boy of four years old, by the small-pox, taken in the common way. I long regretted bitterly, and still regret, that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they never should forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.

These bitter regrets expressed by Franklin show plainly that he, like others of his time, had strong confidence in the efficiency of inoculation.

II. Vaccination

Edward Jenner, the discoverer of vaccination as an effective means of protection against small-pox, was born at Berkeley, Gloucestershire, England, on May 17, 1749. After the death of his parents while he was still a mere child, Edward passed under the guardianship of his eldest brother, the Rev. Stephen Jenner, and was brought up by him with affectionate care and judicious guidance. At a very early age he showed a decided taste for natural history; and after leaving school he began to receive instruction in the elements of surgery and pharmacy from a Mr. Ludlow, an eminent surgeon of Sodbury, near Bristol. As the next step in his education he spent two years under the direction of the celebrated experimental pathologist, John Hunter, of London, in whose family he resided for two years. He was about twenty-one years of age when he went to London.

Already at this early period he showed unmistakable evidences of being a close observer, scrupulous and accurate in his examination of the objects of his studies. He was also gifted with much enterprise and perseverance, characteristics which greatly aided him in mastering difficulties that would have seriously obstructed the progress of an individual possessing an inferior mind. Mr. Hunter, who was at this time in the prime of life, completely won the affection and respect of his pupil, who particularly admired the boldness and independence of his teacher’s character. Jenner was peculiarly alive to virtues of this kind. After completing his professional studies in London he retired from Hunter’s house, but the intimate relations which had been established between these two men persisted up to the time of the latter’s death in October, 1793.

Immediately after his return from London Jenner took up his residence with his brother Stephen, at Berkeley, and began his career as a practitioner of medicine. At the same time, as opportunity afforded, he continued to pursue his favorite studies in natural history. Thus, in a comparatively short period of time, he accumulated a series of specimens illustrative of comparative anatomy, and sufficiently numerous to form a museum of no inconsiderable magnitude.

In describing the manner in which Jenner’s attention was first seriously directed to the subject of cow-pox Dr. Baron, his biographer, uses the following language:—

Jenner was pursuing his professional education in the house of his master at Sodbury; a young country-woman came to seek advice; the subject of small-pox was mentioned in her presence; she immediately observed, “I cannot take that disease, for I have had cow-pox.” This incident riveted the attention of Jenner. It was the first time that the popular notion, which was not at all uncommon in the district, had been brought home to him with force and influence. Most happily the impression which was then made was never effaced. Young as he was, and insufficiently acquainted with any of the laws of physiology or pathology, he dwelt with deep interest on the communication which had been casually made known to him by a peasant, and partly foresaw the vast consequences which were involved in so remarkable a phenomenon. He was the more stimulated to meditations of this sort by frequent opportunities of witnessing the ravages of small-pox; and by retaining the most vivid and painful recollections of the severe discipline which he himself had not long before passed through, preparatory to his inoculation for that disease. “There was”—to use his own words—“bleeding till the blood was thin; purging till the body was wasted to a skeleton; and starving on vegetable diet to keep it so.” The possibility of averting such evils could not arise in a mind like Jenner’s without possessing it fully; and he resolved to let no opportunity escape of acquiring knowledge on so important a subject.... It was not till some years after his return from London that he had an opportunity of examining into the truth of the traditions respecting cow-pox. This was about the year 1775, a date which corresponds with the period specified by him in his tract on “The Origin of Vaccine Inoculation.”

Although during the following five years Jenner’s efforts to learn the full truth about cow-pox brought him very little nearer the goal which he was aiming to reach, he nevertheless pursued with zeal and vigor his studies concerning the nature of this disease and concerning its relations to small-pox. Among the facts which he ascertained during this period the following deserve to receive mention here: (1) There are several different diseases to which milkers are liable when they handle infected cows; but (2) only one of them possesses the power of furnishing protection against small-pox. The discovery of these facts made it easy to understand why vaccination with the virus of what was commonly called cow-pox not infrequently failed to protect the individual so vaccinated from genuine small-pox.

As a result of still further investigations Jenner felt warranted in drawing the conclusion that small-pox, cow-pox and swine-pox had a common origin,—in fact, were varieties of the same disease. Dr. Baron mentions the following incidents or experiences as affording a strong corroboration of the truth of the statements just made:—

In November, 1789, Jenner inoculated his eldest son Edward, who was then about one year and a half old, with swine-pox matter. The progress of the disease seemed similar to that which arises from the insertion of true small-pox matter when the disease is very slight. He sickened on the eighth day; a few pustules appeared; they were late and were slow in their progress and small. Subsequently, at five or six different periods, variolous matter was carefully inserted into his arms without the slightest inflammation being excited in the part.

On April 7, 1791, variolous matter was again inserted by two small incisions through the cutis.

April 9, parts evidently inflamed.

April 10, an efflorescence of the size of a shilling spread around the inferior wound.

April 11, the incision assumed a kind of erysipelatous elevation; the efflorescence much increased.

April 12, still further increase in the efflorescence; a vesicle about the size of a large split pea, and containing a brownish clear fluid, had also formed close to the superior incision; and a still larger one was visible near the edge of the inferior incision. The erysipelas extended to the shoulder and then quickly subsided. The child showed no signs of indisposition the whole time.

In March, 1792, a fresh inoculation was made. A well-marked inflammatory reaction followed.

