White Coat Underground

Who doesn’t hate smallpox?

Smallpox was one of the world’s most devastating diseases, and its eradication one of medicine’s most spectacular successes. Over the course of a couple of centuries, this disease went from killing and maiming millions (200-500 million in the 20th century alone), from helping to depopulate the Americas of their original populations, to an historical artifact. The history of the eradication of smallpox is generally pretty well-known. Most of us learned at some point about Jenner’s discovery of smallpox vaccination and the eventual disappearance of the disease due to the efforts of the WHO. But what is less well-known is the history of opposition to smallpox prevention.

Smallpox is a nasty not-so-little virus (Variola major and minor) that not only causes permanent disfigurement, but often kills about a third of its victims. There hasn’t been such a victim since 1977.

Early battles against smallpox were based on early understanding of disease and on acute observation of patients. Our early colleagues were pretty good observers, and relied on both their historical readings and their own observations. Dr. Andrew Cantwell, an English physician working in France in the mid-18th century, rejected earlier beliefs and observed that:

One might infer that this illness can often be caused by bad weather, like the other epidemic illnesses, such as the malignant fevers, pneumonias, pleurisies, etc. But I say that it is not an intemperate air that produces it, rather it appears because of the miasmas or corpuscles emanating from the bodies of those afflicted, by which it is communicated through the air to healthy people, entering by the stomach or by the lungs, or gaining entry by vessels absorbed from the external surface of the human machine.

He rejected some of the earlier ideas of smallpox being caused by “bad airs”, and instead believed (correctly) that is was somehow passed from person-to-person. Some of his other ideas were more classical, including his descriptions of the potential origins of smallpox in northeastern Africa, using descriptions lifted nearly verbatim from Herodotus. His readings lead him to conclude (probably correctly) that smallpox was being spread across the globe by large human movements. He described it establishing itself in Western Europe as a consequence of the Crusades, and noted regarding its most recent migration:

It is again even more recent in America, and was not know until the Europeans established their colonies…. In 1683 it destroyed almost all of the Sasquenahs, one of the bravest nations in all of North America. Their captain-general Tenoughan appeared to have been the first afflicted, and he died of it. The first time that it declares itself in a foreign country, it is ordinarily deadly, as when it caused infection on its debut in Boston and in several English cities.

His observations serve to establish his credentials, credentials he would need to argue against the new and growing practice of inoculation. Dr. Cantwell was practicing at a crucial time in the history of smallpox. A few decades earlier, inoculation against smallpox (also called “variolation”) had been introduced to Western Europe and the Americas. This ancient practice, popularized in the West by the wife of a British diplomat in Asia Minor (Lady Mary Wortley Montagu), was controversial from the beginning. Lady Montagu wrote in one of her letters:

. . . I am going to tell you a thing that I am sure will make you wish yourself here. The small-pox, so fatal, and so general amongst us, is here entirely harmless by the invention of ingrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation every autumn . . . . The old woman comes with a nutshell full of the matter of the best sort of small-pox, and asks what veins you please to
have opened . . . . She immediately rips open that you offer her with a large needle . . .
and puts into the vein as much venom as can lie upon the head of her needle . . . . Every
year thousands undergo this operation . . . There is no example of any one that has died in
it; and you may believe I am well satisfied of the safety of the experiment . . . . I am
of them that I thought had virture enough to destroy such a considerable branch of their
revenue for the good of mankind (Montagu 1717).

Essentially, pus was gathered from smallpox victims and introduced in various way into healthy people. This practice was viewed with some suspicion.

The Court in England was not about to risk the royal family on Montagu’s word alone, and had inoculation tested on condemned prisoners before they tried it on “real people”. A respected scientist of the time, James Jurin, collected statistics and concluded that the risk of dying from smallpox inoculation was significantly less than the risk from natural infection (about 1:50 vs 1:7). Others also began to collect data and found that the death rate from inoculation was minimal, and that from natural smallpox was quite high. The practice quickly spread through the English-speaking world.

But inoculation had its detractors, and among these was Dr. Cantwell. His objections were rather sophisticated, and familiar. He felt that Jurin was not being careful enough in evaluating this new practice:

Since the time of Mr. Jurin, the arguments for and against this novelty contain several articles that this great man, truly a zealot for the public good, reduced to the two following points:

I: If the smallpox communicated by inoculation is sufficient means to protect one forever, and if there remains the danger of contracting a second smallpox by natural means.

II: If the danger of inoculation is much less than that of the natural smallpox.

If it can be proved at some point that these two propositions are false, it is absolutely necessary to renounce the practice of inoculation.

Cantwell goes on at length to describe cases where smallpox was acquired despite inoculation, and where inoculation proved to be deadly. But he did not collect data as his colleagues in England were doing. Cantwell was not inoculation’s only critic, but his arguments became irrelevant a short time after his death.

(Cantwell’s 1756 “Text on Smallpox” was acquired by me at an ancient book store in Avignon, France. As a little side project, I translated most of it a number of years ago, so any errors in translation are mine.)

At the end of the 18th century, Edward Jenner made his famous observations that mild cowpox infections appeared to protect people against smallpox, and conducted experiments that validated these observations. Vaccination, named for the cowpox virus (vaccinia) was widely adopted as safer than variolation, and laws were passed in England mandating its use as a public health imperative.

Shortly after the passage of these laws, anti-vaccination groups emerged complaining of the attacks on their civil liberties and parental rights:

I. It is the bounden duty of parliament to protect all the rights of man.



–William Hume-Rothery, president, 1878, Anti-Compulsory Vaccination League


Similar movements appeared in the United States and were associated smallpox outbreaks. Opponents to vaccination used all the contemporary tools of propaganda, including editorial cartoons, and characterizations of vaccination as a child-devouring monster.

A colleague sent me a fascinating copy of The Medical Observer (Volume III, No. IX, 1808). A great part of this journal is devoted to “the vaccine controversy”. Perhaps some of the arguments will sound familiar to those of you who follow the vaccine controversy in its present form.

From a letter to the editor (emphasis mine):

As you have devoted one part of your useful work to the important subject of Vaccination it will give me particular satisfaction to communicate through your medium the result of such observations as occur in the course of my practice on this at present doubtful preventive of small pox in public opinion. It is to be regretted that those gentlemen who have become enthusiasts in its favour in their inquiries into the opposite side of the question have not conducted themselves either with the liberality of science or the candour which is in general due to professional etiquette. Dissent of opinion is considered as a heresy of the most damnable dye and any doubt of the efficacy of this favourite delusion is judged worse than the sin of witchcraft.

In the above section, the writer complains that vaccination opponents are unfairly demonized. Sound familiar?

Next comes the common modern complaint that in one person’s opinion, natural disease is safer than vaccination. This opinion is rendered without the benefit of data:

In my opinion the inflammation and sloughing produced by cow pox matter is far more formidable than a full crop of small pox. Every surgeon must admit that the inflammation is of a most unfavourable kind and in some instances has sloughed to that extent as to destroy the life of the child and on many occasions has been so deep as to do such injury to the bone that considerable exfoliations have ensued. Are not such effects more to be dreaded than a full eruption of smallpox?

And then comes the first use I’ve ever seen of something akin to the Pharma Shill Gambit:

It has been said, if not by Dr Jenner at least by his friends, that the first grant of ten thousand pounds by Parliament was inadequate to the expenses which he had incurred in his experiments and correspondence with medical gentlemen on the subject. Now gentlemen, when the practice was first adopted in Gloucestershire every means was employed by Dr Jenner and a Dr. or Mr. Marshall, a supposed partner, to monopolise it. During my residence at Chepstow cow pox was recommended by Dr Jenner to an opulent farmer in the neighbourhood who consented to his children being vaccinated Dr Jenner was in consequence applied to and was very handsomely paid for it.

There are several letters, both pro and con, published here, many of which seem to accuse Jenner of unseemly profit, and many that claim either that vaccination is more dangerous than smallpox, or that it doesn’t protect against smallpox. There is also a letter calling for the wider use of statistics in medicine, something none of the correspondents had done.

There was particular attention to supposed failures of vaccinations, and a vigorous debate regarding whether the failure occurred and why. But the last word will go to a Thomas Key. He writes to refute another letter, in which the writer asserts that a particular case was a vaccination failure, and that this failure argues against all vaccination (emphasis again mine):

An assertion in a Letter published in the The Morning Post… signed John Birch demands some observation…. Vaccination solicits no fraud for its protection it asks only for a free and rational inquiry

In the end, it was not the assertions of vaccination supporters or detractors that decided the issue. It was the results of “free and rational inquiry”, the collection of data, and the use of this data in an organized, global eradication plan that turned smallpox into a distant memory. And yet the same vapid, evidence-free arguments still dominate the debate about vaccination. Two hundred fifty years have done little to change the inherent suspicions and empty arguments of those who battle against vaccination, but despite this, we are still generally winning.


  1. #1 The Gregarious Misanthrope
    May 7, 2010

    I just saw a History Channel show about the Revolutionary War and it discussed a smallpox outbreak at Valley Forge that was quelled by the earlier vaccination method of lancing the skin and smearing pus from a smallpox victim on the wound. They had the same relative mortality statistics you present.

    The program counted this among many factors that led to our vicory over England. Hard to fight a war with dead and disfigured soldiers.

  2. #2 KWombles
    May 7, 2010

    Thank you for an interesting and informative post. Those who cling to superstitions and gut feelings, who choose ignorance and woo, will undoubtedly always be with us. The key to continuing to advance civilization is to countering methodically and scientifically such ignorance, to shine the bright light of knowledge as an antidote to this darkness (or to do like Orac does and blast ’em with snark and ridicule–whatever works!). Surely with the combination of the two, we can beat back the tide.

  3. #3 Sunil
    May 7, 2010

    Really informative, thanks for posting it! I love the phrase “free and rational inquiry”.

  4. #4 LadyDay
    May 9, 2010

    Fascinating points, and great post!