At a later date Jenner learned that there were well-authenticated instances to prove that when the true cow-pox broke out among cattle at a dairy and was communicated to the milkers, even they had subsequently contracted small-pox. The discovery of this fact perplexed him greatly. Indeed, in the case of most men the discovery would probably have led to the abandonment of all further experimentation. But Jenner did not allow himself to be discouraged. It occurred to him that the virus of the cow-pox itself might have undergone some change whereby its specific virtues were lost; that, in this deteriorated state, it might have been capable of producing only a local disease upon the hand, but no such influence upon the constitution as is requisite to render the individual unsusceptible of contracting small-pox. In other words, he believed it possible that the same cow might one day communicate a genuine and efficacious preventive, and, the next, nothing but a local affection that would exert no beneficial influence whatever on the constitution. This most ingenious and forcible reasoning, supported by analogies drawn from the well-known properties of the virus of small-pox itself, received an ample confirmation from experience, and was the basis on which some of the fundamental rules for the practice of vaccination were founded. It was ascertained that it was only in a certain state of the pustule that virus was afforded capable of imparting to the constitution its protecting power; that matter taken after this period might excite a local disease, but not of such a sort as to render the individual proof against the effects of variolous contagion.

In 1796 Jenner had an opportunity to carry his investigations a step further.

“Hitherto,” says his biographer, “he had only observed the casual disease and investigated its laws; it yet remained to be proved whether it was possible to propagate the affection by artificial inoculation from one human being to another, and thereby, at will, communicate security to all who were liable to small-pox. An opportunity occurred, on the fourteenth of May, 1796, of instituting this experiment. Matter was taken from the hand of Sarah Nelmes who had been infected by her master’s cows, and inserted by two superficial incisions into the arms of James Phipps, a healthy boy eight years old. He went through the disease apparently in a regular and satisfactory manner; but the most agitating part of the trial still remained to be performed. It was needful to ascertain whether he was secure from the contagion of small-pox. This point, so full of anxiety to Dr. Jenner, was fairly put to issue on the first of the following July. Variolous matter, immediately taken from a pustule, was carefully inserted by several incisions, but no disease followed.”

Shortly afterward Jenner wrote to his friend Gardner:—

You will be gratified in hearing that I have at length accomplished what I have been so long waiting for, viz., the passing of the vaccine virus (the virus of cow-pox) from one human being to another by the ordinary mode of inoculation.... I was astonished at the close resemblance of the pustules, in some of their stages, to the variolous pustules. But now listen to the most delightful part of my story. The boy has since been inoculated for the small-pox, which, as I ventured to predict, produced no effect. I shall now pursue my experiments with redoubled ardor.

My readers can easily imagine with what deep anxiety mingled with an intense desire for a completely successful result, Jenner, from this time forward, prosecuted his labors. Unfortunately, he was not able, owing to the disappearance of cow-pox from the dairies of the region in which he lived, to resume his experimental work before the spring of 1798. He was also not willing to make a public announcement of the important results which he had obtained until he should have amply confirmed their accuracy by further experimentation. It was therefore not until during the early part of the summer of 1798 that he issued a printed pamphlet of a little more than seventy pages, in the quarto form, and bearing the title “An Inquiry into the Causes and Effects of the Variolae Vaccinae.”

On April 24, 1798, about two months before the publication of his pamphlet, Jenner repaired to London for the purposes of exhibiting the cow-pox and of demonstrating to his professional friends the truth of his assertions. Although he remained in the metropolis nearly three months he was unable to procure a single person on whom he could exhibit the vaccine disease.

Some of the cow-pox virus which Jenner carried with him was consigned to Mr. Cline, a London physician, who, toward the end of July, inserted it by two punctures into the hip of a child. A few days later he reported that “the cow-pox experiment had succeeded admirably.”

As happens in practically every important discovery in therapeutics, there arose soon in many quarters serious doubts as to the prophylactic powers of the method advocated by Jenner. Some men even went so far as to question the accuracy of his statements and to impugn his authority to advocate the practice of vaccination. On the other hand, there were many, and they too of the most learned and respectable, who immediately did justice to the merits of Jenner, and who cordially acknowledged the many important consequences which were involved in the subject that he had so ably and so modestly brought before them.

From a letter which Jenner wrote to one of his friends only a few weeks after he had published the “Inquiry” it appears that already at that early date he foresaw the probability that there would occur, in the further evolution of vaccination as a prophylactic measure, those very complications which, from that time to the present, have interfered so seriously with the universal acceptance of this procedure as a measure of vast beneficence to the human race. These so-called complications were, in the great majority of instances, manifestations of septic infection, brought about by carelessness in the handling of the inoculation wound; but this fact was not at all appreciated in Jenner’s time. During the years immediately following that in which the discovery of the new procedure was announced to the physicians of England vaccination made fairly rapid progress in public favor. Already as early as in June, 1800, Jenner, while on a visit to Oxford, was there presented, by the leading physicians of that city, with a testimonial in which it was declared that cow-pox is an effectual prophylactic agent against the small-pox. Two years later the English Parliament voted Jenner a grant of £10,000 as a reward for the very valuable discovery which he had made and for his prolonged labors in rendering the procedure of great utility to the public.

Strange as it may appear to those who are not familiar with the lives of the most meritorious and most unselfish physicians of bygone centuries this bestowal of £10,000 by Parliament upon Jenner did not add materially to his comfort; in the long run it rather detracted from it. Some of his friends, shortly after he had received the Parliamentary grant of money, induced him to give up his country practice and establish himself in the fashionable part of London; they maintained that his widespread reputation as the discoverer of vaccination and as the physician most capable of conducting this operation in the safest and most effective manner, would speedily bring him a large increase in private practice. Such, however, did not prove to be the case; and Jenner—who, unfortunately, had been overpersuaded to follow this advice,—after the lapse of three or four years, and appreciating the fact that his income was not large enough for such a style of living, removed his residence, first to Cheltenham and not long afterward to Berkeley. He died of cerebral apoplexy in the spring of 1823.

A medal commemorating the discovery of vaccination is pictured in the figure which faces page 108.