  5. #5 Chuck
    May 10, 2010

    I am sure that PAL will correct me if I am wrong with this statistic, but, to the best of my knowledge the smallpox vaccine has the highest recorded adverse reactions for vaccines. My spouse had a life threatening adverse reaction to smallpox prior to NVICP with lifelong pain and suffering even though she was never exposed to the virus. The financial and physical pain continues to this day. The actual necessity of all the recommended vaccines is easily questionable in both our home and our community.

    I can honestly say that everyone in my family HATES the smallpox vaccine.

  6. #6 Nomen Nescio
    May 10, 2010


    really? noone in your family’s much younger than, oh, 35 or so? my partner has the smallpox vaccine scar, but i never got it, being a few years younger; two generations have grown up without it, now, and a third will soon begin.

    which fact is, of course, only possible because of the smallpox vaccine. i suspect your family members might have hated the disease itself even more, but for that.

  7. #7 PalMD
    May 10, 2010

    Historically, smallpox vaccinations were “messy” vaccinations: many more and more significant adverse reactions than more modern vaccines. Of course, world wide eradication of this deadly and disfiguring disease has allowed us to discontinue using it.

  8. #8 JustaTech
    May 10, 2010

    Chuck, I’m sorry you and your family had such a terrible experience. From all that I have read about vaccinia, (I’m young but was vaccinated for work) people who react poorly to the vaccine would similarly have a significantly worse case if they actually got smallpox, which was the rational for vaccinating these people.

    (Now we’d say “Oh, you have eczema? You can’t work with this vaccinia-based vaccine, sorry.”)

  9. #9 Chuck
    May 10, 2010

    You are going on assumptions that are incorrect. My spouse has never been immune compromised or experienced eczema. What I have been able to piece together is that VIG had to be flown in by the Army and treatment was administered at a military facility at the airport because the civilian medical community did not possess the proper treatment at the time.

  10. #10 Jim
    May 13, 2010

    My grandmother was 5’2″ and a spitfire. She was, that is, until she contracted polio. She ended up in an iron lung and delivered her second-born, my mother, while there. Yes, third trimester of pregnancy, labour and delivery while in an iron lung. She kicked metric tonnes of ass.

    She recovered, thankfully, and resumed her vibrant and active life until she began suffering symptoms of Post Polio Syndrome. From the time of diagnosis, it was two years before she went from playing nine holes of golf a day (on a course she’d helped build by hand) to being wheelchair-bound. Seven years later, she died of a brain aneurysm that would’ve been caught were it not masked by the treatments she was receiving for PPS.

    I don’t know what her life would’ve been like had she been vaccinated, but I know that I love her and I miss her and that she would’ve been around longer had she never come down with that horrible, disfiguring disease. And I’m eternally grateful that my mother, me, and my children have little to worry about so far as polio thanks to our vaccination.

    Please recognize, Chuck, that the plural of anecdote is not data. That vaccine hurt someone you love and I understand that makes you fearful, but vaccines do work for the vast majority of people and a part of what has enabled modern civilization.

  11. #11 Calli Arcale
    May 13, 2010

    Chuck: I don’t think he was suggesting your spouse was immune compromised. He just said “those who respond poorly”. There are lots of reasons a person can respond poorly to a disease, and ironically, having a strong immune system can sometimes be one of them. (That’s the case with certain strains of influenza, for instance.) And I think eczema was not an assumption but rather a “for-instance” of one reason why a person might be deferred from vaccination for smallpox today, since eczema (which is caused by a hyperactive immune system, not a weak one) is a known risk factor.

    There is also a “shit happens” factor; sometimes people will have an adverse effect for no known reason. There’s not much that can be done about that, and it’s why the national vaccine injury compensation program was created. I know it didn’t come soon enough to help your spouse, but it did help others, and hopefully that can provide some consolation, as it is because of cases like your spouse that the system has been improved.

    Of course, the only reason people vaccinate against smallpox today is military strategy, and that’s an entirely different kettle of fish. There is no real risk of smallpox, so no reason to get vaccinated any more. (Exception: military personnel on a sort of variation on the “Star Wars” missile shield concept. The idea was that if no missile could penetrate our defenses, nobody would bother launching any at us. Vaccinating the troops against smallpox is supposed to discourage hostile nations from deploying smallpox bioweapons, because they won’t disable our troops but will instead trigger them to respond with massive force.)

    Despite this, there are people working on safer vaccinia vaccines, in hopes of developing a smallpox vaccine that is less dangerous. Which is pretty cool, considering the rather limited market for such a product. Someone genuinely cares, is what that means.

    BTW, the smallpox vaccine does *not* have the highest rate of vaccine side effects. That dubious honor would probably go to variolation, its predecessor, in which people were innoculated not with cowpox but with actual smallpox, and via big gaping wounds in a time before infection control protocols.

  12. #12 Katharine
    May 13, 2010

    I could never be a physician.

    Not because of the difficulty of the schooling/work, but because it requires more compassion than I can manage for people who are stark raving idiots.

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